Factors associated with adherence to low-tidal volume strategy for acute lung injury and acute respiratory distress syndrome and their impacts on outcomes: an observational study and propensity analysis.

BACKGROUND: The purpose of this study was to investigate the factors affecting adherence to the low-tidal volume (LTV) strategy in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) and their impacts on outcomes. METHODS: This prospective observational study included 111 patients with ALI/ARDS admitted to six intensive care units between March 2010 and February 2011. The patients were divided into the LTV group, which received a TV ≤7.5 mL/kg predicted body weight (PBW), and the non-LTV group, which received a TV >7.5 mL/kg PBW. We studied the association of selected clinical factors and adherence to the LTV strategy, and evaluated their impacts on 28-day mortality and 1-year mortality by the propensity-match process. RESULTS: Adherence to the LTV strategy was only 44%, which was related to lung injury severity (odds ratio [OR]: 3.15, P=0.038), muscle relaxant use (OR: 3.28, P=0.031), and depth of sedation (OR: 0.65, P=0.008). Propensity score-based analysis showed that the LTV group had modestly better 28-day survival (P=0.081) and 1-year survival (P=0.067) than the non-LTV group. Moreover, muscle relaxant use was strongly associated with reducing the risk of death at both 28 days (hazard ratio [HR]: 0.122, 95% confidence interval [CI]: 0.027-0.542, P=0.006) and 1 year ([HR]: 0.111, 95% [CI]: 0.030-0.408, P=0.001). CONCLUSION: Adherence to the LTV strategy was strongly associated with the lung injury score, muscle relaxant use, and depth of sedation. Propensity score-based analysis showed that the use of LTV ventilation and muscle relaxants reduced 28-day and 1-year mortality in ALI/ARDS patients.

Diagnostic value of procalcitonin in pleural effusions.

This study was to determine the diagnostic value of procalcitonin (PCT) in the differentiation of infectious and non-infectious causes of pleural effusion. From January 2005 to April 2005, we measured the PCT levels of pleural effusion from 76 patients using an immunoluminometric assay. The types of pleural infusions studied were para-pneumonic effusion (n = 26), empyema (n = 7), tuberculous pleurisy (n = 8), malignant pleural effusion (n = 25) and transudative pleural effusion (n = 8). The PCT levels were low in transudative pleural effusions (0.188 ± 0.077 ng/mL) and tuberculous pleurisy (0.130 ± 0.069 ng/mL), but high in empyema (5.147 ± 3.056 ng/mL), para-pneumonic effusion (1.091 ± 0.355 ng/mL), and malignant pleural effusion (0.241 ± 0.071 ng/mL). The receiver-operating characteristic curve analysis for an optimal discrimination between empyema and para-pneumonic effusion from non-para-pneumonic effusion could be performed at a cut-off point of 0.18 ng/mL with area under the curve of 0.776 (sensitivity: 69.7%, specificity: 72.1%). The correlation was found between pleural effusion PCT and serum PCT levels in 16 patients (r² = 0.967, p < 0.001). In conclusion, a high pleural effusion PCT level suggests the presence of empyema and para-pneumonic effusion.

Candida glabrata fungaemia in intensive care units.

Candidaemia is increasingly important in intensive care units (ICUs). Compared with Candida albicans fungaemia, the impact of C. glabrata fungaemia on ICU patients is not well-known. The aim of this study was to investigate the clinical features, the antifungal susceptibility and the treatment outcomes of C. glabrata fungaemia in ICU patients. The medical records of ICU patients with candidaemia between 2000 and 2005 were reviewed retrospectively, and antifungal susceptibility testing was performed for isolates of C. glabrata. Among 147 episodes of candidaemia occurring in adult ICUs, C. glabrata was the second most common species and accounted for 45 (30%) episodes of candidaemia. The incidence of C. glabrata fungaemia was 1.3/1000 ICU admissions. Fluconazole resistance was found in 11% of C. glabrata isolates. The 30-day all-cause mortality rate was 58%. Therapeutic regimens containing amphotericin B were associated with better outcome. Despite higher fluconazole resistance, C. glabrata candidaemia was not associated with greater mortality than non-glabrata candidaemia in the ICU setting.

Pandrug-resistant Pseudomonas aeruginosa among hospitalised patients: clinical features, risk-factors and outcomes.

Between 1 January 2003 and 31 December 2003, 37 patients had positive cultures of pandrug-resistant Pseudomonas aeruginosa (PDRPA) resistant to all commercially available anti-pseudomonal antimicrobial agents in Taiwan, including anti-pseudomonal penicillins, ceftazidime, fourth-generation cephalosporins, aztreonam, carbapenems, aminoglycosides and ciprofloxacin. Nineteen (51.4%) patients had PDRPA infections, including pneumonia (17 patients), catheter-related bacteraemia (one patient) and anal abscess (one patient). Eighteen patients were classified as having PDRPA colonisation, based on absence of clinical signs or symptoms of infection. In total, 92 isolates were recovered from various specimens, with the majority (85.9%) recovered from respiratory tract secretions (sputa, bronchial washings and pleural effusions), followed by urine (4.3%) and catheter tips (3.3%). Twenty-eight (75.7%) patients yielded cultures of non-PDR P. aeruginosa isolates before isolation of PDRPA, with a mean period between the first isolation of non-PDR P. aeruginosa and the isolation of PDRPA of 128.3 days. Most patients had received beta-lactam antibiotics, fluoroquinolones or carbapenems for prolonged periods. Univariate analysis showed that PDRPA infection, male gender and the presence of fever at the time of PDRPA isolation were associated with increased mortality.

Value of imprint cytology for ultrasound-guided transthoracic core biopsy.

The aim of this study was to investigate the possible additional diagnostic information provided by imprint cytology when performing ultrasound-guided transthoracic core biopsy and to evaluate whether it could optimise the biopsy procedure. A total of 155 transthoracic core biopsies with touch imprint smears were performed under ultrasound guidance, with 127 malignant and 28 benign lesions. The imprint smears were stained using Riu's method and interpreted by a cytopathologist. These were compared with the histopathology of core biopsy specimens and the final diagnosis of malignant versus benign disease. The overall diagnostic accuracy of imprint cytology was 94% (146 out of 155). Histopathological analysis showed an overall accuracy of 94% (146 out of 155), with a sensitivity of 94% (119 out of 127) and negative predictive value of 79% (27 out of 34). The combination of these two methodologies had an increased overall accuracy and negative predictive value of 98% (152 out of 155) and 90% (28 out of 31), respectively. The results of imprint cytology and histopathology were in agreement in 143 patients (92%). In conclusion, imprint cytology of ultrasound-guided transthoracic core biopsy is a sensitive procedure for diagnosing peripheral thoracic lesions, and it may increase the diagnostic accuracy and cancer negative prediction of biopsy alone. With an on-site approach, imprint cytology may help to assess the adequacy of biopsy specimens and optimise the biopsy procedure.

Patient mortality of active pulmonary tuberculosis requiring mechanical ventilation.

Mortality remains high among patients with pulmonary tuberculosis requiring mechanical ventilation (TBMV). This study was carried out to establish the mortality rates of TBMV and to identify factors that contribute to in-hospital mortality. From January 1996-April 2001, there were 825 patients with active pulmonary tuberculosis at the National Taiwan University Hospital, Taipei, Taiwan. Of these, 41 suffered acute respiratory failure and required mechanical ventilation in the intensive care unit (ICU). Of these 41 patients, 38 were followed up for 180 days. In-hospital deaths were documented in the medical records and all possible parameters contributing to mortality were collected. Of the 41 patients, 27 died in the hospital and 14 were discharged alive (in-hospital mortality rate 65.9%), with (mean +/- SD) 40.7 +/- 35.4 admission days before death. Of the 27 that died, 25 died during ICU admission and two died after being transferred to the ward. The mortality rate for the 180-day monitoring period was 79%. Factors contributing to in-hospital mortality included consolidations on chest radiographs and multiple organ failure. The mortality rate in the patients with pulmonary tuberculosis requiring mechanical ventilation is very high, with two factors affecting in-hospital mortality. These factors were multiple organ failure and consolidation on chest radiographs.

Clinical spectrum of acute respiratory distress syndrome in a tertiary referral hospital: etiology, severity, clinical course, and hospital outcome.

BACKGROUND AND PURPOSE: The clinical picture of patients with acute respiratory distress syndrome (ARDS) in Taiwan has seldom been reported, although new definitions of ARDS have been introduced over the past years. The purpose of this study was to investigate the clinical characteristics, modalities of management, and outcomes in patients with ARDS treated in a tertiary referral hospital. METHODS: Case records were selected through a computerized search of diagnosis codified at discharge during the period from January 1995 to June 1997. Patients who met the criteria of the American-European Consensus Conference definition of ARDS were included and their medical records were retrospectively reviewed. RESULTS: A total of 145 patients (91 men, 54 women; mean age, 58 years) who fulfilled the criteria for ARDS were identified. Malignancy (n = 53) and diabetes mellitus (n = 23) were the most common co-morbid conditions. Pneumonia (n = 90), including community-acquired pneumonia in 45 (31%) patients, was the most common risk factor. The lung injury score at the time of ARDS diagnosis was 2.89 +/- 0.40 (mean +/- standard error, SE). The worst value of PaO2/FIO2 was 86.8 +/- 3.8 mm Hg (mean +/- SE). Among the 145 patients, 130 (90%) received mechanical ventilation and 118 (81%) were treated in the intensive care unit. In-hospital mortality was 87%. Seventy (48%) patients received intensive treatment for ARDS, among whom 52 (74%) died; the most common causes of death were multiple organ failure (54%) and respiratory failure (23%). CONCLUSIONS: The mortality in patients with ARDS was high in this tertiary referral institution. Our findings suggest that aggressive ventilatory, pharmacologic, and supportive therapy may be important to achieve a higher survival rate.

Empyema thoracis and lung abscess caused by viridans streptococci.

We retrospectively studied the bacteriology and clinical features of empyema thoracis and lung abscess caused by viridans streptococci in 72 patients seen from January 1984 to September 1996. A total of 76 strains of viridans streptococci were isolated, of which the most common isolates were Streptococcus constellatus (21 strains), S. intermedius (17), and S. sanguis (10). Species belonging to the S. milleri group accounted for the majority (68%) of isolates. In 38 (53%) patients these organisms were recognized as the sole pathogens. Of the 72 patients, 53 had empyema, 14 had lung abscesses, and five had both empyema and lung abscess. Forty-six (64%) patients had underlying diseases. Of these, malignancies were the most common (17 patients), followed by diabetes mellitus (12 patients) and central nervous system diseases (10 patients). Of the 48 patients who underwent chest-tube drainage, 27 (56%) received further treatments, including intrapleural streptokinase (18 cases), surgery (9), and both intrapleural streptokinase and surgery (3). Two (14%) of the patients with lung abscess alone underwent surgical treatment. Although all viridans streptococcal isolates were susceptible to penicillin, the patients in the study had a high mortality (21%). Univariate and multivariate analysis of data for patients with empyema alone (n = 53) showed a significantly increased risk of death in those with underlying malignancy (OR = 16.0, p = 0.023) and those with non-S. milleri-group isolates (OR = 3.72, p = 0.030). These data imply a strong clinical significance of viridans streptococci in the pathogenesis of empyema and lung abscess, as well as the need for species identification of viridans streptococci in patients with pleuropulmonary diseases.

Transendothelial macromolecular transport in the aorta of spontaneously hypertensive rats.

Leaky endothelial junctions occurring during cell turnover have been postulated to be a major pathway for enhanced lipoprotein transport across the vascular endothelial layer, which leads to the development of atherosclerosis. Because hypertension has been well documented as one of the major risk factors for atherosclerosis, we explored the possibility that hypertension accelerates atherogenesis by increasing the turnover of endothelial cells and hence the transendothelial macromolecular permeability. The investigations were performed on thoracic aortas of 10 male 3-4-month-old spontaneously hypertensive rats and eight male age-matched Wistar-Kyoto normotensive rats. In en face preparations of aortic specimens, mitotic endothelial cells were identified by hematoxylin nuclear staining; dying or dead endothelial cells containing cytoplasmic immunoglobulin G were detected by indirect immunoperoxidase technique; and endothelial leakage to Evans blue-albumin conjugate was visualized by fluorescence microscopy. The number of leaky foci per unit endothelial surface area in spontaneously hypertensive rats was found to be approximately three times that in Wistar-Kyoto control rats; the frequencies of both endothelial cell mitosis and death in spontaneously hypertensive rats were also approximately three times the corresponding values in Wistar-Kyoto rats. These findings indicate that hypertension in spontaneously hypertensive rats is accompanied by increased endothelial cell turnover and an attendant enhancement of permeability to macromolecules.