Automatic adjustment of oxygen concentration during high-flow nasal cannula treatment using a targeted SpO2 feedback system.

AIM: To test whether targeted SpO2 feedback (TSF), an automatic control system for fraction of inspired oxygen (FiO2), achieves more time in the optimal SpO2 range and/or reduces the frequency of manual adjustments to administered FiO2 compared with conventional manual titration in patients with hypoxia on high-flow nasal cannula (HFNC) therapy. STUDY DESIGN: Twenty-two patients were recruited from two hospitals. For each, two sessions of manual mode and two sessions of TSF were applied in a random order, each session lasting 2 h. The target SpO2 on TSF was 95%. Oxygen monitoring levels were classified into four SpO2 ranges: hypoxia (≤ 89%), borderline (90%-93%), optimal (94%-96%) and hyperoxia (≥ 97%). The two modes were compared based on the proportion of time spent in each SpO2 range and the number of manual FiO2 adjustments. RESULTS: The proportion of time in the optimal SpO2 range was 20.5% under manual titration mode and 65.4% under TSF (p < .01). The proportions of time in the hypoxia range were 1.1% and 0.4%, respectively (p = .31), in the borderline range 4.7% and 3.5%, respectively (p = .54), and in the hyperoxia range 73.7% and 30.7%, respectively (p < .01). There were statistical differences only in the optimal and hyperoxia SpO2 ranges. During the 8 h, the frequency of manual FiO2 adjustment was 0.7 times for the manual mode and 0.2 times for TSF, showing no statistically significant difference (p = 0.076). CONCLUSION: Compared with manual titration, TSF achieved greater time of the optimal SpO2 and less time of hyperoxia during HFNC. The frequency of manual adjustments on TSF tended to be less than on manual titration mode. RELEVANCE TO CLINICAL PRACTICE: Automatic closed-loop algorithm FiO2 monitoring systems can achieve better oxygen treatments than conventional monitoring and may reduce nurse workloads. In the era of pandemic respiratory diseases, this system can also facilitate contactless SpO2 monitoring during HFNC therapy.

Artificial intelligence-based computer-assisted detection/diagnosis (AI-CAD) for screening mammography: Outcomes of AI-CAD in the mammographic interpretation workflow.

Purpose: To evaluate the stand-alone diagnostic performances of AI-CAD and outcomes of AI-CAD detected abnormalities when applied to the mammographic interpretation workflow. Methods: From January 2016 to December 2017, 6499 screening mammograms of 5228 women were collected from a single screening facility. Historic reads of three radiologists were used as radiologist interpretation. A commercially-available AI-CAD was used for analysis. One radiologist not involved in interpretation had retrospectively reviewed the abnormality features and assessed the significance (negligible vs. need recall) of the AI-CAD marks. Ground truth in terms of cancer, benign or absence of abnormality was confirmed according to histopathologic diagnosis or negative results on the next-round screen. Results: Of the 6499 mammograms, 6282 (96.7%) were in the negative, 189 (2.9%) were in the benign, and 28 (0.4%) were in the cancer group. AI-CAD detected 5 (17.9%, 5 of 28) of the 9 cancers that were intially interpreted as negative. Of the 648 AI-CAD recalls, 89.0% (577 of 648) were marks seen on examinations in the negative group, and 267 (41.2%) of the AI-CAD marks were considered to be negligible. Stand-alone AI-CAD has significantly higher recall rates (10.0% vs. 3.4%, P < 0.001) with comparable sensitivity and cancer detection rates (P = 0.086 and 0.102, respectively) when compared to the radiologists' interpretation. Conclusion: AI-CAD detected 17.9% additional cancers on screening mammography that were initially overlooked by the radiologists. In spite of the additional cancer detection, AI-CAD had significantly higher recall rates in the clinical workflow, in which 89.0% of AI-CAD marks are on negative mammograms.

Predictors of early hospital readmission in patients receiving home mechanical ventilation.

BACKGROUND: Although the proportion of patients with chronic respiratory failure requiring home mechanical ventilation (HMV) is increasing, hospital readmissions in these patients are also increasing. OBJECTIVE: We investigated the factors for early readmission in patients receiving HMV. METHODS: We retrospectively analyzed the data of adult patients readmitted to the hospital within a year who first received HMV and were discharged from the Asan Medical Center between March 2014 and February 2019. We compared the clinical characteristics at discharge before readmission between the early (readmission within 30 days) and late readmission groups (readmission between day 31 and 1 year) and investigated the clinical characteristics and outcomes at readmission. RESULTS: Of the 116 patients identified, 36.2% had been readmitted early. The patients who received invasive HMV had a higher rate of early readmission than those who received non-invasive HMV. Pneumonia was the most common reason of readmission in the two groups. The rate of aspiration was significantly higher in the early readmission group (28.6% vs. 8.1%; P = .003). In multivariate logistic regression analysis, nasogastric tube feeding, sequelae of pneumonia or acute respiratory distress syndrome, and central nervous system disorders as causes for HMV were significantly associated with early readmission. CONCLUSION: Feeding methods and causes for HMV were associated with early readmission. Educating caregivers on respiratory care (suction and feeding methods) is important for preventing early readmission.

Effects of high-flow nasal cannula in patients with mild to moderate hypercapnia: a prospective observational study.

BACKGROUND: Evidence for using high-flow nasal cannula (HFNC) in hypercapnia is still limited. Most of the clinical studies had been conducted retrospectively, and there had been conflicting reports for the effects of HFNC on hypercapnia correction in prospective studies. Therefore, more evidence is needed to understand the effect of the HFNC in hypercapnia. METHODS: We conducted a multicenter prospective observational study after applying HFNC to 45 hospitalized subjects who had moderate hypercapnia (arterial partial pressure of carbon dioxide [PaCO2], 43-70 mm Hg) without severe respiratory acidosis (pH <7.30). The primary outcome was a change in PaCO2 level in the first 24 hours of HFNC use. The secondary outcomes were changes in other parameters of arterial blood gas analysis, changes in respiration rates, and clinical outcomes. RESULTS: There was a significant decrease in PaCO2 in the first hour of HFNC application (-3.80 mm Hg; 95% confidence interval, -6.35 to -1.24; P<0.001). Reduction of PaCO2 was more prominent in subjects who did not have underlying obstructive lung disease. There was a correction in pH, but no significant changes in respiratory rate, bicarbonate, and arterial partial pressure of oxygen/fraction of inspired oxygen ratio. Mechanical ventilation was not required for 93.3% (42/45) of our study population. CONCLUSIONS: We suggest that HFNC could be a safe alternative for oxygen delivery in hypercapnia patients who do not need immediate mechanical ventilation. With HFNC oxygenation, correction of hypercapnia could be expected, especially in patients who do not have obstructive lung diseases.

Follow-Up Intervals for Breast Imaging Reporting and Data System Category 3 Lesions on Screening Ultrasound in Screening and Tertiary Referral Centers.

OBJECTIVE: To assess the appropriate follow-up interval, and rate and timepoint of cancer detection in women with Breast Imaging Reporting and Data System (BI-RADS) 3 lesions on screening ultrasonography (US) according to the type of institution. MATERIALS AND METHODS: A total of 1451 asymptomatic women who had negative or benign findings on screening mammogram, BI-RADS 3 assessment on screening US, and at least 6 months of follow-up were included. The median follow-up interval was 30.8 months (range, 6.8-52.9 months). The cancer detection rate, cancer detection timepoint, risk factors, and clinicopathological characteristics were compared between the screening and tertiary centers. Nominal variables were compared using the chi-square or Fisher's exact test and continuous variables were compared using the independent t test or Mann-Whitney U test. RESULTS: In 1451 women, 19 cancers (1.3%) were detected; two (0.1%) were diagnosed at 6 months and 17 (1.2%) were diagnosed after 12.3 months. The malignancy rates were both 1.3% in the screening (9 of 699) and tertiary (10 of 752) centers. In the screening center, all nine cancers were invasive cancers and diagnosed after 12.3 months. In the tertiary center, two were ductal carcinomas in situ and eight were invasive cancers. Two of the invasive cancers were diagnosed at 6 months and the remaining eight cancers newly developed after 13.1 months. CONCLUSION: One-year follow-up rather than 6-month follow-up may be suitable for BI-RADS 3 lesions on screening US found in screening centers. However, more caution is needed regarding similar findings in tertiary centers where 6-month follow-up may be more appropriate.

Global and Regional Ventilation during High Flow Nasal Cannula in Patients with Hypoxia.

BACKGROUND: High flow nasal cannula (HFNC) is known to increase global ventilation volume in healthy subjects. We sought to investigate the effect of HFNC on global and regional ventilation patterns in patients with hypoxia. METHODS: Patients were randomized to receive one of two oxygen therapies in sequence: nasal cannula (NC) followed by HFNC or HFNC followed by NC. Global and regional ventilation was assessed using electric impedance tomography. RESULTS: Twenty-four patients participated. Global tidal variation (TV) in the lung was higher during HFNC (NC, 2,241 ± 1,381 arbitrary units (AU); HFNC, 2,543 ± 1,534 AU; P < 0.001). Regional TVs for four iso-gravitational quadrants of the lung were also all higher during HFNC than NC. The coefficient of variation for the four quadrants of the lung was 0.90 ± 0.61 during NC and 0.77 ± 0.48 during HFNC (P = 0.035). Within the four gravitational layers of the lung, regional TVs were higher in the two middle layers during HFNC when compared to NC. Regional TV values in the most ventral and dorsal layers of the lung were not higher during HFNC compared with NC. The coefficient of variation for the four gravitational layers of the lung were 1.00 ± 0.57 during NC and 0.97 ± 0.42 during HFNC (P = 0.574). CONCLUSIONS: In patients with hypoxia, ventilation of iso-gravitational regions of the lung during HFNC was higher and more homogenized compared with NC. However, ventilation of gravitational layers increased only in the middle layers. (Clinical trials registration number: NCT02943863).

Erratum: Follow-up Outcomes of Benign Pathology Initially Assigned as Breast Imaging Reporting and Data System Category 4A and 3.

[This corrects the article on p. 304 in vol. 20, PMID: 28970857.].

Follow-up Outcomes of Benign Pathology Initially Assigned as Breast Imaging Reporting and Data System Category 4A and 3.

PURPOSE: This retrospective study investigated if the initially assigned category 4A or 3 in concordant benign lesions, after ultrasound (US)-guided core needle biopsy, could affect follow-up compliance. METHODS: Eight hundred thirty-eight concordant benign lesions, after core needle biopsy (674, initial category 4A group and 164, category 3 group) and follow-up US, were included in our study. If an immediate surgical excision-a surgical excision before the next follow-up-exists, those cases with pathologic reports were collected. Statistical comparisons for the result of follow-up US compliance, additional biopsy, and malignant rates among 6-month, 12-month, and long-term intervals were performed by using the chi-square test. The log-rank test was used to compare compliance rates in the timing of first follow-up between the two groups, with a significance level of 0.05. RESULTS: The number of immediate surgical excision was higher in the category 4A group (11.1%) than in the category 3 group (6.1%); only one cancer was found in the category 4A group. The patients' compliance rate in a 6-month follow-up showed an increase (p=0.003) in the category 4A group. The additional biopsy rate was higher in the initial category 4A group (10.9%) than in the category 3 group (1.9%) with statistical significance (p=0.001); four cancers were found on additional biopsy in the category 4 group. No cancer was detected in the initial category 3 group, both on immediate surgical excision and follow-up. CONCLUSION: The initial category 4A or 3 of the Breast Imaging Reporting and Data System could be a significant factor that affects immediate surgical excision and follow-up compliance. Cancers were detected only in the initial category 4A group of concordant benign lesions. More attention should be paid to the concordant benign lesions from the initial category 4A group than from the category 3 group.

Clinical outcomes of cardiac arrest patients according to opioid use history.

PURPOSE: Opioid analgesics are potent respiratory depressants. The purpose of this study was to describe the effects of opioids administered within 24hours before cardiac arrest on clinical outcomes. MATERIALS AND METHODS: We retrospectively collected the cardiac arrest data of noncancer patients who were admitted to the general ward of Asan Medical Center from January 2008 to August 2012. We investigated the proportion of these patients who received opioids within 24hours of a cardiac arrest event, as well as the cardiac arrest characteristics, survival rates, and opioid administration patterns. RESULTS: Of the 193 patients identified, 58 (30%) had been administered opioids within the previous 24hours (the opioid group), whereas the remaining 135 (70%) had not been administered opioids (the nonopioid group). The survival rate did not differ significantly between these 2 groups. In the opioid group, as-needed opioid administration was associated with a lower 24-hour survival rate than regular opioid administration (9 [33.3%] of 27 patients vs 20 [64.5%] of 31 patients; P=.030). In multivariate logistic regression analysis, as-needed opioid administration was negatively associated with 24-hour survival. CONCLUSIONS: Opioid administration within 24hours before cardiac arrest per se was not associated with adverse outcomes. However, administration of opioid analgesics on an as-needed basis was associated with poorer survival outcomes than regular dosing. Greater attention should be paid to patients who receive as-needed opioid administration in the general ward.

Failure of high-flow nasal cannula therapy may delay intubation and increase mortality.

PURPOSE: Intubation in patients with respiratory failure can be avoided by high-flow nasal cannula (HFNC) use. However, it is unclear whether waiting until HFNC fails, which would delay intubation, has adverse effects. The present retrospective observational study assessed overall ICU mortality and other hospital outcomes of patients who received HFNC therapy that failed. METHODS: All consecutive patients in one tertiary hospital who received HFNC therapy that failed and who then required intubation between January 2013 and March 2014 were enrolled and classified according to whether intubation started early (within 48 h) or late (at least 48 h) after commencing HFNC. RESULTS: Of the 175 enrolled patients, 130 (74.3 %) and 45 (25.7 %) were intubated before and after 48 h of HFNC, respectively. The groups were similar in terms of most baseline characteristics. The early intubated patients had better overall ICU mortality (39.2 vs. 66.7 %; P = 0.001) than late intubated patients. A similar pattern was seen with extubation success (37.7 vs. 15.6 %; P = 0.006), ventilator weaning (55.4 vs. 28.9 %; P = 0.002), and ventilator-free days (8.6 ± 10.1 vs. 3.6 ± 7.5; P = 0.011). In propensity-adjusted and -matched analysis, early intubation was also associated with better overall ICU mortality [adjusted odds ratio (OR) = 0.317, P = 0.005; matched OR = 0.369, P = 0.046]. CONCLUSIONS: Failure of HFNC might cause delayed intubation and worse clinical outcomes in patients with respiratory failure. Large prospective and randomized controlled studies on HFNC failure are needed to draw a definitive conclusion.

Extra-mammary findings detected on breast magnetic resonance imaging: a pictorial essay.

Magnetic resonance imaging (MRI) of the breast is used for various indications. Contrary to computed tomography as a staging tool, breast MRI focuses on the breast parenchyma and axilla. In spite of narrow field of view, many structures such as the anterior portion of the lungs, mediastinum, bony structures and the liver are included which should not be neglected because the abnormalities detected on the above structures may influence the staging and provide a clue to systemic metastasis, which results in the change of treatment strategy. The purpose of this pictorial essay was to review the unexpected extra-mammary findings seen on the preoperative breast MRI.

Anaplastic thyroid cancer: ultrasonographic findings and the role of ultrasonography-guided fine needle aspiration biopsy.

PURPOSE: To investigate the ultrasonographic (US) features of anaplastic thyroid cancer (ATC) and the diagnostic performance of US-guided fine needle aspiration biopsy (FNAB) therein. MATERIALS AND METHODS: Eighteen cases of ATC diagnosed between January 2001 and May 2011 were included. FNAB was performed in all cases. Initial FNAB results were divided into three groups: 1) the cytological ATC group, cytological diagnosis of ATC; 2) the underestimated group, cytological diagnoses of malignancy other than ATC; and 3) the false negative group, cytological diagnoses of atypical, benign and non-diagnostic lesions. We retrospectively reviewed US findings and compared treatment modalities between each group. RESULTS: Among the 18 patients, there were nine in the initially cytological ATC group, four in the underestimated group and five in the false negative group. The most common US features of ATC were a solid (64.7%) and irregular shaped (88.2%) mass with lymph node involvement (76.4%). However, except for lymph node involvement (p=0.003), US findings for each group were not statistically different. The initial cytological diagnostic accuracy of ATC was 50% (9/18). Surgery was performed less in the ATC group (11%) and the false negative group (20%) than the underestimated group (75%). CONCLUSION: The US features of ATC were not especially different from other types of aggressive thyroid cancer. A correct diagnosis of ATC by initial US-FNAB was made in 50% of the patients, which is significant in that therapeutic surgery can be undertaken in lower numbers if correctly diagnosed.

US-guided optical tomography: correlation with clinicopathologic variables in breast cancer.

We tested the relationships between total hemoglobin concentration (THC), as measured with ultrasound (US)-guided optical tomography, and clinicopathologic variables in invasive ductal cancers; and we evaluated the clinical significance of THC. Fifty-three patients with 65 invasive ductal carcinomas underwent US-guided biopsy and were scanned with a hand-held probe consisting of a co-registered US transducer and an NIR (near-infrared) imager. The lesion location provided by co-registered US was used to guide optical imaging. Light absorption was measured at two optical wavelengths. From this measurement, tumor angiogenesis was assessed on the basis of calculated THC. We investigated the relationships between maximum THC and clinicopathologic variables (tumor size [≤2 cm or >2 cm], metastasis to lymph node or distant organ, histologic grade, lymphovascular invasion, status of ER, PR, HER2 and Ki-67, and triple negativity). The mean maximum THC in the breast cancers was 223.3 ± 106.3 µmol/L. In univariate analysis, HER2 positivity, tumor size, and Ki-67 positivity showed significant correlations with maximum THC (p < 0.05). In multivariate analysis including tumor size, and ER, PR, HER2, and Ki-67 status, HER2 positivity correlated with maximum THC significantly (p = 0.007, parameter estimate 76.44). Maximum THC correlated with HER2, Ki-67 and tumor size in this group of ductal breast carcinomas. Thus, US-guided diffuse optical tomography (US-DOT) may potentially be used to predict tumor aggressiveness in patients with invasive breast cancers.

A weaning protocol administered by critical care nurses for the weaning of patients from mechanical ventilation.

PURPOSE: The primary objective of this clinical trial of patients on mechanical ventilation was to determine if a weaning protocol implemented solely by nurses could reduce the weaning time relative to usual care (UC). MATERIALS AND METHODS: This study is a prospective, randomized, controlled trial conducted from January 2007 to January 2009 that compared protocol-based weaning (PBW) with UC. A total of 122 patients who received invasive ventilation in the medical ICU of the Asan Medical Center were examined. Nurses operated the mechanical ventilators according to a predesigned ventilator-weaning protocol for the PBW group (n = 61), and intensive care unit (ICU) physicians managed weaning in the UC group (n = 61). RESULTS: There were no significant differences in the 2 groups at baseline. The number of patients who successfully discontinued mechanical ventilation was similar in the 2 groups (PBW, 46 patients, 75.4%; UC, 47 patients, 77.0%; P = .832). The weaning time was 47 hours (interquartile range, 24-168 hours) in the UC group and 25 hours (interquartile range, 5.75-134 hours) in the PBW group (P = .010). CONCLUSIONS: The weaning protocol administered by the nurses was safe and reduced the weaning time from mechanical ventilation in patients who were recovering from respiratory failure.

Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation.

OBJECTIVE: To determine the prevalence of diaphragmatic dysfunction diagnosed by M-mode ultrasonography (vertical excursion <10 mm or paradoxic movements) in medical intensive care unit patients and to assess the influence of diaphragmatic dysfunction on weaning outcome. DESIGN: Prospective, observational study. SETTING: Twenty-eight-bed medical intensive care unit in a university-affiliated hospital. PATIENTS: Eighty-eight consecutive patients in the medical intensive care unit who required mechanical ventilation over 48 hrs and met the criteria for a spontaneous breathing trial were assessed. Patients with a history of diaphragmatic or neuromuscular disease or evidence of pneumothorax or pneumomediastinum were excluded. INTERVENTIONS: During spontaneous breathing trial, each hemidiaphragm was evaluated by M-mode ultrasonography using the liver and spleen as windows with the patient supine. Rapid shallow breathing index was simultaneously calculated at the bedside. MEASUREMENTS AND MAIN RESULTS: The prevalence of ultrasonographic diaphragmatic dysfunction among the eligible 82 patients was 29% (n = 24). Patients with diaphragmatic dysfunction had longer weaning time (401 [range, 226-612] hrs vs. 90 [range, 24-309] hrs, p < .01) and total ventilation time (576 [range, 374-850] hrs vs. 203 [range, 109-408] hrs, p < .01) than patients without diaphragmatic dysfunction. Patients with diaphragmatic dysfunction also had higher rates of primary (20 of 24 vs. 34 of 58, p < .01) and secondary (ten of 20 vs. ten of 46, p = .01) weaning failures than patients without diaphragmatic dysfunction. The area under the receiver operating characteristics curve of ultrasonographic criteria in predicting weaning failure was similar to that of rapid shallow breathing index. CONCLUSIONS: Using M-mode ultrasonography, diaphragmatic dysfunction was found in a substantial number of medical intensive care unit patients without histories of diaphragmatic disease. Patients with such diaphragmatic dysfunction showed frequent early and delayed weaning failures. Ultrasonography of the diaphragm may be useful in identifying patients at high risk of difficulty weaning.

Combined anomaly of the right hepatic lobe agenesis and absence of the inferior vena cava: a case report.

The absence of the inferior vena cava is an uncommon congenital anomaly that has recently been identified as an important risk factor contributing to the development of deep venous thrombosis. Congenital agenesis of the right hepatic lobe is a rare anomaly which is found incidentally in radiologic examinations. We present a case of a congenital absence of the infrarenal inferior vena cava, combined with agenesis of the right hepatic lobe in a 62-year-old man presented with symptoms of deep venous thrombosis.