Automatic 3D left atrial strain extraction framework on cardiac computed tomography.

BACKGROUND AND OBJECTIVE: Strain analysis provides insights into myocardial function and cardiac condition evaluation. However, the anatomical characteristics of left atrium (LA) inherently limit LA strain analysis when using echocardiography. Cardiac computed tomography (CT) with its superior spatial resolution, has become critical for in-depth evaluation of LA function. Recent studies have explored the feasibility of CT-derived strain; however, they relied on manually selected regions of interest (ROIs) and mainly focused on left ventricle (LV). This study aimed to propose a first-of-its-kind fully automatic deep learning (DL)-based framework for three-dimensional (3D) LA strain extraction on cardiac CT. METHODS: A total of 111 patients undergoing ECG-gated contrast-enhanced CT for evaluating subclinical atrial fibrillation (AF) were enrolled in this study. We developed a 3D strain extraction framework on cardiac CT images, containing a 2.5D GN-U-Net network for LA segmentation, axis-oriented 3D view extraction, and LA strain measure. The segmentation accuracy was evaluated using Dice similarity coefficient (DSC). The model-extracted LA volumes and emptying fraction (EF) were compared with ground-truth measurements using intraclass correlation coefficient (ICC), correlation coefficient (r), and Bland-Altman plot (B-A). The automatically extracted LA strains were evaluated against the LA strains measured from 2D echocardiograms. We utilized this framework to gauge the effect of AF burden on LA strain, employing the atrial high rate episode (AHRE) burden as the measurement parameter. RESULTS: The GN-U-Net LA segmentation network achieved a DSC score of 0.9603 on the test set. The framework-extracted LA estimates demonstrated excellent ICCs of 0.949 (95 % CI: 0.93-0.97) for minimal LA volume, 0.904 (95 % CI: 0.86-0.93) for maximal LA volume, and 0.902 (95 % CI: 0.86-0.93) for EF, compared with expert measurements. The framework-extracted LA strains demonstrated moderate agreement with the LA strains based on 2D echocardiography (ICCs >0.703). Patients with AHRE > 6 min had significantly lower global strain and LAEF, as extracted by the framework than those with AHRE ≤ 6 min. CONCLUSION: The promising results highlighted the feasibility and clinical usefulness of automatically extracting 3D LA strain from CT images using a DL-based framework. This tool could provide a 3D-based alternative to echocardiography for assessing LA function.

Deep learning-based automatic left atrial appendage filling defects assessment on cardiac computed tomography for clinical and subclinical atrial fibrillation patients.

Rationale and objectives: Selecting region of interest (ROI) for left atrial appendage (LAA) filling defects assessment can be time consuming and prone to subjectivity. This study aimed to develop and validate a novel artificial intelligence (AI), deep learning (DL) based framework for automatic filling defects assessment on CT images for clinical and subclinical atrial fibrillation (AF) patients. Materials and methods: A total of 443,053 CT images were used for DL model development and testing. Images were analyzed by the AI framework and expert cardiologists/radiologists. The LAA segmentation performance was evaluated using Dice coefficient. The agreement between manual and automatic LAA ROI selections was evaluated using intraclass correlation coefficient (ICC) analysis. Receiver operating characteristic (ROC) curve analysis was used to assess filling defects based on the computed LAA to ascending aorta Hounsfield unit (HU) ratios. Results: A total of 210 patients (Group 1: subclinical AF, n = 105; Group 2: clinical AF with stroke, n = 35; Group 3: AF for catheter ablation, n = 70) were enrolled. The LAA volume segmentation achieved 0.931-0.945 Dice scores. The LAA ROI selection demonstrated excellent agreement (ICC ≥0.895, p < 0.001) with manual selection on the test sets. The automatic framework achieved an excellent AUC score of 0.979 in filling defects assessment. The ROC-derived optimal HU ratio threshold for filling defects detection was 0.561. Conclusion: The novel AI-based framework could accurately segment the LAA region and select ROIs while effectively avoiding trabeculae for filling defects assessment, achieving close-to-expert performance. This technique may help preemptively detect the potential thromboembolic risk for AF patients.

Chronic obstructive pulmonary disease is associated with a higher risk of functional gastrointestinal disorders.

RATIONALE: The association between chronic obstructive pulmonary disease (COPD) and functional gastrointestinal disorders (FGIDs) remains unclear. METHODS: Using Taiwan's National Health Insurance Research Database, we conducted a nationwide population-based study to explore the relationship of COPD and future FGIDs development. The COPD cohort consisted of 4107 patients with COPD between 2000 and 2005. For a comparison cohort, 12,321 age- and gender-matched patients without COPD were randomly selected. The two cohorts were tracked for 5 year and observed for occurrence of FGIDs. The operational definition of COPD in the Korean Health Insurance Review and Assessment Service database was used to validate the results. The validation study confirmed the accuracy of definitions of COPD (83.5% sensitivity). RESULTS: The adjusted hazard ratios (aHR) of FGIDs in patients with COPD was higher (aHR: 1.63; 95% confidence interval (CI): 1.45-1.83; P < .001) than that of the comparison patients. In our secondary analysis in which FGIDs was divided into gastroesophageal reflux disease, irritable bowel syndrome and functional dyspepsia. Patients with COPD also had higher risk for all three subtypes of FGIDs: irritable bowel syndrome (aHR: 1.55; 95% confidence interval (CI): 1.27-1.90; P < .001), gastroesophageal reflux disease (aHR: 2.10; 95% confidence interval (CI): 1.76-2.49; P < .001), and functional dyspepsia (aHR: 1.34; 95% confidence interval (CI): 1.11-1.62; P = .003). The results in validated COPD group were consistent with those in unvalidated COPD group. CONCLUSION: Patients with COPD appeared to be at higher risk for future FGIDs.

Perception and Willingness to Maintain Continuity of Care by Parents of Children with Asthma in Taiwan.

To investigate caregivers' attitudes toward continuity of care (COC) and their willingness to maintain continuity for their children with asthma under a national health insurance (NHI) system without strict referral management. We sampled 825 individuals from six pediatric outpatient departments in different parts of Taiwan from 2017 to 2018. We used a contingent valuation with a payment card method. Post-stratification weighting adjustment and coarsened exact matching were utilized. Multiple logistic regression was used to compare the willingness to pay and spend extra time maintaining continuity by parents. More than 80% of caregivers in the asthma group believed having a primary pediatrician was important for children's health. Only 27.5% and 15.8% of caregivers in the asthma and control groups, respectively, believed changing pediatricians would negatively affect therapeutic outcomes. Regression analysis showed that the predicted willingness to pay for the asthma and non-asthma groups were NT$508 (SD = 196) and NT$402 (SD = 172), respectively, and there was a significant positive dose-response relationship between household income and willingness to pay for maintaining health care provider continuity. Caregivers' free choices among health care providers may reduce willingness to spend extra effort to maintain high COC. Caregivers should be educated on the importance of COC.

Administrative and Claims Data Help Predict Patient Mortality in Intensive Care Units by Logistic Regression: A Nationwide Database Study.

BACKGROUND: Increasing attention has been paid to the predictive power of different prognostic scoring systems for decades. In this study, we compared the abilities of three commonly used scoring systems to predict short-term and long-term mortalities, with the intention of building a better prediction model for critically ill patients. We used the data from the National Health Insurance Research Database (NHIRD) in Taiwan, which included information on patient age, comorbidities, and presence of organ failure to build a new prediction model for short-term and long-term mortalities. METHODS: We retrospectively collected the medical records of patients in the intensive care unit of a regional hospital in 2012 and linked them to the claims data from the NHIRD. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Elixhauser Comorbidity Index (ECI), and Charlson Comorbidity Index (CCI) were compared for their predictive abilities. Multiple logistic regression tests were performed, and the results were presented as receiver operating characteristic curves and C-statistic. RESULTS: The APACHE II score has the best predictive power for inhospital mortality (0.79; C - statistic = 0.77 - 0.83) and 1-year mortality (0.77; C - statistic = 0.74 - 0.79). The ECI and CCI alone have poorer predictive power and need to be combined with other variables to be comparable to the APACHE II score, as predictive tools. Using CCI together with age, sex, and whether or not the patient required mechanical ventilation is estimated to have a C-statistic of 0.773 (95% CI 0.744-0.803) for inhospital mortality, 0.782 (95% CI 0.76-0.81) for 30-day mortality, and 0.78 (95% CI 0.75-0.80) for 1-year mortality. CONCLUSIONS: We present a new prognostic model that combines CCI with age, sex, and mechanical ventilation status and can predict mortality, comparable to the APACHE II score.

The influence of nurse practitioner staffing on intensive care unit mortality.

BACKGROUND: In Taiwan, nurse practitioners (NPs) have taken on expanded clinical roles in the intensive care unit (ICU) due to insufficient staffing of attending physicians and resident physicians. LOCAL PROBLEM: The objective of this study was to investigate the influence of NP staffing on the quality of patient care in ICUs. METHODS: This is a retrospective study that selected patients from the ICUs of three hospitals during 2015. The mortality risks among the three hospitals were compared after adjusting variables using the Cox regression model. The care qualities of the three hospitals were analyzed using the standardized mortality ratio. INTERVENTIONS: Hospital A consisted of attending physicians and resident physicians. Hospital B consisted of attending physicians and NPs. Hospital C consisted of attending physicians, NPs, and resident physicians. RESULTS: Outcomes were assessed for 2,932 patients. The patients in hospital A had a lower mortality risk than hospital B or C. Septic shock patients received better care quality in hospital B than in hospital A or hospital C. CONCLUSIONS: In regional hospitals with lower NP-to-patient ratios, increasing that ratio could reduce the risk of mortality in the ICU and increase the quality of care.

Comparisons of mortality and rehospitalization between hip-fractured elderly with outpatient rehabilitation and those without: A STROBE-compliant article.

Geriatric patients with hip fractures have high mortality. This study aimed to compare the mortality and rehospitalization of recipient and nonrecipient of outpatient rehabilitation in hip-fractured elderly.This retrospective cohort study used nationwide claims data in Taiwan and included 3585 senior citizen patients admitted for hip fractures between January 1, 2005, and December 31, 2012. Patients were divided into the recipient (717) and nonrecipient (2868) of outpatient rehabilitation during the first 3 months after hospital discharge. Each patient was followed up for 1 year. Mortality rates of hip-fractured elderly after discharge during the first 3-month period in different groups were analyzed with Chi-square test. Cox proportional hazards regression model was employed for both death and rehospitalization risk analyses.The mortality rate of the rehabilitation group was lower than that of the nonrehabilitation group (12.69% vs 16.70%, P < .05). A more beneficial effect was observed for patients receiving continuous rehabilitation. The rehabilitation group had a lower adjusted risk of death [hazard ratio (HR) = 0.74; 95% confidence interval (95% CI): 0.59-0.94] than that of the nonrehabilitation group. However, the rehabilitation group was at a higher risk of rehospitalization (HR = 1.37; 95% CI: 1.22-1.55).Hip-fractured elderly receiving outpatient rehabilitation have a lower risk of death but a higher risk of rehospitalization than those not receiving rehabilitation within 1 year after fracture.

The Use of Hypnotics and Mortality--A Population-Based Retrospective Cohort Study.

BACKGROUND: Sleep disorders, especially chronic insomnia, have become major health problem worldwide and, as a result, the use of hypnotics is steadily increasing. However, few studies with a large sample size and long-term observation have been conducted to investigate the relationship between specific hypnotics and mortality. METHODS: We conducted this retrospective cohort study using data from the National Health Insurance Research Database in Taiwan. Information from claims data including basic characteristics, the use of hypnotics, and survival from 2000 to 2009 for 1,320,322 individuals were included. The use of hypnotics was divided into groups using the defined daily dose and the cumulative length of use. Hazard ratios (HRs) were calculated from a Cox proportional hazards model, with two different matching techniques to examine the associations. RESULTS: Compared to the non-users, both users of benzodiazepines (HR = 1.81; 95% confidence interval [CI] = 1.78-1.85) and mixed users (HR = 1.44; 95% CI = 1.42-1.47) had a higher risk of death, whereas the users of other non-benzodiazepines users showed no differences. Zolpidem users (HR = 0.73; 95% CI = 0.71-0.75) exhibited a lower risk of mortality in the adjusted models. This pattern remained similar in both matching techniques. Secondary analysis indicated that zolpidem users had a reduced risk of major cause-specific mortality except cancer, and that this protective effect was dose-responsive, with those using for more than 1 year having the lowest risk. CONCLUSIONS: The effects of different types of hypnotics on mortality were diverse in this large cohort with long-term follow-up based on representative claims data in Taiwan. The use of zolpidem was associated with a reduced risk of mortality.

Can Tracheostomy Improve Outcome and Lower Resource Utilization for Patients with Prolonged Mechanical Ventilation?

BACKGROUND: It is not clear whether the benefits of tracheostomy remain the same in the population. This study aimed to better examine the effect of tracheostomy on clinical outcome among prolonged ventilator patients. METHODS: Data were from the medical claims data in Taiwan. A total of 3880 patients with ventilator use for more than 14 days between 2005 and 2009 were identified. Among them, 645 patients with tracheostomy conducted within 30 days of ventilator use were compared to 2715 patients without tracheostomy on death during hospitalization and study period, and successful weaning and medical utilization during hospitalization. Cox proportional hazards and linear regression models were used to examine the associations between tracheostomy and the main outcomes. RESULTS: The tracheostomy rate was 30%, and 55% of tracheostomies were performed within 30 days of mechanical ventilation. After adjustments, patients with tracheostomy were at a lower risk of death during hospitalization (hazard ratio [HR] =0.51; 95% confidence interval [CI] =0.43-0.61) and 5-year observation (HR = 0.73; 95% CI = 0.66-0.81), and a lower probability of successful weaning (HR = 0.88; 95% CI = 0.79-0.99). Higher medical use was also observed in patients with tracheostomy. CONCLUSIONS: The beneficial effect for tracheostomy observed in our data was the reduction of death. However, patients with tracheostomy were less likely to wean and more likely to consume medical resources.

Gout and the risk of dementia: a nationwide population-based cohort study.

INTRODUCTION: Uric acid was proposed to have anti-oxidant property and possible neuroprotective effects. We examined the association between gout and dementia with population database. METHODS: The study utilized the claims data from the nationwide representative sample of Taiwan National Health Insurance Research Database (NHIRD). We ascertained patients with gout and dementia covering vascular and non-vascular (including Alzheimer's) subtypes using International Classification of Diseases Ninth Revision, Clinical Modification (ICD9-CM) codes. A control group matched on sex, age, and index date of gout patients was randomly sampled with a ratio of 1:4 from the same database for comparison. RESULTS: From 2002 to 2008, 28,769 gout patients who were older than 50 years old were identified, and 114,742 control patients was matched into the study. During follow-up, 7,119 patients developed dementia (1,214 with gout, and 5,905 without gout). After adjusting for age, sex, and relevant comorbidities, a Cox regression analysis showed that gout patients had a lower risk of developing non-vascular dementia (hazard ratio (HR): 0.77; 95% confidence interval (CI): 0.72-0.83; p < 0.001) and vascular dementia (HR: 0.76; 95% CI: 0.65-0.88; p < 0.001). CONCLUSIONS: Patients with gout have a lower risk of developing dementia. This phenomenon exists for both non-vascular and vascular types of dementia.

The impact of influenza vaccination on hospitalizations and mortality among frail older people.

OBJECTIVES: The objective of this study was to evaluate the benefits of influenza vaccination against hospitalization and mortality on frail elderly people. DESIGN: The design was a population-based retrospective cohort study. SETTING: Taiwan's National Health Insurance claims data. PARTICIPANTS: Participants were 5063 frail seniors, followed up for four years. MEASUREMENTS: Measurements included age, gender, socioeconomic status, living areas, use of annual health examinations, comorbid conditions, use of influenza vaccine, frailty as defined by the Adjusted Clinical Group, hospitalization, and mortality in the observation period. The efficacy was presented as comparing ever versus never vaccinated people during the entire study period without regard to seasons. RESULTS: Compared with those without influenza vaccination, vaccinated elderly individuals were younger, more likely to be men, have higher socioeconomic status, live in rural areas, have a higher rate of receiving a health examination, and have similar medical conditions. In the Cox proportional hazards analysis, influenza vaccination reduced by 7% the risk of hospitalization (95% confidence interval [CI] 0.86-0.99) and by 44% the risk of mortality (95% CI 0.51-0.62). CONCLUSION: Influenza vaccination was effective against hospitalization and mortality among the frail elderly. These results uphold the current universal influenza vaccination policy, and encourage policymakers to adopt strategies to improve vaccination use.

Incidence and renal survival of ESRD in the young Taiwanese population.

BACKGROUND AND OBJECTIVES: ESRD in the young represents a heavy burden to patients, families, and health care systems. This nationwide retrospective study characterized the incidence of ESRD and analyzed diagnoses associated with renal survival in the young population in Taiwan. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Through use of Taiwan's National Health Insurance Research Database, the population of young patients (age<30 years, including children and young adults) with ESRD between January 1998 and December 2009 were enrolled. The medical claims were used to derive the date when the cause of ESRD was first determined. The medical data were reviewed and the renal survival time (time from first diagnosis of the cause to the start of ESRD) was calculated by experts, including clinical physicians and a large-database specialist. RESULTS: The incidence rate of ESRD in the young population was high compared with the worldwide rate at 21.1 per million person-years, whereas the incidence in the pediatric group was still similar to that in other countries at 10.3 per million person-years. A total of 2304 patients with new-onset ESRD and identified renal diseases during the study period were enrolled. All preschool-age patients (100%) began receiving peritoneal dialysis as their initial treatment for ESRD. The leading causes, which varied by sex and onset age, were glomerulonephropathy followed by hypertension for the young adult group and glomerulonephropathy followed by congenital anomalies of the kidney and urinary tract (CAKUT) for the pediatric group. Renal survival was cause-dependent. The median overall renal survival duration was 0.8 year (interquartile range [IQR], 0.7-3.5 years). CAKUT-related ESRD had the longest progression time (median renal survival, 16.0 years; IQR, 10.7-23.5 years); glomerulonephropathy progressed more rapidly into ESRD and had the shortest median renal survival of 0.5 year (IQR, 0.1-2.7 years). CONCLUSIONS: The incidence and causes of ESRD greatly differ between pediatric patients and young adults. Moreover, renal survival in the young population markedly varies depending on the cause of renal disease.

The impact of nationwide education program on clinical practice in sepsis care and mortality of severe sepsis: a population-based study in Taiwan.

OBJECTIVES: We investigated the effect of a nationwide educational program following surviving sepsis campaign (SSC) guidelines. Physicians' clinical practice in sepsis care and patient mortality rate for severe sepsis were analyzed using a nationally representative cohort. METHODS: Hospitalizations for severe sepsis with organ failure from 1997 to 2008 were extracted from Taiwan's National Health Insurance Research Database (NHIRD), and trends in sepsis incidence and mortality rates were analyzed. A before-and-after study design was used to evaluate changes in the utilization rates of SSC items and changes in severe sepsis mortality rates occurred after a national education program conducted by the Joint Taiwan Critical Care Medicine Committee since 2004. A total of 39,706 hospitalizations were analyzed, which consisted of a pre-intervention cohort of 14,848 individuals (2000-2003) and a post-intervention cohort of 24,858 individuals (2005-2008). RESULTS: The incidence rate of severe sepsis increased from 1.88 per 1,000 individuals in 1997 to 5.07 per 1,000 individuals in 2008. The cumulative mortality rate decreased slightly from 48.2% for the pre-intervention cohort to 45.9% for the post-intervention cohort. The utilization rates of almost all SSC items changed significantly between the pre-intervention and post-intervention cohorts. These changes of utilization rates were found to be associated with mild reduction in mortality rate. CONCLUSION: The nationwide education program through a national professional society has a significant impact on physicians' clinical practice and resulted in a slight but significant reduction of severe sepsis mortality rate.

Readmission to the intensive care unit: a population-based approach.

BACKGROUND/PURPOSE: Readmission to the intensive care unit (ICU) results in increased consumption of medical resources and costs, and has been proposed as a marker for quality of care. ICU readmission rates have been estimated at 4-14% and different risk factors have been proposed by various studies. METHODS: Every admission event to the ICU was recorded and readmission episodes were analyzed using a population-based database from the Taiwan National Health Insurance Research Database (NHIRD) for the period from January 1, 2006 to December 31, 2006. RESULTS: The average follow-up time was 206.35 days. From the database of 192,201 patients admitted to the ICU, 25,263 patients were re-admitted, with a readmission rate of 13.13%. The leading etiologies for readmission were identified. Using multivariate analysis, age > 39 years old, female gender, ischemic heart disease, lung related disorders, pneumonia, cerebrovascular disease, sepsis, heart failure, chronic liver disease, diabetes mellitus, and chronic obstructive pulmonary disease were identified as significant risk factors for readmission to the ICU. CONCLUSION: This study uses a novel approach to assess risk factors for readmission to the ICU. Higher risk patients should be assessed more carefully before discharge or transfer from the ICU to prevent readmission episodes.

Which domain of self-rated health best predicts medical care utilization among Taiwanese adults?

BACKGROUND: We attempted to identify the domain of self-rated health (SRH) that best predicts medical care utilization among Taiwanese adults. In addition, we examined the association between SRH and different measure of medical care utilization. METHODS: We analyzed data on 11 987 community-dwelling adults aged 18 to 64 years from the 2005 Taiwan National Health Interview Survey (NHIS). NHIS data were linked to the 2006 National Health Insurance (NHI) administrative database. Then, medical care utilization in 2006, including all outpatient visits, hospitalizations, and mental health outpatient visits, was identified. Domain-specific health ratings were measured by using the Short Form-36 (SF-36) health survey questionnaire. Negative binominal models were used to estimate the contribution of the health domains to medical care utilization. Incidence rate ratios (IRRs) are presented. RESULTS: The IRR for the physical component scale showed that those with the highest scores had 77% of the outpatient visits of those with the lowest scores. The importance of mental health domains was markedly higher in estimating mental health outpatient visits. Those with mental health scores above the median had only 61% of mental health outpatient visits of those with scores below the median. CONCLUSIONS: A person's medical care utilization is reflected in the different domains of general health. Domain-specific measures of subjective health are not interchangeable with global general health ratings, because different domains have independent effects on medical care utilization. Our results are potentially important for medical resource allocation because they identify different health domain experiences that require improvement.

Successful treatment of severe heatstroke with therapeutic hypothermia by a noninvasive external cooling system.

Heatstroke is a life-threatening disease; however, no pharmacologic treatment has proven to be effective. In severe cases with multiple organ dysfunction, the mortality remains high and many patients inevitably develop permanent neurologic damage. We report a near-fatal case of exertional heatstroke with multiple organ dysfunction, including generalized convulsions, acute lung injury, and disseminated intravascular coagulation, successfully treated with induced therapeutic hypothermia (33°C [91.4°F]) by a noninvasive external cooling system. After treatment, the patient completely recovered, without any neurologic sequelae during 1 year of follow-up. To our knowledge, this is the first reported case of using therapeutic hypothermia in heatstroke.

Novel role of AMP-activated protein kinase signaling in cigarette smoke induction of IL-8 in human lung epithelial cells and lung inflammation in mice.

Cigarette smoke (CS) increases chemokine production in lung epithelial cells (LECs), but the pathways involved are not completely understood. AMP-activated protein kinase (AMPK), a crucial regulator of energy homeostasis, may modulate inflammation. Here, we show that cigarette smoke extract sequentially activated NADPH oxidase; increased intracellular reactive oxygen species (ROS) level; activated AMPK, NF-κB, and STAT3; and induced interleukin 8 (IL-8) in human LECs. Inhibition of NADPH oxidase activation by apocynin or siRNA targeting p47(phox) (a subunit of NADPH oxidase) attenuated the increased intracellular ROS level, AMPK activation, and IL-8 induction. Removal of intracellular ROS by N-acetylcysteine reduced the AMPK activation and IL-8 induction. Prevention of AMPK activation by Compound C or AMPK siRNA lessened the activation of both NF-κB and STAT3 and the induction of IL-8. Abrogation of the activation of NF-κB and STAT3 by BAY11-7085 and AG490, respectively, attenuated the IL-8 induction. We additionally show that chronic CS exposure in mice promoted AMPK phosphorylation and expression of MIP-2α (an IL-8 homolog) in LECs and lungs, as well as lung inflammation, all of which were reduced by Compound C treatment. Thus, a novel NADPH oxidase-dependent, ROS-sensitive AMPK signaling is important for CS-induced IL-8 production in LECs and possibly lung inflammation.

Acute renal failure in severe pancreatitis: A population-based study.

INTRODUCTION: Acute pancreatitis (AP) is a common illness with varied mortality and morbidity. Patients with AP complicated with acute renal failure (ARF) have higher mortality than patients with AP alone. Although ARF has been proposed as a leading mortality cause for AP patients admitted to the ICU, few studies have directly analyzed the relationship between AP and ARF. METHODS: We performed a retrospective study using the population-based database from the Taiwan National Health Insurance Research Database (NHIRD). In the period from 1 January 2005 to 31 December 2005, every patient with AP admitted to the ICU was included and assessed for the presence of ARF and mortality risk. RESULTS: In year 2005, there were a total of 221,101 admissions to the ICU. There were 1,734 patients with AP, of which 261 (15.05%) patients also had a diagnosis of ARF. Compared to sepsis and other critical illness, patients with AP had a higher risk of having a diagnosis of ARF, and patients with both diagnoses had a higher mortality rate in the same ICU hospitalization. CONCLUSION: AP is associated with a higher risk of ARF, and, when both conditions exist, a higher risk of mortality is present.

Usefulness of triggering receptor expressed on myeloid cells-1 in differentiating between typical and atypical community-acquired pneumonia.

OBJECTIVES: The purpose of this study is to investigate the clinical use of inflammatory marker triggering receptor expressed on myeloid cells (TREM)-1 at admission for differentiating between typical and atypical bacterial community-acquired pneumonia (CAP). METHODS: A prospective, noninterventional study of patients with CAP hospitalized through the emergency department was performed. Surface expression of TREM-1 was analyzed using flow cytometry on peripheral blood cells, and soluble TREM-1 (sTREM-1) concentration was determined in plasma. RESULTS: Eighty-eight patients with clinical suspicion of CAP were eligible. The causative pathogen was identified in 39 patients (44.3%). After excluding 4 mixed pneumonia cases, 21 typical and 14 atypical bacterial infections were enrolled. Patients with typical bacterial CAP demonstrated increased TREM-1 surface expression on monocytes and neutrophils. Median plasma sTREM-1 levels at admission were 65.2 pg/mL (range, 17.6-138.1 pg/mL) in patients with typical CAP and 25.9 pg/mL (range, 11.5-54.8 pg/mL) in patients with atypical CAP (P < .001). Soluble TREM-1 had good discriminative value to differentiate typical from atypical pathogens with an area under the receiver operating characteristic curve of 0.87 (95% confidence interval, 0.75-0.98). At a cutoff level of 44.2 pg/mL, sTREM-1 yielded a sensitivity of 81%, a specificity of 79%, a positive likelihood ratio of 3.79, and a negative likelihood ratio of 0.24. CONCLUSIONS: In newly admitted patients with CAP, determination of the TREM-1 levels may provide useful additional diagnostic information on the bacterial etiology.