Prediction of hospital mortality among critically ill patients in a single centre in Asia: comparison of artificial neural networks and logistic regression-based model.

INTRODUCTION: This study compared the performance of the artificial neural network (ANN) model with the Acute Physiologic and Chronic Health Evaluation (APACHE) II and IV models for predicting hospital mortality among critically ill patients in Hong Kong. METHODS: This retrospective analysis included all patients admitted to the intensive care unit of Pamela Youde Nethersole Eastern Hospital from January 2010 to December 2019. The ANN model was constructed using parameters identical to the APACHE IV model. Discrimination performance was assessed using area under the receiver operating characteristic curve (AUROC); calibration performance was evaluated using the Brier score and Hosmer-Lemeshow statistic. RESULTS: In total, 14 503 patients were included, with 10% in the validation set and 90% in the ANN model development set. The ANN model (AUROC=0.88, 95% confidence interval [CI]=0.86-0.90, Brier score=0.10; P in Hosmer-Lemeshow test=0.37) outperformed the APACHE II model (AUROC=0.85, 95% CI=0.80-0.85, Brier score=0.14; P<0.001 for both comparisons of AUROCs and Brier scores) but showed performance similar to the APACHE IV model (AUROC=0.87, 95% CI=0.85-0.89, Brier score=0.11; P=0.34 for comparison of AUROCs, and P=0.05 for comparison of Brier scores). The ANN model demonstrated better calibration than the APACHE II and APACHE IV models. CONCLUSION: Our ANN model outperformed the APACHE II model but was similar to the APACHE IV model in terms of predicting hospital mortality in Hong Kong. Artificial neural networks are valuable tools that can enhance real-time prognostic prediction.

[Efficacy and prognosis of newly diagnosed multiple myeloma patients treated with bortezomib, lenalidomide and dexamethasone].

Objective: To evaluate the efficacy of VRD (bortezomib+lenalidomide+dexamethasone) in newly diagnosed multiple myeloma (NDMM) patients as well as the effect of the regimen on the long-term prognosis. Methods: The clinical characteristics, survival rates, response rates and minimal residual disease (MRD) of patients with NDMM at Institute of Hematology & Blood Diseases Hospital from January 1, 2013 to January 1, 2020 were retrospectively analyzed. Subgroup analysis was also performed among groups according to the cytogenetics and autologous stem cell transplantation (ASCT) of patients. Results: A total of 87 patients were retrospectively analyzed. The age[M(Q1,Q3)] of all patients was 56 (51, 61) years and males and females accounted for 58.6% (51/87) and 41.4% (36/87), respectively. The overall response rate (ORR) was 95.9% (71/74) after 2 courses of induction therapy, with 13.5% (10/74) achieving the deep response [complete response (CR) or better] and 51.3% (38/74) of patients achieving a very good partial response (VGPR) or better. After 4 courses of induction therapy, the ORR achieved 95.2% (60/63), and the proportions of the deep response and VGPR or better grew up to 46.0% (29/63) and 77.7% (49/63). According to the treatment, the patients (≤65 years old) were divided into transplantation group and non-transplantation group. After the induction therapy, 88.8% (32/36) of patients in the transplantation group achieved VGPR or better, and 55.5% (20/36) reached the deep response. After the transplantation, the proportion increased to 97.1% (34/35) and 77.2% (27/35), respectively(88.8% vs 97.1%,P=0.174;55.5% vs 77.2%,P=0.055), with the rate of undetectable MRD increasing from 44.4% (16/36) to 77.8% (28/36) (P=0.004). In the non-transplantation group, 74.2% (23/31) of patients achieved VGPR or better after 4 courses of induction therapy, 35.5% (11/31) of the patients achieved deep response and the rate of undetectable MRD was 37.0% (10/27). Compared with the non-transplantation group, transplantation was associated with a higher rate of complete response (89.5% vs 53.1%, P<0.001) and a lower rate of MRD detection(78.4% vs 55.2%, P=0.045). The median follow-up time of all patients was 26.3 months (20.8, 33.8). The median progression-free survival and overall survival were not reached. The three-year PFS and OS rates were 78.4% and 87.2%, respectively. None of the standard-risk group, the high-risk group, the transplantation group and non-transplantation group achieved the median PFS and OS. Conclusions: VRD regimen has a promising efficacy and results in a substantial survival benefit. ASCT after VRD induction therapy is associated with higher rate of deep response, higher rate of undetectable MRD and longer survival.

[Clinical characteristics and prognosis of 46 patients with macrofocal multiple myeloma].

The clinical characteristics, laboratory results, response to treatment, and prognosis of 46 macrofocal multiple myeloma(MFMM) patients at our center from January 2013 to December 2019 were analyzed retrospectively. The other 92 patients were selected as matched-controls based on diagnostic period and treatment. Among the 1 137 MM patients, 46 patients met the definition criteria of MFMM (4.0%), with median age 56 years, which was not statistically different from whole MM population (P=0.066). According to the international staging system (ISS) and Revised ISS, the proportion of patients with advanced stage in MFMM group was less common than that of controls (P<0.05). More plasmacytomas in MFMM patients were presented (43.5% vs. 18.5%, P<0.05). Regarding cytogenetic abnormalities, there were minor patients manifesting high-risk features in MFMM group (15.8% vs. 32.2%, P=0.058). Translocation(11;14) could be detected in 32.4% MFMM patients and 9.4% typical myeloma patients (P<0.05). The treatment regimens were comparable. As to the best response of treatment, the complete response (CR) rate in MFMM group was significantly higher than that of controls (78.3% vs. 60.9%, P<0.05). The median follow-up time was 37.9 months. The median progression-free survival in MFMM and control groups were 77.5 vs. 39.8 months, respectively (P<0.05). The overall survival (OS) of MFMM patients was significantly longer (not reached vs. 68.2 months, P<0.05).

[Mechanism of paeoniflorin inhibiting apoptosis of hippocampal neurons of rats induced by lead acetate].

Objective: To investigate the effect and underlying mechanism of paeoniflorin on hippocampal neuron apoptosis induced by lead acetate. Methods: In September 2020, primary hippocampal neuronal cells were isolated and cultured from fetal rats, and identified using cellular immunofluorescent. MTT assay was used to measure the cell viability to determine the concentration and time of lead acetate-induced hippocampal neuron apoptosis. MTT was also used to evaluate the effect of paeoniflorin concentration on the apoptosis of hippocampal neurons induced by lead acetate. According to the results, different concentrations of paeoniflorin were selected to intervene hippocampal neuron cells, after 24 h, lead acetate was added to the cells, meanwhile, blank and model groups were set up, the content of reactive oxygen species (ROS) , superoxide dismutase (SOD) , lactate dehydrogenase (LDH) , malondialdehyde (MDA) and Caspase-3 were measured. Extracellular signal regulated kinase (ERK) , phosphorylated ERK (p-ERK) , p38 mitogen -activated protein kinases (p38MAPK) , phosphorylated p38MAPK (p-p38MAPK) , c-Jun N-terminal kinase (JNK) and phosphorylated JNK (p-JNK) protein expression in hippocampal neuronal cells were determined by Western blotting. Results: The isolated and cultured hippocampal neurons were identified by immunofluorescence chemical staining and then treated with lead acetate, MTT results showed that lead acetate had the best toxicity effect when treated for 24 h at a concentration of 25 µmol/L. Paeoniflorin showed no cytotoxic effect on hippocampal neuronal cells when the concentrations below 80 µmol/L. Compared with the model group, the activity of hippocampal neuronal cells was significantly increased after treating with 20, 40 or 80 µmol/L paeoniflorin (P<0.05) . Compared with the blank group, the ROS activity, LDH release level, MDA content and caspase-3 content were significantly increased (P<0.01) , and the SOD activity was significantly decreased (P< 0.01) in the hippocampal neuronal cells of the model group. Compared with the model group, the ROS activity, LDH release level, MDA content and caspase-3 content were obviously decreased (P<0.05) , SOD activity was significantly increased (P <0.01) after hippocampal neuronal cells were treated with 40 or 80 µmol/L paeoniflorin. Relative to the model group, the ratio of p-ERK/ERK were significantly up-regulated (P<0.01) , while the ratios of p-p38MAPK/p38MAPK and p-JNK/JNK were significantly down-regulated after hippocampal neuronal cells were treated with 40 or 80 µmol/L paeoniflorin (P<0.05) . Conclusion: Paeoniflorin may down-regulate the expression of p-p38MAPK and p-JNK protein, up-regulate the expression of p-ERK protein, and inhibit the apoptosis of hippocampal neurons induced by lead acetate through the MAPK signaling pathway.

Admission triage tool for adult intensive care unit admission in Hong Kong during the COVID-19 outbreak.

Intensive care is expensive, and the numbers of intensive care unit (ICU) beds and trained specialist medical staff able to provide services in Hong Kong are limited. The most recent increase in coronavirus disease 2019 (COVID-19) infections over July to August 2020 resulted in more than 100 new cases per day for a prolonged period. The increased numbers of critically ill patients requiring ICU admission posed a capacity challenge to ICUs across the territory, and it may be reasonably anticipated that should a substantially larger outbreak occur, ICU services will be overwhelmed. Therefore, a transparent and fair prioritisation process for decisions regarding patient ICU admission is urgently required. This triage tool is built on the foundation of the existing guidelines and framework for admission, discharge, and triage that inform routine clinical practice in Hospital Authority ICUs, with the aim of achieving the greatest benefit for the greatest number of patients from the available ICU resources. This COVID-19 Crisis Triage Tool is expected to provide structured guidance to frontline doctors on how to make triage decisions should ICU resources become overwhelmed by patients requiring ICU care, particularly during the current COVID-19 pandemic. The triage tool takes the form of a detailed decision aid algorithm based on a combination of established prognostic scores, and it should increase objectivity and transparency in triage decision making and enhance decision-making consistency between doctors within and across ICUs in Hong Kong. However, it remains an aid rather than a complete substitute for the carefully considered judgement of an experienced intensive care clinician.

Impact of appropriate empirical antibiotics on clinical outcomes in Klebsiella pneumoniae bacteraemia.

INTRODUCTION: Klebsiella pneumoniae infections can cause septic shock, multiorgan failure, and death. METHODS: This retrospective cohort study included adults with K pneumoniae bacteraemia treated from 1 January 2009 to 30 June 2017. Demographics, microbiology, and outcomes were analysed. The primary outcome was 90-day all-cause mortality; secondary outcomes were intensive care unit (ICU) and hospital mortalities, ICU and hospital lengths of stay, and ICU ventilator duration. RESULTS: In total, 984 patients had K pneumoniae bacteraemia; of them, 686 received appropriate empirical antibiotics. Overall, 205 patients required intensive care. Older age (odds ratio [OR]=1.60; 95% confidence interval [CI]=1.120-2.295; P=0.010), chronic kidney disease (OR=1.81; 95% CI=1.181- 2.785; P=0.007), mechanical ventilation (OR=1.79; 95% CI=1.188-2.681; P=0.005), pneumonia (OR=1.50; 95% CI=1.030-2.187; P=0.034), and carbapenem-resistant or extended-spectrum betalactamase (ESBL)-producing isolates (OR=12.51; 95% CI=7.886-19.487; P<0.001) were associated with greater risk of inappropriate empirical treatment. Ninety-day mortality was significantly higher among patients with inappropriate empirical treatment; independent predictors included pneumonia (hazard ratio [HR]=2.94; 95% CI=2.271-3.808; P<0.001), gastrointestinal infection (HR=2.77; 95% CI=2.055-3.744; P<0.001), failed empirical antibiotics (HR=2.45; 95% CI=1.928-3.124; P<0.001), older age (HR=1.79; 95% CI=1.356-2.371; P<0.001), solid tumour (HR=1.77; 95% CI=1.401-2.231; P<0.001), carbapenem-resistant or ESBL-producing isolates (HR=1.64; 95% CI=1.170-2.297; P=0.004), patients admitted through the Department of Medicine (HR=1.39; 95% CI=1.076-1.800; P=0.012), and higher total Sequential Organ Failure Assessment score (HR=1.09; 95% CI=1.058-1.112; P=0.023). Among ICU patients, inappropriate empirical antibiotic treatment was significantly associated with increased ventilator duration and 90-day mortality. CONCLUSIONS: Klebsiella pneumoniae bacteraemia was associated with high 90-day and ICU mortalities; 90-day mortality increased with inappropriate empirical antibiotic treatment.

[Immunoglobulin M multiple myeloma: a six-case report and literature review].

Objective: To investigate the clinical characteristics, responses, and prognosis of immunoglobulin M multiple myeloma (IgM MM) . Methods: The clinical characteristics, laboratory results, bone marrow biopsy results, response, and prognosis of six cases of IgM MM in the Blood Diseases Hospital, Chinese Academy of Medical Sciences, from December 18, 2009 to October 29, 2020 were collected and analyzed. Results: All six cases met the diagnosis criteria of IgM MM. There were four males and two females. The median age at first diagnosis was 70 (59-81) years. According to Durie-Salmon (DS) staging, 2 cases were in ⅠA, and 4 cases were in ⅢA. According to the International Staging System (ISS) , 4 cases were in Ⅱ, and 2 cases were in Ⅲ. The initial symptoms were as follows: 4 cases of bone pain, 3 cases of hyperviscosity, and 2 cases of lymphadenopathy or hepatosplenomegaly. Laboratory results showed the following: median blood M protein: 39.11 (3.61-75.56) g/L; median serum IgM: 69.35 (4.35-137.00) g/L; median hemoglobin: 87.0 (70-131) g/L; median blood creatinine: 83.6 (53.0-129.6) µmol/L; median blood calcium: 2.12 (2.11-2.50) mmol/L. The median ratio of bone marrow plasma cells was 0.390 (0.255-0.590) , and in four cases, plasma cells were observed in blood smears. Karyotype analysis and fluorescence in situ hybridization (FISH) examination showed the following: 1 case of hypodiploidy, 2 cases of P53 gene deletion, 1 case of 1q21 amplification positive, and 4 cases of RB-1 gene deletion positive. The immunoglobulin heavy chain (IgH) rearrangement was positive in all cases, of which 3 cases were CCND1/IgH fusion gene-positive identified with t (11;14) rearrangement. Immunophenotyping revealed that all cases were positive for CD38, CD138, and monoclonal light chain and four cases were weakly positive for CD20. All cases accepted proteasome inhibitor-based regimens and attained the response of partial remission to strict complete remission. Conclusion: In addition to the typical clinical manifestations of myeloma, IgM MM is also characterized by hyperviscosity, lymphadenopathy, or hepatosplenomegaly, and t (11;14) is the most frequent cytogenetics aberration. Furthermore, the response and prognosis of IgM MM are similar to other common myeloma subtypes.

Burden of pneumococcal disease: 8-year retrospective analysis from a single centre in Hong Kong.

PURPOSE: Streptococcus pneumoniae is a common pathogen involved in community-acquired pneumonia. Invasive pneumococcal disease is often associated with higher co-morbidity rates, but mortality-related findings have been inconclusive. This study investigated predictors of 30-day mortality and invasive pneumococcal disease. METHODS: This retrospective analysis included adults with pneumococcal disease who were admitted to Pamela Youde Nethersole Eastern Hospital from 1 January 2011 to 31 December 2018. Demographics, microbiological characteristics, and outcomes were compared between 30-day survivors and non-survivors, and between patients with invasive disease and those with non-invasive disease. Intensive care unit (ICU) subgroup analysis was performed. The primary outcome was 30-day all-cause mortality; secondary outcomes were ICU and hospital mortalities, and ICU and hospital lengths of stay. RESULTS: In total, 792 patients had pneumococcal disease; 701 survived and 91 (11.5%) died within 30 days. Notably, 106 (13.4%) patients had invasive pneumococcal disease and 170 (21.5%) patients received intensive care. Vasopressor use (odds ratio [OR]=4.96, P<0.001), chronic kidney disease (OR=3.62, P<0.001), positive urinary antigen test results (OR=2.57, P=0.001), and advanced age (OR=2.19, P=0.010) were independent predictors for 30-day mortality by logistic regression analysis. Among critically ill patients, chronic kidney disease (OR=4.64, P<0.001), higher APACHE IV score (OR=3.73, P=0.016), and positive urinary antigen test results (OR=2.94, P=0.008) were predictors for 30-day mortality. Logistic regression analysis revealed that chronic kidney disease (OR=3.10, P<0.001) was a risk factor for invasive pneumococcal disease. CONCLUSION: Advanced age, vasopressor use, chronic kidney disease, and positive urinary antigen test results were independent predictors for 30-day mortality in patients with pneumococcal disease.

Value of sTNF-R1 and linc0597 as indicators for disease activity and diagnosis of lupus nephritis.

OBJECTIVE: To explore whether Soluble tumor necrosis factor-receptor 1 (sTNF-R1) and linc0597 can be used as indicators for disease activity and diagnosis of lupus nephritis (LN). PATIENTS AND METHODS: Eighty LN patients treated in our hospital were enrolled as the LN group, while 60 Systemic Lupus Erythematosus (SLE) patients without nephritis were included in the SLE group, and 50 healthy subjects who conducted physical examination during the same period as the control group. After admission, 5 mL of venous blood was taken from all the study subjects to measure sTNF-R1 level and linc0597 expression by enzyme-linked immunosorbent assay (ELISA) and RT-qPCR respectively. In addition, the receiver operating characteristic (ROC) curves were employed to evaluate the diagnostic value of serum sTNF-R1 and linc0597 for LN, and Spearman correlation coefficient was adopted for the correlation between sTNF-R1, linc0597, and LN clinical disease Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Moreover, the logistic multiple regression analysis was applied to analyze the independent risk factors affecting the complication of LN in SLE patients. RESULTS: The LN group presented significantly higher serum sTNF-R1 and linc0597 levels than the control group and the SLE group. Besides, ROC curve analysis revealed that sTNF-R1 and linc0597 had good clinical diagnostic value in LN and SLE. Furthermore, Spearman correlation coefficient indicated that serum sTNF-R1 and linc0597 were positively correlated with disease activity index SLEDAI (r=0.551, p<0.001; R =0.604, p<0.001). Moreover, multivariate Logistic regression analysis demonstrated that age (p=0.001), fever (p=0.004), arthralgia (p=0.034), serum uric acid (p=0.019), decreased complement C3 (p=0.023), ANA peripheral type (p=0.007), anti-ds-DNA antibody (p=0.003), ANCA (p=0.002), sTNF-R1 (p=0.001), and linc0597 (p<0.001) were all independent risk factors affecting the complication of LN in SLE patients. CONCLUSIONS: STNF-R1 and linc0597 can be used as the indicators for disease activity and diagnosis of LN.

[Analysis of the first national public health practice skills competition among college students].

To analyze the difficulty, distinction and result of the first national public health practice skills competition among college students, it showed the general situation of this competition, and discussed the present situation, problems and countermeasures of skills training for students majoring in preventive medicine. Based on such competition, educators can promote teaching reform and post competency training.

Effects of red blood cell aggregation on the blood flow in a symmetrical stenosed microvessel.

In order to figure out whether red blood cell (RBC) aggregation is beneficial or deleterious for the blood flow through a stenosis, fluid mechanics of a microvascular stenosis was examined through simulating the dynamics of deformable red blood cells suspended in plasma using dissipative particle dynamics. The spatial variation in time-averaged cell-free layer (CFL) thickness and velocity profiles indicated that the blood flow exhibits asymmetry along the flow direction. The RBC accumulation occurs upstream the stenosis, leading to a thinner CFL and reduced flow velocity. Therefore, the emergence of stenosis produces an increased blood flow resistance. In addition, an enhanced Fahraeus-Lindqvist effect was observed in the presence of the stenosis. Finally, the effect of RBC aggregation combined with decreased stenosis on the blood flow was investigated. The findings showed that when the RBC clusters pass through the stenosis with a throat comparable to the RBC core in diameter, the blood flow resistance decreases with increasing intercellular interaction strength. But if the RBC core is larger and even several times than the throat, the blood flow resistance increases largely under strong RBC aggregation, which may contribute to the mechanism of the microthrombus formation.

Impact of Dysnatremia and Dyskalemia on Prognosis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study.

BACKGROUND: Electrolyte disturbance is one of the complications of subarachnoid hemorrhage (SAH) and its prognostic value is not fully understood. The focus of this study is to evaluate the impact of dysnatremia and dyskalemia on functional outcomes in patients with aneurysmal SAH. MATERIALS AND METHODS: Patients with spontaneous aneurysmal SAH who were admitted to our intensive care unit (ICU) between 1st January 2011 and 31st December 2016 were included. Demographic data, biochemical parameters from days 1 to day 11 of ICU admission, disease severity, and clinical outcome were recorded. The prognosis was estimated using the Glasgow outcome scale (GOS) at 3 months after the initial insult. RESULTS: A total of 244 patients were included in this study. There were 139 patients (57.0%) with hyponatremia (Na < 135 mmol/L) while 82 patients (33.6%) had hypernatremia (Na >146 mmol/L). Hyponatremia, hypernatremia, and sodium fluctuation >12 mmol/L were more commonly found in those patients with poor outcome. However, both hypokalemia and hyperkalemia were not shown to have a significant effect on the patient's prognosis. Logistic regression analysis identified the following independent predictors of poor outcome (GOS 1-3 at 3 months): age >55 years old, acute physiology and chronic health evaluation IV (APACHE IV) score >50, World Federation of Neurosurgical Societies (WFNS) grade >3, Fisher grade >2, presence of intracranial hemorrhage (ICH)/intraventricular hemorrhage (IVH), use of mannitol, use of loop diuretic aneurysms, involving posterior circulation, and hypernatremia >146 mmol/L. CONCLUSION: Hypernatremia, but not hyponatremia, in patients with aneurysmal SAH is associated with poor outcome. Both hypokalemia and hyperkalemia were not shown to have a significant effect on the patient's prognosis. Further studies are required to determine whether the treatment of dysnatremia can influence outcomes. CLINICAL SIGNIFICANCE: Dysnatremia and dyskalemia are common in patients with aneurysmal SAH, but only hypernatremia is associated with poor outcome. Further studies are required to determine whether the treatment of dysnatremia can influence outcomes. HOW TO CITE THIS ARTICLE: Tam CWY, Shum HP, Yan WW. Impact of Dysnatremia and Dyskalemia on Prognosis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study. Indian J Crit Care Med 2019;23(12):562-567.

Modeling Cell Adhesion and Extravasation in Microvascular System.

The blood flow behaviors in the microvessels determine the transport modes and further affect the metastasis of circulating tumor cells (CTCs). Much biochemical and biological efforts have been made on CTC metastasis; however, precise experimental measurement and accurate theoretical prediction on its mechanical mechanism are limited. To complement these, numerical modeling of a CTC extravasation from the blood circulation, including the steps of adhesion and transmigration, is discussed in this chapter. The results demonstrate that CTCs prefer to adhere at the positive curvature of curved microvessels, which is attributed to the positive wall shear stress/gradient. Then, the effects of particulate nature of blood on CTC adhesion are investigated and are found to be significant in the microvessels. Furthermore, the presence of red blood cell (RBC) aggregates is also found to promote the CTC adhesion by providing an additional wall-directed force. Finally, a single cell passing through a narrow slit, mimicking CTC transmigration, was examined under the effects of cell deformability. It showed that the cell shape and surface area increase play a more important role than the cell elasticity in cell transit across the narrow slit.

[Therapeutic effect of miR-489 in a mouse model of silica-induced matured pulmonary fibrosis].

Objective: To explore the potential therapeutic role of miR-489 in silica-induced pulmonary fibrosis mouse models. Methods: A total of 32 C57BL/6 male mice were randomly divided into four groups: saline, silica, silica plus miRNA control and silica plus miR-489 agomir (n=8 in each group) . The mice were instilled with silica particles suspended in saline or sterile saline intratracheally. Subsequently, miR-489 agomir or miRNA control was injected via the tail vein into each mouse at days 28, 35, 42 and 49, the miR-489 levels, histological examination, collagen deposition, fibrotic biomarkers (E-cadherin, α-SMA, Vimentin, Fibronectin) and transforming growth factor-ß(1) (TGF-ß(1)) protein levels in mouse lung tissues were measured. Results: miR-489 levels in silica plus miR-489 group were significantly increased in lung tissues compared with silica plus miRNA control group (P<0.05) . Histological examination showed attenuated inflammation, less severe fibrotic foci and less destruction of alveolar architecture in the silica plus miR-489 group. Additionally, both the severity and distribution of lung lesions were ameliorated in silica plus miR-489 group compared with the silica plus miRNA control group (P<0.05) . The collagen deposition and hydroxyproline levels in silica plus miR-489 group were significantly decreased compared with the silica plus miRNA control group (P<0.05) . These changes were supported by decreased protein levels of α-SMA, Vimentin, Fibronectin, TGF-ß1 along with increased protein levels of E-cadherin in silica plus miR-489 group (P<0.05) . Conclusion: Our data indicate that the upregulation of miR-489 has potential therapeutic role in silica-induced pulmonary fibrosis in vivo, which may be associated with the depression of TGF-ß1 release.

A case of severe empyema with acute respiratory distress syndrome caused by Slackia exigua requiring veno-venous extracorporeal membrane oxygenation.

Slackia exigua (S. exigua) is an obligatory anaerobic coccobacillus under the family of Coriobacteriaceae. It is a rare cause of pyogenic extraoral infections. We report a 58-year-old lady with good past health presented with fulminant community-acquired pneumonia causing acute respiratory distress syndrome caused by S. exigua requiring veno-venous extra-corporeal membrane oxygenation (VV-ECMO). Bacterial identification can be challenging and often require 16 S rRNA and MALDI-TOF MS. The patient was treated with amoxicillin-clavulanic acid according to sensitivity and made significant recovery.

Clinical predictors and outcomes of Klebsiella pneumoniae bacteraemia in a regional hospital in Hong Kong.

BACKGROUND: Klebsiella pneumoniae (KP) infection is associated with high morbidity and mortality. Multidrug resistance, especially extended-spectrum ß-lactamase (ESBL) production, in KP is endemic worldwide. AIM: To evaluate the clinical characteristics and outcomes of patients with KP bacteraemia in critical care and general ward settings. METHODS: Adult patients admitted to a regional hospital in Hong Kong from January 1st, 2009 to June 30th, 2016 (7.5 years) with KP bacteraemia were included. Demographics, clinical features, microbiological characteristics, and outcomes were analysed. FINDINGS: Among 853 patients, 178 (20.9%) required critical care and 176 (20.6%) died within 30 days of hospital admission. Thirty-day survivors were younger (P<0.001), had milder disease (defined by Sequential Organ Failure Assessment score) (P<0.001), presented with hepatobiliary sepsis (P<0.001) or urosepsis (P<0.001), less septic shock (P=0.013), fewer invasive organ supports (P<0.001), and had appropriate empirical antibiotics (P<0.001). Cox regression analysis showed that respiratory tract infection (hazard ratio: 2.99; 95% confidence interval: 2.061-4.337; P≤0.001), gastrointestinal tract infection (excluding hepatobiliary system) (2.763; 1.761-4.337; P≤0.001), mechanical ventilation (2.202; 1.506-3.221; P≤0.001), medical case (1.830; 1.253-2.672; P=0.002), inappropriate empirical antibiotics (1.716; 1.267-2.324; P≤0.001), female (1.699; 1.251-2.307; P<0.001), age >65 years (1.692; 1.160-2.467; P=0.006), and presence of solid tumour (1.457; 1.056-2.009; P=0.022) were independent risk factors for 30-day mortality. Unexpectedly, diabetes mellitus was associated with better 30-day survival (P=0.002). A total of 102 patients (12.0%) had infections with ESBL-producing strains, which were not associated with higher 30-day mortality. CONCLUSION: KP bacteraemia is associated with high 30-day mortality. Site of infection, patients' comorbidities and appropriate use of empirical antibiotic are important predictors of patients' outcomes.