Comparison of respiratory parameters and plasma cytokine levels between treatment with Salmeterol/fluticasone and ipratropium/terbutaline/budesonide in mechanically ventilated COPD patients.

BACKGROUND: It is unknown whether the bronchodilation and anti-inflammatory effects of inhaled salmeterol and fluticasone (SF) are better than those of traditionally inhaled ipratropium, terbutaline and budesonide (ITB) in mechanically ventilated patients with chronic obstructive pulmonary disease (COPD). METHODS: Nineteen stable COPD patients with respiratory failure were randomly enrolled into two groups. Patients were treated with inhaled SF delivered by a metered-dose inhaler with a spacer or with inhaled nebulized ITB. Respiratory parameters were measured for 7 days and plasma cytokine levels were measured on days 1 and 7. RESULTS: The kinetic curve of the rapid shallow index (RSI) from day 1 to day 7 was significant lower in the SF group than that in the ITB group. There were no significant differences in minute ventilation, intrinsic positive end expiratory pressure, and airway resistance between the ITB and SF groups from day 1 to day 7. There were no differences in plasma interleukin (IL)-6, IL-10, IL- 12, and transforming growth factor-beta1 levels between day 1 and day 7 in the ITB or SF group. CONCLUSIONS: Patients with inhaled SF treatment had a lower RSI. The effects of bronchodilators and anti-inflammation were similar between inhaled SF and ITB in COPD patients with ventilator support.

An unusual cause of dyspnea in a patient with cervical herpes zoster.

Motor involvement in acute herpes zoster does occur,but is rare. Most causes of zoster paresis are due to the extension of the inflammation to the anterior horn and/or anterior motor roots. We report a female patient with an unusual diaphragmatic paralysis caused by cervical herpes zoster. The lesion, diagnosed by MRI, involved the anterior horn of the cervical spinal cord.

Functional haplotypes in the promoter region of transcription factor Nrf2 in chronic obstructive pulmonary disease.

Nuclear factor (erythroid-derived 2)-like 2 (Nrf2) protects against oxidative stress which is important in the pathogenesis of chronic obstructive pulmonary disease (COPD). Three single nucleotide polymorphisms and 1 triplet repeat polymorphism are found in the promoter region of the Nrf2 gene. Molecular haplotyping of the Nrf2 promoter region was performed using DNA obtained from the peripheral blood of 69 COPD patients. The luciferase activities of Nrf2 promoter constructs containing all possible combinations of the 4 polymorphisms were determined and found to differ among the 16 haplotypes.The haplotypes isolated from the subjects were divided into 3 groups (L: low; M: medium; H: high) on the basis of luciferase activities. The proportions of subjects belonging to global initiative for chronic obstructive lung disease stage 3 or 4 decreased from the group with the LL haplotype to that with the HH haplotype. Presence of the LH or MM haplotype (hazard ratio, 3.36; 95% confidence interval, 1.16-9.69), gender (0.13; 0.02-0.67), and post-bronchodilator FEV1 value of predicted (0.95; 0.91-0.99) are significant predictors of respiratory failure development.The haplotype of the Nrf2 gene promoter affects its activity, and is associated with the severity and the development of respiratory failure in COPD.

Comparative antimicrobial susceptibility of aerobic and facultative bacteria from community-acquired bacteremia to ertapenem in Taiwan.

BACKGROUND: Ertapenem is a once-a-day carbapenem and has excellent activity against many gram-positive and gram-negative aerobic, facultative, and anaerobic bacteria. The susceptibility of isolates of community-acquired bacteremia to ertapenem has not been reported yet. The present study assesses the in vitro activity of ertapenem against aerobic and facultative bacterial pathogens isolated from patients with community-acquired bacteremia by determining and comparing the MICs of cefepime, cefoxitin, ceftazidime, ceftriaxone, ertapenem, piperacillin, piperacillin-tazobactam, ciprofloxacin, amikacin and gentamicin. The prevalence of extended broad spectrum beta-lactamases (ESBL) producing strains of community-acquired bacteremia and their susceptibility to these antibiotics are investigated. METHODS: Aerobic and facultative bacteria isolated from blood obtained from hospitalized patients with community-acquired bacteremia within 48 hours of admission between August 1, 2004 and September 30, 2004 in Chang Gung Memorial Hospital at Keelung, Taiwan, were identified using standard procedures. Antimicrobial susceptibility was evaluated by Etest according to the standard guidelines provided by the manufacturer and document M100-S16 Performance Standards of the Clinical Laboratory of Standard Institute. Antimicrobial agents including cefepime, cefoxitin, ceftazidime, ceftriaxone, ertapenem, piperacillin, piperacillin-tazobactam, ciprofloxacin, amikacin and gentamicin were used against the bacterial isolates to test their MICs as determined by Etest. For Staphylococcus aureus isolates, MICs of oxacillin were also tested by Etest to differentiate oxacillin-sensitive and oxacillin-resistant S. aureus. RESULTS: Ertapenem was highly active in vitro against many aerobic and facultative bacterial pathogens commonly recovered from patients with community-acquired bacteremia (128/159, 80.5 %). Ertapenem had more potent activity than ceftriaxone, piperacillin-tazobactam, or ciprofloxacin against oxacillin-susceptible S. aureus (17/17, 100%)and was more active than any of these agents against enterobacteriaceae (82/82, 100%). CONCLUSION: Based on the microbiology pattern of community-acquired bacteremia, initial empiric treatment that requires coverage of a broad spectrum of both gram-negative and gram-positive aerobic bacteria, such as ertapenem, may be justified in moderately severe cases of community-acquired bacteremia in non-immunocompromised hosts.

Pneumoconiosis and liver cirrhosis are not risk factors for tuberculosis in patients with pulmonary infection.

BACKGROUND AND OBJECTIVE: It is unclear whether patients with liver cirrhosis and coal miners with pneumoconiosis are at increased risk of developing pulmonary tuberculosis (TB). Furthermore, little is known of the likelihood of pneumonia in patients with bronchiectasis, haemodialysis, diabetes mellitus or advanced lung cancer being due to TB. To answer these questions, patients with these clinical comorbidities were analysed. METHODS: The study was retrospective and included 264 TB patients, 478 non-TB pneumonia patients, and as negative controls, 438 subjects without pneumonia. The parameters analysed were age, gender and the presence of pneumoconiosis, bronchiectasis, liver cirrhosis, haemodialysis, diabetes mellitus and advanced lung cancer. RESULTS: Male gender was the only significant factor increasing the risk of pulmonary TB. When compared with non-TB pneumonia and control patients, the odds ratios were 1.862 and 2.182, respectively. Patients with liver cirrhosis did not show an increased risk of pulmonary TB after regression analysis. Pneumoconiosis resulted in a 2.260 (P = 0.003) odds ratio for pulmonary TB, compared with the controls. However, there was no difference in pneumoconiosis between TB and non-TB pneumonia patients. Patients with bronchiectasis, lung cancer and those receiving haemodialysis had a lower risk for pulmonary TB in lower respiratory tract infection, with odds ratios of 0.342, 0.311 and 0.182, respectively. CONCLUSION: Physicians should first consider non-TB bacterial infection rather than Mycobacterium tuberculosis infection in pneumonia in patients with bronchiectasis, lung cancer or those receiving haemodialysis.

Comparison of in vitro activities of levofloxacin, ciprofloxacin, ceftazidime, cefepime, imipenem, and piperacillin-tazobactam against aerobic bacterial pathogens from patients with nosocomial infections.

BACKGROUND AND PURPOSE: There is a rapid worldwide emergence of multidrug-resistant pathogens, especially in nosocomial isolates. This study compared the in vitro activities of levofloxacin, ciprofloxacin, ceftazidime, cefepime, imipenem, and piperacillin-tazobactam against 208 aerobic bacterial pathogens that caused 197 nosocomial infections in 184 patients. METHODS: Antimicrobial susceptibility was evaluated by E test in accordance with the guidelines of the National Committee for Clinical Laboratory Standards. RESULTS: Most (140/208, 67%) of the isolates were facultative Gram-negative bacilli. Levofloxacin and ciprofloxacin were the most effective (22/22, 100%) against oxacillin-sensitive Staphylococcus aureus. None of the antibiotics tested were found to be effective (0/25) against oxacillin-resistant S. aureus. Of the 11 isolates of Acinetobacter baumannii that were not pandrug-resistant (PDR), only 9 isolates (9/11, 81%) were sensitive to imipenem and 5 isolates (5/11, 45%) were sensitive to levofloxacin, ciprofloxacin, and ceftazidime. Another 22 isolates of A. baumannii that were PDR were completely resistant to all 6 antibiotics. The majority of isolates of Pseudomonas aeruginosa were sensitive to these 6 antimicrobial agents with 10/11 (91%) sensitive to levofloxacin and ciprofloxacin, 9/11 (83%) sensitive to ceftazidime, cefepime and piperacillin-tazobactam, and 8/11 (75%) sensitive to imipenem. CONCLUSIONS: The majority of the bacterial isolates causing nosocomial infections were found to be sensitive to the 6 antibiotics tested. Bacterial isolates of nosocomial infections that were completely resistant to these 6 antibiotics were PDR A. baumannii, PDR P. aeruginosa, and oxacillin-resistant S. aureus. More potent antimicrobial agents are needed to treat infections caused by PDR A. baumannii and PDR P. aeruginosa.

Gene polymorphisms of fibrinolytic enzymes in coal workers' pneumoconiosis.

The authors assessed the gene polymorphisms of missense C/T polymorphism in exon 6 of the urokinase-plasminogen activator (PLAU) gene (PLAU P141L), Alu-repeat in intron 8 of the tissue-type plasminogen activator (PLAT) gene (PLAT TPA25 Alu insertion), and 4G/5G in the promoter region of the serine proteinase inhibitor, clade E (SERPINE) or plasminogen activator inhibitor type 1 gene (SERPINE1 -675 4G/5G) in 153 healthy volunteers and 154 retired coal miners with coal miners' pneumoconiosis (CWP). The CWP subjects included 94 individuals with simple pneumoconiosis and 60 individuals with progressive massive fibrosis presenting with worse pulmonary function. The distributions of genotypes of these three genes did not differ between the control and CWP subjects or between subjects with simple pneumoconiosis and those with progressive massive fibrosis. However, by assessing duration of work and its interaction with genotypes by means of logistic regression, the authors found the missense C/T polymorphism in exon 6 of the PLAU gene to be an effect modifier of the association between work duration and the development of progressive massive fibrosis.

The significance of mycobacterium tuberculosis antibody, antigen 60 IgG in patients with abnormal chest radiography.

BACKGROUND: The identification of acid-fast bacilli (AFB) in sputum or tissue is the definite diagnosis of tuberculosis. However, this method of diagnosis is restricted by certain limitations. The serologic diagnosis of tuberculosis has been used for a long time. The aim of this study was to determine the sensitivity and specificity of Antigen 60 (A60) immunoglobulin G (IgG) in patients with abnormal chest radiography and to assess its application in the serologic diagnosis of pulmonary tuberculosis. METHODS: Data on patients who had been diagnosed using results of culture and pathology as having active pulmonary tuberculosis (N=178), other non-tuberculosis pulmonary disease (N=34), or no pulmonary disease (N=117) was collected from January 2001 through December 2002. The data of A60 IgG using enzyme-linked immunosorbent assay (ELISA), chest radiography, tuberculosis culture and pathology were obtained retrospectively. The cutoff value of A60 IgG was chosen according to a receiver operating characteristic (ROC) analysis. The sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratio for positive and negative test were determined. RESULTS: The chosen cutoff value of 261.2 units defined the sensitivity (49.4%) and specificity (79.5%) of the test. The positive predictive value and likelihood ratio were 95.7% and 4.20, respectively, for patients with abnormal chest radiography and 88.2% and 2.97, respectively, for patients with abnormal chest radiography and negative AFB in sputum smear. CONCLUSIONS: Because of the high positive predictive value and likelihood ratio, a positive A60 IgG test in the presence of an abnormal chest radiography can help make an accurate clinical diagnosis of pulmonary tuberculosis.