Respiratory Center Research Articles

Ubiquity of the SARS-CoV-2 receptor ACE2 and upregulation in limbic regions of Alzheimer's disease brain.

The major route of entry for the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) into human host cells is by means of the angiotensin-converting enzyme-2 (ACE2) transmembrane receptor. This zinc-containing carboxypeptidase and membrane-integral surface receptor is ubiquitous and widely expressed in multiple cell types. Hence SARS-CoV-2, an unusually large RNA virus that causes coronavirus disease 2019 (COVID-19) has the remarkable capacity to invade many different types of human host cells simultaneously. Although COVID-19 is generally considered to be primarily an acute respiratory disease SARS-CoV-2 also targets specific anatomical regions of the central nervous system (CNS). In the normal CNS the highest ACE2 levels of expression are found within the medullary respiratory centers of the brainstem and this, in part, may explain the susceptibility of numerous COVID-19 patients to severe respiratory distress. About ~35% of all COVID-19 patients experience neurological and neuropsychiatric symptoms, and apre-existing diagnosis of Alzheimer's disease (AD) predicts the highest risk of COVID-19 yet identified, with the highest mortality among elderly AD patients. In the current study of multiple anatomical regions of AD brains compared to age-, post-mortem interval- and gender-matched controls (n = 10 regions, n = 32 brains), ACE2 expression was found to be significantly up-regulated in AD in the occipital lobe, temporal lobe neocortex and hippocampal CA1. The temporal lobe and hippocampus of the brain are also targeted by the inflammatory neuropathology that accompanies AD, suggesting asignificant mechanistic overlap between COVID-19 and AD, strongly centered on invasion by the neurotropic SARS-CoV-2 virus via the increased presence of ACE2 receptors in limbic regions of the AD-affected brain.

Frequency of respiratory diseases in Al-Ramadi respiratory consultation clinic

Background: Respiratory disease, or lung disease, are pathological conditions affecting the organs and tissues that make gas exchange difficult in air breathing animals. They include conditions of the respiratory tract including the trachea, bronchi, bronchioles, alveoli, pleurae, pleural cavity, the nerves and muscles of respiration. Respiratory diseases range from mild and self-limiting, such as the common cold, influenza, and pharyngitis to life threatening diseases such as bacterial pneumonia, pulmonary embolism, tuberculosis, acute asthma, lung cancer, and severe acute respiratory syndromes, such as COVID-19. Objective: To determine the frequency of different types of respiratory disease among patients attending Ramadi respiratory consultation clinic. Methods: A cross sectional study was carried out on patients with different type of respiratory disease attended to AL- Ramadi Respiratory consultation clinic during the period between 1st September 2020 to 1st April 2012. Total of 4334 patients 2066 male and 2268 female who was attended al Ramadi Respiratory center constituted the study group. Results: Of the 5685 patients studied, 2718 of them were males and 2967 were females and the female to male ratio was found to be 1.08. The P-value was not significant (P-value >0.05). In this study chronic bronchitis and acute bronchitis were noticed in higher percentages shown in table 1. With respect to the age group we notice a marked increase in the number of patients in the age group above 20 years old and below 40 years old (young group). Conclusion: This current study provides evidence that respiratory illnesses account for significant and increasing the number of patients during winter season and during this period we find markedly increase the number of patients with chronic bronchitis, acute bronchitis and allergic bronchitis, which represent the leading cause of attending respiratory consultation clinic followed by pneumonia.

Case Presentation on ROHHAD Syndrome

Rapid-onset obesity with hypothalamic dysregulation, hypoventilation and autonomic dysregulation (ROHHAD) is a rare, potentially life-threatening disorder of respiratory control and autonomic nervous system with endocrine system abnormalities. Aetiology is unknown, but some hypotheses suggest a genetic predisposition or an autoimmune reaction for the occurrence of the disorder. Patients with ROHHAD have impairment of respiratory centre in the brain stem which may cause respiratory depression. Children may experience the following symptoms such as rapid-onset obesity, hyperphagia and endocrine abnormalities. Along with these symptoms, children may experience central alveolar hypoventilation, intestinal abnormalities, body temperature irregularities, difficulty with mobility and eye abnormalities. Children should undergo many investigations to rule out the ROHHAD syndrome such as X-ray, magnetic resonance imaging, electroencephalography and gene analysis. There is no specific treatment for ROHHAD syndrome. Management of a child with ROHHAD syndrome is a multidisciplinary team approach based on the child's symptoms such as diet, exercise, hormone replacement, behavioural therapy, support with artificial ventilation and medication. Nurses have a vital role in supporting the children with ROHHAD syndrome and their families.

Применение технологий бережливого производства для оптимизации работы скорой медицинской помощи в условиях распространения COVID‑19

The pandemic of new coronavirus infection COVID‑19 has become a serious challenge for the national health systems, including Russia, setting ambitious goals aimed at preventing the spread of infection and maintaining the availability of medical care in environment of increasing pressure. The aim of the study was to develop, based on the principles of lean production, a set of measures to increase the availability of emergency medical services for patients diagnosed with or suspected of a new coronavirus infection COVID‑19 in the Tomsk Region. Standard tools of lean manufacturing are applied to the work process of the admission department of the respiratory center in RSBHI «Medical sanitary station № 2». As a result of implementation of target state map, which provides for the optimization of process of transferring a patient diagnosed or suspected of a new coronavirus infection COVID‑19 to admission department, a positive dynamics of local (5.4 times increase in the proportion of calls completed within 15 minutes after the patient was delivered to the admission department) and system (an increase of 1.3 times in the proportion of calls with the time the ambulance team reaches the patient within 20 minutes) indicators of the ambulance service was achieved. The study confirms the effectiveness of lean manufacturing tools for optimizing the work of ambulance and allows us to recommend them for use in a pandemic and other risks of emergency.

Neurotropism of SARS-CoV 2 and others Coronavirus in Children: Mechanisms and Clinical Manifestations

Neurotropism of SARS-CoV 2 and others Coronavirus in Children: Mechanisms and Clinical Manifestations

Trend of sputum smear positivity among presumptive tuberculosis cases visiting respiratory disease centre of Western Maharashtra, India

Introduction: India amounts to about a quarter of the tuberculosis (TB) burden worldwide. In 2016 about 28 lakh cases occurred and 4.5 lakh people died due to TB. In March 2017 the Government of India (GoI) declared that the new aim for TB in India was the elimination of TB by 2025. Objectives: To estimate the trends and gender distribution of sputum smear positive tuberculosis among presumptive TB cases visiting respiratory disease centre of Western Maharashtra. Materials and Methods: A Record based cross sectional study was conducted in a respiratory disease centre of Western Maharashtra, India during Jan 2018. All registered patients suspected of TB visiting the respiratory disease centre from year 2013 to 2017 were included as study population. Patients having incomplete data were excluded from study. Data was collected from master register at department of pathology of respiratory disease centre and was compiled and entered into MS Excel 2007. The trend of case detection, gender and TB, Sputum positive / negative cases were analyzed. The trend was statistically analysed for 2013-2017 by using chi – square test for trend. Trend was considered significant if p value is less than 0.05. Results: Among total suspected cases, proportion of sputum positive cases showed upward trend of TB from year 2013 to 2015 but thereafter linear downward by 2017. Out of total sputum smear positive cases 94.12% were males and 5.88% were females. Conclusion: Data indicates that tuberculosis is a great challenge in Western Maharashtra, India and need to strengthen the awareness programme about TB and involvement of public private partnership, early case detection and adherence with treatment to control the burden of TB. Keywords: Pulmonary tuberculosis, Sputum smear positivity, Trends, Gender.

Timing, Outcome, and Risk Factors of Intracranial Hemorrhage in Acute Respiratory Distress Syndrome Patients During Venovenous Extracorporeal Membrane Oxygenation.

Intracranial hemorrhage is a serious complication in patients receiving venovenous extracorporeal membrane oxygenation during treatment of the acute respiratory distress syndrome. We analyzed timing, outcome, and risk factors of intracranial hemorrhage in patients on venovenous extracorporeal membrane oxygenation. Retrospective cohort study. Single acute respiratory distress syndrome referral center. Patients receiving venovenous extracorporeal membrane oxygenation were identified from a cohort of 1,044 patients with acute respiratory distress syndrome. Patients developing an intracranial hemorrhage during venovenous extracorporeal membrane oxygenation therapy were compared with patients without evidence for intracranial hemorrhage. The primary objective was to assess the association of intracranial hemorrhage with 60-day mortality. Further objectives included the identification of risk factors for intracranial hemorrhage and the evaluation of clinical cutoff values. None. Among 444 patients treated with venovenous extracorporeal membrane oxygenation, 49 patients (11.0% [95% CI, 8.3-14.4%]) developed an intracranial hemorrhage. The median time to intracranial hemorrhage occurrence was 4 days (95% CI, 2-7 d). Patients who developed an intracranial hemorrhage had a higher 60-day mortality compared with patients without intracranial hemorrhage (69.4% [54.4-81.3%] vs 44.6% [39.6-49.6%]; odds ratio 3.05 [95% CI, 1.54-6.32%]; p = 0.001). A low platelet count, a high positive end expiratory pressure, and a major initial decrease of Paco2 were identified as independent risk factors for the occurrence of intracranial hemorrhage. A platelet count greater than 100/nL and a positive end expiratory pressure less than or equal to 14 cm H2O during the first 7 days of venovenous extracorporeal membrane oxygenation therapy as well as a decrease of Paco2 less than 24 mm Hg during venovenous extracorporeal membrane oxygenation initiation were identified as clinical cutoff values to prevent intracranial hemorrhage (sensitivity 91% [95% CI, 82-99%], 94% [85-99%], and 67% [48-81%], respectively). Intracranial hemorrhage occurs early during venovenous extracorporeal membrane oxygenation and is a determinant for 60-day mortality. Appropriate adjustment of identified modifiable risk factors might lower the prevalence of intracranial hemorrhage during venovenous extracorporeal membrane oxygenation therapy.

Outcomes of critically ill COVID-19 patients managed in a high-volume severe respiratory failure and ECMO centre in the United Kingdom.

During the Coronavirus Disease 2019 (COVID-19) pandemic institutions have needed to develop pragmatic clinical pathways to balance the excess critical care demand and local resources. In this single-centre retrospective cohort study we describe the outcomes of COVID-19 patients admitted to Guy's and St. Thomas' NHS Foundation Trust (GSTT) critical care service. Patients were managed according to a local respiratory failure management pathway that was predicated on timely invasive ventilation when indicated and tailored ventilatory strategies according to pulmonary mechanics. Between 2 March and 25 May 2020 GSTT critical care service admitted 316 patients with confirmed COVID-19. Of the 201 patients admitted directly through the Emergency Department (ED) with a completed critical care outcome, 71.1% survived to critical care discharge. These favourable outcomes may serve to inform the wider debate on optimal organ support in COVID-19.

Specific pathogens as predictors of poor long-term prognosis after hospital discharge for community-acquired pneumonia

BackgroundSome studies have reported that long-term prognosis after pneumonia is poor. Our aim was to determine predictors of long-term outcomes with special attention to community-acquired pneumonia (CAP) etiology. MethodsWe studied 1930 patients who were hospitalized with CAP from January 2002 through November 2017 at Saitama Cardiovascular and Respiratory Center and were discharged alive. We conducted a retrospective study for calculation of survival rate using the Kaplan-Meier method and analysis of prognostic factors by multivariate analysis using a Cox proportional hazard model. ResultsThe median follow-up period was 442.5 (range 1–5514) days. During this period, 321 patients died. Median survival time was 11.9 years, and 1-year and 5-year survival rates were 93.8% and 74.0%, respectively. Among the patients’ demographics factors, old age, poor performance status (PS) score, pneumococcal vaccination history, some underlying respiratory diseases, and chronic heart failure were significant independent factors of poor prognosis. Among pathogens, Streptococcus pneumoniae (hazard ratio [HR]: 1.35, 95% confidence interval [CI]: 1.03, 3.07, P = 0.038) and Pseudomonas aeruginosa (HR: 1.68, 95% CI: 1.07, 2.64, P = 0.024) were significant independent factors of poor prognosis, whereas influenza virus tended to predict a good prognosis (HR: 0.60, 95% CI: 0.36, 1.02, P = 0.058). Respiratory disease accounted for 59% of all causes of death after CAP, and the rate of death from pneumonia was the largest at 22%. ConclusionNot only age, general condition, and comorbidities but also specific pathogens were predictors of long-term prognosis after hospital discharge for CAP.

The Clinical Application of the Tracheostomy Decision-Making Program in Respiratory Care Center Prolonged Mechanical Ventilation Patients in Taiwan.

BackgroundWe applied the tracheostomy decision-making program for respiratory care center prolonged mechanical ventilation patients. Our objectives are to correct the misconception of patients about tracheostomy. We expect to understand whether the program is effective in educating patients and whether the patients are satisfied with the results of their decision-making. We compared the prognostic differences between patients receiving tracheostomy and those who continue to have an endotracheal tube, which serves as our basis to provide suggestions for patients in the shared decision-making program.Patients and MethodsA retrospective study was conducted in Dalin Tzu Chi Hospital from January 2017 to December 2019. We set up a tracheostomy decision-making program. The medical team identified eligible patients. We tracked the survival of each patient and followed up on each patient to ask whether they thought they had made an optimal decision based on the results of their participation in the tracheostomy decision-making program in January 2020. Data of respiratory care center prolonged mechanical ventilation patients who participated in the tracheostomy decision-making program were collected and analyzed.ResultsFifty-seven respiratory care center patients attended the tracheostomy decision-making program. At the end of the study, 37 patients underwent tracheostomy (64.9%), and 20 patients maintained endotracheal tube intubation (35.1%). The survival rate of patients undergoing tracheostomy was 86.5% and 32 participants (86.5%) believed that they made an optimal decision after participating in the tracheostomy decision-making program. The survival rate of patients who maintained endotracheal tube intubation was 40%, and twenty (100%) participants believed that they made an optimal decision after participating in the tracheostomy decision-making program.ConclusionThe clinical application of the tracheostomy decision-making program ensures that patients have a clearer understanding of the methods of tracheostomy and endotracheal tube intubation. Overall, 91.2% of the participants believed that they made an optimal decision despite the end result.

A graphic elicitation technique to represent patient rights

BackgroundA patient charter is an explicit declaration of the rights of patients within a particular health care setting. In early 2020 the Save the Children Emergency Health Unit deployed to Cox’s Bazar Bangladesh to support the establishment of a severe acute respiratory infection isolation and treatment centre as part of the COVID-19 response. We developed a charter of patient rights and had it translated into Bangla and Burmese; however, the charter remained inaccessible to Rohingya and members of the host community with low literacy.MethodsTo both visualise and contextualise the patient charter we undertook a graphic elicitation method involving both the Rohingya and host communities. We carried out two focus group discussions during which we discussed the charter and agreed how best to illustrate the individual rights contained therein.ResultsLogistical constraints and infection prevention and control procedures limited our ability to follow up with the original focus group participants and to engage in back-translation as we had planned; however, we were able to elicit rich descriptions of each right. Reflecting on our method we were able to identify several key learnings relating to: 1) our technique for eliciting feedback on the charter verbatim versus a broader discussion of concepts referenced within each right, 2) our decision to include both men and women in the same focus group, 3) our decision to ask focus group participants to describe specific features of each illustration and how this benefited the inclusivity of our illustrations, and 4) the potential of the focus groups to act as a means to introduce the charter to communities.ConclusionsThough executing our method was operationally challenging we were able to create culturally appropriate illustrations to accompany our patient charter. In contexts of limited literacy it is possible to enable access to critical clinical governance and accountability tools.

Olfactory transmucosal SARS-CoV-2 invasion as a port of central nervous system entry in individuals with COVID-19.

The newly identified severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19, a pandemic respiratory disease. Moreover, thromboembolic events throughout the body, including in the CNS, have been described. Given the neurological symptoms observed in a large majority of individuals with COVID-19, SARS-CoV-2 penetrance of the CNS is likely. By various means, we demonstrate the presence of SARS-CoV-2 RNA and protein in anatomically distinct regions of the nasopharynx and brain. Furthermore, we describe the morphological changes associated with infection such as thromboembolic ischemic infarction of the CNS and present evidence of SARS-CoV-2 neurotropism. SARS-CoV-2 can enter the nervous system by crossing the neural-mucosal interface in olfactory mucosa, exploiting the close vicinity of olfactory mucosal, endothelial and nervous tissue, including delicate olfactory and sensory nerve endings. Subsequently, SARS-CoV-2 appears to follow neuroanatomical structures, penetrating defined neuroanatomical areas including the primary respiratory and cardiovascular control center in the medulla oblongata.

Variation de la réponse ventilatoire au CO2 chez des patients appareillés par ventilation non invasive

There are many mechanisms for improving the clinical and blood gas status of patients with the obesity hypoventilation syndrome (OHS) or chronic obstructive pulmonary disease (COPD) by non-invasive ventilation (NIV) at home. Our objective was to set up a pilot study to evaluate the potential modification of the sensitivity of the respiratory centers to CO2 by NIV in paired new COPD and OHS patients. We assessed the sensitivity of the respiratory centers to CO2 by the Read method in 3 COPD patients and 3 OHS patients newly treated by NIV and again 3 months later. We compared their results to those of 6 control subjects. All the patients included had altered ventilatory responses to CO2 with slopes of less of than 1 L.min-1.mmHg-1. Mean coefficients of variation were significantly higher in patients than in healthy subjects (P=0.007). Patients who improved their CO2 sensitivity slope were those most observant of NIV. This work showed significant changes in the ventilatory response to hypercapnia in patients with either OHS or COPD after NIV therapy. The significance of these changes deserves to be studied.

COVID-19 Pulmonary Failure and Extracorporeal Membrane Oxygenation: First Experience from Three European Extracorporeal Membrane Oxygenation Centers.

On April 17, 2020, a coronavirus disease 2019 (COVID-19) webinar was held by selected international experts in the field of intensive care and specialized respiratory ECMO centers from Germany, Italy, Spain, and the United Kingdom, which was hosted by the German Heart Centre Berlin/Charité. The experts shared their experience about the treatment of 42 patients with severe acute respiratory failure requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). Patients were predominantly male (male-to-female ratio: 3:1), with a mean age of 51 years (range: 25-73 years). VV-ECMO support was indicated in 30% of the ventilated COVID-19 patients. The mean time requiring mechanical ventilation was 16.5 days, with a mean duration of ECMO support of 10.6 days. At the time of the webinar, a total of 17 patients had already been decannulated from ECMO, whereas six died with multiorgan failure. 18 patients remained on ECMO, with their final outcomes unknown at the time of the webinar. Hospital mortality was 25.6% (as of April 17, 2020). In this respect, VV-ECMO, provided by expert centers, is a recognized and validated mode of advanced life-support during the recent COVID-19 pandemic with good outcomes.

IMMU-51. NEUROLOGIC IMMUNE-RELATED ADVERSE EVENTS MIMICS, RISK FACTORS, AND MECHANISMS: CLIPPERS AND ASEPTIC MENINGITIS

Abstract Neurological immune-related adverse events (irAEs) are rare toxicities that occur following immune checkpoint blockade. It is imperative to distinguish between irAEs and their mimics for successful treatment. We present the first case of CLIPPERS-like lesions in a patient with thymic cancer, thymoma, and a family history of neuromyelitis optica, following treatment with pembrolizumab. The brainstem lesion was in the anatomic location of the respiratory and cardiac centers. We also present a second case of aseptic meningitis irAE in a patient with prior graft-versus-host-disease following a single dose of nivolumab. These cases add to the growing evidence of CNS complications from immune checkpoint inhibitors. Risk factors for irAEs are not well established, and we explore potential risk factors and a possible mechanism from dysfunctional regulatory T cells.

Identification and Discrimination of Mycobacterium tuberculosis Complex with Traditional and Real-Time PCR in Different Specimens in Iraq

Background: Tuberculosis (TB) is a major public health issue and a main cause of global morbidity and mortality. TB is the world's ninth leading cause of death despite the numerous treatment strategies for managing the disease.Objective: To assess the traditional method (direct smear examination and culture) against real-time PCR as pulmonary and extrapulmonary tuberculosis laboratory diagnostic techniques.Cases and methods: Samples were collected from (612) TB cases, (409) of whom were pulmonary tuberculosis (PTB) and (203) were extrapolmonary tuberculosis (EPTB). The cases were seeking care at the Specialized Chest and Respiratory Disease Center/ National Reference Laboratory for Tuberculosis (NRL) in Baghdad, during the period 1st of May -1st of October 2019. Direct smear examination, Lowenstein-Jensen culture and Real Time PCR were used to diagnose TB.Results: Out of 612 samples received, 82(13.4%) were positive by smear microscopy, while 90(14.7%) were able to grow on Lowenstein-Jensen (LJ) media. Ninety DNA extracts from the samples which were positive on LJ media and 25 control specimens, were diagnosed with molecular analysis by using real time PCR to determine the species of Mycobacterium tuberculosis complex. The results revealed that the 71 samples (78.9%) were M. tuberculosis, three specimens (3.3%) were combined M. bovis and M. tuberculosis, and one M. tuberculosis, M. bovis, and M. bovis BCG, while15 (16.7%) were negative and subsequently excluded from study.Conclusion: The comparison between molecular diagnostic methods by using Real time PCR with conventional diagnostic methods, provides a new promising technique and is potentially a practical and rapid alternative to the slower traditional pulmonary and EPTB diagnostic culture. The results show M. bovis overall contribution on human TB in comparison to M. tuberculosis is minor among PTB and EPTB cases in the sample studied.

Incidence of Vascular Thromboembolic Events in Outpatients with Mild COVID-19

IntroductionHypercoagulability is a hallmark of COVID-19, the disease caused by the severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2).1 While studies have investigated vascular thromboembolic events (VaTE) in critically ill and hospitalized patients with COVID-19, less is known about thrombotic complications in patients with mild symptoms.2 Our current institutional management protocol recommends prophylactic anticoagulation for COVID-19 patients admitted to the hospital but not for outpatients with less severe disease. We evaluated the incidence of VaTE in outpatients diagnosed with COVID-19 at our institution in order to assess the potential need for thromboprophylaxis in outpatient COVID-19 management.MethodsWe conducted a retrospective analysis of electronic medical record data of outpatients in the University of North Carolina Health System who tested positive for Sars-CoV-2 between March 15 and June 20, 2020. Patients were diagnosed at one of 17 ambulatory respiratory diagnostic centers (n=706), or diagnosed and subsequently discharged from one of 11 emergency departments (n=1967) in the UNC system. Diagnosis was made using reverse transcriptase polymerase chain reaction testing of nasopharyngeal or oropharyngeal swab samples. The study outcome was the diagnosis of a vascular thromboembolic event within 30 days of COVID-19 diagnosis. This included deep vein thrombosis, pulmonary embolism, superficial thrombophlebitis, myocardial infarction, ischemic stroke, and systemic arterial thromboembolism. VaTE was defined based on documentation of an associated ICD-10 code in the patient's electronic medical record within the specified time frame. Outcomes data were reported as incidence rates for the entire study population.Results2673 outpatients were diagnosed with COVID-19 in the study period. The mean age for this cohort was 37.9 ± 17.3 years and 54% were female. 20 unique individuals (0.7%) experienced a VaTE within 30 days of diagnosis. Of these, 3 (15%) experienced venous thromboembolic events, 16 (80%) experienced arterial events, and 1 patient experienced both. Mean time to VaTE was 12.8 ± 9.3 days. Within 30 days of diagnosis, 188 of these patients (7%) had an emergency department visit or experienced hospital observation or inpatient admission.ConclusionsWe found that the incidence of VaTE in outpatients with mild COVID-19 is low. Limitations of this study include that patients were not routinely screened for VaTE and may have sought treatment for thrombotic complications outside the hospital system. This may have led to an underestimate of the true incidence; however, the findings are in line with data showing that non-hospitalized COVID-19 patients tend to be younger and have fewer medical comorbidities than hospitalized patients.3 This argues against the routine use of thromboprophylaxis in outpatients with COVID-19.

A dominant strain of Elizabethkingia anophelis emerged from a hospital water system to cause a three-year outbreak in a respiratory care center

Elizabethkingia species are ubiquitous bacteria but uncommonly cause human infection. An outbreak of Elizabethkingia anophelis bacteraemia was observed in a respiratory care center of a tertiary hospital in Taiwan from 2015 to 2018. Clinical and environmental isolates were collected for the outbreak investigation. Pulsed-field gel electrophoresis (PFGE) and complete-genome sequencing were conducted to elucidate the mechanism of transmission. The three-year outbreak involved 26 patients with E.anophelis bacteraemia and the incidence significantly increased during the outbreak period compared with that observed from 2010 to 2014 (P<0.05). All 26 clinical isolates during the outbreak period belonged to a cluster by PFGE analysis. In contrast, the PFGE pattern was heterogeneous among comparative historical strains. Hospital tap water was highly contaminated by Elizabethkingia species (18/34, 52.9%); among that, five E.anophelis belonged to the outbreak cluster (5/18, 27.8%). As for the inanimate surface survey, 3.4% sites (4/117) revealed positive growth of E.anophelis including two from feeding tubes/bags and two from sputum suction regulators. All four isolates belonged to the outbreak clone. The outbreak strain had no apparent relationship to currently known E.anophelis strains worldwide through complete-genome sequencing analysis. Specific infection control strategies aimed at water source control and environmental disinfection were implemented subsequently and the outbreak ended in mid-2018. A specific E.anophelis strain was identified from a three-year outbreak. The elucidation of the mechanism of dominance and intra-hospital transmission is crucial for development of corresponsive infection control policies and outbreak control.

Neurotransmitter Modulation of Carotid Body Germinal Niche.

The carotid body (CB), a neural-crest-derived organ and the main arterial chemoreceptor in mammals, is composed of clusters of cells called glomeruli. Each glomerulus contains neuron-like, O2-sensing glomus cells, which are innervated by sensory fibers of the petrosal ganglion and are located in close contact with a dense network of fenestrated capillaries. In response to hypoxia, glomus cells release transmitters to activate afferent fibers impinging on the respiratory and autonomic centers to induce hyperventilation and sympathetic activation. Glomus cells are embraced by interdigitating processes of sustentacular, glia-like, type II cells. The CB has an extraordinary structural plasticity, unusual for a neural tissue, as it can grow several folds its size in subjects exposed to sustained hypoxia (as for example in high altitude dwellers or in patients with cardiopulmonary diseases). CB growth in hypoxia is mainly due to the generation of new glomeruli and blood vessels. In recent years it has been shown that the adult CB contains a collection of quiescent multipotent stem cells, as well as immature progenitors committed to the neurogenic or the angiogenic lineages. Herein, we review the main properties of the different cell types in the CB germinal niche. We also summarize experimental data suggesting that O2-sensitive glomus cells are the master regulators of CB plasticity. Upon exposure to hypoxia, neurotransmitters and neuromodulators released by glomus cells act as paracrine signals that induce proliferation and differentiation of multipotent stem cells and progenitors, thus causing CB hypertrophy and an increased sensory output. Pharmacological modulation of glomus cell activity might constitute a useful clinical tool to fight pathologies associated with exaggerated sympathetic outflow due to CB overactivation.

Effect of minimally invasive surgery on the sleep quality and work ability of patients with obstructive sleep apnea-hypopnea syndrome.

To explore the effect of minimally invasive surgical treatment on the sleep quality and work ability of patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). Fifty-one patients who underwent minimally invasive surgery in the Sleep Respiratory Disease Diagnostic and Treatment Center of the West China Fourth Hospital of Sichuan University from January 2017 to January 2019 were selected as study subjects. All subjects completed polysomnography monitoring (PSG), an Epworth sleepiness scale (ESS), and a work ability index (WAI) before and 1year after the minimally invasive surgery so that the changes could be compared. (1) The apnea-hypopnea index (AHI), microarousal index (MAI), ESS, longest duration of apnea, and longest duration of hypoventilation in OSAHS patients decreased, while the lowest blood oxygen saturation (LsaO2) increased after minimally invasive surgery. The differences were statistically significant (p < 0.05). (2) The WAI questionnaire score increased from (37.76 ± 4.46) to (40.00 ± 4.53) after minimally invasive surgery (P < 0.05). (3) The change in the WAI questionnaire score after minimally invasive surgery was influenced by the occupational category and the change in ESS. Minimally invasive surgical treatment shows significant benefit in improving the sleep quality and working ability of patients with OSAHS.