Higher Incidence Of Respiratory Failure Research Articles

Elevated hyaluronic acid levels in severe SARS-CoV-2 infection in the post-COVID-19 era.

Human identical sequences of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) promoted the coronavirus disease 2019 (COVID-19) progression by upregulating hyaluronic acid (HA) via NamiRNA-enhancer network, based on previous experimental research. This study aimed to investigate the predictive value of HA for the severity of SARS-CoV-2 infection in the post-COVID-19 era. A total of 217 consecutive patients with COVID-19 were enrolled at Beijing Ditan Hospital between July 2023 and October 2023. HA levels were analyzed using biochemical detector. Logistic regression analysis was used to screen independent factors for severe COVID-19. The predictive performance of HA for severe infection was assessed by ROC curve. Furthermore, the relationship between HA levels and COVID-19 severity was investigated using multivariate logistic regression models after adjustment for potential confounders. According to the cut-off value of HA, COVID-19 patients were divided into HA < 90 ng/mL group (80 cases) and HA ≥ 90 ng/mL group (137 cases). High HA levels were positively associated with the severe SARS-CoV-2 infection, including elevated inflammatory indicators, severe lung involvement, prolonged clinical course, and higher incidence of respiratory failure and death (P < 0.05). Logistic regression analysis suggested that HA was an independent predictor of severe COVID-19 (OR = 4.540, 95% CI = 2.105-9.790, P < 0.001). ROC curve analysis showed that the AUC of HA for severe infection was 0.724. HA levels were significantly higher in COVID-19 cases compared to the healthy population (123.9 (82.6, 174.1) vs. 50.5 (37.8, 66.8), P < 0.001), but similar to those with non-SARS-CoV-2 lung infection (121.6 (78.5, 175.6) vs. 106.0 (66.5, 149.7), P = 0.244). We also found that the first COVID-19 infections had higher HA levels (118.8 (79.5, 174.3) vs. 85.0 (61.1, 128.8), P < 0.001) and a higher proportion of severe infection (37.1% vs. 21.3%, P = 0.043) than re-infections. However, HA expression failed to fully return to normal levels with infection recovery (204.7 (152.9, 242.2) vs. 97.0 (69.3, 137.3), P < 0.001). HA was associated with severe SARS-CoV-2 infection and could be used as a novel serum biomarker to predict the risk of COVID-19 progression in the post-COVID-19 era.

Initial indicators for the prognosis of Acinetobacter Baumannii bacteremia in children

BackgroundRisk factors related to mortality due to Acinetobacter baumannii (AB) bacteremia have been unveiled previously, but early clinical manifestations of AB bacteremia based on prognosis remain uncovered.MethodsThe demographic characteristics, clinical features, antibiotic susceptibility, and outcomes of 37 hospitalized children with laboratory-confirmed AB bacteremia from Suzhou, China, were collected and analyzed retrospectively.ResultsOf the 37 children with AB bacteremia included in this study, 23 were males and 14 were females, with a median age of 4.83 (0.60 to 10.15) years. Among the children, 18 died (48.65%, 18/37) and 19 survived (51.35%, 19/37). The dead group had a significantly higher incidence of respiratory failure (p = 0.008), shock (P = 0.000), MODS (p = 0.000), neutropenia (< 1.5 × 109/L) (p = 0.000) and serious neutropenia (< 0.5 × 109/L) (p = 0.000) than those in the survival group. The death group had significantly more invasive procedures (2 or more) than that in the survival group at 2 weeks before onset (p = 0.005). The proportion of MDR-AB in the death group was significantly higher than that in the survival group (p = 0.000), while the PICS score was significantly lower in the survival group than that in the death group (p = 0.000). There was no significant difference in effective antibiotic use within 24 h between these two groups (p = 0.295). Among the 37 children with bloodstream infection of AB, 56.76% (21/37) of the underlying diseases were hematological diseases and oncology. Among them, 17 (81.00%) were died in the hospital. The proportion of white blood cells (p = 0.000), neutrophils (p = 0.042), eosinophils (p = 0.029), the ANC (p = 0.000) and lymphocyte (p = 0.000), the NLR(p = 0.011), hemoglobin (p = 0.001), platelets (p = 0.000), prealbumin (P = 0.000), LDH (p = 0.017), blood gas pH (p = 0.000), and serum potassium (p = 0.002) in the death group were significantly lower than those in the survival group. However, CRP (p = 0.000) and blood glucose(p = 0.036) were significantly higher in the death group than those in the survival group. By further multivariate analysis, CRP [OR (95% CI): 1.022(1.003, 1.041), p = 0.021] and neutropenia [OR (95% CI): 21.634 (2.05, 228.313, p = 0.011] within 24 h of infection were independent risk factors for death in children with AB bacteremia. When CRP was higher than 59.02 mg/L, the sensitivity of predicting mortality was 88.9%, and the specificity was 78.9%. And the sensitivity and specificity of neutropenia for predicting mortality were 83.3% and 84.2%.ConclusionsAB bacteremia has a high mortality in children, especially in patients with hematological diseases and oncology. Many early indicators were associated with poor prognosis, while elevated CRP and neutropenia were the independent predictors for the 30-day mortality of children with laboratory-confirmed AB bacteremia.

Clinical manifestations and outcomes of fungus-associated asthma: A multi-institution database study in Taiwan

BackgroundDifferences in the clinical phenotypes and outcomes of fungus-associated asthma remain unclear. We aimed to investigate the presentation of asthmatics with fungal sensitization and/or positive fungal isolates. MethodsClinical characteristics, pulmonary function, microbiological data, allergy test reports, emergency department (ED) visits and hospitalizations were retrieved from the Chang Gung Research Database between 2010 and 2018; the largest electronic medical record-based database in Taiwan. Follow-up care was provided to each patient for 3 years. ResultsA total of 30,754 asthmatics were enrolled, and 7976 were eligible for analysis after applying the exclusion criteria. Of these patients, 694 had sputum examinations for fungi. The patients were divided into four groups: group 1, neither fungal sensitization nor fungal isolates in the sputum (n = 386); group 2, positive fungal sensitization (n = 58); group 3, positive fungal isolates (n = 217); and group 4, concomitant positive fungal sensitization and positive fungal isolates (n = 33). Asthmatic patients with fungal sensitization (groups 2 and 4) demonstrated significantly higher IgE levels compared with those without (groups 1 and 3). Group 4 patients had a higher frequency of hospitalization. Amongst patients under Global Initiative for Asthma (GINA) step 4–5 therapies, group 4 asthmatics possessed significantly higher incidence of respiratory failure. ConclusionsThe prevalence of fungal sensitization and fungal isolates from sputum were even across asthmatic severities, but the clinical impact of fungi may be more significant among patients with more severe disease.

309. TB Quantiferon Testing Predicts Mortality in Patients with COVID-19

BackgroundFinding reliable clinical predictors for severity of COVID-19 has been challenging. Interferon gamma (IFNG) plays an important role in viral replication. QuantiFERON-TB (QFT) test relies on IFNG release in response to antigens. A positive or negative test signifies adequate IFNG response, whereas an indeterminate result is obtained when such a response is lacking. In this study, we have attempted to see if an indeterminate QFT result can provide prognostic information on patients with COVID–19.Survival Probability in patients with Covid - 19 and an indeterminate TB Quantiferon test result MethodsThis is a retrospective study of patients who were admitted at our institute with COVID–19 and had a QFT done within one month of the positive SARS-CoV-2 nucleic acid amplification test result. Patient charts were analyzed for clinical course and outcomes, including in-hospital mortality (primary outcome), 90-day mortality, respiratory failure, requirement for intubation and other complications that would portend a more severe disease course.ResultsA total of 120 patient charts were analyzed, out of which 43 (35.8%) had an indeterminate QFT. All the indeterminate results were due to an inadequate mitogen response. The indeterminate QFT group had a 41.86% (18/43) in-hospital mortality vs. 9.09% (7/77) in the negative or positive QFT group (p-value of < 0.001). The 90-day mortality was similar between the two groups. Patients with indeterminate QFT also had a higher incidence of respiratory failure (97.7% vs. 75.3%; p-value = 0.020), requirement for mechanical ventilation (55.8% vs. 23.4%; p-value < 0.001), requirement of ECMO (25.58% vs. 0%; p-vale < 0.001), requirement of pressor (48.83% vs. 14.28%; p-value < 0.001) and requirement for renal replacement therapy (32.5% vs. 1.3%; p-value < 0.001), when compared to patients with a negative or positive QFT. Patients in indeterminate group had a higher hospital length of stay than the other group (p-value = 0.035). ConclusionOur study indicates that patients with COVID-19 who fail to mount an adequate IFNG mitogen response in QFT assay have worse clinical outcomes and a more complicated and protracted clinical course. Evaluating cell-mediated immune responses through commercially available IFNG release assays may yield a promising strategy to predict COVID-19 clinical outcomes. Disclosures All Authors: No reported disclosures

Hypophosphatemia at Admission is Associated with Increased Mortality in COVID-19 Patients.

BackgroundElectrolyte disturbances are commonly observed in patients with coronavirus disease 2019 (COVID-19) and associated with outcome in these patients. Our study was designed to examine whether hypophosphatemia is associated with mortality in COVID-19 patients.MethodsPatients diagnosed with COVID-19 and hospitalized in Renmin Hospital of Wuhan University between January 30 and February 24, 2020 were included in this study. Patients were divided into two groups, a hypophosphatemia group and a non-hypophosphatemia group, based on a serum phosphate level of 0.8 mmol/L. Logistic regression was performed to analyze the relationship between hypophosphatemia and mortality. A locally weighted scatterplot smoothing (LOWESS) curve was plotted to show the detailed association between mortality rate and serum phosphate level. A Kaplan–Meier survival curve was drawn to compare the difference in cumulative survival between the two groups.ResultsHypophosphatemia at admission occurred in 33 patients, with an incidence of 7.6%. The hypophosphatemia group had a significantly higher incidence of respiratory failure (54.5% vs 32.6%, p=0.013) and mortality (57.6% vs 15.2%, p<0.001). Multivariate logistic regression indicated that age (OR=1.059, p<0.001), oxygen saturation (OR=0.733, p<0.001), white blood cells (OR=1.428, p<0.001), lymphocytes (OR=0.075, p<0.001) and hypophosphatemia (OR=3.636, p=0.015) were independently associated with mortality in the included patients. The hypophosphatemia group had significantly shorter survival than the non-hypophosphatemia group (p<0.001).ConclusionHypophosphatemia at admission is associated with increased mortality in COVID-19 patients. More attention and medical care should be given to COVID-19 patients with hypophosphatemia at admission.

Regional Differences in Epidemiological and Clinical Characteristics, Treatment, and Clinical Outcomes of COVID-19 in Wuhan and Remote Areas of Hubei Province.

Background: The Coronavirus disease 2019 (COVID-19) pandemic has been a major threat to global health. Regional differences in epidemiological and clinical characteristics, treatment and outcomes of patients have not yet been investigated. This study was conducted to investigate these differences amongCOVID-19 patients in Hubei Province, China.Methods: This retrospective cross-sectional study analyzed data on 289 COVID-19 patients from designated hospitals in three regions:Urban (Wuhan Union West Hospital), Suburban areas of Wuhan (Hannan Hospital) and Enshi city, between February 8 and 20, 2020. The final date of follow-up was December 14th, 2020. The outcomes were case fatality rate and epidemiological and clinical data.Results: Urban Wuhan experienced a significantly higher case fatality rate (21.5%) than suburban Wuhan (5.23%) and rural area of Enshi (3.51%). Urban Wuhan had a higher proportion of patients on mechanical ventilation (24.05%) than suburban Wuhan (0%) and rural Enshi (3.57%). Treatment with glucocorticoids was equivalent in urban and suburban Wuhan (46.84 and 45.75%, respectively) and higher than Enshi (25.00%). Urban Wuhan had a higher proportion of patients with abnormal tests including liver function and serum electrolytes and a higher rate of pneumonia (p < 0.01 for all). Urban Wuhan also had a higher incidence of respiratory failure, heart disease, liver disease and shock, compared with the other two regions (all p < 0.05).Conclusions: Our findings revealed that there are regional differences in COVID-19. These findings provide novel insights into the distribution of appropriate resources for the prevention, control and treatment of COVID-19 for the global community.

Predictors of Long-term Outcomes in Patients Undergoing Tricuspid Valve Surgery with Right Ventricular Failure

Objective: To investigate and identify the prognostic indicators of cardiac surgical outcomes in patients with pulmonary hypertension (PH) with or without right ventricle (RV) dysfunction. Methods: In this retrospective observational study, all the patients with preoperative PH who underwent isolated mitral valve and tricuspid valve surgery from May 2011 to December 2019, were enrolled in the study (n=80, age 66.7±13.4 yo). This cohort was then classified as Group 1 (RV dysfunction; n=27, 34%) and Group 2 (RV normal; n=53, 66%), according to the function of the RV. PH was defined as a mean pulmonary arterial pressure (mPAP)≥25mmHg, or pulmonary artery systolic pressure (PASP)≥38mmHg. RV dysfunction was defined based on American Society of Echocardiography guidelines. Results: The cumulative mortality at 30 days was 11% (n=9) with no statistical difference between the two groups (Group 1: n=4, 15%; Group 2: n=5, 9%; x2= 1.23, p=0.266). Instead, a significant difference in the mortality rate was observed between the type of surgery performed: mitral valve replacement and tricuspid valve repair was associated with higher mortality rate (n=8, 23%; x2= 7.01, p=0.030) when compared with mitral repair. In univariate analysis, RV dysfunction was correlated with a lower ejection fraction (61.4±10 vs 55.6±10, p=0.017), higher incidence of respiratory failure (OR:9; CI:0.9-85; p=0.042) and higher length of stay (median 8 days (IQR:1-25), p=0.042). The type of surgery was a predictor risk in a Cox regression analysis (Hazard ratio: 0.08; CI:0.01-0.7; p=0.022). Conclusions: In patients with PH and/or RV dysfunction, mitral valve replacement alone represents an independent risk factor for mortality, irrespective of the aetiology. RV dysfunction is related to longer length of stay and incidences of peri-operative morbidity.

Clinical Characteristics and Morbidity Associated With Coronavirus Disease 2019 in a Series of Patients in Metropolitan Detroit

In late December 2019, an outbreak caused by a novel severe acute respiratory syndrome coronavirus 2 emerged in Wuhan, China. Data on the clinical characteristics and outcomes of infected patients in urban communities in the US are limited. To describe the clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) and to perform a comparative analysis of hospitalized and ambulatory patient populations. This study is a case series of 463 consecutive patients with COVID-19 evaluated at Henry Ford Health System in metropolitan Detroit, Michigan, from March 9 to March 27, 2020. Data analysis was performed from March to April 2020. Laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection. Demographic data, underlying comorbidities, clinical presentation, complications, treatment, and outcomes were collected. Of 463 patients with COVID-19 (mean [SD] age, 57.5 [16.8] years), 259 (55.9%) were female, and 334 (72.1%) were African American. Most patients (435 [94.0%]) had at least 1 comorbidity, including hypertension (295 patients [63.7%]), chronic kidney disease (182 patients [39.3%]), and diabetes (178 patients [38.4%]). Common symptoms at presentation were cough (347 patients [74.9%]), fever (315 patients [68.0%]), and dyspnea (282 patients [60.9%]). Three hundred fifty-five patients (76.7%) were hospitalized; 141 (39.7%) required intensive care unit management and 114 (80.8%) of those patients required invasive mechanical ventilation. Male sex (odds ratio [OR], 2.0; 95% CI, 1.3-3.2; P = .001), severe obesity (OR, 2.0; 95% CI, 1.4-3.6; P = .02), and chronic kidney disease (OR, 2.0; 95% CI, 1.3-3.3; P = .006) were independently associated with intensive care unit admission. Patients admitted to the intensive care unit had longer length of stay and higher incidence of respiratory failure and acute respiratory distress syndrome requiring invasive mechanical ventilation, acute kidney injury requiring dialysis, shock, and mortality (57 patients [40.4%] vs 15 patients [7.0%]) compared with patients in the general practice unit. Twenty-nine (11.2%) of those discharged from the hospital were readmitted and, overall, 20.0% died within 30 days. Male sex (OR, 1.8; 95% CI, 1.1-3.1; P = .03) and age older than 60 years (OR, 5.3; 95% CI, 2.9-9.7; P < .001) were significantly associated with mortality, whereas African American race was not (OR, 0.98; 95% CI, 0.54-1.8; P = .86). In this review of urban metropolitan patients with COVID-19, most were African American with a high prevalence of comorbid conditions and high rates of hospitalization, intensive care unit admission, complications, and mortality due to COVID-19.

Acute kidney injury and the risk of mortality in patients with methanol intoxication

BackgroundMethanol poisoning is a serious public health issue in developing countries, but few data are available in the literature on acute kidney injury (AKI) after methanol intoxication.MethodsThis study examined the clinical features, spectrum and outcomes of AKI in patients with methanol intoxication and evaluated the predictors of mortality after methanol intoxication. A total of 50 patients with methanol intoxication were seen at Chang Gung Memorial Hospital between 2000 and 2013. Patients were grouped according to the status of renal damage as AKI (n = 33) or non-AKI (n = 19). Demographic, clinical, laboratory, and mortality data were obtained for analysis.ResultsMost patients were middle-aged (47.8 ± 14.9 years), predominantly male (74.0%), and habitual alcohol consumers (70.0%). Most incidents were oral exposures (96.0%) and unintentional (66.0%). Two (4.0%) patients attempted suicide by intravenous injection of methanol. Five (10.0%) patients suffered methanol intoxication after ingestion of methomyl pesticide that contained methanol as a solvent. Compared to non-AKI patients, the AKI patients were older (50.9 ± 13.7 versus 41.6 ± 15.6 years, P = 0.034), predominantly male (90.9% versus 42.8%, P = 0.000), more habitual alcohol users (84.8% versus 41.2%, P = 0.001) and had more unintentional exposures (82.8% versus 35.3%, P = 0.001). Furthermore, there was a higher incidence of respiratory failure (63.6% versus 29.4%, P = 0.022) in the AKI group than in the non-AKI group, respectively. The laboratory studies revealed that the AKI patients suffered from more severe metabolic acidosis than the non-AKI patients. By the end of this study, 13 (39.5%) AKI patients and 1 (5.9%) non-AKI patient had died. The overall in-hospital hospital mortality rate was 28%. In a multivariate binary logistic regression model, it was demonstrated that AKI (odds ratio 19.670, confidence interval 1.026–377.008, P = 0.048) and Glasgow coma scale score (odds ratio 1.370, confidence interval 1.079–1.739, P = 0.010) were significant factors associated with mortality. The Kaplan-Meier analysis disclosed that AKI patients suffered lower cumulative survival than non-AKI patients (log-rank test, chi-square = 5.115, P = 0.024).ConclusionsAKI was common (66.0%) after methanol intoxication and was predictive of in-hospital hospital mortality. The development of AKI was associated with a 19.670-fold higher risk of in-hospital mortality.

Emergency cholecystectomy versus percutaneous transhepatic gallbladder drainage followed by delayed cholecystectomy in patients with moderate acute cholecystitis

Objective: To analysis the curative effect of emergency cholecystectomy (EC) and percutaneous transhepatic gallbladder drainage (PTGBD) followed by delayed cholecystectomy (DC) on the patients with moderate acute cholecystitis. Methods: The perioperative dataof patients in EC group (n=47) and in PTGBD-DC group (n=49) were compared retrospectively. Results: Compared to PTGBD+ DC group, EC patients had a significantly more postoperative abdominal drainage time [(9.0±12.9) vs (3.4±2.1) days, P=0.041], more postoperative hospital stay after cholecystectomy [(8.2±3.2) vs (5.1±1.8) days, P=0.004], more intraoperative bleeding [(101±125) vs (33±37) ml, P=0.003], more patients of LC conversion to open cholecystectomy (OC) (19.1% vs 4.1%, P=0.021) and more patients of OC(14.9% vs 0, P=0.005). Also, there were higher incidence of respiratory failure(14.8% vs 2.0%, P=0.029), and admission for ICU(21.3% vs 2.0 %, P=0.003). Also, patients of total OC in non-biliary surgeons group were more than that of biliary surgeons group statistically(63.2% vs 14.3 %, P=0.001). Conclusion: PTGBD followed by DC in the treatment of moderate acute cholecystitis was better than EC, especially in patients with complicated comorbidities and in non-biliary surgeons.

The evolution of intraoperative conversion in video assisted thoracoscopic lobectomy.

INTRODUCTION Unplanned conversion to thoracotomy remains a major concern in video assisted thoracoscopic surgery (VATS) lobectomy. This study aimed to investigate the development of a VATS lobectomy programme over a five-year period, with a focus on the causes and consequences of unplanned conversions. METHODS A single centre retrospective review was performed of patients who underwent complete anatomical lung resection initiated by VATS between January 2010 and April 2015. RESULTS In total, 1,270 patients underwent a lobectomy in the study period and 684 (53.9%) of these were commenced thoracoscopically. There were 75 cases (10.9%) with unplanned conversion. The proportion of lobectomies started as VATS was significantly higher in the second half of the study period (2010-2012: 277/713 [38.8%], 2013-2015: 407/557 [73.1%], p<0.001). The conversion rate dropped initially from 20.4% (11/54) in 2010 to 9.9% (15/151) in 2013 and then remained consistently under 10% until 2015. Conversions were most commonly secondary to vascular injury (26/75, 34.7%). Patients undergoing unplanned conversion had a longer length of stay than VATS completed patients (9 vs 6 days, p<0.001). There was a higher incidence of respiratory failure (10/75 [14.1%] vs 23/607 [3.8%], p<0.001) and 30-day mortality (7/75 [9.3%] vs 6/607 [1.0%], p=0.003) in patients with unplanned conversion than in those with completed VATS. CONCLUSIONS As our VATS lobectomy programme developed, the unplanned conversion rate dropped initially and then remained constant at approximately 10%. With increasing unit experience, it is both safe and technically possible to complete the majority of lobectomy procedures thoracoscopically.

Lung injury associated with severe Epstein-Barr virus (EBV) infection

Severe Epstein-Barr (EB) virus infection is potentially a devastating process that often leads to death encountered in pediatrics recently. Inappropriate control of EB virus replication may cause severe infection resulting in multiple organ dysfunction. However, little information is available on pulmonary complications associated with EB virus infection. The aim of the present study was to investigate severe EB virus (EBV) infection complicated with lung injury in pediatric intensive care unit (PICU), including clinical characteristics, laboratory or imaging feature and outcomes. A total of 45 children with severe EBV infection seen in PICU of Shanghai Children's Hospital between January 2011 and December 2014 were retrospectively reviewed. According to clinical characteristics and imaging feature, 45 children were divided into non-lung injury group (n =27), lung injury without pulmonary fibrosis group(n = 12) and pulmonary fibrosis group (n = 6). In totally 45 cases of severe EBV infection, 21 (46.7%) were male and 24 (53. 3%) were female, mean age was 2. 4 years; 18 cases were complicated with lung injury, including 8 male and 10 female, median age was 31. 2 months. All of 18 cases presented with fever and cough, 15 of them exhibited dyspnea,12 cases were complicated with gasping, and 6 cases with ARDS. Eight cases accepted mechanical ventilation for acute respiratory distress; 6 cases who developed pulmonary fibrosis had tachypnea, refractory hypoxemia and hypercapnia, severe pulmonary air leak. The average EBV-DNA level in peripheral blood was 4. 42 x 10(6) copies/ml (range: 3. 25 x 10(3) - 6.59 x 10(7) copies/ml). Anti-EBV antibodies were positive in 41 cases, 18 cases were positive (+) for VCA-IgM, 15 cases were VCA-IgG and EA-IgG (+), 8 cases VCA-IgM and VCA-IgG (+). The radiographic findings revealed pulmonary interstitial infiltrates in all 18 cases with lung injury, 4 cases with segmental consolidation and 2 cases showed pleural effusions. HRCT scanning found EBV associated fibrosis including multifocal patches and diffuse ground-glass attenuation in both lungs, reticular opacities and honeycombing changes were observed 4 weeks after illness onset. There were significant differences in respiratory failure, PICU stay (days), Pediatric risk of mortality III (PRISM III) and pediatric clinical illness score(PCIS), serum TNF-α, EBV-DNA levels, percentage of NK cells and CD4+/CD8+ T cell ratio among non-lung injury group, lung injury without pulmonary fibrosis group and pulmonary fibrosis group (X2 =27. 12, F = 85. 23, 78. 23, 88. 68, 323. 80, 7. 35, χ2 = 6. 71, 12. 15; all P < 0. 05). COX regression analysis revealed that EBV-DNA and serum TNF-α levels were correlated with pulmonary fibrosis significantly (OR = 3. 92, P = 0. 04; OR = 5. 95, P = 0. 01). The patients with EBV-associated hemophagocytic lymphohistiocytosis (EBV-HLH) had higher incidence of pulmonary fibrosis compared with non-EB-HLH (70% vs. 13%, χ2 = 4. 82, P = 0. 03). Of 18 cases, 8 cases died, including 3 cases with pulmonary fibrosis. The surviving cases with pulmonary fibrosis needed longer additional oxygen. Chest HRCT imaging of 3 cases with pulmonary fibrosis was improved at 6 months and oxygen therapy was discontinued at 18 months after discharge. EB virus infection complicated with lung injury had higher incidence of respiratory failure, pulmonary fibrosis with a fatal outcome. EBV-DNA and serum TNF-α level were found to be statistically significant indicators of pulmonary fibrosis. Pulmonary fibrosis associated with severe EB virus infection may be reversible.

Does Arhgef7, a guanine nucleotide exchange factor, regulate epithelial sodium channel activity and lung aeration?

Preterm infants have higher incidence of respiratory failure than term infants. These respiratory disorders are caused in part by delayed clearance of lung fluid. At birth, lung fluid clearance and aeration are mediated by active salt and water transport by epithelial sodium channel (ENaC) activity. Our lab has shown that oxidative environments can enhance ENaC activity, most likely via Nadph oxidase (Nox)‐mediated O2− release. In this highly regulated process, we have shown that the small G‐protein Rac1 plays an important role upstream of Nox signaling. However, the Rac1‐guanine nucleotide exchange factors (GEFs) involved in Nox‐mediated ENaC activity are unknown. Herein, we utilized quantitative real‐time PCR analysis to examine the expression profile of Rac1‐GEFs that may play an important role in ENaC regulation in the neonatal lung. Our major findings thus far are that transcript expression of Arhgef7&gt;;&gt;;&gt;;Sos1&gt;;Rasgrf2&gt;;Tiam1&gt;;Sos2, and that Arhgef7 transcript is expressed 1.5‐fold higher in neonatal (post‐partum day 7) mouse lung than adult mouse lung (n=8). This evidence suggests that Arhgef7 may play an integral role in neonatal lung aeration. Funding support: R00HL09226 awarded to MNH; Children's Center for Development in Lung Biology Grant awarded to MNH; and Emory University Summer Undergraduate Stipend awarded to DT.

Risk factors associated with pediatric intensive care unit admission and mortality after pediatric stem cell transplant: possible role of renal involvement

Hematopoietic stem-cell transplant (HSCT) is associated with many risk factors for life-threatening complications. Post-transplant critical illness often requires admission to the pediatric intensive care unit (PICU). A retrospective analysis was made on the risk factors associated with PICU admission and mortality of all HSCT patients at Helen DeVos Children's Hospital from October 1998 to November 2008. One hundred and twenty-four patients underwent HSCT, with 19 (15.3%) requiring 29 PICU admissions. Fifty patients received autologous, 38 matched sibling, and 36 matched un-related donor HSCT, with 10%, 13% and 25% of these patients requiring PICU admission, respectively (P=0.01). Among the HSCT patients, those who were admitted to the PICU were more likely to have renal involvement by either malignancy requiring nephrectomy or a post transplant complication increasing the likelihood of decreased renal function (21.1% vs. 4.8%, P=0.03). PICU admissions were also more likely to receive pre-transplant total body irradiation (52.6% vs. 27.6%, P=0.03). Among 29 patients with PICU admission, 3 died on day 1 after admission, and 5 within 30 days (a mortality rate of 17%). Thirty days after PICU admission, non-survivors had a higher incidence of respiratory failure and septic shock on admission compared with survivors (80% vs. 16.7%, P=0.01 and 80% vs. 4.2%, respectively, P=0.001). Two survivors with chronic renal failure underwent renal transplantation successfully. Total body irradiation and renal involvement are associated with higher risk for PICU admissions after HSCT in pediatric patients, while septic shock upon admission and post-admission respiratory failure are associated with mortality.

Clinical Characteristics and Outcomes of Patients with Obstructive Sleep Apnoea Requiring Intensive Care

We reviewed the clinical characteristics, required intervention and short- and long-term outcomes in obstructive sleep apnoea (OSA) patients requiring intensive care. A retrospective, single-centre, observational cohort study was undertaken in a multidisciplinary teaching medical and surgical intensive care unit. Adult patients with OSA (apnoea-hypopnoea index of 5 or higher) requiring intensive care from January 2000 to January 2005 were included. Thirty-seven OSA patients (age: 58 +/- 14 years, male:female 27:10) were admitted due to respiratory (n=12, 32%), cerebrovascular (n=8, 22%), cardiovascular (n=16, 43%) and infectious events (n=1, 2.7%). Comparing the clinical features, polysomnographic data and outcome among these groups, we found that OSA patients admitted due to respiratory events had significantly higher Acute Physiology and Chronic Health Evaluation II scores, lower arterial blood gas pH, higher PaCO2, a higher incidence of respiratory failure (92%) and required non-invasive ventilation after extubation (73%), and higher intensive care unit readmission rates than patients admitted due to cerebrovascular events and cardiovascular events (P < 0.05). No difference was found in the in-hospital and long-term mortality rate. The most common reason for intensive care unit admission in critically ill OSA patients was a cardiovascular event, followed by respiratory and cerebrovascular events. The baseline polysomnographic data of the OSA patients were not correlated with their clinical features and outcomes in the intensive care unit. A more complicated clinical course and higher intensive care unit readmission rate were encountered in OSA patients admitted due to respiratory events. Further studies would be required to evaluate the efficacy of non-invasive ventilation for facilitation of extubation in OSA patients presenting with hypercapnic respiratory failure.

Outcome of Older Critically lIl Patients: A Matched Cohort Study

Background: Admission of older patients to intensive care units is a controversial issue. Objective: To estimate age-associated mortality of critically ill patients. Methods: A prospective matched cohort study in the Medical-Surgical Intensive Care Unit of a tertiary hospital was conducted. We included 100 consecutive patients older than 70 years admitted to the intensive care unit (cases) and 100 patients younger than 70 years (controls). The matching criterion was the severity of illness at admission to the intensive care unit as estimated by the simplified acute physiological score (SAPS II) without including age in its calculation. Results: Mortality in the intensive care unit was higher, but not statistically significant, in the older group: 26% vs. 19% (p = 0.23). Patients older than 70 years had a longer duration of mechanical ventilation (median 7 vs. 3 days) and longer stay in the intensive care unit (median 8 vs. 5 days). There were no differences in organ dysfunctions, except for a higher incidence of respiratory failure in the older group (p < 0.001). The use of invasive procedures was similar in both groups. There were more orders for the withholding/withdrawal of treatment in patients older than 70 years (9 vs. 3%, p = 0.07). Conclusion: In our study, age was not related with a significant higher mortality. In the older patients included in our study the survival was greater than 70% with a similar resource utilization except for a longer stay in the intensive care unit.

Gallstone Pancreatitis – Who Really Needs an ERCP?

Gallstone Pancreatitis – Who Really Needs an ERCP?

OUTCOME AND QUALITY OF LIFE AFTER CARDIAC SURGERY IN OCTOGENARIANS

Cardiac surgery is being performed with increasing frequency in octogenarians. The purpose of the present study was to determine the outcome and quality of life of octogenarians after cardiac surgery in a single surgeon series and in a newly established cardiac surgery unit. Prospective data collection and analysis were undertaken of octogenarians having cardiac surgery from 1997 to 2003 by a single surgeon in a single institution. The outcome was compared to septuagenarians operated on by the same surgeon in the same time frame, specifically to see if there were any significant differences in outcomes between these two close age groups. Follow up was conducted by sending a questionnaire, interviewing patients or their general practitioner. There were significantly less octogenarians with airway disease but more with class III and IV New York Heart Association heart failure. There were no significant differences in the incidence of left main disease, urgent operations, renal impairment and cerebrovascular disease between the two groups. There was a trend towards increased operative mortality in octogenarians when the group was taken as a whole (8%vs 2%, P = 0.052). They also had a significantly higher incidence of respiratory failure (6%vs 2%, P = 0.029). The incidence of stroke, renal failure and low cardiac output was not significantly different between the two groups. Blood product usage was significantly higher in octogenarians (19%vs 9%, P = 0.042), but re-operation for bleeding was not significantly different (3%vs 4%). Intensive care unit median length of stay was significantly longer in the case of Octogenarians (1.0 vs 0.9 days, P = 0.039), but the duration of hospital stay was similar (6.5 vs 6.4 days, P = 0.165). Follow up was 94.5% complete, 85% of the octogenarians responded to the questionnaire sent to them. All patients were free of angina, 98% of them had improved by at least one New York Heart Association heart failure class and 86.7% felt that they were less dependent on others after cardiac surgery. In retrospect, 94.2% said that they would have the procedure again. Octogenarians can be operated on with acceptable mortality and morbidity to achieve significant improvement in quality of life. The outcome of surgery in these patients in a new unit is comparable with established units.

QT c prolongation indicates a poor prognosis in patients with organophosphate poisoning

This study reviewed emergency department electrocardiograms of 223 patients with organophosphate poisoning from January 1982 to June 1994: 97 (43.5%) had QT c prolongation and were placed in group A; 126 patients without QT c prolongation were designated as group B. Compared with group B, group A patients had a higher mortality (19.6% v 4.8%, P < .001) and a higher incidence of respiratory failure (56.7% v 20.6%, P < .001). Serum cholinesterase levels were determined in the 223 patients: 92 (41.3%) were classified as severe poisoning, 32 (14.3%) as moderate, 41 (18.1%) as mild, and 58 (25.7%) as very mild. The severe group had a high incidence of QT c prolongation ( P < .001), a high incidence of respiratory failure ( P < 0.001), and a higher mortality rate ( P < 0.001) than the other groups. Of the QT c prolongation patients, 59.8% ( 55 92 ) had a high incidence of respiratory failure (78.2% v 35.1%, P < .0001) and a higher mortality rate (29.1% v 8.1%, P < 0.05) compared with 40.2% ( 37 92 ) of the patients without QT c prolongation in the severe group. In conclusion, a complete electrocardiogram at the emergency department is important and of prognostic value.