Chun-Ta Huang

Factors influencing visibility and diagnostic yield of transbronchial biopsy using endobronchial ultrasound in peripheral pulmonary lesions

Background and objective:  Endobronchial ultrasound (EBUS) has increased the diagnostic yield of bronchoscopic biopsy of peripheral pulmonary lesions (PPL). However, certain lesions cannot be localized by EBUS, and the factors associated with the visibility of PPL by EBUS have not been investigated. This study evaluated the factors predicting the visualization of EBUS in PPL and the diagnostic yield of EBUS‐guided transbronchial biopsy (TBB).

Revisiting tuberculous pleurisy: pleural fluid characteristics and diagnostic yield of mycobacterial culture in an endemic area

Background Tuberculous pleurisy is traditionally indicated by extreme lymphocytosis in pleural fluid and low yield of effusion culture. However, there is considerable inconsistency among previous study results. In addition, these data should be updated due to early effusion studies and advances in culture methods. Methods From January 2004 to June 2009, patients with tuberculous pleurisy were retrospectively identified from the mycobacteriology laboratories and the pathology and tuberculosis registration databases of two hospitals in Taiwan where tuberculosis is endemic. Pleural fluid characteristics and yields of mycobacterial cultures using liquid media were evaluated. Results A total of 382 patients with tuberculous pleurisy were identified. The median lymphocyte percentage of total cells in pleural fluids was 84% (IQR 64–95%) and 17% of cases had a lymphocyte percentage of <50%. The lymphocyte percentage was negatively associated with the probability of a positive effusion culture (OR 0.97; 95% CI 0.96 to 0.99). The diagnostic yields were 63% for effusion culture, 48% for sputum culture, 79% for the combination of effusion and sputum cultures, and 74% for histological examination of pleural biopsy specimens. Conclusion The degree of lymphocyte predominance in tuberculous pleurisy was lower than was previously thought. The lymphocyte percentage in pleural fluid was negatively associated with the probability of a positive effusion culture. With the implementation of a liquid culture method, the sensitivity of effusion culture was much higher than has been previously reported, and the combination of effusion and sputum cultures provided a good diagnostic yield.

A rare constellation of empyema, lung abscess, and mediastinal abscess as a complication of endobronchial ultrasound-guided transbronchial needle aspiration

The introduction of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) brought about significant advancement in the field of bronchoscopy. The major indications for EBUS-TBNA are lung cancer staging and diagnosis of mediastinal lymphadenopathy. This procedure is minimally invasive and cost saving, and no complications have been described in large-scale studies. In this report, we present a case of empyema, lung abscess, and mediastinal abscess that developed in a patient undergoing EBUS-TBNA; the patient subsequently recovered uneventfully after aggressive surgical debridement and antimicrobial therapy.

Exploring the heterogeneity of effects of corticosteroids on acute respiratory distress syndrome: a systematic review and meta-analysis

IntroductionThe effectiveness of corticosteroid therapy on the mortality of acute respiratory distress syndrome (ARDS) remains under debate. We aimed to explore the grounds for the inconsistent results in previous studies and update the evidence.MethodsWe searched MEDLINE, Cochrane Central Register of Controlled Trials and Web of Science up to December 2013. Eligible studies included randomized clinical trials (RCTs) and cohort studies that reported mortality and that had corticosteroid nonusers for comparison. The effect of corticosteroids on ARDS mortality was assessed by relative risk (RR) and risk difference (RD) for ICU, hospital, and 60-day mortality using a random-effects model.ResultsEight RCTs and 10 cohort studies were included for analysis. In RCTs, corticosteroids had a possible but statistically insignificant effect on ICU mortality (RD, −0.28; 95% confidence interval (CI), −0.53 to −0.03 and RR, 0.55; 95% CI, 0.24 to 1.25) but no effect on 60-day mortality (RD, −0.01; 95% CI, −0.12 to 0.10 and RR, 0.97; 95% CI, 0.75 to 1.26). In cohort studies, corticosteroids had no effect on ICU mortality (RR, 1.05; 95% CI, 0.74 to 1.49) but non-significantly increased 60-day mortality (RR, 1.30; 95% CI, 0.96 to 1.78). In the subgroup analysis by ARDS etiology, corticosteroids significantly increased mortality in influenza-related ARDS (three cohort studies, RR, 2.45, 95% CI, 1.40 to 4.27).ConclusionsThe effects of corticosteroids on the mortality of ARDS differed by duration of outcome measures and etiologies. Corticosteroids did not improve longer-term outcomes and may cause harm in certain subgroups. Current data do not support routine use of corticosteroids in ARDS. More clinical trials are needed to specify the favorable and unfavorable subgroups for corticosteroid therapy.

Skin and soft-tissue infection caused by non-tuberculous mycobacteria in Taiwan, 1997-2008.

The aim of this study was to investigate the clinical, microbiological, and pathological characteristics and the outcomes of skin and soft-tissue infection (SSTI) caused by non-tuberculous mycobacteria (NTM). Medical records of 50 patients with SSTI caused by NTM identified from 2005 to 2008 and 63 patients previously reported in a medical centre from 1997 to 2004 were reviewed. The annual incidence (per 100,000 outpatients and in-patients) ranged from 0·57 in 2005, 0·38 in 2007, to 1·1 in 2008, with an average of 0·62/100,000. From 1997 to 2008, the average incidence was 1·39/100,000 patients. The average annual incidence of SSTI caused by NTM was 0·62/100,000 outpatients and in-patients during 2005 and 2008. Of the total of 113 patients identified during the 12-year period, patients infected with Mycobacterium fortuitum and M. marinum were younger than those infected with M. avium-intracellulare complex (MAC) (36 and 44 years vs. 55 years, P=0·004 and P=0·056, respectively), and were more likely to have previous invasive procedures than those infected with MAC and M. abscessus (81·8% and 72·0% vs. 27·8% and 54·8%, P=0·007), and less likely to have associated immunosuppression (9·1% and 24% vs. 66·7% and 45·2%, P=0·006). Granuloma was more often observed in immunocompetent patients (60·1% vs. 40%, P=0·019), and in M. marinum-infected specimens (78·3%). There were significant differences in the demographic and clinical features of patients with NTM SSTI, including immunosuppression, trauma experience, and depth of tissue infections.

Effects of pre-emptive drug treatment on astrocyte activation in the cuneate nucleus following rat median nerve injury

&NA; In this study, we examined the relationship between astrocyte activation in the cuneate nucleus (CN) and behavioral hypersensitivity after chronic constriction injury (CCI) of the median nerve. In addition, we also examined the effects of pre‐emptive treatment with a number of drugs on astrocyte activation and hypersensitivity development in this model. Using immunohistochemistry and immunoblotting, little glial fibrillary acidic protein (GFAP; an astrocyte marker) immunoreactivity was detected in the CN of the normal rats. As early as 3 days after CCI, there was a significant increase in GFAP immunoreactivity in the lesion side of CN, and this reached a maximum at 7 days, and was followed by a decline. Counting of GFAP‐immunoreactive astrocytes revealed that astrocytic hypertrophy, but not proliferation, contributes to increased GFAP immunoreactivity. Furthermore, microinjection of the glial activation inhibitor, fluorocitrate, into the CN at 3 days after CCI attenuated injury‐induced behavioral hypersensitivity in a dose‐dependent manner. These results suggest that median nerve injury‐induced astrocytic activation in the CN modulated the development of behavioral hypersensitivity. Animals received MK‐801 (glutamate N‐methyl‐d‐aspartate (NMDA) receptor antagonist), clonidine (&agr;2‐adrenoreceptor agonist), tetrodotoxin (TTX, sodium channel blocker) or lidocaine (local anesthetic) 30 min prior to median nerve CCI. Pre‐treatment with MK‐801, TTX, and 2% lidocaine, but not clonidine, attenuated GFAP immunoreactivity and behavioral hypersensitivity following median nerve injury. In conclusion, suppressing reactions to injury, such as the generation of ectopic discharges and activation of NMDA receptors, can decrease astrocyte activation in the CN and attenuate neuropathic pain sensations.

Infections due to Candida haemulonii: species identification, antifungal susceptibility and outcomes

Here we report the clinical features and treatment outcomes of three patients with Candida haemulonii infection. Candida haemulonii was confirmed by sequence analysis of the internal transcribed spacer (ITS) regions of the rRNA genes and the 18S rRNA genes. Two of the three isolates were associated with fungaemia and reduced susceptibility to fluconazole [minimum inhibitory concentrations (MICs) of 16 mg/L] and amphotericin B (MICs of 2 mg/L). However, one of these two patients responded to fluconazole therapy. Echinocandins, voriconazole and posaconazole demonstrated excellent in vitro potency against the isolates.

Pulmonary infection caused by nontuberculous mycobacteria in a medical center in Taiwan, 2005–2008

The aim of this study was to investigate the epidemiology and clinical characteristics of pulmonary infections caused by nontuberculous mycobacteria (NTM) in a university hospital in Taiwan from 2005 to 2008. During the study period, a total of 312 patients with NTM pulmonary infection were identified. Most patients with NTM pulmonary infection had preexisting pulmonary diseases or malignancies. The incidence (per 100,000 inpatients and outpatients) of patients with NTM isolations (6.67 in 2005 and 9.28 in 2008, P < .0001) from respiratory specimens and the incidence of patients with NTM pulmonary infection (3.54 in 2005 and 4.45 in 2008, P < .0141) increased significantly annually. The most common pathogens in patients with NTM-associated pulmonary infections were Mycobacterium avium complex (n = 110, 35.3%), followed by M. abscessus (n = 66, 21.2%). Incidence (per 100,000 inpatients and outpatients) of patients with pulmonary infections caused by rapidly growing mycobacteria (RGM) also increased significantly (1.06 in 2005 and 2.00 in 2008, P = .008). In conclusion, RGM, especially M. abscessus, had an increasingly important role in NTM pulmonary infections.

Impact of non-tuberculous mycobacteria on pulmonary function decline in chronic obstructive pulmonary disease

OBJECTIVE Although chronic obstructive pulmonary disease (COPD) is a common form of structural lung disease associated with pulmonary non-tuberculous mycobacteria (NTM) infection, no longitudinal studies have investigated the role of NTM in COPD disease progression. DESIGN From 2000 to 2008, spirometry-confirmed COPD patients with sputum specimens sent for mycobacterial cultures were included. Analysis of clinical, microbiological and pulmonary function data was performed. RESULTS The 251 patients were divided into three groups according to the number of NTM isolates: multiple (n = 47), single (n = 63), and no (n = 141) isolates. Mycobacterium avium complex was the most common species in multiple isolates (36.2%) and single isolate (28.6%) groups. Overall, 24.7% of COPD patients had been admitted for exacerbations at least once a year, and patients with multiple and single NTM isolates were more than twice as likely as those with no isolate to experience such exacerbations (38.3% vs. 31.7% vs. 17.0%). After controlling for confounders, patients with multiple NTM isolates had a greater decline in forced expiratory volume in one second than those with single or no isolates (-79.4 ± 32.8 ml vs. -61.6 ± 31.9 ml and -56.2 ± 31.5 ml). CONCLUSION This study suggests that NTM may play a role in disease progression and deterioration of pulmonary function in COPD patients.

Clinical significance of isolation of nontuberculous mycobacteria in pulmonary tuberculosis patients.

BACKGROUND Clinical significance of isolation of nontuberculous mycobacteria (NTM) from respiratory specimens in patients with pulmonary tuberculosis is unknown. This study aimed to investigate the prevalence and clinical impact of NTM in pulmonary tuberculosis patients. METHODS We retrospectively reviewed data of patients with culture-confirmed pulmonary tuberculosis from 2000 to 2006. Those in whom NTM were isolated from respiratory specimens collected within two months before and nine months after the index culture of tuberculosis was plated were compared with those without NTM. Patients were followed for one year after initiation of anti-tuberculous treatment. RESULTS Among 2133 patients with pulmonary tuberculosis, 48 (2.3%) with multiple and 106 (5.0%) with one isolate(s) of NTM were identified. Another 144 without NTM were selected and compared. The one-year mortality rates were similar among three groups. Patients with multiple NTM isolates were more likely to be symptomatic, sought medical help earlier, had smear-positive respiratory specimens, and received anti-tuberculous treatment later than those with single/no isolate(s). Cavities were more commonly visualized radiographically in patients with multiple/single NTM isolate(s) than those without NTM isolates. The mean duration of anti-tuberculous treatment was 8.8 months for patients with multiple NTM isolates, significantly longer than that in patients with single (7.6 months) and no NTM isolate(s) (7.5 months). CONCLUSIONS NTM were present in the respiratory tract of 7.3% of patients with pulmonary tuberculosis. Although the outcomes were similar, the presence of NTM was associated with different clinical manifestations and had a significant impact on the treatment of tuberculosis.