Han-Pin Kuo

A mobile telephone-based interactive self-care system improves asthma control

The self-management of asthma can improve clinical outcomes. Recently, mobile telephones have been widely used as an efficient, instant personal communication tool. This study investigated whether a self-care system will achieve better asthma control through a mobile telephone-based interactive programme. This was a prospective, controlled study in outpatient clinics. From 120 consecutive patients with moderate-to-severe persistent asthma, 89 were eventually recruited for the study, with 43 in the mobile telephone group (with a mobile telephone-based interactive asthma self-care system). In the mobile telephone group, mean±sem peak expiratory flow rate significantly increased at 4 (378.2±9.3 L·min−1; n = 43; p = 0.020), 5 (378.2±9.2 L·min−1; n = 43; p = 0.008) and 6 months (382.7±8.6 L·min−1; n = 43; p = 0.001) compared to the control group. Mean±sem forced expiratory volume in 1 s significantly increased at 6 months (65.2±3.2% predicted; n = 43; p<0.05). Patients in the mobile telephone group had better quality of life after 3 months, as determined using the Short Form-12® physical component score, and fewer episodes of exacerbation and unscheduled visits than the control group. Patients in the mobile telephone group significantly increased their mean daily dose of either systemic or inhaled corticosteroids compared with the control group. The mobile telephone-based interactive self-care system provides a convenient and practical self-monitoring and -management of asthma, and improves asthma control.

Risk factors for the development of early-onset delirium and the subsequent clinical outcome in mechanically ventilated patients.

OBJECTIVES The aim of the study was to investigate the risk factors of developing early-onset delirium in mechanically ventilated patients and determine the subsequent clinical outcomes. METHODS Confusion assessment method for the intensive care unit (ICU) was used to assess the enrolled mechanically ventilated patients for delirium. The risk factors of developing delirium and clinical outcomes were determined in these subjects. RESULTS Delirium was present in 31 (21.7%) of 143 patients in the first 5 days. In multivariable analysis, hypoalbuminemia (odds ratio, 5.94; 95% confidence interval, 1.23-28.77) and sepsis (odds ratio, 3.65; 95% confidence interval, 1.03-12.9) increased the risk of developing delirium in mechanically ventilated patients. The patients with delirium had a higher in-hospital mortality (67.7% vs 33.9%, respectively; P = .001) and longer duration of mechanical ventilation (19.5 +/- 15.8 vs 9.3 +/- 8.8 days, respectively; P = .003) than patients without delirium. The incidence of nosocomial pneumonia was increased in delirious patients (64.5% vs 38.4%, P = .01) compared with nondelirious patients, whereas the lengths of ICU or hospital stay were similar between both groups. CONCLUSIONS Mechanically ventilated patients with sepsis or hypoalbuminemia were more vulnerable to develop delirium in their early stay in the ICU. Early-onset delirium is associated with prolonged duration of mechanical ventilation and higher incidence of nosocomial pneumonia, leading to a higher mortality.

An outcome analysis of self-expandable metallic stents in central airway obstruction: a cohort study.

BackgroundSelf-expandable metallic stents (SEMSs) have provided satisfactory management of central airway obstruction. However, the long-term benefits and complications of this management modality in patients with benign and malignant obstructing lesions after SEMS placement are unclear. We performed this cohort study to analyze the outcomes of Ultraflex SEMSs in patients with tracheobronchial diseases.MethodsOf 149 patients, 72 with benign and 77 with malignant tracheobronchial disease received 211 SEMSs (benign, 116; malignant, 95) and were retrospectively reviewed in a tertiary hospital.ResultsThe baseline characteristics of patients who received SEMS implantation for benign conditions and those who underwent implantation for malignant conditions were significantly different. These characteristics included age (mean, 63.9 vs. 58; p < 0.01), gender (male, 62% vs. 90%; p < 0.0001), smoking (47% vs. 85%; p < 0.0001), forced expiratory volume in 1 second (mean, 0.9 vs. 1.47 L/s; p < 0.0001), follow-up days after SEMS implantation (median; 429 vs. 57; p < 0.0001), and use of covered SEMS (36.2% vs. 94.7%; p < 0.0001). Symptoms improved more after SEMS implantation in patients with benign conditions than in those with malignant conditions (76.7% vs. 51.6%; p < 0.0001). The overall complication rate after SEMS implantation in patients with benign conditions was higher than that in patients with malignancy (42.2% vs. 21.1%; p = 0.001). Successful management of SEMS migration, granulation tissue formation, and SEMS fracture occurred in 100%, 81.25%, and 85% of patients, respectively.ConclusionsPatients who received SEMS implantation owing to benign conditions had worse lung function and were older than those who received SEMS for malignancies. There was higher complication rate in patients with benign conditions after a longer follow-up period owing to the nature of the underlying diseases.

Factors leading to tracheobronchial self-expandable metallic stent fracture

OBJECTIVE This retrospective study was to determine factors that contribute to self-expandable metallic stent fracture in patients with tracheobronchial disease. METHODS From 2001 to 2006, 139 patients (age, 62.1 +/- 15.4 years; range, 23-87 years) with benign (n = 62) and malignant (n = 77) tracheobronchial disease received 192 Ultraflex (Boston Scientific, Natick, Mass) self-expandable metallic stents (98 in patients with benign disease and 94 in patients with malignant disease). RESULTS Seventeen fractured self-expandable metallic stents were found; the incidence was 12.2% (17/139 patients) among patients with tracheobronchial disease. Tortuous airway (odds ratio, 4.06; 95% confidence interval, 1.04-18.34; P = .04) independently predicted self-expandable metallic stent fracture. Most self-expandable metallic stent fractures (64.7%, 11/17) were detected 500 to 1000 days after self-expandable metallic stent implantation. Clinical presentations for patients with fractured self-expandable metallic stents included dyspnea exacerbation (70.6%, 12/17) and cough (23.5%, 4/17). CONCLUSIONS Self-expandable metallic stent fracture is not uncommon in patients with tracheobronchial disease. Tortuous airway is an independent predictor for it. Although management of the fractured self-expandable metallic stent in our study was feasible and safe, self-expandable metallic stents should be restricted to a more select population.

Inadequate Antimicrobial Treatment for Nosocomial Infection is a Mortality Risk Factor for Systemic Lupus Erythematous Patients Admitted to Intensive Care Unit

Introduction:Infection is a frequent cause of death in patients with systemic lupus erythematous (SLE) admitted to the intensive care unit (ICU). Complicated clinical features of SLE patients may delay or cause inadequate antimicrobial treatment. This study aimed to determine if inadequate antimicrobial treatment is an independent risk factor for mortality in SLE patients in the ICU. Methods:Fifty-eight SLE patients admitted to the ICU were evaluated in a retrospective analysis. Inadequate antimicrobial treatment was defined by patient receiving antibiotics ≥24 hours after the diagnostic criteria for nosocomial infection and/or the identified microorganism did not exhibit in vitro sensitivity to the antibiotics administered in the ICU. Results:Multivariate logistic regression analysis identified the risk factors. Thirty-three (56.9%) SLE patients died during their ICU stay. The nonsurvivor group (n = 33), exhibited lower platelet count (P = 0.025), prolonged hospital stay before ICU admission (P = 0.015), higher Acute Physiology and Chronic Health Evaluation II score (P = 0.015), and higher prevalence of multiple organ failure (P = 0.044) and inadequate antimicrobial treatment (P = 0.002) compared with the survivor group (n = 25). In multivariate logistic regression analysis, inadequate antimicrobial treatment was the most significant factor for mortality (odds ratio = 12.02, 95% confidence interval = 1.24–116.10, P = 0.032). Patients with prolonged hospitalization prior ICU admission had a mild risk for mortality (odds ratio = 1.06, 95% confidence interval = 1.00–1.12, P = 0.045). Conclusions:SLE patients in the ICU receiving inadequate antimicrobial treatment or with prior prolonged hospital stay have a higher risk of mortality. Clinical efforts should ensure adequate antimicrobial treatment in SLE patients with prior prolonged hospital stay before ICU admission.

Endobronchial ultrasound increases the diagnostic yields of polymerase chain reaction and smear for pulmonary tuberculosis.

OBJECTIVES Our objective was to determine the contribution of endobronchial ultrasound in the diagnostic yields of acid-fast bacillus smear, nucleic acid amplification tests, and culture in bronchoalveolar lavage fluid for pulmonary tuberculosis. METHODS During a 1-year interval, 99 patients who had initial sputum-negative acid-fast bacillus smears or no sputum but were later proven to have a positive culture for Mycobacterium tuberculosis in their sputum or bronchoalveolar lavage fluid were retrospectively studied. Among them, 56 patients underwent bronchoscopy with endobronchial ultrasound (EBUS group) and 43 patients received conventional bronchoscopy for bronchoalveolar lavage (non-EBUS group). RESULTS The diagnostic yields of the nucleic acid amplification tests (89.3%, 50/56; P = .006), acid-fast bacillus smear (30.4%, 17/56; P = .013), and M tuberculosis culture in bronchoalveolar lavage fluid (67.9%, 38/56; P = .041) were significantly higher in the EBUS group of patients. The results of those who underwent conventional bronchoscopy were 65.1% (28/43), 9.3% (4/43), and 46.5% (20/43), respectively. Combining bronchoalveolar lavage fluid smear and nucleic acid amplification tests, we made a rapid diagnosis of pulmonary tuberculosis in 51 (91.1%) of the 56 EBUS patients and 29 (67.4%; P = .004) of the 43 non-EBUS patients. CONCLUSIONS The introduction of endobronchial ultrasound increases the diagnostic yield of the nucleic acid amplification tests, acid-fast bacillus smear, and M tuberculosis culture from bronchioalveolar lavage fluid in patients with pulmonary tuberculosis who have negative sputum smear or no sputum production.

The Potential Regimen of Target-Controlled Infusion of Propofol in Flexible Bronchoscopy Sedation: A Randomized Controlled Trial

Objectives Target-controlled infusion (TCI) provides precise pharmacokinetic control of propofol concentration in the effect-site (Ce), eg. brain. This pilot study aims to evaluate the feasibility and optimal TCI regimen for flexible bronchoscopy (FB) sedation. Methods After alfentanil bolus, initial induction Ce of propofol was targeted at 2 μg/ml. Patients were randomized into three titration groups (i.e., by 0.5, 0.2 and 0.1 μg/ml, respectively) to maintain stable sedation levels and vital signs. Adverse events, frequency of adjustments, drug doses, and induction and recovery times were recorded. Results The study was closed early due to significantly severe hypoxemia events (oxyhemoglobin saturation <70%) in the group titrated at 0.5 μg/ml. Forty-nine, 49 and 46 patients were enrolled into the 3 respective groups before study closure. The proportion of patients with hypoxemia events differed significantly between groups (67.3 vs. 46.9 vs. 41.3%, p = 0.027). Hypotension events, induction and recovery time and propofol doses were not different. The Ce of induction differed significantly between groups (2.4±0.5 vs. 2.1±0.4 vs. 2.1±0.3 μg/ml, p = 0.005) and the Ce of procedures was higher at 0.5 μg/ml titration (2.4±0.5 vs. 2.1±0.4 vs. 2.2±0.3 μg/ml, p = 0.006). The adjustment frequency tended to be higher for titration at 0.1 μg/ml but was not statistically significant (2 (0∼6) vs. 3 (0∼6) vs. 3 (0∼11)). Subgroup analysis revealed 14% of all patients required no further adjustment during the whole sedation. Comparing patients requiring at least one adjustment with those who did not, they were observed to have a shorter induction time (87.6±34.9 vs. 226.9±147.9 sec, p<0.001), a smaller induction dose and Ce (32.5±4.1 vs. 56.8±22.7 mg, p<0.001; 1.76±0.17 vs. 2.28 ±0.41, p<0.001, respectively), and less hypoxemia and hypotension (15.8 vs.56.9%, p = 0.001; 0 vs. 24.1%, p = 0.008, respectively). Conclusion Titration at 0.5 μg/ml is risky for FB sedation. A subgroup of patients required no more TCI adjustment with fewer complications. Further studies are warranted to determine the optimal regimen of TCI for FB sedation. Trial Registration ClinicalTrials.gov NCT01101477

Remove Airway Ultraflex Stents by Flexible Bronchoscope

Introduction:Despite removal of airway metallic stents by rigid bronchoscope was presented, there are few reports describing such removal by flexible bronchoscope. Methods:36 patients who had airway Ultraflex stents removed by flexible bronchoscope from 2002 to 2009 were reviewed. Factors contributing to removal method and complications during and after removal were analyzed by multinomial logistic regression. Results:Among 36 patients with stent extraction; 17 stents (47.2%) were removed by a single procedure and 19 (52.8%) by multiple procedures. There was no mortality or severe morbidity during or after stent removal. There were 21 complications after stent removal, including retained stent pieces (n = 9), mucosal tear with bleeding (n = 5), and re-obstruction requiring silicone stent placement (n = 7). Stent indwelling time >10 months (adjusted odds ratio: 9.5; 95% confidence interval: 7.9–11.1, P=0.01), obstructive granulation tissue formation before stent removal (adjusted odds ratio: 5.2; 95% confidence interval: 2.2–8.6, P=0.01), and stent fracture before removal (adjusted odds ratio: 3.5; 95% confidence interval: 1.8–15.4, P=0.04) were independent predictors of the need for multiple procedures for stent removal. Stent indwelling time >10 months (adjusted odds ratio: 4.2; 95% confidence interval: 2.1–8.9, P=0.01), obstructive granulation tissue formation before stent removal (adjusted odds ratio: 16.5; 95% confidence interval, 1.8–49.6, P=0.01), and multiple procedures required for removal (adjusted odds ratio: 6.9; 95% confidence interval, 1.1–43.5, P=0.04) were independent predictors of removal complications. Conclusions:A flexible bronchoscope can be used to remove stents in patients with central airway obstruction and stent-related complications. This procedure should be performed in centers with experienced multidisciplinary teams.

Circulating Angiopopietin-1 Correlates With the Clinical Course of Multiple Organ Dysfunction Syndrome and Mortality in Patients With Severe Sepsis

AbstractTo determine plasma concentrations of angiopoietin (Ang)-1, Ang-2, Tie-2, and vascular endothelial growth factor (VEGF) in patients with sepsis-induced multiple organ dysfunction syndrome (MODS) and determine their association with mortality.The study prospectively recruited 96 consecutive patients with severe sepsis in a l intensive care unit of a tertiary hospital. Plasma Ang-1, Ang-2, Tie-2, and VEGF levels and MODS were determined in patients on days 1, 3, and 7 of sepsis. Univariate and Cox proportional hazards analysis were performed to develop a prognostic model.Days 1, 3, and 7 plasma Ang-1 concentrations were persistently decreased in MODS patients than in non-MODS patients (day1: 4.0 ± 0.5 vs 8.0 ± 0.5 ng/mL, P < 0.0001; day 3, 3.2 ± 0.6 vs 7.3 ± 0.5 ng/mL, P < 0.0001, day 7, 2.8 ± 0.6 vs 10.4 ± 0.7 ng/mL, P < 0.0001). In patients with resolved MODS on day 7 of sepsis, Ang-1 levels were increased from day 1 (4.7 ± 0.6 ng/mL vs 9.1 ± 1.4 ng/mL, n = 43, P = 0.004). Plasma Ang-1 levels were lower in nonsurvivors than in survivors on days 1 (4.0 ± 0.5 vs 7.1 ± 0.5 ng/mL, P < 0.0001), 3 (3.8 ± 0.6 vs 7.1 ± 0.5 ng/mL, P < 0.0001), and 7 (4.7 ± 0.7 vs 11.0 ± 0.8 ng/mL, P < 0.0001) of severe sepsis. In contrast, plasma Ang-2 levels were higher in nonsurvivors than in survivors only on day 1 (15.8 ± 2.0 vs 9.5 ± 1.2 ng/mL, P = 0.035). VEGF and Tie-2 levels were not associated with MODS and mortality. Ang-1 level less than the median value was the only independent predictor of mortality (hazard ratio, 2.57; 95% CI 1.12–5.90, P = 0.025).Persistently decreased Ang-1 levels are associated with MODS and subsequently, mortality in patients with sepsis.

Airway Ultraflex Stenting in Esophageal Cancer with Esophagorespiratory Fistula

Introduction: Esophagorespiratory fistula (ERF) caused by esophageal cancer has a poor prognosis. This study describes the clinical effects of airway ultraflex stenting as an alternative method for ERF caused by esophageal cancer. Methods: In an university-affiliated hospital, consecutive patients with ERF caused by esophageal cancer and confirmed by bronchoscopy were included. The demography, clinical manifestations and survival between groups with and without airway stenting were compared by case-control study. Results: From 2001 to 2007, 817 patients with esophageal cancer received bronchoscopy. Among these patients, 59 patients with ERF were included in this study. The demography and clinical manifestations between groups with and without airway stenting were similar, but survival improved in group with airway stenting, which was compared using log-rank test [P = 0.04; hazard ratio, 0.56; 95% confidence interval (CI), 0.31–0.99]. After adjusted with age and gender by multinominal logistic regression, airway stenting [adjusted odds ratio (OR), 5.2; P = 0.01; 95% CI, 1.4–18.8], performance status (adjusted OR, 6.1; P = 0.004; 95% CI, 1.8–20.8), further treatment (adjusted OR, 8.7; P = 0.001; 95% CI, 2.3–32.8) and prolonged pneumonia (adjusted OR, 0.14; P = 0.008; 95% CI, 0.03–0.59) remained as significant factors that impacted survival. Conclusions: Surgical treatment remains the first choice in patients with esophageal cancer with ERF; however, the authors provided an alternative airway stenting for those patients whom surgery is unsuitable. It improved survival in the group with airway stenting than those without. Performance status improvement and further treatment for esophageal cancer may improve survival, but prolonged pneumonia may worsen survival.