Kuang-Yao Yang

Decoy Receptor 3 Levels in Peripheral Blood Predict Outcomes of Acute Respiratory Distress Syndrome

RATIONALEnAcute respiratory distress syndrome (ARDS), a serious inflammatory reaction to acute lung injury, is associated with high mortality rates. Decoy receptor (DcR) 3 is a soluble protein with immunomodulatory effects. Biomarkers that reliably predict outcomes in ARDS are not currently available.nnnOBJECTIVESnComparing DcR3 with the Acute Physiology and Chronic Health Evaluation (APACHE) II scores and three other plasma markers to explore the association of DcR3 and the clinical outcome in ARDS.nnnMETHODSnEighty-eight patients with ARDS were studied. Baseline APACHE II scores and clinical data were recorded. Plasma levels of DcR3, soluble triggering receptor expressed on myeloid cells (sTREM)-1, tumor necrosis factor (TNF)-alpha, and IL-6 were measured on Day 1 and later time points, and correlated with the survival status on Day 28 after the onset of ARDS. For validation, 59 patients with ARDS from another medical center were studied.nnnMEASUREMENTS AND MAIN RESULTSnAmong the biomarkers evaluated, only DcR3 discriminated the survivors and nonsurvivors at all time points in the first week of ARDS. DcR3 independently associated with and best predicted the 28-day mortality of patients with ARDS. Plasma DcR3 levels most correlated to multiple-organ dysfunction and ventilator dependence. Compared with survivors, the nonsurvivors had higher DcR3 levels regardless of the APACHE II scores. Kaplan-Meier survival analysis showed higher mortality in patients with ARDS with higher DcR3 levels. The outcome prediction of patients with ARDS by plasma DcR3 levels was recapitulated by the validation cohort.nnnCONCLUSIONSnHigh plasma DcR3 levels correlate with development of multiple-organ dysfunction and independently predict the 28-day mortality in patients with ARDS.

Abnormal Renal Resistive Index in Patients with Mild-to-moderate Chronic Obstructive Pulmonary Disease

Abstract Background: Arterial rigidity and endothelial dysfunction are systemic manifestations of chronic obstructive pulmonary disease (COPD). The decrease in renal vascular resistance in order to adapt the increase in glomerular filtration rate after oral protein loading is known as normal renal functional reserve. We tested the hypothesis that COPD patients, even in those with mild-to-moderate airflow obstruction, are affected by systemic inflammation associated with abnormal renal functional reserve. Materials and Methods: The study enrolled 24 current smokers with a cigarette smoking history ^25 pack-years and 8 nonsmokers with normal spirometry as control. Doppler sonography detected the renal resistive index (RRI) before and after oral protein loading to determine the renal functional reserve. Pulmonary function and serum tumor necrosis factor 〈 (TNF-〈) levels were analyzed to compare with the renal functional reserve. Results: The smokers were stratified into 3 groups (Group 1: smokers with normal spirometry, Group 2: mild COPD, Group 3: moderate COPD); nonsmokers as Group 4. The baseline RRI levels were similar in Group 1 and Group 4. After protein loading, the RRI elevated in all smoking groups; moreover, Group 3 had the highest RRI and with longer duration than other groups. The smokers with higher serum TNF-〈 levels had a longer RRI elevation. Multiple linear regression revealed forced expiratory volume in one second (FEV1), serum TNF-〈 levels and aging were independently predictive factors of impaired renal functional reserve. Conclusions: A greater impairment in renal functional reserve of COPD patients was correlated with more severe airway obstruction and inflammation.

Septic pulmonary embolism associated with a peri-proctal abscess in an immunocompetent host

Septic pulmonary embolism is an uncommon disease in which septic thrombi are mobilised from an infectious nidus and transported in the vascular system of the lungs. It is usually associated with tricuspid valve vegetation, septic thrombophlebitis or infected venous catheters. We report an immunocompetent young man who presented with fever and pleuritic chest pain. Chest roentgenography and CT showed multiple ill-defined nodules, with central cavitation and feeding vessels. He was found to have a clinically infectious source of methicillin-resistant staphylococcus aureus (MRSA) cultured from the peri-proctal abscess with the same bacteraemia. Pulmonary septic embolism from peri-proctal abscess was diagnosed by image study and bacterial culture correlation. All of the clinical presentations improved after the incision of the peri-proctal abscess and anti-MRSA antibiotics treatment.

Pulmonary Nocardiosis Manifesting as a Solitary Mass and Acute Respiratory Distress Syndrome in an Immunocompetent Host

Nocardiosis is caused by Nocardia spp., which is a ubiquitous, aerobic, Gram-positive, weakly acid-fast bacillus found in soil and water, and on vegetables. The predisposing factors for pulmonary nocardiosis include organ transplantation, malignancy, tuberculosis, acquired immunodeficiency syndrome (AIDS), alveolar proteinosis, alcohol abuse, and chronic obstructive pulmonary disease (COPD). Hematogenous dissemination to almost every organ system has been reported, especially to the central nervous system and the skin. Chest radiography shows varying changes, which present from mild infiltration to a single or multiple large cavitary mass. Pleural effusion or empyema is noted in about 50% of patients. The mortality rate is correlated with the immune status; it approaches 50% in those with central nervous system lesions, and is less than 10% in those with pulmonary disease only. Acute respiratory distress syndrome (ARDS) caused by solitary pulmonary nocardiosis has rarely been reported, thus we present and discuss in detail this unusual manifestation. A 61-year-old previously healthy man complained of fever with cough and shortness of breath lasting for 1 week. His chest radiography initially showed a mass in the right upper lobe and massive right side pleural effusion. Later, pulmonary nocardiosis was diagnosed by means of a culture of the material obtained from fine-needle aspiration. A relatively rare species, N. caviae (N. otitidiscaviarum), was isolated 3 weeks later. Localized pulmonary nocardiosis rapidly developed into septic shock with ARDS, with frequent attacks of paroxysmal supraventricular tachycardia (PSVT). After 4 weeks of intravenous imipenem and amikin, he was weaned from the mechanical ventilator. Antibiotics were then shifted to oral trimethoprim-sulfamethoxazole for 3 months. In a stable condition, the patient was transferred to a respiratory care ward for tracheostomy care.