Ming-Tzer Lin

Mycobacterium tuberculosis and polymorphonuclear pleural effusion: incidence and clinical pointers.

BACKGROUND Delayed diagnosis and treatment of a polymorphonuclear cell (PMN)-predominant pleural effusion due to Mycobacterium tuberculosis (MTB) are associated with poor outcome and the risk of tuberculosis transmission. We investigated the clinical differences of PMN-predominant pleural effusion due to MTB or other microorganisms. METHODS From January 2000 to April 2007, a total of 354 patients with tuberculous pleurisy were identified. Among them, 39 (11.0%) adults had PMN-predominant pleural effusion (MTB group). Their clinical characteristics were compared with the 117 age-/gender-matched controls (1:3) selected from 715 patients with PMN-predominant pleural effusion due to other microorganisms. RESULTS Among patients with PMN-predominant septic pleural effusion, 5.2% were due to MTB. The in-hospital mortality rate in the MTB group was 36%, similar to that of the control group. Sputum samples were culture-positive for MTB in 41%. Weight loss (p=0.006), initial leukocyte count <or=11,000/microL (p=0.007), and poor clinical response to empirical antibiotics in the first 3 days (p=0.002) were independent factors suggestive of tuberculous pleurisy. A shift toward mononuclear cell predominance of pleural effusions within 1 week was significantly associated with tuberculous pleurisy. In the MTB group, if anti-tuberculous treatment was started more than 14 days after the initial visit, there was a worse prognosis (p=0.034). Among those with delayed treatment, 96.2% had finding(s) suggestive of tuberculous pleurisy. CONCLUSIONS A high index of clinical suspicion can identify MTB in about 5.2% of patients presenting with PMN-predominant septic pleural effusions. Awareness of the clinical pointers can lead to early diagnosis and improved clinical outcome.

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

RATIONALE Acute 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. OBJECTIVES Comparing 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. METHODS Eighty-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. MEASUREMENTS AND MAIN RESULTS Among 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. CONCLUSIONS High plasma DcR3 levels correlate with development of multiple-organ dysfunction and independently predict the 28-day mortality in patients with ARDS.

Afatinib combined with cetuximab for lung adenocarcinoma with leptomeningeal carcinomatosis

We report a patient with non-small cell lung cancer (NSCLC) developed leptomeningeal carcinomatosis (LMC) after 4 years of multiple treatments. High-dose tyrosine kinase inhibitor (TKI) was given for LMC at first but was not effective. She then received dual therapy combining of afatinib and cetuximab. Brain magnetic resonance imaging (MRI) showed a partial response of disease and the patient experienced a clinical benefit. Our case suggests that dual targeting of epidermal growth factor receptor (EGFR) by a combination of afatinib and cetuximab can be a potential novel treatment option in treating LMC when high-dose TKI failed.

Soluble triggering receptor expressed on myeloid cells-1 as an infection marker for patients with neutropenic fever.

Objective:To assess the value of soluble triggering receptor expressed on myeloid cells-1 as a biomarker of infection in patients with neutropenic fever comparing with procalcitonin and C-reactive protein. Design:Prospective, comparative, single-center study. Setting:Hematology ward at a university hospital. Subjects:Seventy-five patients with neutropenic fever after chemotherapy for their hematologic malignancies. Intervention:None. Measurements and Main Results:A total of 137 episodes of neutropenic fever in 75 patients were classified into 75 episodes of documented infections and 62 low likelihood of infection. The level of soluble triggering receptor expressed on myeloid cells-1 was significantly elevated in the group of documented infection. The area under the receiver operating characteristic curve for the diagnosis of infection was 0.719 (95% confidence interval, 0.632–0.806; p < .0001) for soluble triggering receptor expressed on myeloid cells-1, which was larger than the values of 0.501 for procalcitonin (0.465–0.657; p = .218) and 0.491 for C-reactive protein (0.394–0.589, p = .858). The fitted marginal logistic regression model of all episodes contained two statistically significant predictors of infection: soluble triggering receptor expressed on myeloid cells-1 (per 1-pg/mL increase; odds ratio [OR], 1.0002; 95% CI, 1.0001–1.0003; p < .0001) and procalcitonin (per 1-ng/mL increase; OR, 1.0094; 95% CI, 1.0005–1.0184; p = .0002). In a diagnostic panel with soluble triggering receptor expressed on myeloid cells-1 and procalcitonin, the sensitivity and specificity were 88% and 48%, respectively. Conclusions:Soluble triggering receptor expressed on myeloid cells-1 is better than procalcitonin in the prediction of infection at the onset of neutropenic fever. By applying soluble triggering receptor expressed on myeloid cells-1 and procalcitonin together, low or high risk for infection can be defined at the onset of neutropenic fever.

Pleurocutaneous fistula after tube thoracostomy: sonographic findings.

Pleurocutaneous fistula is defined as a pathologic communication between the pleural space and the subcutaneous tissues. It can occur as a complication of an infectious process, neoplasm, foreign body aspiration, or iatrogenic procedures. Diagnosis is usually made on imaging studies, such as CT. We describe a 72‐year‐old woman with esophageal cancer who underwent chest tube placement for postesophagectomy drainage. After removal of the chest tube, a right chest wall mass was noted. Transcutaneous sonographic evaluation confirmed the diagnosis of pleurocutaneous fistula.

Serum Soluble Triggering Receptor Expressed on Myeloid Cells-1 in Acute Respiratory Distress Syndrome: A Prospective Observational Cohort Study

Background/Purpose Serum soluble triggering receptor expressed on myeloid cells-1 (sTREM-1), a detector of acute inflammatory response to microbial products and a good marker for diagnosing sepsis and pneumonia, has not yet been described as a predictor for infection or a prognostic factor in patients with acute respiratory distress syndrome (ARDS). Methods This prospective observational cohort study enrolled 63 ventilated adult patients with ARDS; 50 as septic and 13 as non-septic, and followed them for 28 days in intensive care units at a university hospital in Taiwan. Serial serum sTREM-1 levels and cytokines, such as interleukin (IL)-1, IL-8, and tumor necrosis factor-α, on days 1, 3, 5, 7 and 14 were measured by an enzyme-linked immunosorbent assay. The association between biomarkers and clinical infectious diagnosis/outcome in ARDS was explored. Results Serum sTREM-1 and cytokine levels could not differentiate septic from non-septic ARDS. Serum log sTREM-1 and inflammatory cytokine levels were correlated positively (r = 0.325 for IL-1β; r = 0.247 for IL-8; r = 0.480 for tumor necrosis factor-α). As prognostic factors, higher serum sTREM-1 level on day 1 and increasing levels over time, especially in the first 5 days, were independent predictors of mortality on day 28, using a multivariate Cox regression model. Serum sTREM-1 levels remained stable or even increased in the non-surviving patients, but decreased in the survivors. Conclusion Serum sTREM-1 level might not be a reliable marker for infection in ARDS patients. However, as an inflammatory marker, initial serum sTREM-1 level and its trend over time, especially in the first 5 days, could be predictive of short-term mortality. A progressive decline in serum sTREM-1 levels during follow-up indicates a favorable outcome, whereas persistently elevated sTREM-1 indicates a poor prognosis and should lead to a re-evaluation of therapy.

Combining MAD and CPAP as an effective strategy for treating patients with severe sleep apnea intolerant to high-pressure PAP and unresponsive to MAD

Introduction This study aimed to determine the effect of combining positive airway pressure (PAP) therapy and mandibular advancement device (MAD) in patients with severe obstructive sleep apnea (OSA) who were pressure intolerant for PAP and were unresponsive to MAD. Methods This retrospective study reviewed the medical records of severe OSA patients with apnea-hypopnea index (AHI) ≥ 30/hr who were diagnosed between October 1, 2008 and June 30, 2014. Patients were initially treated with 2 weeks of PAP, and those who were intolerant to high-pressure PAP (≥15 cm H2O) were switched to 12 weeks of MAD, which is a monobloc designed at 75% of maximum protrusion. Patients who had high residual AHI (≥15/hr) on MAD underwent 12 weeks of combination therapy (CT) with MAD and CPAP and were enrolled in the present study. Enrolled subjects who completed the 12-week CT were followed-up until June 30, 2016. Results A total of 14 male patients were included. All three treatments effectively reduced AHI, oxygen desaturation index (ODI), and total sleep time with SpO2 <90% (% TST-SpO2<90%) compared to pretreatment values. The residual AHI and ODI on CT was lower than that on MAD or PAP. The residual % TST-SpO2<90% was lower than that on MAD and similar to that on PAP. The therapeutic pressure on CT was on average 9.2 cm H2O lower than that on PAP. For the 11 patients who completed CT, only CT reduced ESS compared to pretreatment value. No treatment had significant impact on % slow wave sleep or overnight change of blood pressure. For patients who completed CT, the average usage was 5.9±1.7 hr/night at 12th week and 6.4±1.5 hr/night at a median follow-up of 36.5-months. Conclusions Combining MAD and CPAP showed additive effects on reducing AHI and ODI, and lowered the therapeutic pressures.

Successful treatment of intractable hemothorax with recombinant factor VIIa in a nonhemophilic patient.

Recombinant factor VIIa (rFVIIa) was developed for the treatment of bleeding in hemophilic patients with inhibitors. It has also been used to stop bleeding in nonhemophilic patients who fail to respond to conventional treatment. We report a case of catastrophic hemothorax in which bleeding was stopped by administration of rFVIIa. A 68-year-old woman with chronic hepatitis C-related liver cirrhosis was admitted due to pneumonia and parapneumonic effusion. The patient developed hemothorax and hypovolemic shock after thoracentesis. Conventional therapies including tube thoracostomy and transarterial embolization failed to stop the life-threatening bleeding. The bleeding stopped after administration of rFVIIa 100 microg/kg/BW at 2-hour intervals for a total of two doses on the 3rd day of hospitalization. Despite intensive care, however, the patient died due to nosocomial infection and multiple organ failure on the 12th day of hospitalization. Hemothorax in a nonhemophilic patient can be successfully treated with rFVIIa.

Timely diagnosis and treatment of sleep apnea reduce cardiovascular sequelae in patients with myocardial infarction

Background The present study aimed to test if the temporal sequence between sleep apnea (SA) diagnosis and incident myocardial infarction (MI) was associated with the long-term mortality and cardiovascular event in a community-based cohort. Methods We retrieved data from 9,453 incident MI patients between Jan. 1st 2000 and Dec. 31st 2012 from the Taiwan National Health Insurance Research Database. The study subjects included 207 MI patients with SA (SA-MI), further stratified into 110 with pre-existing SA before MI (SA-bMI) and 96 diagnosed with SA after MI (SA-pMI). The median follow-up period was 4.2 years. Propensity-score-matched controls were selected from 9,246 non-SA MI patients (non-SA-MI). The association of SA and outcomes including all-cause mortality and major adverse cardiac and cerebrovascular events (MACCEs) were analyzed by a Cox proportional hazards model. Results The result showed that SA was not associated with mortality regardless of the timing of SA diagnosis. SA-pMI was associated with increased risk of MACCEs (Hazard ratio [HR]: 1.412, 95% confidence interval [CI]: 1.037~1.923, p = 0.029) including re-MI or revascularization and ischemic heart disease hospitalization. Such an association was most significant for SA diagnosed within one year after MI (HR: 2.029, 95% CI: 1.265~3.254, p = 0.003), which was not seen in patients treated with continuous positive airway pressure (CPAP). Conclusion The temporal sequence and the time interval between SA diagnosis and incident MI was associated with the cardiovascular events after MI, especially within one year after MI. Early assessment for the presence of SA after incident MI and early CPAP intervention may reduce the risk of further adverse cardiovascular events.

Intrabronchiolar Involvement in Early Stage Pulmonary Sarcoidosis Presenting as Air Trapping: A Case Report

Pulmonary sarcoidosis can be expressed only as a mosaic pattern of air trapping on an expiratory high-resolution computed tomography (HRCT) scan in the early stage, without the typical findings of pulmonary involvement. This radiologic finding indicates small airway disease, but the site of airflow obstruction and the type of involvement have only been speculated about thus far. We describe herein a female with proven sarcoidosis stage I whose HRCT scan showed air trapping during expiration and lung biopsy via video-assisted thoracoscopy (VAT) revealed air trapping-related emphysema and non-necrotizing granulomas with peribronchiolar compression and intrabronchiolar involvement. These findings could explain the impaired diffusion capacity and limited mid-expiratory flow rate in the pulmonary function test, and were compatible with a radiologic mosaic pattern. Her airway obstruction and oxygenation improved after oral corticosteroid treatment.