Yi-Chun Lai

Readmission to the intensive care unit: A population-based approach

BACKGROUND/PURPOSE Readmission to the intensive care unit (ICU) results in increased consumption of medical resources and costs, and has been proposed as a marker for quality of care. ICU readmission rates have been estimated at 4-14% and different risk factors have been proposed by various studies. METHODS Every admission event to the ICU was recorded and readmission episodes were analyzed using a population-based database from the Taiwan National Health Insurance Research Database (NHIRD) for the period from January 1, 2006 to December 31, 2006. RESULTS The average follow-up time was 206.35 days. From the database of 192,201 patients admitted to the ICU, 25,263 patients were re-admitted, with a readmission rate of 13.13%. The leading etiologies for readmission were identified. Using multivariate analysis, age > 39 years old, female gender, ischemic heart disease, lung related disorders, pneumonia, cerebrovascular disease, sepsis, heart failure, chronic liver disease, diabetes mellitus, and chronic obstructive pulmonary disease were identified as significant risk factors for readmission to the ICU. CONCLUSION This study uses a novel approach to assess risk factors for readmission to the ICU. Higher risk patients should be assessed more carefully before discharge or transfer from the ICU to prevent readmission episodes.

Acute renal failure in severe pancreatitis: A population-based study

Abstract Introduction. Acute pancreatitis (AP) is a common illness with varied mortality and morbidity. Patients with AP complicated with acute renal failure (ARF) have higher mortality than patients with AP alone. Although ARF has been proposed as a leading mortality cause for AP patients admitted to the ICU, few studies have directly analyzed the relationship between AP and ARF. Methods. We performed a retrospective study using the population-based database from the Taiwan National Health Insurance Research Database (NHIRD). In the period from 1 January 2005 to 31 December 2005, every patient with AP admitted to the ICU was included and assessed for the presence of ARF and mortality risk. Results. In year 2005, there were a total of 221,101 admissions to the ICU. There were 1,734 patients with AP, of which 261 (15.05%) patients also had a diagnosis of ARF. Compared to sepsis and other critical illness, patients with AP had a higher risk of having a diagnosis of ARF, and patients with both diagnoses had a higher mortality rate in the same ICU hospitalization. Conclusion. AP is associated with a higher risk of ARF, and, when both conditions exist, a higher risk of mortality is present.

Gefitinib-Related Interstitial Lung Disease in Taiwanese Patients With Non–Small-Cell Lung Cancer

BACKGROUND Gefitinib (Iressa; AstreZeneca, Wilmington, DE) is effective in the treatment of NSCLC, especially in the Asian population. However, ILD is usually a serious pulmonary adverse effect and almost leads to cessation of gefitinib treatment. In this study, we investigated the incidence, clinical features, and prognosis of gefitinib-related ILD in Taiwanese patients with NSCLC. PATIENTS AND METHODS This was a retrospective observational study conducted in 2 medical centers and a local teaching hospital. RESULTS A total of 1080 patients with NSCLC, who received at least 1 dose (250 mg per day) of gefitinib treatment, were enrolled. Of these, 42 patients were diagnosed with ILD. Twenty-five of the 42 patients were diagnosed with gefitinib-related ILD (incidence, 2.3%). The main manifestations of ILD included dyspnea, cough, and hypoxemia. Six of the 25 patients (24%) with gefitinib-related ILD required invasive mechanical ventilation and all patients were treated with steroids. Twenty-two patients (88%) discontinued gefitinib treatment without further rechallenge. Ten (40%) patients died directly from ILD and in-hospital mortality was 52%. Eleven patients received subsequent cytotoxic chemotherapy with a mean of 33.5 days after ILD events. Kaplan-Meier analysis demonstrated that gefitinib nonresponder and gefitinib use rather than first-line treatment were associated with poor prognosis when ILD developed during gefitinib treatment. CONCLUSION Taiwanese patients with NSCLC had a relatively high incidence of ILD during gefitinib treatment. Gefitinib-related ILD is usually life-threatening, especially in gefitinib nonresponders and gefitinib use rather than first-line treatment.

Successful Treatment of Severe Heatstroke With Therapeutic Hypothermia by a Noninvasive External Cooling System

Heatstroke is a life-threatening disease; however, no pharmacologic treatment has proven to be effective. In severe cases with multiple organ dysfunction, the mortality remains high and many patients inevitably develop permanent neurologic damage. We report a near-fatal case of exertional heatstroke with multiple organ dysfunction, including generalized convulsions, acute lung injury, and disseminated intravascular coagulation, successfully treated with induced therapeutic hypothermia (33°C [91.4°F]) by a noninvasive external cooling system. After treatment, the patient completely recovered, without any neurologic sequelae during 1 year of follow-up. To our knowledge, this is the first reported case of using therapeutic hypothermia in heatstroke.

Hemoglobin Levels and Weaning Outcome of Mechanical Ventilation in Difficult-To-Wean Patients: A Retrospective Cohort Study

Introduction The effect of hemoglobin levels on the weaning outcomes of mechanically ventilated patients remains under debate, particularly for the patients with difficult weaning. This study aims to evaluate the effect of hemoglobin levels on weaning outcomes in difficult-to-wean patients. Methods This retrospective cohort study was conducted in a university-affiliated teaching hospital in Taiwan. Patients who fulfilled the criteria of difficult weaning were enrolled. Medical records were reviewed to obtain data on hemograms, biochemistry tests, transfusion records, comorbidities and weaning outcome. The association between hemoglobin levels and 30-day weaning outcomes was evaluated using a logistic regression model. Results A total of 751 patients received mechanical ventilation during the study period, 138 of whom fulfilled the criteria of difficult weaning. Compared with the patients whose hemoglobin was <8 g/dL, those with higher hemoglobin levels were more likely to be successfully weaned (odds ratio [OR], 3.69; 95% CI, 1.22–11.15 for hemoglobin 8–10 g/dL and OR, 4.16, 95% CI, 1.30–13.29 for hemoglobin >10 g/dL). Multivariate analysis showed that the odds ratio for weaning success remained significant for hemoglobin levels of 8–10 g/dL (adjusted OR, 3.3; 95% CI, 1.07–10.15) with borderline significance for hemoglobin level > 10 g/dL (adjusted OR, 2.95, 95% CI, 0.88–9.96). Conclusions Hemoglobin level is independently associated with weaning outcome in difficult-to-wean patients. Further studies are needed to evaluate whether a restrictive transfusion trigger for acute critical illness is also appropriate for such patients.

Bacterial pneumonia following acute ischemic stroke

Background: The most common serious complication following acute ischemic stroke is pneumonia, which may increase mortality and worsen clinical outcomes. The purpose of this study was to investigate the predictors of 30‐day mortality in patients with pneumonia following acute ischemic stroke. Methods: From June 2006 to May 2011, we retrospectively included 51 patients with pneumonia following acute ischemic stroke. We analyzed the clinical features, microbiologic data, and outcomes. Predictors of 30‐day mortality were investigated by univariate and multivariate analysis. Results: The acute ischemic strokes were caused by large‐artery atherosclerosis in 37 (72.5%) of the 51 patients. We found that the most common pathogen responsible for poststroke pneumonia was Klebsiella pneumoniae, followed by Pseudomonas aeruginosa and Escherichia coli. Ultimately, 12 patients died of progressive sepsis due to pneumonia after the acute ischemic stroke. The 30‐day mortality rate was 23.5%. In the univariate analysis, patients who died within 30 days had higher National Institutes of Health Stroke Scale scores, higher CURB‐65 scores, elevated instability of hemodynamic status, and lower Glasgow Coma Scale (GCS) scores. In Cox regression analysis, a GCS score of <9 on the day of pneumonia onset was only significant indicator for 30‐day mortality (hazard ratio, 6.72; 95% confidence interval, 2.12–21.30, p = 0.001). Conclusion: Pneumonia after acute ischemic stroke is a severe complication. Once stroke‐related pneumonia develops, neurologic assessment, CURB‐65 score, and shock can be used to predict the ultimate prognosis.

Barotrauma related extensive pneumothorax, pneumomediastinum, and subcutaneous emphysema in a patient with acute respiratory distress syndrome with low tidal volume

An 84-year-old woman with a past history of type 2 diabetes was admitted to our hospital due to fever and worsening dyspnoea. Chest computed tomography (CT) revealed right middle lobe pneumonia with left pleural effusion (figure 1A). She was intubated because of suspected acute respiratory distress syndrome (ARDS) and treated with 100% oxygen, low tidal volume of 6 ml/kg, and high positive end expiratory pressure (PEEP) of 22 cm H2O with peak inspiratory pressure (PIP) of 30 cm H2O. Unfortunately, 2 weeks after admission, diffuse subcutaneous emphysema was noted. Chest CT (figure 1B) revealed extensive pneumomediastinum and extensive subcutaneous emphysema. PEEP was discontinued and conservative treatment with oxygen therapy and sedation was implemented. …

CBX3/heterochromatin protein 1 gamma is significantly upregulated in patients with non–small cell lung cancer

Lung cancer is typically categorized into small cell lung cancer (SCLC) and non–small cell lung cancer (NSCLC). NSCLC comprises of the majority of lung cancer with a poor prognosis in advanced cases. Transcriptional profiling studies, including microarrays and RNA‐sequencing studies, have significantly enriched our knowledge of gene expression patterns in NSCLC. A recent transcriptional profiling study identified high prevalence of CBX3/HP1‐gamma upregulation in human NSCLC samples. CBX3/HP1‐gamma is an isoform of the heterochromatin protein 1 family, which plays a role in heterochromatin formation and is linked to cancer.

Video-assisted thoracoscopic surgical decortication in the elderly with thoracic empyema: Five years' experience

Background Video‐assisted thoracoscopic surgery (VATS) with decortication is a major treatment for thoracic empyema in the fibropurulent stage. Compared to open thoracotomy, VATS decortication has similar efficacy but fewer postoperative complications in the treatment of thoracic empyema. The role of VATS decortication in the elderly had rarely been investigated. Methods From January 2006 to August 2011, we retrospectively enrolled 33 patients older than 65 years diagnosed as thoracic empyema and treated with VATS decortication. We analyzed the outcomes of this geriatric population, including surgical effectiveness, postoperative morbidity, and mortality. Results A total of 33 patients with mean age of 73.6 ± 7.1 years received VATS decortication for their empyema. Twenty‐one (63.6%) patients were male. Only one patient died of progressive sepsis, due to pulmonary infection 9 days after VATS decortication. The 30‐day mortality was 3% after the surgery. The major etiology (87.9%) of thoracic empyema was pneumonia. The main causes of postoperation morbidity included respiratory failure requiring mechanical ventilation for >7 days (15.2%) and septic shock (15.2%), followed by persistent air leakage for >7 days (9.1%). Twenty‐four (75%) of 32 patients had good re‐expansion of the affected lung 3 months after VATS decortication. Conclusion We concluded that VATS decortication in the treatment of thoracic empyema is effective in elderly patients. The major concerns of postoperative complications are respiratory failure and sepsis.

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.