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Physical exercise improves the physical condition of women who have been undergone surgery for breast cancer. This study evaluated the effect of a new martial arts program that combined aerobic endurance and muscle strength exercises on improving upper limb function and aerobic performance of women who have undergone breast cancer surgery. Fifty-three women who had previously undergone breast cancer surgery with axillary lymph node dissection, radiotherapy and/or chemotherapy participated in the twelve-week program. Participants were randomly assigned to two groups; a study group (28 participants) in which participants carried out a synchronized pedaling with martial arts routine of 2 sessions per week, and a control group (22 participants) who received usual care. Study group participants demonstrated a significant increase in right hand and quadriceps strength, maximum oxygen consumption, max power-to-weight ratio, muscle mass percentage and a decrease in fat mass percentage (p≤0.05). A controlled training system like synchronized pedaling with martial arts, which combines aerobic and strength exercises, appears suitable for improving the muscle strength and aerobic capacity of these breast cancer participants.

Limited data are available regarding the etiologic impact of health care-associated pneumonia (HCAP) in lung transplant recipients. Therefore, our aim was to evaluate the microbiologic differences between HCAP and hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) in lung transplant recipients with a radiographically confirmed diagnosis of pneumonia.We performed a retrospective cohort study of lung transplant recipients with pneumonia at one transplant center over a 7-year period. Eligible patients included lung transplant recipients who developed a first episode of radiographically confirmed pneumonia ≥ 48 h following transplantation. HCAP, HAP, and VAP were classified according to the American Thoracic Society/Infectious Diseases Society of America 2005 guidelines. χ² and Student t tests were used to compare categorical and continuous variables, respectively.Sixty-eight lung transplant recipients developed at least one episode of pneumonia. HCAP (n = 42; 62%) was most common, followed by HAP/VAP (n = 26; 38%) stratified in HAP (n = 20; 77%) and VAP (n = 6; 23%). Pseudomonas aeruginosa was the predominantly isolated organism (n = 22; 32%), whereas invasive aspergillosis was uncommon (10%). Multiple-drug resistant (MDR) pathogens were less frequently isolated in patients with HCAP compared with HAP/VAP (5% vs 27%; P = .009). Opportunistic pathogens were less frequently identified in lung transplant recipients with HCAP than in those with HAP/VAP (7% vs 27%; P = .02). Lung transplant recipients with HCAP had a similar mortality at 90 days (n = 9 [21%] vs n = 4 [15%]; P = .3) compared with patients with HAP/VAP.HCAP was the most frequent infection in lung transplant recipients. MDR pathogens and opportunistic pathogens were more frequently isolated in HAP/VAP. There were no differences in 30- and 90-day mortality between lung transplant recipients with HCAP and those with HAP/VAP.

Background and objective Current guidelines recommend empirical treatment against Pseudomonas aeruginosa in community-acquired pneumonia (CAP) patients with specific risk factors. However, evidence to support these recommendations is limited. We evaluate the risk factors and the impact of antimicrobial therapy in patients hospitalized with CAP due to P. aeruginosa. Methods We performed a retrospective population-based study of >150 hospitals. Patients were included if they had a diagnosis of CAP and P. aeruginosa was identified as the causative pathogen. Univariate and multivariate analyses were performed using the presence of risk factors and 30-day mortality as the dependent measures. Results Seven hundred eighty-one patients with P. aeruginosa pneumonia were identified in a cohort of 62 689 patients with pneumonia (1.1%). Of these, 402 patients (0.6%) were included in the study and 379 (0.5%) were excluded due to health care-associated pneumonia or immunosuppression. In patients with CAP due to P. aeruginosa, 272 (67.8%) had no documented risk factors. These patients had higher rates of dementia and cerebrovascular disease. Empirical antibiotic therapy against P. aeruginosa within the first 48 h of presentation was independently associated with lower 30-day mortality in patients with CAP due to P. aeruginosa (hazard ratio (HR) 0.42, 95% confidence interval (CI): 0.23–0.76) and in patients without risk factors for P. aeruginosa CAP (HR 0.40, 95% CI: 0.21–0.76). Conclusions Risk factor recommended by current guidelines only detect one third of the patients admitted with CAP due to P. aeruginosa. Risk factors did not define the whole benefit observed due to empirical therapy covering P. aeruginosa.

Background and objective Severity assessment is made at the time of the initial clinical presentation in patients with community-acquired pneumonia (CAP). It is unclear how the gap between time of presentation and duration of symptoms onset may impact clinical outcomes. Here we evaluate the association of prolonged onset of symptoms (POS) and the impact on clinical outcomes among hospitalized patients with CAP. Methods This was a prospective, multicentre study of CAP in Spain. The primary outcomes were the clinical factors associated with POS defined as days from symptoms onset to pneumonia diagnosis >7 days. The secondary outcomes were intensive care unit (ICU) admission, the presence of suppurative complications, septic shock and 30-day mortality. Results We enrolled 1038 patients diagnosed of CAP: 152 (14.6%) patients had a POS. In multivariate analysis, the presence of prior corticosteroid therapy, alcohol abuse, prior antibiotic therapy, and confusion, urea, respiratory rate, blood pressure and age 65 years or older score 0–1 was independently associated with POS. Patients with POS had a higher incidence of suppurative complications, but not of 30-day mortality when compared with a shorter onset of symptoms. Conclusions Approximately 15% of patients diagnosed with CAP had POS. Risk factors associated with POS were previous corticosteroids and antibiotic therapy, alcoholism and less severe pneumonia. POS was associated with a higher rate of suppurative complications and less need for ICU admission.

Lung transplantation has become an accepted therapeutic procedure for the treatment of end-stage pulmonary parenchymal and vascular disease. Despite improved survival rates over the decades, lung transplant recipients have lower survival rates than other solid organ transplant recipients. The morbidity and mortality following lung transplantation is largely due to infection- and rejection-related complications. This article will review the common infections that develop in the lung transplant recipient, including the general risk factors for infection in this population, and the most frequent bacterial, viral, fungal and other less frequent opportunistic infections. The epidemiology, diagnosis, prophylaxis, treatment and outcomes for the different microbial pathogens will be reviewed. The effects of infection on lung transplant rejection will also be discussed.

Ventilator-associated pneumonia (VAP) is associated with high morbidity, mortality, and costs. Interventions to prevent VAP are a high priority in the care of critically ill patients requiring mechanical ventilation (MV). Multiple interventions are recommended by evidence-based practice guidelines to prevent VAP, but there is a growing interest in those related to the endotracheal tube (ETT) as the main target linked to VAP. Microaspiration and biofilm formation are the two most important mechanisms implicated in the colonization of the tracheal bronchial tree and the development of VAP. Microaspiration occurs when there is distal migration of microorganisms present in the secretions accumulated above the ETT cuff. Biofilm formation has been described as the development of a network of secretions and attached microorganisms that migrate along the ETT cuff polymer and inside the lumen, facilitating the transfer to the sterile bronchial tree. Therefore, our objective was to review the literature related to recent advances in ETT technologies regarding their impact on the control of microaspiration and biofilm formation in patients on MV, and the subsequent impact on VAP.

Background Several studies have described a clinical benefit of macrolides due to their immunomodulatory properties in various respiratory diseases. We aimed to assess the effect of macrolide therapy on mortality in patients hospitalized for Pseudomonas aeruginosa community-acquired pneumonia (CAP). Methods We performed a retrospective population-based study of > 150 hospitals in the US Veterans Health Administration. Patients were included if they had a diagnosis of CAP and P aeruginosa was identified as the causative pathogen. Patients with health-care-associated pneumonia and immunosuppression were excluded. Macrolide therapy was considered when administered within the first 48 h of admission. Univariate and multivariable analyses were performed using 30-day mortality as the dependent measure. Results We included 402 patients with P aeruginosa CAP, of whom 171 (42.5%) received a macrolide during the first 48 h of admission. These patients were older and white. Macrolide use was not associated with lower 30-day mortality (hazard ratio, 1.14; 95% CI, 0.70-1.83; P = .5). In addition, patients treated with macrolides had no differences in ICU admission, use of mechanical ventilation, use of vasopressors, and length of stay (LOS) compared with patients not treated with macrolides. A subgroup analysis among patients with P aeruginosa CAP in the ICU showed no differences in baseline characteristics and outcomes. Conclusions Macrolide therapy in the first 48 h of admission is not associated with decreased 30-day mortality, ICU admission, need for mechanical ventilation, and LOS in hospitalized patients with P aeruginosa CAP. Larger cohort studies should address the benefit of macrolides as immunomodulators in patients with P aeruginosa CAP.

Aspiration of colonized oropharyngeal secretions is a major factor in the pathogenesis of ventilator-associated pneumonia (VAP). A tapered-cuff endotracheal tube (ETT) has been demonstrated to reduce aspiration around the cuff. Whether these properties are efficacious in reducing VAP is not known.This 2-period, investigator-initiated observational study was designed to assess the efficacy of a tapered-cuff ETT to reduce the VAP rate. All intubated, mechanically ventilated patients over the age of 18 were included. During the baseline period a standard, barrel-shaped-cuff ETT (Mallinckrodt Hi-Lo) was used. All ETTs throughout the hospital were then replaced with a tapered-cuff ETT (TaperGuard). The primary outcome variable was the incidence of VAP per 1,000 ventilator days.We included 2,849 subjects, encompassing 15,250 ventilator days. The mean ± SD monthly VAP rate was 3.29 ± 1.79/1,000 ventilator days in the standard-cuff group and 2.77 ± 2.00/1,000 ventilator days in the tapered-cuff group (P = .65). While adherence to the VAP prevention bundle was high throughout the study, bundle adherence was significantly higher during the standard-cuff period (96.5 ± 2.7%) than in the tapered-cuff period (90.3 ± 3.5%, P = .01).In the setting of a VAP rate very near the average of ICUs in the United States, and where there was high adherence to a VAP prevention bundle, the use of a tapered-cuff ETT was not associated with a reduction in the VAP rate.

Severe pneumonia is a complex systemic process that requires a careful clinical assessment, the consideration of comorbidities and potential complications, and an understanding of the pathophysiology of inflammation. Severity assessment in pneumonia is important for risk stratification, prognosis and to determine the need for intensive care unit (ICU) admission. This information is imperative, given that delayed transfer to the ICU is associated with adverse outcomes in patients with community-acquired pneumonia1 (CAP). Several clinical scores have been validated to identify patients with CAP and healthcare-associated pneumonia requiring ICU admission, and among them, the 2007 Infectious Diseases Society of America/American Thoracic Society minor criteria appear to be a suitable predictor of ICU admission and 30-day mortality.2,3 However, none of these clinical scores have been substantially successful in assessing the severity and predicting the need for ICU admission in severe pneumonia. In recent years, the limitations in clinical scores have increased the focus on biomarkers, which alone, or as a complement of clinical scores, have become an important tool in predicting severity of pneumonia.2 Elevated serum levels of biomarkers can be found in the presence of inflammation, infection and comorbid conditions.2 These assays have attractive characteristics, including rapid results, simplicity and reproducibility, and in most cases, they are cost-effective. Furthermore, biomarkers may be useful in predicting short- and long-term prognosis of patients with pneumonia. Among available biomarkers, procalcitonin and C-reactive protein are commonly used in CAP, as indicators of severity of disease and predictors of mortality.4 In addition, procalcitonin assists clinicians in the decision for the need for antibiotic therapy. Midregional pro-adrenomedullin, a cardiac biomarker, increases the accuracy of the clinical assessment scores (pneumonia severity index and CURB-65) and is a better predictor of short- and long-term mortality in CAP.5 Pro-B-type natriuretic peptide (BNP) is a prohormone secreted in response to myocardial stretch, volume overload and elevated end-diastolic pressure from cardiac myocytes. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a 76 amino acid peptide produced by the cleavage of proBNP into an active BNP and an inactive NT-proBNP.6 NT-proBNP appears to have a longer half-life and fewer preanalytic issues than those seen with BNP.6 Both peptides have been used in the assessment and prognosis of congestive heart failure, myocardial infarction, pulmonary embolism and sepsis. In pneumonia, NT-proBNP, BNP and midregional proatrial natriuretic peptide have shown to have good correlation with clinical scores and to be important predictors of short- and long-term mortality in the emergency department and in hospitalized patients with CAP.7 In this issue of Respirology, Lin and colleagues present important information about the potential value of NT-proBNP as a prognostic marker for pneumonia in the ICU setting. The authors report, prospectively, the plasma levels of this biomarker measured upon ICU admission in a cohort of 216 patients with pneumonia (40% healthcare-associated pneumonia, 35% CAP and 25% hospital-acquired pneumonia).8 The mean NT-proBNP levels in 30-day survivors (5658 ± 9240 pg/mL) was significantly lower than the levels in 30-day non-survivors (11 938 ± 13 121 pg/mL, P = 0.001). The area under the curve of the NT-proBNP was comparable to that of APACHE II score and Infectious Diseases Society Of America/American Thoracic Society 2007 minor criteria (0.715, 0.75, 0.65, respectively) in predicting 30-day mortality. After adding NT-proBNP to the APACHE II score, the area under the curve increased from 0.754 to 0.794 (P = 0.048); however, no increase was seen when added to the Infectious Diseases Society Of America/American Thoracic Society 2007 minor criteria. Patients with acute cardiac events were excluded, and the proportion of patients with underlying congestive heart failure or coronary artery disease was not different between survivors and non-survivors. These findings are in line with two recent studies evaluating cardiac biomarkers in pneumonia, but unique for being the first study in patients admitted to the ICU and excluding acute cardiac events. In a study by Nowak and collaborators in patients with CAP presenting to the emergency department, NT-proBNP, BNP and midregional proatrial natriuretic peptide levels were higher among short- and long-term non-survivors, when compared with survivors.7 The area under the curve for the three biomarkers was comparable to that of pneumonia severity index score for prediction of short- and long-term mortality.7 Similarly, in a retrospective study of hospitalized patients with CAP, non-survivors had higher NT-proBNP levels as compared with survivors.9 NT-proBNP was an independent predictor of mortality with the area under the curve comparable to pneumonia severity index and CURB-65, but inferior to that of APACHE II score which did not significantly increase when the biomarker was added to the score.9 This latter finding differs from those reported by Lin and collaborators.8 Therefore, NT-proBNP, midregional proatrial natriuretic peptide and midregional pro-adrenomedullin are cardiac biomarkers that can significantly predict mortality, highlighting the high frequency and importance of cardiovascular complications in CAP.10 Because there is an important association of pneumonia and secondary heart disease, cardiac biomarkers may provide more discriminating information about prognosis in CAP than inflammatory biomarkers. In addition, the fact that the use of cardiovascular biomarkers as presented by Lin et al. in the current study raise a concern that severity of disease and subsequent mortality in patients with pneumonia maybe associated with cardiovascular events that occur during hospitalization or after discharge, and not necessarily present on admission. Severe pneumonia, like other severe infections, has systemic repercussions. This paradigm has been tested by a large number of clinical prediction methods with some limitations. Clinical scores take into account measurement of variables at one specific time although many of these variables are dynamic. Biomarkers do not allow individual prediction of aetiology, but may provide additional information regarding clinical evolution, as biomarkers are dynamic and can be measured daily. In fact, biomarkers may improve the prognostic information provided by clinical scoring systems and aid the clinician in the decision-making process when considering ICU admission. Until new data are available, both clinical scores and biomarkers should be incorporated in the physician’s clinical decision-making process, when considering prognosis and ICU admission in patients with severe pneumonia. Future research studies should couple diagnostic and subsequent intervention strategies in order to improve outcomes in critically ill patients with pneumonia.

Ventilator-associated pneumonia (VAP) is classified as early-onset or late-onset, in part, to identify subjects at risk for infection with resistant pathogens. We assessed differences in the bacterial etiology of early-onset versus late-onset VAP.Subjects enrolled in 2004-2006 in 2 clinical studies of doripenem versus imipenem or piperacillin/tazobactam, with a diagnosis of VAP (n = 500) were included in the analysis. Subjects were classified by ventilator status: early-onset VAP (5 d of ventilation) or late-onset VAP (≥ 5 d of ventilation). Baseline demographics and bacterial etiology were analyzed by VAP status.Late-onset VAP subjects had higher Acute Physiology and Chronic Health Evaluation (APACHE II) scores (mean 16.6 versus 15.5, P = .008). There were no significant differences in Clinical Pulmonary Infection Score, sex, age, or presence of bacteremia between the groups. A total of 496 subjects had a baseline pathogen, and 50% of subjects in each group had ≥ 2 pathogens. With the exception of Staphylococcus aureus, which was common in early-onset VAP, the pathogens (including potentially multidrug-resistant (MDR) pathogens) isolated from early-onset versus late-onset VAP were not significantly different between groups. Acinetobacter baumannii or Pseudomonas aeruginosa with decreased susceptibility to any study drug was observed in early-onset and late-onset VAP subjects.There were no significant differences in the prevalence of potential MDR pathogens associated with early-onset or late-onset VAP, even in subjects with prior antibiotics. Empiric therapy for early-onset VAP should also include agents likely to be effective for potential MDR pathogens. Further prospective studies should evaluate microbiology trends in subjects with VAP.

Pulmonary mucormycosis is an uncommon but life-threatening opportunistic fungal infection.[1][1],[2][2] It typically affects immunocompromised patients, such as recipients of stem cell or organ transplant, and has worse outcomes in those with hematologic malignancy or neutropenia.[1][1],[3][3] In

To improve 2007 Infectious Disease Society of America/American Thoracic Society (IDSA/ATS) severity criteria to predict intensive care unit (ICU) admission in patients hospitalized with pneumonia.A composite score that included the 2007 IDSA/ATS criteria for severe pneumonia and additional significant variables identified by recent publications was tested in patients hospitalized with community-acquired pneumonia.Among 787 patients hospitalized with community-acquired pneumonia, 156 (19.8%) required admission to the ICU. We identified one major criterion (arterial pH7.30), and 4 minor criteria (tachycardia125 bpm, arterial pH 7.30-7.34, sodium130 mEq/L and glucose250 mg/dL) to be associated with ICU admission. Adding arterial pH7.30 to the 2 2007 IDSA/ATS major criteria increased sensitivity from 61.5% to 71.8% and area under the curve (AUC) from 0.80 to 0.86. Adding in sequence the four minor criteria to the 2007 IDSA/ATS minor criteria, increased sensitivity from 41.7% to 53.8%, and AUC from 0.65 to 0.69. In the new composite score, combining 1 of 3 major criteria with 3 of 12 minor criteria showed a sensitivity of 92.9% and an AUC of 0.88.The addition of arterial pH7.30 to the 2007 IDSA/ATS major criteria improves sensitivity and AUC to identify patients who will require ICU care.

Community-acquired pneumonia (CAP) remains a common and serious worldwide health problem. Despite all the advances in therapy, significant interest has focused on the identification of patients with CAP who require intensive care unit admission to improve their outcomes. The severity assessment of CAP provides an important guide to clinicians in deciding the site of care and the use of empiric antibiotics and adjuvant therapy. For years, several clinical assessment scores have been suggested and validated to achieve this goal. The recent introduction of biomarkers as prognostic indicators of severe CAP, whether used alone or in conjunction with other clinical severity of illness scores, has been investigated. An objective scoring system with a high level of sensitivity and specificity to predict the severity of CAP and the need for high levels of care do not exist. Today, the addition of clinical scores and biomarkers to clinical judgment is the best approach to optimize the care of severe CAP. Future research will allow validation of these and newer tools to improve the prognosis of patients with CAP.

Air-fluid levels within emphysematous lung bullae are a relatively uncommon occurrence in patients with preexisting bullous disease, and are not commonly reported. We report 2 cases of new onset air-fluid levels in patients with underlying bullous disease with substantially different clinical presentations but with clinical improvement after medical therapy only.

A high variability in the practice of medicine has contributed, in part, to higher healthcare costs and poor adherence to evidence-based interventions. For this reason, protocol-based strategies have been developed to reduce the lack of concordance in an attempt to improve clinical outcomes. In the