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Introduction: Patients with end-stage renal disease (ESRD(Pos)) usually have multiple comorbidities and are predisposed to acute organ failure and in-hospital mortality. We assessed the effect of ESRD on the poorly understood long-term mortality risk after a first-ever mechanical ventilation (1-MV) for acute respiratory failure.Methods: The data source was Taiwan's National Health Insurance (NHI) Research Database. All patients given a 1-MV between 1999 and 2008 from one million randomly selected NHI beneficiaries were identified (n = 38,659). Patients with or without ESRD (ESRD(Neg)) after a 1-MV between 1999 and 2008 were retrospectively compared and followed from the index admission date to death or the end of 2011. ESRD(Pos) patients (n = 1185; mean age: 65.9 years; men: 51.5 %) were individually matched to ESRD(Neg) patients (ratio: 1:8) using a propensity score method. The primary outcome was death after a 1-MV. The effect of ESRD on the risk of death after MV was assessed. A Cox proportional hazard regression model was used to assess how ESRD affected the mortality risk after a 1-MV.Results: The baseline characteristics of the two cohorts were balanced, but the incidence of mortality was higher in ESRD(Pos) patients than in ESRD(Neg) patients (342.30 versus 179.67 per 1000 person-years; P <0.001; covariate-adjusted hazard ratio: 1.43; 95 % confidence interval: 1.31-1.51). For patients who survived until discharge, ESRD was not associated with long-term (>4 years) mortality.Conclusions: ESRD increased the mortality risk after a 1-MV, but long-term survival seemed similar. [ABSTRACT FROM AUTHOR]

Nutritional status could affect clinical outcomes in critical patients. We aimed to determine the prognostic accuracy of the modified Nutrition Risk in Critically Ill (mNUTRIC) score for hospital mortality and treatment outcomes in patients with severe community-acquired pneumonia (SCAP) compared to other clinical prediction rules. We enrolled SCAP patients in a multi-center setting retrospectively. The mNUTRIC score and clinical prediction rules for pneumonia, as well as clinical factors, were calculated and recorded. Clinical outcomes, including mortality status and treatment outcome, were assessed after the patient was discharged. We used the receiver operating characteristic (ROC) curve method and multivariate logistic regression analysis to determine the prognostic accuracy of the mNUTRIC score for predicting clinical outcomes compared to clinical prediction rules, while 815 SCAP patients were enrolled. ROC curve analysis showed that the mNUTRIC score was the most effective at predicting each clinical outcome and had the highest area under the ROC curve value. The cut-off value for predicting clinical outcomes was 5.5. By multivariate logistic regression analysis, the mNUTRIC score was also an independent predictor of both clinical outcomes in SCAP patients. We concluded that the mNUTRIC score is a better prognostic factor for predicting clinical outcomes in SCAP patients compared to other clinical prediction rules. [ABSTRACT FROM AUTHOR]

Background/Aims The results of dengue-infected adult patients requiring admission to the intensive care unit (ICU) remain unclear. We evaluated clinical outcomes and prognostic factors in patients with severe dengue fever. The predictors of liver complications and the associations with failure of other organs were reviewed; for example, age, gender, clinical manifestations, disease severity scores, underlying conditions, laboratory examinations, and outcomes. The primary endpoint was to find the predictors of ICU mortality. Methods In this retrospective study, all patients with laboratory-confirmed severe dengue infections were admitted to the ICU during the large outbreak period. Data is collected periodically and analyzed retrospectively. Results Overall, the minimum platelet count was 35,000 (SD, 43,000)/mm3 and was restored to 151,000 (SD, 107,000)/mm3 before the patient was discharged from the ICU. The highest levels of aspartate aminotransferase (AST/GOT) and alanine aminotransferase (ALT/GPT) were 1,126.4 IU/L (SD, 2,488.5 IU/L) and 395.7 IU/L (SD, 739.8 IU/L), respectively, with survivors. Compared to the activated part of the death group, thromboplastin time, lactic acid, AST/GOT and ALT/GPT levels were significantly elevated. However, the death of patients with albumin, hemoglobin and hematocrit was significantly reduced, and the trough and recovery platelet counts before they were discharged from the ICU were lower than survivors. Conclusions In conclusion, the mortality of severe dengue patients admitted to the ICU remains high, and the mortality was associated with lower GCS scores, lower platelet count before being discharged from the ICU discharge, and more organ failures. In addition, a significant portion of patients with severe dengue who die in the ICU have bacterial infections. These new treatment modalities should be considered for use on a case by-case basis, and more data is needed to support their usage. [ABSTRACT FROM AUTHOR]

Successful weaning from prolonged mechanical ventilation (MV) is an important issue in respiratory care centers (RCCs). Delayed or premature extubation increases both the risk of adverse outcomes and healthcare costs. However, the accurate evaluation of the timing of successful weaning from MV is very challenging in RCCs. This study aims to utilize artificial intelligence algorithms to build predictive models for the successful timing of the weaning of patients from MV in RCCs and to implement a dashboard with the best model in RCC settings. A total of 670 intubated patients in the RCC in Chi Mei Medical Center were included in the study. Twenty-six feature variables were selected to build the predictive models with artificial intelligence (AI)/machine-learning (ML) algorithms. An interactive dashboard with the best model was developed and deployed. A preliminary impact analysis was then conducted. Our results showed that all seven predictive models had a high area under the receiver operating characteristic curve (AUC), which ranged from 0.792 to 0.868. The preliminary impact analysis revealed that the mean number of ventilator days required for the successful weaning of the patients was reduced by 0.5 after AI intervention. The development of an AI prediction dashboard is a promising method to assist in the prediction of the optimal timing of weaning from MV in RCC settings. However, a systematic prospective study of AI intervention is still needed. [ABSTRACT FROM AUTHOR]

Background: Chronic respiratory failure is a common cause of ventilator dependence in the intensive care unit (ICU). The causes of chronic respiratory failure include primary disease or complications, such as ICU-acquired weakness. Traditional practice requires patients to remain immobile and bedridden; however, recent evidence suggests that early adequate exercise promotes recovery without increasing risks. In this study, we explored the efficacy of planned progressive abdominal sandbag training in promoting the successful withdrawal of patients with chronic respiratory failure from mechanical ventilation., Methods: This study was conducted between April 2019 and November 2020. Patients were recruited and divided into two groups: abdominal sandbag training group and control group (no training). The training group participated in a 3-month daily pulmonary rehabilitation program, which involved a 30-min session of progressive sandbag loading on the upper abdomen as a form of diaphragmatic resistant exercise. The pressure support level of the ventilator was adjusted to maintain a tidal volume of 8 mL/kg. To investigate the effect of abdominal sandbag training on patients with chronic respiratory failure, we compared tidal volume, shallow breathing index, maximum respiratory pressure, and diaphragm characteristics between the training and control groups., Results: This study included 31 patients; of them, 17 (54.8 %) received abdominal sandbag training and 14 (45.2 %) did not. No significant between-group difference was found in baseline characteristics. Compared with the control group, the training group exhibited considerable improvements in ventilation-related parameters (p < 0.001): the tidal volume markedly increased (p = 0.012), rapid shallow breathing index declined (p = 0.016), and maximum respiratory pressure increased (p < 0.001) in the training group. The diaphragm motion value (p = 0.048) and diaphragm thickness (p = 0.041) were greater in the training group than in the control group. Nine patients (52.9 %) in the training group were removed from the ventilator compared with 1 (7.1 %) in the control group (p = 0.008)., Conclusion: Abdominal sandbag training may be beneficial for patients dependent on a ventilator. The training improves the function of the diaphragm muscle, thereby increasing tidal volume and reducing the respiratory rate and rapid shallow breathing index, thus facilitating withdrawal from ventilation. This training approach may also improve the thickness and motion of the diaphragm and the rate of ventilator detachment., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Patients admitted to intensive care units (ICU) and receiving mechanical ventilation (MV) may experience ventilator-associated adverse events and have prolonged ICU length of stay (LOS). We conducted a survey on adult patients in the medical ICU requiring MV. Utilizing big data and artificial intelligence (AI)/machine learning, we developed a predictive model to determine the optimal timing for weaning success, defined as no reintubation within 48 hours. An interdisciplinary team integrated AI into our MV weaning protocol. The study was divided into 2 parts. The first part compared outcomes before AI (May 1 to Nov 30, 2019) and after AI (May 1 to Nov 30, 2020) implementation in the medical ICU. The second part took place during the COVID-19 pandemic, where patients were divided into control (without AI assistance) and intervention (with AI assistance) groups from Aug 1, 2022, to Apr 30, 2023, and we compared their short-term outcomes. In the first part of the study, the intervention group (with AI, n = 1107) showed a shorter mean MV time (144.3 hours vs 158.7 hours, P = .077), ICU LOS (8.3 days vs 8.8 days, P = .194), and hospital LOS (22.2 days vs 25.7 days, P = .001) compared to the pre-intervention group (without AI, n = 1298). In the second part of the study, the intervention group (with AI, n = 88) exhibited a shorter mean MV time (244.2 hours vs 426.0 hours, P = .011), ICU LOS (11.0 days vs 18.7 days, P = .001), and hospital LOS (23.5 days vs 40.4 days, P < .001) compared to the control group (without AI, n = 43). The integration of AI into the weaning protocol led to improvements in the quality and outcomes of MV patients., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Previous studies have revealed higher mortality rates in patients of severe influenza coinfected with invasive pulmonary aspergillosis (IPA) than in those without the coinfection; nonetheless, the clinical outcome of IPA in critically ill patients without influenza remains unclear., Patients and Methods: This retrospective study was conducted in three institutes. From 2016-2018, all adult patients diagnosed with IPA in the intensive care units (ICUs) were identified. The logistic regression was used to identify the potential risk factors associated with in-hospital mortality in patients with non-influenza IPA. The stratified analysis of IPA patients with and without antifungal therapy was also performed. The final model was established using a forward approach, selecting variables with p-values less than 0.05., Results: Ninety patients were included during the study period, and 63 (70%) were men. The most common comorbidity was diabetes mellitus (n = 24, 27%), followed by solid cancers (n = 22, 24%). Antifungal therapy was administered to 50 (56%) patients, mostly voriconazole (n = 44). The in-hospital mortality rate was 49% (n = 44). Univariate analysis revealed that the risk factors for mortality included daily steroid dose, APACHE II score, SOFA score, C-reactive protein (CRP) level, carbapenem use, antifungal therapy, and caspofungin use. Multiple regression analysis identified four independent risk factors for mortality: age (Odds ratio [OR], 1.052, p = 0.013), daily steroid dose (OR, 1.057, p = 0.002), APACHE II score (OR, 1.094, p = 0.012), and CRP level (OR, 1.007, p = 0.008). Furthermore, the multivariable analysis identified that more physicians would initiate antifungal therapy for patients with prolonged steroid use (p = 0.001), lower white blood cell count (p = 0.021), and higher SOFA score (p = 0.048). Thus, under the selection bias, the independent risk factors for mortality in the antifungal treatment subgroup were daily steroid dose (OR, 1.046, p = 0.001) and CRP (OR, 1.006, p = 0.018), whereas the independent risk factor for mortality in the untreated group became APACHE II score (OR, 1.232, p = 0.007)., Conclusions: Patients with IPA had a substantially high mortality. Overall, age, steroid use, APACHE II score, and CRP level were identified as the independent risk factors for mortality in patients in the ICU., Competing Interests: Declaration of Competing Interest We have no conflict of interest to declare., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

In 2014-2015, a significant outbreak of dengue fever occurred in southern Taiwan, with a subsequent decline in dengue incidence. Despite this, there is emerging concern about virus-associated aspergillosis, yet limited research has explored coinfections involving dengue and aspergillosis. We conducted a retrospective study at a single center in Southern Taiwan, specifically focusing on dengue patients admitted to the intensive care unit during the period between July and November 2015. Among the 142 dengue patients studied, only 8.06 % (10/142) underwent serum galactomannan testing, with a single patient undergoing bronchoalveolar lavage (BAL) galactomannan assay. Out of those tested, 20 % (2/10) returned positive serum galactomannan results. Herein, we present two consecutive cases of coinfection involving dengue and pulmonary aspergillosis in immunocompetent patients., Competing Interests: Declaration of Competing Interest The authors have no interest to declare., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

The objective was to compare the clinical efficacy of cefoperazone-sulbactam with piperacillin-tazobactam in the treatment of severe community-acquired pneumonia (SCAP). The retrospective study was conducted from March 1, 2018 to May 30, 2019. Clinical outcomes were compared for patients who received either cefoperazone-sulbactam or piperacillin-tazobactam in the treatment of SCAP. A total of 815 SCAP patients were enrolled. Among them, 343 received cefoperazone-sulbactam, and 472 received piperacillin-tazobactam. Patients who received cefoperazone-sulbactam presented with higher Charlson Comorbidity Index scores. (6.20 ± 2.77 vs 5.72 ± 2.61; P = .009). The clinical cure rates and effectiveness for patients receiving cefoperazone-sulbactam and piperacillin-tazobactam were 84.2% versus 80.3% (P = .367) and 85.4% versus 83.3% (P = .258), respectively. In addition, the overall mortality rate of the cefoperazone-sulbactam group was 16% (n = 55), which was also comparable to the piperacillin-tazobactam group (17.8%, n = 84, P = .572). The primary clinical outcomes for patients receiving cefoperazone-sulbactam were superior compared to those receiving piperacillin-tazobactam after adjusting disease severity status. The clinical efficacy of cefoperazone-sulbactam in the treatment of adult patients with SCAP is comparable to that of piperacillin-tazobactam. After adjusting for disease severity, cefoperazone-sulbactam tended to be superior to piperacillin-tazobactam., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: For the intensivists, accurate assessment of the ideal timing for successful weaning from the mechanical ventilation (MV) in the intensive care unit (ICU) is very challenging., Purpose: Using artificial intelligence (AI) approach to build two-stage predictive models, namely, the try-weaning stage and weaning MV stage to determine the optimal timing of weaning from MV for ICU intubated patients, and implement into practice for assisting clinical decision making., Methods: AI and machine learning (ML) technologies were used to establish the predictive models in the stages. Each stage comprised 11 prediction time points with 11 prediction models. Twenty-five features were used for the first-stage models while 20 features were used for the second-stage models. The optimal models for each time point were selected for further practical implementation in a digital dashboard style. Seven machine learning algorithms including Logistic Regression (LR), Random Forest (RF), Support Vector Machines (SVM), K Nearest Neighbor (KNN), lightGBM, XGBoost, and Multilayer Perception (MLP) were used. The electronic medical records of the intubated ICU patients of Chi Mei Medical Center (CMMC) from 2016 to 2019 were included for modeling. Models with the highest area under the receiver operating characteristic curve (AUC) were regarded as optimal models and used to develop the prediction system accordingly., Results: A total of 5,873 cases were included in machine learning modeling for Stage 1 with the AUCs of optimal models ranging from 0.843 to 0.953. Further, 4,172 cases were included for Stage 2 with the AUCs of optimal models ranging from 0.889 to 0.944. A prediction system (dashboard) with the optimal models of the two stages was developed and deployed in the ICU setting. Respiratory care members expressed high recognition of the AI dashboard assisting ventilator weaning decisions. Also, the impact analysis of with- and without-AI assistance revealed that our AI models could shorten the patients' intubation time by 21 hours, besides gaining the benefit of substantial consistency between these two decision-making strategies., Conclusion: We noticed that the two-stage AI prediction models could effectively and precisely predict the optimal timing to wean intubated patients in the ICU from ventilator use. This could reduce patient discomfort, improve medical quality, and lower medical costs. This AI-assisted prediction system is beneficial for clinicians to cope with a high demand for ventilators during the COVID-19 pandemic., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Liu, Hung, Ko, Cheng, Chao, Sung, Hsing, Wang, Chen, Lai, Chen and Chiu.)

Purpose: To compare the clinical effectiveness of branded versus generic piperacillin-tazobactam for treating severe community-acquired pneumonia (CAP)., Patients and Methods: We identified patients with severe CAP who received piperacillin-tazobactam based on a nine-center registry database. Furthermore, we classified the patients in three hospitals, which used only branded piperacillin-tazobactam as the study group, and the patients in six other hospitals, which used both branded and generic products as the control group., Results: A total of 472 patients (n = 263 in the study group and n = 209 in the control group) with severe CAP were included. The study group using branded piperacillin-tazobactam had higher odds of clinical cure (adjusted odds ratio [OR] = 3.77, 95 % confidence interval [CI], 1.93-7.37) and lower odds of treatment failure (adjusted OR = 0.28, 95 % CI, 0.13-0.58) than the control group receiving either branded or generic piperacillin-tazobactam. In addition, the study group was associated with higher odds of clinical effectiveness (adjusted OR = 2.95, 95 % CI, 1.46-6.11), less odds of clinical ineffectiveness (adjusted OR = 0.39, 95 % CI, 0.18-0.81), and lower risk of in-hospital mortality (adjusted OR = 0.39, 95 % CI, 0.21-0.73)., Conclusion: Based on the findings of the present study using indirect comparison, the clinical effectiveness of generic piperacillin-tazobactam for treating patients with severe CAP might not be as good as that of brand-name products., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The main objective of this study was to evaluate the outcomes of extremely elderly patients receiving orotracheal intubation and mechanical ventilation after planned extubation. This retrospective cohort study included extremely elderly patients (>90 years) who received mechanical ventilation and passed planned extubation. We reviewed all intensive care unit patients in a medical center between January 1, 2010, and December 31, 2017. There were 19,518 patients (aged between 20 and 105 years) during the study period. After application of the exclusion criteria, there were 213 patients who underwent planned extubation: 166 patients survived, and 47 patients died. Compared with the mortality group, the survival group had lower Acute Physiology and Chronic Health Evaluation II scores and higher Glasgow Coma Scale (GCS) scores, with scores of 19.7 ± 6.5 (mean ± standard deviation) vs 22.2 ± 6.0 (P = .015) and 9.5 ± 3.5 vs 8.0 ± 3.0 (P = .007), respectively. The laboratory data revealed no significant difference between the survival and mortality groups except for blood urea nitrogen (BUN) and hemoglobin. After multivariate logistic regression analysis, a lower GCS, a higher BUN level, weaning beginning 3 days after intubation and reintubation during hospitalization were associated with poor prognosis. In this cohort of extremely elderly patients undergoing planned extubation, a lower GCS, a higher BUN level, weaning beginning 3 days after intubation and reintubation during hospitalization were associated with mortality.

Epidemiological studies indicate that prolonged micro-aspiration of gastric fluid is associated in gastroesophageal reflux disease with the development of chronic respiratory diseases, possibly caused by inflammation-related immunomodulation. Therefore, we sought to ascertain the effect of gastric fluid exposure on pulmonary residential cells. The expression of α-smooth muscle actin as a fibrotic marker was increased in both normal human pulmonary fibroblast cells and mouse macrophages. Gastric fluid enhanced the proliferation and migration of HFL-1 cells and stimulated the expression of inflammatory cytokines in an antibody assay. Elevated expression of the Rho signaling pathway was noted in fibroblast cells stimulated with gastric fluid or conditioned media. These results indicate that gastric fluid alone, or the mixture of proinflammatory mediators induced by gastric fluid in the pulmonary context, can stimulate pulmonary fibroblast cell inflammation, migration, and differentiation, suggesting that a wound healing process is initiated. Subsequent aberrant repair in pulmonary residential cells may lead to pulmonary fibroblast differentiation and fibrotic progression. The results point to a stimulatory effect of chronic GERD on pulmonary fibroblast differentiation, and this may promote the development of chronic pulmonary diseases in the long term., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Truth-telling is an important step toward reducing the cognitive gap between physicians and patients as well as reducing the psychological pressures applied to physicians by family members. There is a lack of research on the truth-telling experience and needs in the intensive care unit from the perspective of patient family members., Purpose: This study is designed to explore the experiences and needs of families in the intensive care unit., Methods: A descriptive phenomenology method was used in this study. In-depth interviews were conducted with five participants who had family members assessed with acute physiology and chronic health evaluation II scores ≥ 20. Data were analyzed using Giorgi's phenomenological methods and Nvivo 11., Results: Four experience themes were examined, including (1) nothing is clear, requires explanation; (2) helpless to find answers, need a nurse to resolve this issue; (3) professional conduct makes us feel helpless, longing for love from the medical team; (4) decisions are very difficult, hoping to get more help., Conclusions / Implications for Practice: The family members expressed that they were unable to understand the underlying causes of the progression in patient condition because the medical team only presented outcomes to the family and did not discuss related causes. Thus, it is recommended that medical teams learn to recognize the cognitive processes of patient family members and consider their emotions, including their needs and expectations, in order to provide individualized explanations based on a patient's status and progress.

Depression is common after patients are discharged from the intensive care unit (ICU) and has a negative impact on quality of life and mortality. There is inconsistent information about ICU admission and the risk of depression. The aim of our study was to investigate the association between the risk of depression and length of ICU stay.ICU survivors between 20 and 65 years old were enrolled in this study using data from Taiwan's nationwide population database. All study subjects were followed for a maximum of 1 year or until they were diagnosed with new-onset depression. The association between the length of ICU stay and the depression risk among ICU survivors was estimated using a Cox regression model. The screened diagnostic records of ICU survivors with depression were also investigated to find the potential disease effect of depression.Compared to patients with ICU stays between 8 and 14 days, the adjusted HR (95% confidence interval) for depression in patients with ICU stays between 1 to 3 days, 4 to 7 days, 15 to 21 days, and ≥22 days were 1.08 (1.03-1.13), 1.01 (0.96-1.05), 1.08 (1.01-1.14), and 1.12 (1.06-1.19), respectively. For patients with depression after discharge from the ICU, the most common primary diagnosis was intracerebral hemorrhage.There is a risk of depression after ICU discharge, and the incidence of depression may be higher among patients between 20 and 49 years old. The risk of depression was U-shaped, with higher risks associated with ICU stays of 1 to 3 days and more than 15 days.

This study aims to construct a neural network to predict weaning difficulty among planned extubation patients in intensive care units.This observational cohort study was conducted in eight adult ICUs in a medical center about adult patients experiencing planned extubation.The data of 3602 patients with planned extubation in ICUs of Chi-Mei Medical Center (from Dec. 2009 through Dec. 2011) was used to train and test an artificial neural network (ANN) model. The input features contain 47 clinical risk factors and the outputs are classified into three categories: simple, difficult, and prolonged weaning. A deep ANN model with four hidden layers of 30 neurons each was developed. The accuracy is 0.769 and the area under receiver operating characteristic curve for simple weaning, prolonged weaning, and difficult weaning are 0.910, 0.849, and 0.942 respectively.The results revealed that the ANN model achieved a good performance in prediction the weaning difficulty in planned extubation patients. Such a model will be helpful for predicting ICU patients' successful planned extubation.

This study aims to compare the impact of early and late post-discharge cardiopulmonary rehabilitation on the outcomes of intensive care unit (ICU) survivors.The retrospective, cohort study used a sub-database of the Taiwan National Health Insurance Research Database (NHIRD) that contained information of all patients had ICU admission between 2000 and 2012. Early group was defined if patients had received cardiopulmonary rehabilitation within 30 days after ICU discharge, and late group was define as if patients had received cardiopulmonary rehabilitation between 30 days and 1 year after ICU discharge. The end points were mortality and re-admission during the 3-year follow-up.Among 2136 patients received cardiopulmonary rehabilitation after ICU discharge, 994 was classified early group and other 1142 patients were classified as late group. Overall, early group had a lower mortality rate (6.64% vs. 10.86%, P = .0006), and a lower ICU readmission rate (47.8% vs. 57.97%, P < 0.0001) than late group after 3-year follow-up. Kaplan-Meier analysis showed that early group had significantly lower mortality (P = .0009) and readmission rate (P < .0001) than late group. In multivariate analysis, the risk of ICU readmission was found to be independently associated with late group (hazard ratio, [HR], 1.28; 95% confidence intervals, [CI], 1.13-1.47).Early post-discharge cardiopulmonary rehabilitation among ICU survivors has the long-term survival benefit and significantly decreases the readmission rate.

Purpose: This study assessed clinical manifestations and prognostic factors of critically ill patients with severe influenza admitted to the intensive care unit (ICU) in Taiwan's recent outbreak., Methodology: Patients admitted to ICU for severe influenza between January 1, 2015, and March 31, 2016, were identified and their medical records were retrospectively reviewed. The primary endpoints were outcomes and predictors of in-hospital mortality., Results: There were 125 patients with an average Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 20.8. Hypertension (62.4 %) and diabetes mellitus (40.8 %) were the two most common underlying diseases. Ninety-eight (78.4 %) patients had at least one organ failure: the lungs were the most common (71.2 %), followed by the heart (53.6 %). Two of the most common symptoms of patients at ICU admission were fever (68.0 %) and cough (78.4 %). Thirty-three patients (26.4 %) died; most (40.9 %) were middle-aged (50-65 years old). A Cox regression analysis showed that multiple organ failure (MOF) [hazard ratio (HR)=3.618; 95 % CI=1.058-13.662] was significantly associated with higher risk of death. In contrast, a fluid-negative balance within 7 days of admission (HR=0.362; 95 % CI=0.140-0.934) was significantly associated with a lower risk of death., Conclusion: The mortality rate of severe influenza patients admitted to the ICU was high, especially in middle-aged adults. The risk of mortality was associated with ≥2 organ failures. A negative fluid balance predicts survival.

Objective: To investigate the concordance between novel and conventional surveillance paradigms for ventilator-associated pneumonia (VAP)., Methods: This study was conducted at a regional teaching hospital in southern Taiwan with 5 acute intensive care units. To assess the validity of novel ventilator-associated event (VAE) surveillance, we retrospectively applied the VAE algorithm to analyze all VAP cases that were identified using conventional definitions between April 2010 and February 2014. Patient outcomes, including ventilator days, hospital stay lengths, and in-hospital mortality were recorded., Results: Among 165 episodes of conventional VAP, 55 (33.3%), 40 (24.2%), 20 (12.1%), and 2 (1.2%) episodes were classified as a ventilator-associated condition, an infection-related ventilator-associated complication, possible VAP, and probable VAP, respectively, according to the new VAE algorithm. Changes in positive end-expiratory pressure and inspired oxygen fraction levels during the development of VAP were significant higher among each VAE category than for conventional VAP (all P < .001). In-hospital mortality was significantly higher among patients with ventilator-associated condition than for patients with conventional VAP (P = .0185)., Conclusions: In our study population, novel VAE surveillance only detected one-third of conventional VAP cases. Thus, more studies are needed to further validate VAE surveillance compared with conventional VAP by using strong microbiologic criteria, particularly bronchoalveolar lavage with a protected specimen brush for diagnosing VAP., (Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The mortality rate of patients with acute respiratory distress syndrome (ARDS) is still high despite the use of protective ventilatory strategies. We sought to examine the pharmacological effects of glutamine (GLN) in a two-hit model of endotoxin-induced inflammation followed by ventilator-induced lung injury (VILI). We hypothesized that the administration of GLN ameliorates the VILI., Methods: Sprague-Dawley rats were anesthetized and given lipopolysaccharide (LPS) intratracheally as a first hit to induce lung inflammation, followed 24 h later by a second hit of mechanical ventilation (MV) with either low tidal volume (6 mL/kg) with 5 cmH2O of positive end-expiratory pressure (PEEP) or high tidal volume (22 mL/kg) with zero PEEP for 4 h. GLN or lactated Ringer's solution as the placebo was administered intravenously 15 min prior to MV., Results: In the LPS-challenged rats ventilated with high tidal volume, the treatment with GLN improved lung injury indices, lung mechanics and cytokine responses compared with the placebo group., Conclusions: The administration of GLN given immediately prior to MV may be beneficial in the context of reducing VILI.

Background and Purpose: Leptospirosis is a major cause of fever in subtropical and tropical areas. The clinical manifestations are protean, ranging from very mild and nonspecific symptoms to severe septic shock and death. This retrospective study investigated the demographic and clinical features of leptospirosis in central Taiwan over 3 years, with emphasis on pulmonary manifestations., Methods: We analyzed the clinical characteristics of serologically-confirmed leptospirosis cases at a tertiary teaching hospital from October 2002 to October 2005., Results: Twenty three confirmed cases were included and Leptospira santarosai serovar Shermani was the most commonly identified serovar (77.3%). The male-to-female ratio was 2.67:1 and the average age was 42.4 years. Nineteen cases (82.6%) were hospitalized, 3 were diagnosed in the outpatient setting and 1 died before admission. The majority of cases (63.6%) occurred in rainy months (from June to October). Fever (incidence, 100%), anorexia (74%), headache (61%), gastrointestinal upset (53%), myalgia (48%), and cough (48%) were the common clinical manifestations. Fifteen cases (63%) had respiratory symptoms and twelve (52%) had chest roentgenography abnormalities. Multiple nodular densities pattern (42%) was the most common abnormal finding on chest plain film. Three patients met the criteria of Weil's syndrome. The overall mortality rate was 4.3%., Conclusions: Respiratory symptoms or abnormal findings on chest X-ray were not uncommon in patients with leptospirosis. In addition to hepatic or renal dysfunction, leptospirosis should be seriously considered in patients with pulmonary symptoms and fever, especially in subtropical and tropical areas.

Melioidosis is an endemic disease in southeast Asia and northern Australia, caused by Burkholderia pseudomallei. A typhoon-related outbreak occurred in southern Taiwan in July 2005. High mortality in melioidosis associated with bacteremic pneumonia and septic shock. We report a patient with life-threatening melioidosis who developed rapid progression of bacteremic pneumonia with acute respiratory distress syndrome, septic shock and multiple organ dysfunction and was successfully treated with recombinant human activated protein C (rhAPC) and meropenem. Although rhAPC has been reported to reduce the mortality of severe septic shock caused by various pathogens, to our best knowledge, this is the first reported case of rhAPC application in life-threatening melioidosis.

Background and Purpose: Group B streptococcus (GBS) [Streptococcus agalactiae] is an emerging cause of disease in non-pregnant adults with underlying diseases. This retrospective study analyzed 90 episodes of GBS bacteremia in adults occurring over a 4-year period., Methods: Basic and clinical data were collected by reviewing medical charts of patients. Blood cultures were performed on admission of patients suspected of bacteremia. Presence of underlying diseases, such as liver disease, heart disease, urinary tract disorders, and female-specific cancers, as well as possible portals of entry of infection was analyzed., Results: In 56 episodes (62.2%), patients were aged 60 years or older and 40 (44.4%) episodes occurred in males. Skin and soft tissue were the most common sources of GBS bacteremia (22/90, 24.4%). GBS bacteremia was classified as primary in 50% of the episodes (45 patients). Liver diseases were more common in males, while malignancy was more common in females. Portals of entry with a significant gender predominance included skin and soft tissue in women (p=0.018), bone and joint in women (p=0.016), and urinary tract in men (p=0.042). The overall mortality rate was 18.9% and the attributable mortality rate was 7.8%., Conclusions: Elderly people and those with underlying diseases are particularly susceptible to GBS infections. Preventive strategies, including GBS vaccine and skin care, are likely to be particularly important in these high-risk groups.

Necrotizing fasciitis is a life-threatening soft-tissue infection primarily involving the superficial fascia. This study investigated the microbiologic characteristics and determinants of mortality of this disease. The medical records of 87 consecutive patients with a diagnosis of necrotizing fasciitis from 1999 to 2004 were retrospectively reviewed. A single pathogen was identified as the infectious agent in 59 patients (67.8%), multiple pathogens were identified in 17 patients (19.6%), and no organism was identified in 11 patients (12.6%). Klebsiella pneumoniae, identified in 17 patients, was the most commonly isolated species. The most common comorbidity was diabetes mellitus (41 patients; 53.2%). Multivariate logistic regression analysis showed that more than 1 comorbidity, thrombocytopenia, anemia, more than 24 h delay from onset of symptoms to surgery and age greater than 60 were independently associated with mortality. This study found that K. pneumoniae was the most common cause of necrotizing fasciitis. Early operative debridement was independently associated with lower mortality.