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The integral membrane, Kunitz-type serine protease inhibitors HAI-1 and HAI-2 can suppress the proteolytic activity of the type 2 transmembrane serine protease matriptase with high specificity and potency. High levels of extracellular matriptase proteolytic activity have, however, been observed in some neoplastic B-cells with high levels of endogenous HAI-2, indicating that HAI-2 may be an ineffective matriptase inhibitor at the cellular level. The different effectiveness of the HAIs in the control of extracellular matriptase proteolytic activity is examined here. Upon inducing matriptase zymogen activation in the HAI Teton Daudi Burkitt lymphoma cells, which naturally express matriptase with very low levels of HAI-2 and no HAI-1, nascent active matriptase was rapidly inhibited or shed as an enzymatically active enzyme. With increasing HAI-1 expression, cellular matriptase-HAI-1 complex increased, and extracellular active matriptase decreased proportionally. Increasing HAI-2 expression, however, resulted in cellular matriptase-HAI-2 complex levels reaching a plateau, while extracellular active matriptase remained high. In contrast to this differential effect, both HAI-1 and HAI-2, even at very low levels, were shown to promote the expression and cell-surface translocation of endogenous matriptase. The difference in the suppression of extracellular active matriptase by the two closely related serine protease inhibitors could result from the primarily cell surface expression of HAI-1 compared to the mainly intracellular localization of HAI-2. The HAIs, therefore, resemble one another with respect to promoting matriptase expression and surface translocation but differ in their effectiveness in the control of extracellular matriptase enzymatic activity.

Unplanned extubation (UE) occurs among 2%-16% of patients with mechanical ventilation (MV). Failed UE requiring reintubation could be associated with several adverse events.The aim of this study was to investigate the outcomes and prognostic factors of patients with UE in intensive care units (ICUs).We prospectively registered the patients who had UE and retrospectively reviewed the electronic medical records for 96-bed ICUs between 1 January 2009, and 31 December 2020.A total of 392 patients had UE, and 234 patients (59.7%) were ≥65 years (older adult group). The median Acute Physiology and Chronic Health Evaluation (APACHE) II score were 17 and the median Glasgow Coma Scale score was 10. In total, 205 patients (52.3%) were reintubated within 48 h (due to failed UE) and 75 patients (19.1%) died during hospitalization. Multivariate analyses were performed to evaluate those factors predicting failed UE and mortality. These analyses demonstrated that higher positive end-expiratory pressure (PEEP) and the admission APACHE II scores predicted failed UE. A higher fraction of inspiration OWe concluded that among patients who had UE, higher FiOPatients with high disease severity indices who have an increased risk of UE required special attention to techniques to prevent endotracheal tubes from accidental removal.

Resumen Propósitos: COVID-19 causado por SARS-CoV-2 se ha convertido en un brote de pandemia desde enero de 2020. Taiwán ha contenido efectivamente la transmisión comunitaria de COVID-19. Por otra mano, la influenza tambien es una enfermedad se asocia con una alta carga y morbilidades. El objetivo del estudio es para validar si combatir la COVID-19 podría ayudar a controlar otras infecciones respiratorias en Taiwán. Métodos: Recopilamos datos semanales de casos de influenza grave, infecciones invasivas por Streptococcus pneumoniae y número de muertes por neumonía, que se informaron a los CDC de Taiwán, entre las 25 semanas de la temporada de influenza durante cuatro años (2016-2020). Comparamos las diferencias de tendencia y pendiente entre los años. Resultados: Se observó una tendencia a la baja de la influenza grave, la infecciones invasivas por Streptococcus pneumoniae, y el número de muertes por neumonía por semana en la temporada de infleunza de 2019/2020. Se observaron diferencias significativas en la tendencia en comparación con las temporadas anteriores, especialmente después del inicio de varias medidas de prevención de enfermedades para combatir el posible brote de COVID -19 en Taiwán. Conclusiones: Por el número de casos reportados a los CDC de Taiwán, encontramos que la lucha contra COVID-19 logró beneficios colaterales en reducciones significativas de la carga de la influenza grave, la infecciones invasivas por Streptococcus pneumoniae, y el número de muertes por neumonía.

Acute respiratory failure requiring mechanical ventilation is a major indicator of intensive care unit (ICU) admissions in cirrhotic patients and is an independent risk factor for ICU mortality. This retrospective study aimed to investigate the outcome and mortality risk factors in patients with liver cirrhosis (LC) who required prolonged mechanical ventilation (PMV) between 2006 and 2013 from two databases: Taiwan’s National Health Insurance Research Database (NHIRD) and a hospital database. The hospital database yielded 58 LC patients (mean age: 65.3 years; men: 65.5%). The in-hospital mortality was significantly higher than in patients without LC. Based on the NHIRD database of PMV cases, patients were age-gender matched in a ratio of 1:2 for patients with and without LC. Model for End-Stage Liver Disease (MELD) score was calculated. The mortality was higher in patients with LC (19.5%) than those without LC (18.12%), though not statistically significant (p = 0.0622). Based on the hospital database, risk factor analysis revealed that patients who died had significant higher MELD score than the survivors (18.9 vs 13.7, p = 0.036) and patients with MELD score of >23 had higher risk of mortality than patients with MELD score of ≤23 (adjusted OR:9.26, 95% CI: 1.96–43.8). In conclusion, the in-hospital mortality of patients with high MELD scores who required PMV was high. MELD scores may be useful predictors of mortality in these patients.

Previous studies have revealed higher mortality rates in patients with severe influenza who are coinfected with invasive pulmonary aspergillosis (IPA) than in those without IPA coinfection, nonetheless, the clinical impact of IPA on economic burden and risk factors for mortality in critically ill influenza patients remains undefined. The study was retrospectively conducted in three institutes. From 2016 through 2018, all adult patients with severe influenza admitted to an intensive care unit (ICU) were identified. All patients were classified as group 1, patients with concomitant severe influenza and IPA, group 2, severe influenza patients without IPA, and group 3, severe influenza patients without testing for IPA. Overall, there were 201 patients enrolled, including group 1 (n = 40), group 2 (n = 50), and group 3 (n = 111). Group 1 patients had a significantly higher mortality rate (20/40, 50%) than that of group 2 (6/50, 12%) and group 3 (18/11, 16.2%), p &lt, 0.001. The risk factors for IPA occurrence were solid cancer and prolonged corticosteroid use in ICU of &gt, 5 days. Group 1 patients had significantly longer hospital stay and higher medical expenditure than the other two groups. The risk factors for mortality in group 1 patients included patients’ Charlson comorbidity index, presenting APACHE II score, and complication of severe acute respiratory distress syndrome. Overall, IPA has a significant adverse impact on the outcome and economic burden of severe influenza patients, who should be promptly managed based on risk host factors for IPA occurrence and mortality risk factors for coinfection with both diseases.

Aspergillus-associated infection might comprise up to 23–29% of severe influenza patients from the community throughout stay in an intensive care unit (ICU). In Taiwan, cases of severe influenza with aspergillosis are increasingly reported. Therefore, we describe the relative risk of mortality among severe influenza patients with aspergillosis and other coinfections compared to severe influenza patients without Aspergillus coinfections. Methods: We retrospectively reviewed 124 adult patients with severe influenza in a tertiary medical center in southern Taiwan from January 2015 through March 2016. The definition of probable aspergillosis required abnormal radiological findings and positive Aspergillus galactomannan (GM) antigen and/or Aspergillus isolation. Results: Probable aspergillosis (detected throughout the whole course) and other coinfections (only community-acquired) were diagnosed in 21 (17%) and 38 (31%) of all patients respectively. Klebsiella pneumoniae (36.8%), Pseudomonas aeruginosa (31.6%) and Staphylococcus aureus (31.6%) were the most frequent isolates of other coinfections. In-ICU mortality of Aspergillus group (66.7%) was significantly higher than other coinfections (23.7%, p = 0.001) or control group without coinfections (15.4%, p

Objective To evaluate the effects of a quality improvement program to introduce early mobilization on the outcomes of patients with mechanical ventilation (MV) in the intensive care unit (ICU). Design A retrospective observational study. Setting Nineteen-bed ICU at a medical center. Participants Adults patients with MV (N=153) admitted to a medical ICU. Interventions A multidisciplinary team (critical care nurse, nursing assistant, respiratory therapist, physical therapist, patient's family) initiated the protocol within 72 hours of MV when patients become hemodynamically stable. We did early mobilization twice daily, 5d/wk during family visits (30min each time), and cooperated with family, if possible. Main Outcome Measures MV duration, rate of successful weaning, and length of ICU and hospital stay. Results We enrolled 63 patients in the before protocol group and 90 in the after protocol group. The 2 groups were well matched in age, sex, body height, body weight, body mass index, disease severity, cause of intubation, number of comorbidities, and most underlying diseases. After protocol group patients had shorter MV durations (4.7d vs 7.5d; P Conclusions The introduction of early mobilization for patients with MV in the ICU shortened MV durations and ICU stays. A multidisciplinary team that includes the patient's family can work together to improve the patient's clinical outcomes.

BACKGROUND: Reasons for the prolonged critical care support include uncertainty of outcome, the complex dynamic created between physicians with care team members and the patient’s family over a general unwillingness to surrender to unfavorable outcomes. The purpose of this study was to investigate outcomes and identify risk factors of patients with acute respiratory failure (ARF) who required a prolonged intensive care unit (ICU) stay (≥21 days). It may provide reference to screen patients who are suitable for hospice care. METHODS: The medical records of all ARF patients with a prolonged ICU stay were retrospectively reviewed. The primary outcome was in-hospital mortality. RESULTS: We identified 1,189 patients. Sepsis (n=896, 75.4%) was the most common cause of prolonged ICU stays, following by renal failure (n=232, 19.5%), and unstable hemodynamic status vasopressors or arrhythmia (n=208, 17.5%). Using multivariable logistic regression, we identified eight risk factors of death: age >75 years, ICU stay for more than 28 days, APACHE II score ≥25, unstable hemodynamic status, renal failure, hepatic failure, massive gastrointestinal tract bleeding, and using a fraction of inspired oxygen (FiO(2)) ≥40%. The overall in-hospital mortality rate was 53.6% (n=637), and it up to 75.3% (216/287) for patients with at least three risk factors. CONCLUSIONS: The outcome of patients with ARF who required prolonged ICU stay was poor. They had a high risk of in-hospital mortality. Palliative care should be considered as a reasonable option for the patients at high risk of death.

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Background The groin flap represents a milestone in the history of flap development, since it was the first successful free cutaneous flap. Once widely used, it is currently less popular owing to the variations in vascular anatomy and the small, short pedicle. To enhance the clinical applications of the groin flap, its merits need to be promoted and its faults improved, including making some useful innovations. Methods From February 2010 to February 2014, we successfully treated 35 patients with soft tissue defects in the extremities (28 patients), buttock (1 patient), and head (6 patients) using new designs in groin flaps: axial free (34 patients) or pedicle (1 patient) groin flaps. Results All types of axial groin flaps survived successfully in the 2 to 38 months' (mean, 15.6 months) follow-up. The branches of the superficial circumflex iliac artery used for the axial flap design were 2 to 4 (mean, 3.09). The flap size ranged from 1×1.5 cm to 11×30 cm. No significant complications developed in any of the patients, with the exception of 2 mildly bulky flaps. Conclusions This axial design of freestyle groin flaps not only preserves the earlier merits of the groin flap but also creates many new advantages: (1) reliability is greater, (2) ability to tailor the dimensions and flap paddles to the lesions, (3) options available to "lengthen" flap pedicles, and (4) local anesthesia usable with free flaps for reconstruction.

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.

This study investigated the prognostic factors and outcomes of unplanned extubation (UE) in patients in a medical center’s 6 intensive care units (ICUs) and calculated their mortality risk. We retrospectively reviewed the medical records of all adult patients in Chi Mei Medical Center who underwent UE between 2009 and 2015. During the study period, there were 305 episodes of UE in 295 ICU patients (men: 199 [67.5%]; mean age: 65.7 years; age range: 18–94 years). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 16.4, mean therapeutic intervention scoring system (TISS) score was 26.5, and mean Glasgow coma scale score was 10.4. One hundred thirty-six patients (46.1%) were re-intubated within 48 h. Forty-five died (mortality rate: 15.3%). Multivariate analyses showed 5 risk factors—respiratory rate, APACHE II score, uremia, liver cirrhosis, and weaning status—were independently associated with mortality. In conclusion, five risk factors including a high respiratory rate before UE, high APACHE II score, uremia, liver cirrhosis, and not in the process of being weaned—were associated with high mortality in patients who underwent UE.

Lung ischemia reperfusion injury (LIRI) is one of important complications following lung transplant and cardiopulmonary bypass. Although patients on hemodialysis are still excluded as lung transplant donors because of the possible effects of renal failure on the lungs, increased organ demand has led us to evaluate the influence of chronic kidney disease (CKD) on LIRI. A CKD model was induced by feeding Sprague-Dawley rats an adenine-rich (0.75%) diet for 2, 4 and 6 weeks, and an isolated rat lung in situ model was used to evaluate ischemia reperfusion (IR)-induced acute lung injury. The clinicopathological parameters of LIRI, including pulmonary edema, lipid peroxidation, histopathological changes, immunohistochemistry changes, chemokine CXCL1, inducible nitric oxide synthase (iNOS), proinflammatory and anti-inflammatory cytokines, heat shock protein expression, and nuclear factor-κB (NF-κB) activation were determined. Our results indicated that adenine-fed rats developed CKD as characterized by increased blood urea nitrogen and creatinine levels and the deposition of crystals in the renal tubules and interstitium. IR induced a significant increase in the pulmonary arterial pressure, lung edema, lung injury scores, the expression of CXCL1 mRNA, iNOS level, and protein concentration of the bronchial alveolar lavage fluid (BALF). The tumor necrosis factor-α levels in the BALF and perfusate; the interleukin-10 level in the perfusate; and the malondialdehyde levels in the lung tissue and perfusate were also significantly increased by LIRI. Counterintuitively, adenine-induced CKD significantly attenuated the severity of lung injury induced by IR. CKD rats exhibited increased heat shock protein 70 expression and decreased activation of NF-κB signaling. In conclusion, adenine-induced CKD attenuated LIRI by inhibiting the NF-κB pathway.

Background: The goal of the study was to implement sepsis bundles and examine the effect on patients with severe sepsis or septic shock in intensive care units (ICUs). Methods: All patients with severe sepsis or septic shock admitted to the 13-bed ICU were included. Sepsis bundles were implemented within 24 hours after admission. The implementation of sepsis bundles was categorized into preintervention (January to April 2010), education (July to October 2010), operational (November to December 2010), and postintervention (January to April 2011) phases. Comparison of bundle compliance and outcome between each phase were examined. We also found mortality predictors between preintervention and postintervention phases. Results: There were 164 patients included in the study. Compared with the preintervention phase, the bundle compliance of each phase (education, operation, and postintervention separately) was higher (43.3%, 84.6%, and 79.2%, respectively, vs. 20.0%, p

Aim Visceral fat is more significantly correlated with inflammation markers and oxidative stress than is subcutaneous fat. Myeloperoxidase is one inflammatory signal secreted after polymorphonuclear leukocytes are stimulated. However, few studies discuss the correlation between visceral fat and the inflammatory response in patients with chronic kidney disease (CKD). Methods Sixty-six patients with CKD were enrolled and 60 healthy participants. Visceral fat levels were obtained using bioelectrical impedance analysis. Traditional risk factors for myeloperoxidase were analyzed. Results Baseline myeloperoxidase levels were significantly different between patients and controls, and were correlated with visceral fat after they had been adjusted for residual renal function. A multivariate linear regression model revealed that the neutrophil count and visceral fat and serum albumin levels were significant predictors of plasma myeloperoxidase in patients with CKD, but not in controls. The neutrophil count was correlated with myeloperoxidase only in the CKD group. Conclusion Visceral fat predicted plasma myeloperoxidase in patients with CKD, but not in healthy controls. Myeloperoxidase was probably contributed by primed and activated neutrophils that had been irritated by visceral fat in patients with CKD.

We investigated the clinical features of intensive care unit (ICU) patients with concomitant severe dengue infection and bacteraemia to identify risk factors for this comorbidity. The records of all ICU dengue patients admitted during the period of 31 July–30 November 2015 were reviewed. Patients with ‘concurrent bacteremia’ (positive bacterial blood culture within 72 h of ICU admission) were identified. ICU admission was required for 142 patients, of which 22 (15.5 %) had concurrent bacteraemia. Species of the genus Streptococcus was the most common pathogens, followed by Escherichia coli then species of the genus Staphylococcus. Patients with a severe dengue infection and bacteraemia had higher APACHE II and TISS scores, C-reactive protein (CRP) levels and leukocyte counts, positive fluid balances, longer activated partial thromboplastin times (APTTs), higher lactate levels and more kidney failure, but controls (severe dengue patients without bacteraemia) had higher Glasgow Coma Scale (GCS) scores, higher albumin levels and more abdominal pain (all P

We found significant correlation between the incidence of severe influenza and Aspergillus antigenemia among medical intensive care unit patients for 7-month observation (coefficient γ=0.976, p

Introduction: Vibrio vulnificus infection, an uncommon but life-threatening illness, manifests as two main types, primary septicemia and primary wound infections. Little information regarding the seasonality of V. vulnificus infections in tropical areas and prognostic factors of primary V. vulnificus wound infections is available. Methodology: This retrospective study was conducted to include 159 V. vulnificus -infected admissions at our institution in southern Taiwan, 63 with primary septicemia (Group 1) and 96 with primary wound infections (Group 2), from 1999 to 2008, for analysis. Results: The case-fatality rate was 24%. Eighty-eight percent of these cases occurred during April to November. During December to March, patients in Group 2 were less likely to have acquired the infection compared with those in Group 1. Group 1 was more likely to have comorbidities and a higher case-fatality rate compared to Group 2. In multivariate analysis, hemorrhagic bullous skin lesions/necrotizing fasciitis ( P =0.024), lesions involving two or more limbs ( P =0.043), and shock on admission ( P =0.015) were related to an increased mortality risk, while surgery < 24 hours after admission ( P =0.001) was related to a decreased mortality risk in Group 1; however, hemorrhagic bullous skin lesions/necrotizing fasciitis ( P =0.045) was the only prognostic factor in Group 2. Conclusion: The presence of hemorrhagic bullous lesion/necrotizing fasciitis is the main prognostic factor for primary septicemia or primary wound infections caused by V. vulnificus . Persons with an underlying immunocompromised status should avoid consuming raw/undercooked seafood or exposing wounds to seawater and should wear clothing during handling of seafood/fishing, especially in warmer months.

Vibrio vulnificus causes potentially life-threatening and rapidly progressing infections. Therefore, the severity-of-illness assessment appears to be important for V vulnificus-infected patients at the time of admission. The aim of our study was to evaluate the performance of the severity-of-illness scoring model on admission in V vulnificus-infected patients.One hundred seventy-one consecutive patients (mean age: 63.1 ± 12.3 years) with V vulnificus infection who were admitted to a teaching hospital between January 1999 and June 2010 were included in the study. Demographic and clinical characteristics, illness severity on admission, treatment, and outcomes were collected for each patient and extracted for analysis. Logistic regression and receiver operating characteristic curve analyses were performed.The mean Rapid Emergency Medicine Score (REMS) on admission was 6.5 ± 3.0 points. During hospitalization, 68 patients (40%) required intensive care. The overall case-fatality rate was 25%. In multivariate analysis, the presence of underlying liver disease (P = .002), hemorrhagic bullous lesions/necrotizing fasciitis (P = .012), and higher REMS values on admission (P.0001) were associated with increased mortality risk; a time span24 hours between arrival and surgical treatment was associated with a decreased mortality risk (P = .007). Additionally, the area under the receiver operating characteristic (ROC) curve for the REMS in predicting mortality risk was 0.895 (P.0001). An optimal cut-off REMS ≥8 had a sensitivity of 81% and a specificity of 85%, with a 26.6-fold mortality risk (P.0001) and a 12.5-fold intensive care unit admission risk (P.0001).The REMS could provide clinicians with an effective adjunct risk stratification tool for V vulnificus-infected patients.

The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been verified as a useful diagnostic tool for detecting necrotizing fasciitis (NF). Its application, however, is mainly for NF types I and II. The practical relevance of the LRINEC score for Vibro vulnificus-related skin and soft tissue infection (SSTI) was hardly ever investigated. The aim of this study was to assess the applicability of the LRINEC scoring system and to identify NF-predicting factors in patients with V. vulnificus-caused SSTI.A retrospective study was conducted, enrolling 125 consecutive patients diagnosed with V. vulnificus-related SSTI who were admitted to a teaching hospital between January 2003 and December 2011. Demographics, laboratory data, comorbidities, treatment, and outcomes were collected for each patient and extracted for analysis. Logistic regression and receiver operating characteristic curve analyses were performed.The mean (SD) age of the 125 patients was 63.0 (10.9) years; 58% of the patients were male. The mean (SD) LRINEC score at admission was 2.4 (1.9) points. Of the 125 patents, 72 (58%) had NF. Multivariate analysis revealed that the presence of hemorrhagic bullous lesions (p = 0.002) and higher LRINEC scores at admission (p0.0001) were significantly associated with the presence of NF. In addition, the area under the receiver operating characteristic curve for the LRINEC scoring model for detecting NF was 0.783 (p0.0001). An optimal cutoff LRINEC score of 2 or greater had a sensitivity of 71%, a specificity of 83%, and a positive predictive value of 85%, with an 11.9-fold increased risk for the presence of NF (p0.0001).We have demonstrated that the LRINEC score and hemorrhagic bullous/blistering lesions are significant predictors of NF in patients with V. vulnificus-related SSTI. V. vulnificus-infected patients having hemorrhagic bullous/blistering lesions or with an LRINEC score of 2 or greater should be thoughtfully evaluated for the presence of NF.Diagnostic test study, level II.

Lactic acidosis is common in critical care; by contrast, a subtype called alcohol-associated lactic acidosis (AALA) is rarely encountered. The primary purpose of this study was to determine the prognosis of AALA in critically ill patients and the second aim was to determine whether the survival was associated to the peak blood lactate concentration. An 8-year retrospective analysis of adult patients admitted to the intensive care unit (ICU) with AALA between January 2007 and December 2014 was considered in a tertiary care hospital. In total, 23 patients were analyzed and the median peak blood lactate level was 15.9 mmol/L. Only 2 patients (8.7%) presented peak blood lactate levels

To compare the effectiveness of a third-generation cephalosporin alone, a third-generation cephalosporin plus minocycline, and a fluoroquinolone in patients with necrotizing fasciitis (NF) caused by Vibrio vulnificus.A retrospective review of case notes was performed for 89 patients who presented with NF caused by V. vulnificus and underwent surgical intervention within 24 h of admission between 2003 and 2010. Data on comorbidities, clinical manifestations, laboratory studies, treatments and outcomes were extracted for analysis. These patients were grouped according to the antimicrobials prescribed: those who received only a third-generation cephalosporin (Group 1; n = 18); a third-generation cephalosporin plus minocycline (Group 2; n = 49); or a fluoroquinolone with/without minocycline (Group 3; n = 22).The mean age of the 89 patients included in the study was 64.0 ± 12.0 years (range 33-89 years); 55% of the patients were male. There were no differences in age, sex or clinical characteristics among the three groups except that patients in Group 3 had a higher frequency of underlying chronic renal insufficiency than those in Groups 1 and 2 (P = 0.009). Groups 2 and 3 each had a significantly lower case fatality rate than Group 1 (61% in Group 1 versus 14% in Group 2, P = 0.0003; 61% in Group 1 versus 14% in Group 3, P = 0.0027), while no difference in case fatality rate was noted between Groups 2 and 3.Our data suggested that, in addition to primary surgery, fluoroquinolones or third-generation cephalosporins plus minocycline are the best option for antibiotic treatment of NF caused by V. vulnificus.

SUMMARY Background: Unplanned extubation (UE) is a frequent complication following endotracheal intubation and can increase intensive care unit (ICU) stay and hospital expenditure. We investigated the incidence, outcome, and predictive factors of patients with failed UE (reintubation within 48 hours) in the adult ICU of a medical center in Taiwan. Methods: We reviewed the medical records of patients with UE in ICUs from January 2004 through December 2007. The primary endpoint was factors predicting failed UE, especially in older patients (age ≥ 65 years). The second endpoint was the outcomes by age. Results: There were 539 UEs, representing a rate of 3.6% for all mechanically ventilated patients, a failed UE rate of 48.2% (260/539) and a hospital mortality rate of 16.9% (91/539). In multivariate analyses, the factors predicting failed UE were: not being on a weaning trial (odds ratio, OR, 2.694), accidental extubation (OR, 2.232), older age (OR, 2.028), pulmonary cause of intubation (OR, 1.958), longer intubation time (OR, 1.002), and lower mean arterial pressure (OR, 0.980). Older patients had significant longer ICU and hospital stays than younger ones (15.5 vs. 12.1 days and 37.4 vs. 30.2 days, respectively, both p < 0.05), higher hospital mortality (17.7% vs. 15.8%), and higher hospital costs ($375,700 vs. $337,200 New Taiwan Dollars). Conclusion: Older patients with failed UE had significantly longer ICU and hospital stays and tended to have higher hospital mortality and costs. Many factors predicted failed UE, including age. Physicians should consider age a risk factor for failed UE and adverse events. (International Journal of Gerontology 2010; 4(3): 120-129)

Cytomegalovirus (CMV) colitis usually occurs in immunocompromised patients with human immunodeficiency virus infection, organ transplantation, and malignancy receiving chemotherapy or ulcerative colitis receiving immunosuppressive agents. However, CMV colitis is increasingly recognized in immunocompetent hosts. Notably, CMV colitis coexisting with Clostridium difficile infection (CDI) in apparently healthy individuals has been published in recent years, which could result in high morbidity and mortality. CMV colitis is a rare but possible differential diagnosis in immunocompetent patients with abdominal pain, watery, or especially bloody diarrhea, which could be refractory to standard treatment for CDI. As a characteristic of CDI, however, pseudomembranous colitis may be only caused by CMV infection. Real-time CMV-polymerase chain reaction (PCR) for blood and stool samples may be a useful and noninvasive diagnostic strategy to identify CMV infection when treatment of CDI eventually fails to show significant benefits. Quantitative CMV-PCR in mucosal biopsies may increase the diagnostic yield of traditional histopathology. CMV colitis is potentially life-threatening if severe complications occur, such as sepsis secondary to colitis, massive colorectal bleeding, toxic megacolon, and colonic perforation, so that may necessitate pre-emptive antiviral treatment for those who are positive for CMV-PCR in blood and/or stool samples while pending histological diagnosis.

We conduct a retrospective study of patients with unplanned extubation (UE) in adult intensive care units (ICU) at a medical center. In 2001, a multidisciplinary team of intensivists, senior residents, nurses, and respiratory therapists was established at Chi Mei Medical Center. The improvement interventions, implemented between 2001 and 2015, were organized around 8 key areas: standardizing procedures, improving communication skills, revising sedation and weaning protocols, changing strategies for restraints, establishing a task force for identifying and managing high-risk patients, using new quality-improvement models as breakthrough series and team resource management, using the strategy of accountability without assigning blame, and changing a new method to secure endotracheal tube. We measured the outcome as the annual event and the rate of UE. During this 15-year period, there were 1404 episodes of UE, with 44,015 episodes of mechanical ventilation (MV) (319,158 ventilator-days). The overall rate of UE was 3.19/100 ventilated patients (4.40/1000 ventilator-days). In 2001, there were 188 episodes of UE and the rate of UE was 6.82/100 ventilated patients or 9.0/1000 ventilator-days. After this continue quality improvement project had been implemented, the annual number of episodes of UE declined to 27, and the rate fell to 0.95/100 ventilated patients or 1.36/1000 ventilator-days in 2015. Overall, the trend analysis showed the change was significant with P < .0001. In conclusion, UE in adult ICU can be continuously and effectively reduced using multidisciplinary and sequential quality improvement interventions.

Outcomes of adult patients with dengue infections requiring intensive care unit (ICU) admissions remain unclear. We assessed the clinical manifestations and prognostic factors of patients critically ill with severe dengue. This retrospective study was done in a tertiary referral hospital with 96 adult ICU beds. All of the patients with laboratory-confirmed severe dengue infections and admitted to the ICU were enrolled between July 31 and November 31, 2015, during the large outbreak period. The medical records of all the recruited patients were reviewed for the following information: age, gender, clinical manifestations, disease severity scores, underlying conditions, laboratory examinations, and outcomes. The primary endpoint was to find the predictors of ICU mortality. During the study period, 4787 patients with dengue infections required ICU admission. One hundred forty-three (2.99%) were critically ill (mean age: 69.7 years). Hypertension (n = 90, 62.9%) and diabetes mellitus (n = 70, 49.0%) were the 2 most common underlying diseases. Eighty critically ill patients (55.9%) had cobacterial infections, and 33 had cobacteremia. The hematologic system failed most often, followed by thoracic and cardiovascular systems. Fever was the most common presentation (n = 112; 78.3%), followed by anorexia (n = 47; 32.9%) and abdominal pain (n = 46; 32.2%). Overall, 33 patients died (mortality rate: 23.1%). Multivariate analysis showed that ICU mortality was significantly associated with lower Glasgow Coma Scale (GCS) scores, lower platelet counts before ICU discharge, and more organ failures. The number of severe dengue patients who require ICU admission remains high. The mortality rate was associated with lower GCS scores, lower platelet counts, and more organ failures. In addition, more than half of the critically ill dengue patients had comorbid bacterial infections.

Background The aim of this study was to evaluate the impact of timing of surgery on mortality risk in patients with necrotizing fasciitis (NF) caused by Vibrio vulnificus infection. Methods Medical records of 121 patients (mean age, 65.2 ± 11.6 years) with V vulnificus –related NF who underwent surgical intervention between July 1998 and June 2011 were collected and reviewed retrospectively. These patients were divided into 3 groups according to the time between admission and surgical treatment as follows: those who received surgical treatment less than 12 hours after admission, those who received treatment 12 to 24 hours after admission, and those who received treatment more than 24 hours after admission. Cox regression analysis was performed to assess the effect of the timing of surgery after admission on mortality risk across the 3 groups by adjusting for potential confounding covariates. Results During their hospitalization, 35 patients died, yielding a case-fatality rate of 29%. After adjustment for potential confounding covariates (age, sex, duration of prodrome before admission, severity of illness on admission, the presence of primary septicemia, hepatic disorders, chronic renal insufficiency, blood pressure less than 90/60 mm Hg on admission, surgical and antibiotic modalities, and intensive care needed), patients who underwent surgery less than 12 hours after admission had a significantly lower mortality risk compared with those who had surgery either 12 to 24 hours after admission (adjusted hazard ratio [HR], .064; 95% confidence interval [CI], 1.6 × 10 −7 to .25; P = .037) or more than 24 hours after admission (adjusted HR, .0043; 95% CI, 2.1 × 10 −5 to .0085; P = .002). There was no difference in mortality risk between patients who underwent surgery 12 to 24 hours after admission and those who had surgery more than 24 hours after admission ( P = .849). Conclusions Our data provide important clinically based evidence for the beneficial effects of surgical treatment within 12 hours of admission for V vulnificus –related NF.

Vibrio vulnificus infection is uncommon but potentially life-threatening. The aim of this study was to evaluate clinical outcomes and prognostic factors for patients with V. vulnificus infections admitted to an intensive care unit.Retrospective study.Multidisciplinary intensive care unit in a 2300-bed teaching hospital.Eighty-five adult patients (≥ 18 yrs) with V. vulnificus infections who required intensive care were enrolled and reviewed during a 10-yr period.None.Thirty-four of the 85 patients died, giving an intensive care unit mortality rate of 40%. The mean Acute Physiology and Chronic Health Evaluation II score on intensive care unit admission was 18.4 (95% confidence interval, 17.1-19.8). The most common underlying disease was hepatic disease (48%) followed by diabetes mellitus (22%). Multivariate analysis showed that risk factors for intensive care unit mortality were the presence of hemorrhagic bullous skin lesions/necrotizing fasciitis (relative risk, 2.4; 95% confidence interval, 1.3-4.5; p = .006), skin/soft tissue infections involving two or more limbs (relative risk, 2.5; 95% confidence interval, 1.1-5.7; p = .025), and higher Acute Physiology and Chronic Health Evaluation II scores on intensive care unit admission (relative risk, 1.2; 95% confidence interval, 1.1-1.3; p = .0001). In contrast, surgical treatment24 hrs after arrival was inversely associated with intensive care unit mortality (relative risk, 0.35; 95% confidence interval, 0.15-0.79; p = .012). In addition, the area under the receiver operating characteristic curve for Acute Physiology and Chronic Health Evaluation II for predicting intensive care unit mortality was 0.945 (95% confidence interval, 0.873-0.983; p = .0001). An optimal cutoff Acute Physiology and Chronic Health Evaluation II score of ≥ 20 had a sensitivity of 97% and a specificity of 86% with a 41.4-fold increased risk of fatality (p = .0003).This study found that V. vulnificus-infected patients with hemorrhagic bullous skin lesions/necrotizing fasciitis, skin/soft tissue infections involving two or more limbs, or higher Acute Physiology and Chronic Health Evaluation II scores have high risks of intensive care unit mortality. However, patients receiving prompt surgical treatments within 24 hrs after admission have better prognoses.

Escherichia coli remains one of the most common etiologies of secondary peritonitis. CMY-2 is the most prevalent AmpC enzyme identified in nosocomial E. coli isolates causing bacteremia in Taiwan. This report is of a patient who underwent surgery for intestinal perforations due to blunt abdominal trauma and developed unexpected CMY-2-producing E. coli septicemia in the early postoperative period. The AmpC-type CMY-2 enzyme might partially contribute to the poor response to antimicrobial therapy of amoxicillin-clavulanic acid or flomoxef. Late changes in antibiotic therapy to an appropriate regimen of cefpirome based on the culture results did not result in a positive outcome and the patient died. Whether selection of an anti-AmpC regimen is appropriate as first-line treatment for traumatic abdomen-associated septicemia should be an area of further investigation in Taiwan.

To investigate the characteristics and outcomes of surgical patients who were readmitted to the intensive care unit (ICU).The data were collected for all readmissions to the surgical ICUs in a tertiary hospital in the year 2003.Of all the 945 ICU discharges, 110 patients (11.6%) were readmitted. They had a longer initial ICU stay (8.05 +/- 7.17 vs 5.22 +/- 4.95, P0.001) and were older and in a more severe condition than those not readmitted, but with a longer hospital stay and higher mortality rate (40% vs 3.6%, P0.001). A total of 26.4% of the readmission patients had an early readmission (48 h), with a lower mortality rate than those with a late readmission (24.1% vs 45.7%, P = 0.049). A total of 46.4% of the patients were readmitted with the same diagnosis while the rest were readmitted with a new complication. Respiratory disease was the most common diagnosis for patients readmitted with a new complication (66.1%). The nonsurvivors had a significantly higher second Acute Physiology and Chronic Health Evaluation (APACHE II) score (22.1 +/- 8.8 vs.14.6 +/- 7.4, P0.001) and second Therapeutic Intervention Scoring System (TISS) score (30.1 +/- 8.7 vs 24.7 +/- 7.6, P = 0.001) and a longer stay in the first ICU admission (10.4 +/- 9 days vs 6.4 +/- 5 days, P = 0.010). A multivariate analysis showed that the first ICU length of stay and the APACHE II score at the time of readmission were the two risk factors for mortality.The mortality of surgical patients with ICU readmission was high with respiratory complications being the most important issue.

Background The increased incidence of pyogenic liver abscess caused by Klebsiella pneumoniae (K.pneumoniae) was reported in the recent literature. This study was conducted retrospectively to investigate the clinical characteristics and outcomes of these patients. Methods Microbiological and medical databases of a medical center were searched from January 2000 to June 2003. Eighty-four patients with liver abscess caused by K.pneumoniae were analyzed. Results In the 84 patients, 52 men and 32 women aged (58.2 +/- 13.3) years on average, 64.4% had concomitant diabetes mellitus and 23.8% had biliary disease. The most common clinical symptoms were fever (98.8%), chills (69.0%) and abdominal pain (58.3%). 85.7% of the 84 patients received catheter drainage for the abscess. The length of hospital stay was (17.4 +/- 8.7) days. The mortality rate was 7.1%. Older age and presence of biliary disease were associated with mortality. Conclusions The low mortality of our patients was probably related to the high proportion of patients who received catheter drainage. Older age and presence of biliary disease were associated with the mortality.

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.