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The echogenic swirling pattern has a role in predicting malignant pleural effusion (MPE). However, its predictive ability is suboptimal, and its clinical utility remains to be defined. The aim of this study was to assess the diagnostic potential of the echogenic swirling pattern combined with pleural carcinoembryonic antigen (CEA) and routine laboratory tests of pleural effusion in MPE. The 80 consecutive patients with underlying malignancy and pleural effusions were recruited. All patients underwent one diagnostic thoracentesis with a cytologic examination of pleural fluid. Our study showed that the sensitivity of echogenic swirling patterns in MPE diagnosis was 67.7%, specificity was 72.2%, positive predictive value (PPV) was 89.4%, and negative predictive value (NPV) was 39.4%. Both CEA and lactate dehydrogenase (LDH) had acceptable sensitivity (71.0% and 60.7%) and specificity (72.2% and 77.8%). Combining the echogenic swirling pattern, pleural CEA, and pleural LDH, the highest sensitivity (95.2%) with a good PPV (86.8) was reached. In this clinical study, we found that combining the echogenic swirling pattern, pleural CEA, and pleural LDH had a higher sensitivity and a high positive predictive value for the diagnosis of MPE. This combination is a potentially suitable method for MPE screening in cancer patients with pleural effusions.

Background and objective Tuberculosis (TB) and sarcoidosis are both granulomatous diseases with potential interassociations. However, much uncertainty remains; thus, the present study aimed to clarify the association between these diseases. Methods We established two cohorts in this retrospective longitudinal cohort study using data obtained from the Taiwan National Health Insurance Database from 2000 to 2015. One cohort, which comprised 31 221 patients with TB and 62 442 age-, sex- and index year-matched controls, was used to analyse the risk of sarcoidosis; the other cohort comprised 2442 patients with sarcoidosis and 9688 controls and was used to assess the risk of TB. A Cox proportional hazards model adjusted for potential confounders was used in each cohort. Results Patients with TB showed an 8.09-fold higher risk of developing sarcoidosis than non-TB subjects (95% CI = 3.66-17.90), whereas patients with sarcoidosis showed a 1.85-fold higher risk of developing TB than non-sarcoidosis subjects (95% CI = 1.36-2.50). The TB subtype analysis revealed the highest risk of developing sarcoidosis in patients with extrapulmonary TB, and the highest risk of developing extrapulmonary TB was observed in patients with sarcoidosis compared with non-sarcoidosis subjects. Patients with TB showed a higher risk of developing sarcoidosis throughout the follow-up period, but patients with sarcoidosis only showed a higher risk of developing TB within the first year. Conclusion TB is a risk factor for developing sarcoidosis. The results of this bidirectional cohort study also highlight the clinical difficulty of diagnosing sarcoidosis and TB.

Backgrounds: Severe influenza infection causes substantial morbidity and mortality worldwide and remains an important threat to global health. This study addressed factors related to treatment outcomes in subjects of complicated influenza infection with acute respiratory distress syndrome (ARDS) during the Taiwan epidemic in the Spring of 2016. Methods: This is a retrospective study conducted by Taiwan Severe Influenza Research Consortium (TSIRC), including eight tertiary referral medical centers. Patients with virology-proven influenza infection admitted to intensive care unit (ICU) between January and March 2016 were included for analysis. Results: We identified 263 patients with complicated influenza infection who fulfilled ARDS criteria; the mean age was 59.8 ± 14.6 (years), and 66.1% (166/263) were male. Type A influenza (77.9%, 205/263) virus was the main pathogen during this epidemic. The 30-day mortality rate was 23.2% (61/263). The mean tidal volume (VT) in the first three days after intubation was greater than 8 mL/kg of predicted body weight (PBW). Patients whose first measured VT was >8 mL/kg PBW had an increased 30-day mortality (p = 0.04, log-rank test). In a multivariate Cox proportional hazard regression model, an increase of 1 mL/kg PBW of first VT was associated with 26.1% increase in 30-day mortality (adjusted hazard ratio 1.261, 95% confidence interval [CI] 1.072–1.484, p

Background Corticosteroid treatment has been widely used in the treatment of septic shock, influenza, and ARDS, although some previous studies discourage its use in severe influenza patients. This multicenter retrospective cohort study conducted in the intensive care units (ICUs) of eight medical centers across Taiwan aims to determine the real-world status of corticosteroid treatment in patients with influenza-associated acute respiratory distress syndrome (ARDS) and its impact on clinical outcomes. Between October 2015 and March 2016, consecutive ICU patients with virology-proven influenza infections who fulfilled ARDS and received invasive mechanical ventilation were enrolled. The impact of early corticosteroid treatment (≥ 200 mg hydrocortisone equivalent dose within 3 days after ICU admission, determined by a sensitivity analysis) on hospital mortality (the primary outcome) was assessed by multivariable logistic regression analysis, and further confirmed in a propensity score-matched cohort. Results Among the 241 patients with influenza-associated ARDS, 85 (35.3%) patients receiving early corticosteroid treatment had similar baseline characteristics, but a significantly higher hospital mortality rate than those without early corticosteroid treatment [43.5% (37/85) vs. 19.2% (30/156), p p Conclusions Early corticosteroid treatment was associated with a significantly increased hospital mortality in adult patients with influenza-associated ARDS. Earlier treatment and higher dosing were associated with higher hospital mortality. Clinicians should be cautious while using corticosteroid treatment in this patient group.

ObjectivesCurrent mortality prediction models used in the intensive care unit (ICU) have a limited role for specific diseases such as influenza, and we aimed to establish an explainable machine learning (ML) model for predicting mortality in critically ill influenza patients using a real-world severe influenza data set.Study designA cross-sectional retrospective multicentre study in TaiwanSettingEight medical centres in Taiwan.ParticipantsA total of 336 patients requiring ICU-admission for virology-proven influenza at eight hospitals during an influenza epidemic between October 2015 and March 2016.Primary and secondary outcome measuresWe employed extreme gradient boosting (XGBoost) to establish the prediction model, compared the performance with logistic regression (LR) and random forest (RF), demonstrated the feature importance categorised by clinical domains, and used SHapley Additive exPlanations (SHAP) for visualised interpretation.ResultsThe data set contained 76 features of the 336 patients with severe influenza. The severity was apparently high, as shown by the high Acute Physiology and Chronic Health Evaluation II score (22, 17 to 29) and pneumonia severity index score (118, 88 to 151). XGBoost model (area under the curve (AUC): 0.842; 95% CI 0.749 to 0.928) outperformed RF (AUC: 0.809; 95% CI 0.629 to 0.891) and LR (AUC: 0.701; 95% CI 0.573 to 0.825) for predicting 30-day mortality. To give clinicians an intuitive understanding of feature exploitation, we stratified features by the clinical domain. The cumulative feature importance in the fluid balance domain, ventilation domain, laboratory data domain, demographic and symptom domain, management domain and severity score domain was 0.253, 0.113, 0.177, 0.140, 0.152 and 0.165, respectively. We further used SHAP plots to illustrate associations between features and 30-day mortality in critically ill influenza patients.ConclusionsWe used a real-world data set and applied an ML approach, mainly XGBoost, to establish a practical and explainable mortality prediction model in critically ill influenza patients.

Supplemental material, Author_Response for Risk factor analysis of nosocomial lower respiratory tract infection in influenza-related acute respiratory distress syndrome by Wei-Chih Chen, Kuo-Chin Kao, Chau-Chyun Sheu, Ming-Cheng Chan, Yu-Mu Chen, Ying-Chun Chien, Chung-Kan Peng, Shinn-Jye Liang, Han-Chung Hu, Ming-Ju Tsai, Wen-Feng Fang, Wann-Cherng Perng, Hao-Chien Wang, Chieh-Liang Wu and Kuang-Yao Yang in Therapeutic Advances in Respiratory Disease

Additional file 1. Additional tables and figures.

Supplemental material, Reviewer_1_v.1 for Risk factor analysis of nosocomial lower respiratory tract infection in influenza-related acute respiratory distress syndrome by Wei-Chih Chen, Kuo-Chin Kao, Chau-Chyun Sheu, Ming-Cheng Chan, Yu-Mu Chen, Ying-Chun Chien, Chung-Kan Peng, Shinn-Jye Liang, Han-Chung Hu, Ming-Ju Tsai, Wen-Feng Fang, Wann-Cherng Perng, Hao-Chien Wang, Chieh-Liang Wu and Kuang-Yao Yang in Therapeutic Advances in Respiratory Disease

Supplemental material, Supplementary_Tables for Risk factor analysis of nosocomial lower respiratory tract infection in influenza-related acute respiratory distress syndrome by Wei-Chih Chen, Kuo-Chin Kao, Chau-Chyun Sheu, Ming-Cheng Chan, Yu-Mu Chen, Ying-Chun Chien, Chung-Kan Peng, Shinn-Jye Liang, Han-Chung Hu, Ming-Ju Tsai, Wen-Feng Fang, Wann-Cherng Perng, Hao-Chien Wang, Chieh-Liang Wu and Kuang-Yao Yang in Therapeutic Advances in Respiratory Disease

Background/purposeLung cancer is a heterogeneous disease with varied outcomes. Molecular markers are eagerly investigated to predict a patient's treatment response or outcome. Previous studies used frozen biopsy tissues to identify crucial genes as prognostic markers. We explored the prognostic value of peripheral blood (PB) molecular signatures in patients with advanced non-small cell lung cancer (NSCLC).MethodsPeripheral blood mononuclear cell (PBMC) fractions from patients with advanced NSCLC were applied for RNA extraction, cDNA synthesis, and real-time polymerase chain reaction (PCR) for the expression profiling of eight genes: DUSP6, MMD, CPEB4, RNF4, STAT2, NF1, IRF4, and ZNF264. Proportional hazard (PH) models were constructed to evaluate the association of the eight expressing genes and multiple clinical factors [e.g., sex, smoking status, and Charlson comorbidity index (CCI)] with overall survival.ResultsOne hundred and forty-one patients with advanced NSCLC were enrolled. They included 109 (77.30%) patients with adenocarcinoma, 12 (8.51%) patients with squamous cell carcinoma, and 20 (14.18%) patients with other pathological lung cancer types. A PH model containing two significant survival-associated genes, CPEB4 and IRF4, could help in predicting the overall survival of patients with advanced stage NSCLC [hazard ratio (HR) = 0.48, p

Various animal studies have shown beneficial effects of hypercapnia in lung injury. However, in patients with acute respiratory distress syndrome (ARDS), there is controversial information regarding the effect of hypercapnia on outcomes. The duration of carbon dioxide inhalation may be the key to the protective effect of hypercapnia. We investigated the effect of pre-treatment with inhaled carbon dioxide on lipopolysaccharide (LPS)-induced lung injury in mice. C57BL/6 mice were randomly divided into a control group or an LPS group. Each LPS group received intratracheal LPS (2 mg/kg), the LPS groups were exposed to hypercapnia (5% carbon dioxide) for 10 min or 60 min before LPS. Bronchoalveolar lavage fluid (BALF) and lung tissues were collected to evaluate the degree of lung injury. LPS significantly increased the ratio of lung weight to body weight, concentrations of BALF protein, tumor necrosis factor-&alpha, and CXCL2, protein carbonyls, neutrophil infiltration, and lung injury score. LPS induced the degradation of the inhibitor of nuclear factor-&kappa, B-&alpha, (I&kappa, ) and nuclear translocation of NF-&kappa, B. LPS increased the surface protein expression of toll-like receptor 4 (TLR4). Pre-treatment with inhaled carbon dioxide for 10 min, but not for 60 min, inhibited LPS-induced pulmonary edema, inflammation, oxidative stress, lung injury, and TLR4 surface expression, and, accordingly, reduced NF-&kappa, B signaling. In summary, our data demonstrated that pre-treatment with 10-min carbon dioxide inhalation can ameliorate LPS-induced lung injury. The protective effect may be associated with down-regulation of the surface expression of TLR4 in the lungs.

Background: Prone positioning has demonstrated decreased mortality in severe acute respiratory distress syndrome (ARDS) patients. The aim of this study was to investigate the effect of prone positioning in patients with influenza pneumonia-related severe ARDS. Methods: This retrospective study includes eight tertiary referral centers. All the patients with influenza pneumonia induced severe ARDS and receiving prone positioning were enrolled. Demographic data, laboratory data, treatment record, ventilator setting data and outcomes were collected. PaO2 responders were defined as the PaO2/FiO2 ratio increasing by ≥20% or ≥20 mm Hg, while PaCO2 responders were defined as PaCO2 decreasing by ≥1 mm Hg after prone positioning for one day. Results: Sixty-five patients receiving prone positioning were enrolled, with 37 (57%) were PaO2 responders and 33 (51%) were PaCO2 responders. Mortality rates were not significantly different between responders and non-responders. PaCO2 responder survivors had significantly shortened length of stay at the ICU (21.0 ± 13.5 vs. 31.7 ± 18.5 days, P = 0.038) and hospital (30.2 ± 16.6 vs. 43.0 ± 16.3 days, P = 0.013) than did non-responders. Multivariate analysis revealed younger age (odds ratio 0.903, 95% confidence interval 0.824-0.989; P = 0.028) and higher PaCO2 level before prone positioning (odds ratio 1.121 confidence interval 1.020-1.231; P = 0.017) were the predictors of PaCO2 responders. Conclusions: In this multicenter retrospective cohort study of influenza pneumonia patients with severe ARDS receiving prone positioning, PaCO2 responders had modestly better clinical outcomes. Younger age and higher PaCO2 level before prone positioning were the predictors of PaCO2 responders. Keywords: Prone positioning, Acute Respiratory Distress Syndrome, Influenza, Gas exchange, Outcome

Peripheral blood mononuclear cell (PBMC)-derived gene signatures were investigated for their potential use in the early detection of non-small cell lung cancer (NSCLC). In our study, 187 patients with NSCLC and 310 age- and gender-matched controls, and an independent set containing 29 patients for validation were included. Eight significant NSCLC-associated genes were identified, including DUSP6, EIF2S3, GRB2, MDM2, NF1, POLDIP2, RNF4, and WEE1. The logistic model containing these significant markers was able to distinguish subjects with NSCLC from controls with an excellent performance, 80.7% sensitivity, 90.6% specificity, and an area under the receiver operating characteristic curve (AUC) of 0.924. Repeated random sub-sampling for 100 times was used to validate the performance of classification training models with an average AUC of 0.92. Additional cross-validation using the independent set resulted in the sensitivity 75.86%. Furthermore, six age/gender-dependent genes: CPEB4, EIF2S3, GRB2, MCM4, RNF4, and STAT2 were identified using age and gender stratification approach. STAT2 and WEE1 were explored as stage-dependent using stage-stratified subpopulation. We conclude that these logistic models using different signatures for total and stratified samples are potential complementary tools for assessing the risk of NSCLC.

Pei-Ju Chen,1 Kuang-Yao Yang,2,3 Wann-Cherng Perng,4 Kuan-Chia Lin,5,6 Kwua-Yun Wang7 1School of Nursing, National Yang-Ming University, Taipei, Taiwan, Republic of China; 2Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China; 3Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China; 4Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China; 5Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan, Republic of China; 6Communty Medicine Research Center, Preventive Medicine Research Center, National Yang-Ming University, Taipei, Taiwan, Republic of China; 7Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, Republic ofChina Purpose: Chronic obstructive pulmonary disease (COPD) impacts health-related quality of life in men more than in women. In patients with dyspnea, frailty is more likely to develop and aggravate disability. Despite this, few studies have addressed frailty in men with COPD. The present study investigated the effects of dyspnea and its related factors on frailty in men with COPD. Patients and methods: This cross-sectional observational study selected 125 participants by voluntary sampling at the thoracic outpatient clinics of two medical centers in Taiwan. The modified Medical Research Council questionnaire was used as the basis to classify dyspnea. Data were collected using questionnaires and analyzed using IBM SPSS Statistics for Windows, version 24.0 (IBM Corporation., Armonk, NY, USA). Results: There were 85.90% and 26.70% patients with COPD assessed in the unfit stage among the dyspnea and non-dyspnea groups, respectively. Additionally, the number of medication use and the COPD Assessment Test (CAT) scores were correlated with the period from fitness to unfitness among the dyspnea group and non-dyspnea group. Conclusion: COPD with dyspnea was more common in the unfit stages. The total number of medication use and CAT scores were significantly related to frailty. Keywords: chronic obstructive, dyspnea, frail elderly, men, pulmonary disease

Background: Nemonoxacin, a novel nonfluorinated quinolone, has broad-spectrum antibacterial activity, including activity against antibiotic-resistant strains, and was developed for treating community-acquired pneumonia (CAP). This report provides an integrated safety summary of oral nemonoxacin from two phase II and one phase III clinical studies. Methods: Patients with mild CAP were randomized for treatment with nemonoxacin 500 mg (NEMO-500MG), nemonoxacin 750 mg (NEMO-750MG), or levofloxacin 500 mg (LEVO), orally, once daily, for 7–10 days. Hematological, gastrointestinal, and hepatic disorders; electrocardiography abnormalities; and reported quinolone-associated clinical concerns were included in this analysis. Results: A total of 520, 155, and 320 subjects were assigned to receive NEMO-500MG, NEMO-750MG, and LEVO, respectively. The incidence of adverse events (AEs) was the highest (54.8%) in the NEMO-750MG group (NEMO-500MG, 36.9%; NEMO-750MG, 54.8%; LEVO, 39.7%) and that of drug-related AEs was comparable between the three groups (NEMO-500MG, 22.9%; NEMO-750MG, 31.0%; LEVO, 22.5%). The majority (>80%) of the patients showed mild drug-related AEs and the distribution based on severity was similar between the groups. The most commonly reported drug-related AEs included neutropenia (NEMO-500MG, 2.5%; NEMO-750MG, 8.4%; LEVO, 4.4%), nausea (NEMO-500MG, 2.5%; NEMO-750MG, 7.1%; LEVO, 2.5%), leukopenia (NEMO-500MG, 2.3%; NEMO-750MG, 4.5%; LEVO, 3.1%), and increased alanine aminotransferase level (NEMO-500MG, 4.4%; NEMO-750MG, 0%; LEVO, 2.5%). Conclusion: Nemonoxacin was well tolerated and no clinically significant safety concerns were identified, suggesting that it possesses a desirable safety and tolerability profile similar to that of levofloxacin, and may be a suitable alternative to fluoroquinolones for treating patients with CAP. Keywords: Community-acquired pneumonia, Fluoroquinolone, Levofloxacin, Nemonoxacin, Safety

Background Patients with influenza complicated with pneumonia are at high risk of rapid progression to acute respiratory distress syndrome (ARDS). Prone positioning with longer duration and lung-protective strategies might reduce the mortality level in ARDS. The aim of this study is to investigate the survival predictors of prone positioning in patients with ARDS caused by influenza pneumonia. Methods This retrospective study was conducted by eight tertiary referral centers in Taiwan. From January 1 to March 31 in 2016, all of the patients in intensive care units with virology-proven influenza pneumonia were collected, while all of those patients with ARDS and receiving prone positioning were enrolled. Demographic data, laboratory examinations, management records, ventilator settings and clinical outcomes were collected for analysis. Results During the study period, 336 patients with severe influenza pneumonia were screened and 263 patients met the diagnosis of ARDS. Totally, 65 patients receiving prone positioning were included for analysis. The 60-day survivors had lower Acute Physiology and Chronic Health Evaluation (APACHE) II score, pneumonia severity index (PSI), creatinine level and lower rate of receiving renal replacement therapy than non-survivors (22.4 ± 8.5 vs. 29.2 ± 7.4, p = 0.003; 106.6 ± 40.9 vs. 135.3 ± 48.6, p = 0.019; 1.2 ± 0.9 mg/dL vs. 3.1 ± 3.6 mg/dL, p = 0.040; and 4% vs. 42%, p

Additional file 1. Cox regression analysis of clinical variables associated with 60-day mortality ininfluenza pneumonia-related ARDS with prone positioning.

Background: The study was designed to compare the efficacy and tolerability of a fixed combination of extra-fine beclomethasone and formoterol, with the fixed combination fluticasone and salmeterol in Taiwanese asthmatic patients. Methods: This was a phase III, multicentre, randomized, two-arm parallel groups, controlled study. Patients with moderate to severe asthma were randomized to a 12-week treatment with either beclomethasone 100 mcg plus formoterol 6 mcg (BDP/F) or fluticasone 125 mcg plus salmeterol 25 mcg (FP/S), both delivered 2 inhalations twice daily. The efficacy and tolerability of these two combinations were compared. Results: Among the 253 randomized subjects, 244 patients were evaluable (119 in the BDP/F group and 125 in the FP/S group). A significant improvement from baseline to the end of treatment period was observed in both BDP/F and FP/S groups in forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), morning and evening peak expiratory flow (PEF), Asthma Control Test (ACT) score and the use of rescue medication. FVC increase from pre-dose was significant after 5 min post inhalation in the BDP/F group only, while statistically significant within group improvement was not achieved until 30 min post inhalation in the FP/S group. Conclusion: The BDP/F combination is comparable in efficacy and tolerability to FP/S combination in Taiwanese asthmatic patients, with the advantage of rapid onset of improvement of FVC, consistent with the faster improvement of pulmonary hyperinflation with BDP/F. Keywords: Asthma, Combination therapy, Inhaled corticosteroid, Long acting beta2-agonist, Pulmonary hyperinflation

Background Fluid balance is a fundamental management of patients with sepsis, and this study aimed to investigate the impact of cumulative fluid balance on critically ill patients with influenza admitted to an intensive care unit (ICU). Methods This multicenter retrospective cohort study was conducted by the Taiwan Severe Influenza Research Consortium (TSIRC) which includes eight medical centers. Patients with virology-proven influenza infection admitted to ICUs between October 2015 and March 2016 were included for analysis. Results A total of 296 patients were enrolled (mean age: 61.4±15.6 years; 62.8% men), and 92.2% (273/296) of them required mechanical ventilation. In the survivors, the daily fluid balance was positive from day 1 to day 3, and then gradually became negative from day 4 to day 7, whereas daily fluid balance was continuously positive in the non-survivors. Using the cumulative fluid balance from day 1–4 as a cut-off point, we found that a negative cumulative day 1–4 fluid balance was associated with a lower 30-day mortality rate (log-rank test, P = 0.003). To evaluate the impact of shock on this association, we divided the patients into shock and non-shock groups. The positive correlation between negative day 1–4 fluid balance and mortality was significant in the non-shock group (log-rank test, P = 0.008), but not in the shock group (log-rank test, P = 0.396). In a multivariate Cox proportional hazard regression model adjusted for age, sex, cerebrovascular disease, and PaO2/FiO2, day 1–4 fluid balance was independently associated with a higher 30-day mortality rate (aHR 1.088, 95% CI: 1.007–1.174). Conclusions A negative day 1–4 cumulative fluid balance was associated with a lower mortality rate in critically ill patients with influenza. Our findings indicate the critical role of conservative fluid strategy in the management of patients with complicated influenza.

Background/Purpose: Nemonoxacin is a novel nonfluorinated quinolone with excellent in vitro activity against most pathogens in community-acquired pneumonia (CAP), especially Gram-positive isolates. The purpose of this study was to assess the efficacy and safety of nemonoxacin compared with levofloxacin in patients with CAP. Methods: A phase 3, multicenter, randomized (2:1) controlled trial was conducted in adult CAP patients receiving nemonoxacin 500 mg or levofloxacin 500 mg orally once daily for 7–10 days. Clinical, microbiological response and adverse events were assessed. Non-inferiority was determined in terms of clinical cure rate of nemonoxacin compared with that of levofloxacin in a modified intention-to-treat (mITT) population. NCT registration number: NCT01529476. Results: A total of 527 patients were randomized and treated with nemonoxacin (n = 356) or levofloxacin (n = 171). The clinical cure rate at test-of-cure visit was 94.3% (300/318) for nemonoxacin and 93.5% (143/153) for levofloxacin in the mITT population [difference (95% CI), 0.9% (−3.8%, 5.5%)]. The microbiological success rate was 92.1% (105/114) for nemonoxacin and 91.7% (55/60) for levofloxacin in the bacteriological mITT population [difference (95% CI), 0.4% (−8.1%, 9.0%)]. The incidence of adverse events (AEs) was comparable between nemonoxacin (33.1%, 118/356) and levofloxacin (33.3%, 57/171) (P > 0.05). Conclusion: Nemonoxacin 500 mg once daily for 7–10 days is as effective and safe as levofloxacin for treating adult CAP patients in terms of clinical cure rates, microbiological success rates, and safety profile.ClinicalTrials.gov identifier: NCT01529476. Keywords: Clinical outcome, Community-acquired pneumonia, Levofloxacin, Nemonoxacin, Randomized controlled trial, Safety

Stanniocalcin-1 (STC1) is an endogenous glycoprotein whose anti-inflammatory effects occur through induction of uncoupling proteins to reduce oxidative stress. In this study, we tested the hypothesis that exogenous recombinant human STC1 (rhSTC1) protects against lipopolysaccharide (LPS)-induced acute lung injury in mice. Anesthetized C57BL/6 mice underwent intratracheal spraying of LPS (20 µg/10 g body wt), and lung injury was assessed 24h later by analyzing pulmonary edema, bronchoalveolar lavage fluid, and lung histopathology. Lung inflammation, oxidative stress, and expression of STC1 and its downstream uncoupling protein 2 (UCP2) were analyzed at specific time points. Expression of UCP2 was suppressed initially but was subsequently upregulated after STC1 elevation in response to intratracheal administration of LPS. Intratracheal rhSTC1 treatment 1h before or after LPS spraying significantly attenuated pulmonary inflammation, oxidative stress, cell apoptosis, and acute lung injury. Pretreatment with STC1 short interfering RNA 48 h before LPS spraying inhibited the expression of STC1 and UCP2 and significantly increased the extent of lung injury. These findings suggest that STC1 is an endogenous stress protein that may counteract LPS-induced lung injury by inhibiting the inflammatory cascade and inducing antioxidant and antiapoptotic mechanisms. However, the potential clinical application of STC1 and the direct linkage between UCP2 and LPS-induced lung injury remain to be further investigated.

Aims and objectives To explore health literacy status in asthma patients and to examine the causal model linking health literacy to health outcome–related factors via mediator and moderator variables. Background Understanding how low health literacy may influence health outcomes is important. Design This is a cross-sectional survey study. Methods A total of 326 asthma patients aged 20 years and older (average: 51 ± 18·3 years) were recruited by purposive sampling from pulmonary medicine outpatient departments at three medical centres and a regional teaching hospital in northern Taiwan. Data were collected via structured questionnaires, including measures of socio-demographic and disease characteristics; medical decision-making; asthma knowledge, attitudes and self-efficacy; healthcare experience and health outcome–related factors (metered-dose inhaler/dry-powder inhaler usage proficiency, medical use, self-management behaviour). Three hundred patients who met the inclusion criteria and completed the questionnaire survey were analysed. Results Overall, 217 subjects (72·3%) had adequate functional health literacy, 42 (14%) had inadequate functional health literacy, and 41 (13·7%) had marginal functional health literacy. Subjects' average asthma knowledge, attitudes and self-efficacy scores were 7·23 ± 2·69, 51·46 ± 6·18 and 58·31 ± 8·10, respectively. Health literacy correlated positively with asthma knowledge (r = 0·605), attitudes (r = 0·192) and medical decision-making (r = 0·413). Conclusions Health literacy is positively associated with proficiency in metered-dose inhaler usage, asthma knowledge, attitudes and medical decision-making, but is not significantly associated with medical care use and self-management behaviour. Health literacy had an indirect effect on self-management behaviour through the mediation effect of asthma attitudes. No moderator was found for the effect of health literacy on health outcome–related factors. Relevance to clinical practice Results of this study may help to develop adequate intervention strategies to improve the health outcomes of asthma patients.

Earlier studies have demonstrated an association between N-acetyltransferase 2 (NAT2) catalytic activity and the genotype of a recently published tag single nucleotide polymorphism (SNP), rs1495741. There have been no reports on the relationship between the rs1495741 genotype and antituberculosis drug-induced hepatotoxicity (ATDIH) to date.The aim of the present study was to determine the frequency of the NAT2 tag SNP (rs1495741) in the Taiwanese and its relation to the incidence of ATDIH.A total of 348 tuberculosis patients were enrolled to determine the frequency of NAT2 tag SNP rs1495741 and its relation to the incidence of ATDIH. The conventional NAT2 variants alleles have also been investigated. Furthermore, to evaluate the correlation of NAT2 activity and rs1495741 genotypes, a pharmacokinetic study of isoniazid was also conducted in healthy volunteers.Among the 348 tuberculosis patients, 20 (5.7%) were diagnosed with ATDIH. The frequencies of the three rs1495741 genotypes, viz., AA, AG, and GG, were 24.7, 52.3, and 23.0%, respectively. Signifilig;cant differences among rs1495741 genotypes and susceptibility to hepatotoxicity were noted (odds ratio=14.068, P0.05). Moreover, the rs1495741 genotypes showed an association with the isoniazid dosage required for induction of hepatotoxicity. In the pharmacokinetic study, NAT2 activity was strongly associated with genotype categories (P0.001).The present study demonstrated that the three genotypes according to rs1495741 were in good accordance with conventional NAT2 alleles-inferred phenotypes and the tag SNP could be used as a proxy to determine the susceptibility to ATDIH.

Introduction Gastro-oesophageal reflux disease (GORD) is common among chronic obstructive pulmonary disease (COPD) patients and may have a deleterious effect on COPD prognosis. However, few studies have investigated whether GORD increases the risk of severe outcomes such as intensive care unit (ICU) admittance or mechanical ventilator use among COPD patients. Methods Propensity score matching by age, sex, comorbidities and COPD severity was used to match the 1,210 COPD patients with GORD sourced in this study to 2,420 COPD patients without GORD. The Kaplan-Meier method was used to explore the incidence of ICU admittance and machine ventilation with the log rank test being used to test for differences. Cox regression analysis was used to explore the risk of ICU admittance and mechanical ventilation use for patients with and without GORD. Results During the 12-month follow-up, GORD patients and non-GORD patients had 5.22 and 3.01 ICU admittances per 1000 person-months, and 4.34 and 2.41 mechanical ventilation uses per 1000 person-month, respectively. The log rank test revealed a difference in the incidence of ICU admittance and machine ventilation between the two cohorts. GORD was found to be an independent predicator of ICU admittance (adjusted hazard ratio (HRadj) 1.75, 95% confidence interval (CI) 1.28-2.38) and mechanical ventilation (HRadj 1.92, 95% CI 1.35-2.72). Conclusion This is the first investigation to detect a significantly higher incidence rate and independently increased risk of admission to an ICU and mechanical ventilation use among COPD patients who subsequently developed GORD during the first year following their GORD diagnosis than COPD patients who did not develop GORD.

BACKGROUND: Adaptive support ventilation (ASV) facilitates ventilator liberation in postoperative patients in surgical intensive care units (ICU). Whether ASV has similar benefits in patients with acute respiratory failure is unclear. METHODS: We conducted a pilot study in a medical ICU that manages approximately 600 mechanically ventilated patients a year. The ICU has one respiratory therapist who manages ventilators twice during the day shift (8:00 am to 5:00 pm). No on-site respiratory therapist was present at night. We prospectively enrolled 79 patients mechanically ventilated for ≥ 24 hours on pressure support of ≥ 15 cm H2O, with or without synchronized intermittent mandatory ventilation, FIO2 ≤ 50%, and PEEP ≤ 8 cm H2O. We switched the ventilation mode to ASV starting at a “%MinVol” setting of 80–100%. We defined spontaneous breathing trial (SBT) readiness as a frequency/tidal-volume ratio of < 105 (breaths/min)/L on pressure support of ≤ 8 cm H2O and PEEP of ≤ 5 cm H2O for at least 2 h, and all spontaneous breaths. The T-piece SBT was considered successful if the frequency/tidal-volume ratio remained below 105 (breaths/min)/L for 30 min, and we extubated after successful SBT. The control group consisted of 70 patients managed with conventional ventilation modes and a ventilator protocol during a 6-month period immediately before the ASV study period. RESULTS: Extubation was attempted in 73% of the patients in the ASV group, and 80% of the patients in the non-ASV group. The re-intubation rates in the ASV and non-ASV groups were 5% and 7%, respectively. In the ASV group, 20% of the patients achieved extubation readiness within 1 day, compared to 4% in the non-ASV group ( P =

BACKGROUND Limited evidence is available on the use of budesonide inhalation suspension (BIS) for the treatment of mild to severe acute asthma exacerbations (AAE) in adults in an inpatient setting. This study was conducted to evaluate the efficacy of a five-day course of BIS compared with oral prednisolone (OP) in the management of adults with AAE. METHODS A retrospective study examined the response of 28 patients hospitalized with mild to severe acute asthma exacerbation from January 2003 to December 2003. These patients, who were steroid free ≥ 1 yr, were administered a five-day course of BIS (2 × 2 mg bid) or OP (2 × 15 mg bid). PEF, FEV(1) and asthma symptom scores were recorded daily. RESULTS The BIS (n = 13) and OP (n = 15) treatment groups were comparable at baseline for demographic characteristics and prebronchodilator (fenoterol) FEV(1) of 52.4% predicted normal value and 54.6% predicted normal value, respectively. Mean change of morning PEF was 152 L/min during BIS treatment and 130 L/min for OP treatment; the mean changes of morning forced expiratory volumes in 1 s (FEV(1)) were 1.0 and 0.7 L, respectively. The mean change in daytime symptom scores were -1.6 and -1.3 in the BIS and the OP groups, respectively. Improvements in PEF, FEV(1) and daytime symptom scores were significantly different between baseline and after treatment in each treatment group (p < 0.05). However, improvements in both BIS and OP groups were similar. CONCLUSION Budesonide inhalation suspension may be an alternative treatment of acute asthma exacerbation in adults who are at risk for systemic corticosteroids.

Removing the artificial airway is the last step in the mechanical ventilation withdrawal process. In order to assess cough effectiveness, a critical component of this process, we evaluated the involuntary cough peak flow (CPFi) to predict the extubation outcome for patients weaned from mechanical ventilation in ICUs.One hundred fifty patients were weaned from ventilators, passed a spontaneous breathing trial (SBT), and were judged by their physician to be ready for extubation in the Tri-Service General Hospital ICUs from February 2003 to July 2003. CPFi was induced by 2 mL of normal saline solution at the end of inspiration and measured using a hand-held respiratory mechanics monitor. All patients were then extubated.Of 150 enrolled patients for this study, 118 (78.7%) had successful extubation and 32 (21.3%) failed. In the univariate analysis, there were higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores (16.0 vs 18.5, P = .018), less negative maximum inspiratory pressure (-45.0 vs -39.0, P = .010), lower cough peak flows (CPFs) (74.0 vs 42.0 L/min, P.001), longer postextubation hospital stays (15.0 vs 31.5 days, P.001), and longer postextubation ICU stays (1.0 vs 9.5 days, P.001) in the extubation failures compared with the extubation successes. In the multivariate analysis, we found that a higher APACHE II score and a lower CPF were related to increasing risk of extubation failure (odds ratio [OR] = 1.13; 95% CI, 1.03-1.25; and OR = 0.95; 95% CI, 0.93-0.98, respectively). The receiver operator characteristic curve cutoff point for CPF was 58.5 L/min, with a sensitivity of 78.8% and specificity of 78.1%.CPFi as an indication of cough reflex has the potential to predict successful extubation in patients who pass an SBT.

Mycobacterium tuberculosisinfection is a major world health issue. The early identification of patients at risk for a poor response to anti-M. tuberculosistherapy would help elucidate the key players in the anti-M. tuberculosisresponse. The objective of the present study was to correlate the modulation of cytokine expression (interleukin-1 [IL-1], IL-6, IL-8, IL-10, IL-12, gamma interferon [IFN-γ], interferon-inducible protein [IP-10], and monocyte chemotactic protein 1 [MCP-1]) with the clinical response to 2 months of intensive therapy. From January to December 2007, 40M. tuberculosis-infected patients and 40 healthy patients were recruited. After exclusion for diabetes, 32 patients and 36 controls were analyzed. The clinical responses of theM. tuberculosis-infected patients on the basis of the findings of chest radiography were compared to their plasma cytokine levels measured before and after 2 months of intensive anti-M. tuberculosistherapy and 6 months of therapy with human cytokine antibody arrays. Chest radiographs of 20 of 32M. tuberculosis-infected patients showed improvement after 2 months of intensive therapy (early responders), while theM. tuberculosisinfections in 12 of 32 of the patients resolved after a further 4 months (late responders). The levels of expression of TNF-α, MCP-1, IFN-γ, and IL-1β were decreased; and the level of IL-10 increased in early responders. After adjustment for age, gender, and the result of sputum culture forM. tuberculosis, significant differences in the levels of MCP-1 and IP-10 expression were observed between the early and the late responders after 2 months of intensive anti-M. tuberculosistherapy. Due to the interpatient variability in IP-10 levels, intrapatient monitoring of IP-10 levels may provide more insight into theM. tuberculosisresponder status than comparison between patients. Plasma MCP-1 levels were normalized in patients who had resolved theirM. tuberculosisinfections. Further studies to evaluate the association of the modulation in MCP-1 levels with early and late responses are warranted.

1. Glutamine is an amino acid that is used to treat various diseases. Glutamine has been reported to have protective effects in human pulmonary epithelia-like cells exposed to hyperoxia. However, the effects of glutamine in hyperoxia-induced lung injury have not been investigated in vivo. 2. Mice treated with saline or glutamine [(750 mg/kg) intravenously] were randomly exposed to hyperoxia for 48 or 72 h. Control mice treated with saline or glutamine were exposed to room air. Cytokine levels in bronchoalveolar lavage fluid (BALF), heat shock protein (HSP) 70, the wet/dry (W/D) weight ratio, malondialdehyde (MDA) levels, myeloperoxidase (MPO) activity and pathoglogical findings in lung tissue were evaluated to determine the effects of glutamine on acute lung injury. In addition, survival was monitored. 3. Lung expression of HSP70 was significantly enhanced in both the control (room air) and 48 and 72 h hyperoxic glutamine-treated mice. The W/D ratio, BALF concentrations of tumour necrosis factor-alpha and interleukin-6, MDA levels, MPO activity, neutrophil infiltration and interstitial oedema in lung tissue were significantly lower at 48 and 72 h of hyperoxia in glutamine-treated mice compared with saline-treated mice. 4. In a separate series of experiments evaluating survival, after 96 h continuous exposure to hyperoxia, all saline-treated mice died. In contrast, all glutamine-treated mice died after 108 h exposure to hyperoxia. 5. The data suggest that glutamine administered to mice during hyperoxia has a protective effect against hyperoxia-induced acute lung injury and improves survival.

Background Acute respiratory distress syndrome (ARDS) associated with pulmonary lipiodol embolism is a rare complication of transcatheter arterial chemoembolization (TACE). We performed a survey of ARDS associated with pulmonary lipiodol embolism after TACE. Methods A retrospective analysis of the cases of all patients with hepatic tumors who received transcatheter arterial embolization or TACE between January 2006 and December 2006 was performed. The diagnosis of pulmonary lipiodol embolism was confirmed by chest computed tomography (CT). Results The diagnosis of ARDS associated with pulmonary lipiodol embolism was confirmed in 4 patients. All had large (≥ 5 cm) and hypervascular tumors. There was no evidence of hepatocellular carcinoma arteriovenous shunting in any of our patients as determined by angiography and multidetector CT. The volumes of lipiodol infused in the 4 patients were 50, 20, 30, and 20 mL. Only 2 patients received injections of carcinostatic agents. The onset of respiratory symptoms occurred between 1 hour and 4 days after TACE. Respiratory symptoms consisted of dyspnea and tachypnea. Chest CT scans revealed linear high-density shadows, suggestive of lipiodol retention in both lungs of all patients. Conclusion Pulmonary lipiodol embolism after TACE can occur within a short time frame. Whether or not there is intrahepatic arteriovenous shunting detected by multidetector CT and angiography, clinicians should avoid high doses of iodized oil and carcinostatic agents. We suggest that CT should be used for the diagnosis of pulmonary lipiodol embolism.

Hyperglycemia and hypoxia synergistically retard diabetic wound healing. We investigated the direct effect of hyperbaric and normobaric hyperoxia on skin fibroblasts cultured in a high-glucose medium. Detroit 551 human dermal fibroblasts cultured in Dulbecco's modified Eagle's medium containing d-glucose had reduced cell survival compared with cells grown in normal glucose medium; survival was 27.5+/-3.8% lower in 25 mM glucose and 30.6+/-3.7% lower in 50 mM glucose. Cell survival decreased because of inhibition of cell proliferation and enhanced cell death. Daily hyperbaric oxygen therapy at 2.5 atmosphere absolute for 90 minutes on 3 consecutive days reduced cell proliferation and increased cell death in normal cultured fibroblasts. Hyperbaric oxygen therapy and high-glucose medium had a synergistic effect and reduced survival by 37.6+/-4.4% (25 mM glucose) and 39.6+/-5.1% (50 mM glucose). The effects of hyperbaric oxygen and high-glucose medium were associated with overproduction of reactive oxygen species. Our results suggest that direct exposure of skin fibroblasts to hyperbaric oxygen affects cell growth and superimposes the toxic effect of high glucose. This cytotoxicity may be related to the production of reactive oxygen species in the fibroblasts.

There has been no human epidemiological data regarding the hepatic injuries of hexachloroethane–zinc oxide (HC/ZnO) inhalation. This is the first epidemiological study to investigate whether HC/ZnO inhalation exposure can induce hepatic dysfunction in exposed soldiers. Twenty soldiers, exposed to high concentration of HC/ZnO smoke for 3–10 min in a narrow tunnel (0.6 m in width) during military training, were recruited as exposed group and they were divided into high-exposed group (n = 10) and low-exposed group (n = 10) by the distance from the explosion locale as a surrogate of exposure condition. Another 64 soldiers, not visiting the explosion areas, were recruited as referents. Venous blood was collected for liver function analyses. After log transformation of alanine aminotransferase (ALT) and adjustment for potential confounders, serum ALT in high-exposed soldiers was statistically significantly higher than those of referents for the 3 weeks following exposure. The serum ALT in low exposed soldiers was statistically significantly higher than those of referents at the 3rd week following exposure. The mean ALT levels also showed decreasing gradients by the distance from exposure locale. In addition, the proportions of abnormality on ALT (>40 U/L) were also significantly different among three exposure conditions. Follow-up study showed that the hepatic dysfunction started from 1 to 2 weeks and peaked from 3rd to 5th week after exposure. ALT level was then returned to normal within 6–8 weeks after removing from HC/ZnO smoke exposure. No sequelas in hepatic dysfunction were found until 72 weeks follow-up. Conclusion: We concluded that inhalation of HC/Zn smoke can induce acute, dose-dependent and definite temporal relationship hepatic dysfunction.

The purpose of this study was to investigate an outbreak of tuberculosis (TB) in a bacillus Calmette-Guérin-vaccinated military population and propose an appropriate method of control. We divided 593 subjects into "close contacts" and "non-close contacts" of an index case and examined all subjects by chest X-radiography (CXR). For "close contacts," we performed several tests for patients with abnormal CXRs. "Non-close contacts" had no pulmonary infiltration and no evidence of TB. We administered tuberculin skin tests (TST) to 21 "close contacts" who had pulmonary infiltrations. Seven patients had a TSTor =18 mm, two of whom had active pulmonary TB. We administered antituberculous agents to all seven patients for 6 months. Fourteen subjects with TSTs18 mm had no evidence of TB during the 18-month follow-up period. Among the other 178 "close contact" subjects with no infiltrations evident on the initial CXR, one patient developed TB pleuritis. We conclude that it is important to use early treatment for "close contacts" of a TB index case by performing the TST and testing for pulmonary infiltration on CXRs.

Background: Obstructive sleep apnea (OSA) and gout are associated with coronary heart disease (CHD). Interrelationship between these diseases is rarely discussed in the literature. This study investigated whether gout increased CHD risk in OSA patients. Methods: Random samples of 1 million individuals were collected from Taiwan9s National Health Insurance database from 2000 to 2010. Total 717 OSA patients with gout were matched without gout OSA patients by a 1:1 propensity score method, matching by age, sex, comorbidities and socioeconomic status. The Kaplan-Meier method was used to explore the incidence of CHD with the log rank test being used to test for differences. Cox regression analysis was used to explore the risk of CHD for patients with and without gout. Results: During the 10-year follow-up period, OSA patients with gout or not had 39.55 and 26.20 CHD per 1000 person-years respectively (p = 0.0002). Following adjustment for sex, age, hypertension, diabetes mellitus, hyperlipidemia, arrhythmia, chronic obstructive pulmonary disease, and obesity, Cox regression analysis revealed a difference in the incidence of CHD between the two cohorts. Gout demonstrated an increased risk of CHD in OSA patients (adjusted HR 1.55, 95% CI 1.25-1.93). Conclusion: OSA patients with gout had a significantly higher risk of CHD compared with patients without gout.

Background: Due to the non-adherence after the training program, the benefits of pulmonary rehabilitation (PR) in patients with COPD might fade away with time. Accordingly, a psychological intervention is indispensable for improving the adherence of PR exercise. Objectives: To test the effectiveness of combined a biofeedback with PR on improving adherence to regular exercise and the quality of life in patients with COPD. Methods: This is a randomized controlled trial. Thirty-six subjects were recruited from a medical center in Taiwan, and were randomly assigned to usual care, PR alone, or combined PR and biofeedback group. All subjects received twice a week supervised hospital training and a weekly unsupervised home training for four weeks. Psychophysiological indices were measured at pre-, post-training, and 3-month follow-up. Results: Combined PR and biofeedback group had significantly higher adherence to regular exercise at 3 months follow-up than the other two groups (χ2 =12.6, p= 0.01). Both PR alone and combined PR and biofeedback groups showed significantly improve 6MWD at 3-month follow-up (p Conclusion: PR exercise can improve exercise tolerance and quality of life for COPD patients. Integrated biofeedback with PR exercise can further improve adherence to regular exercise and physical component of quality of life.

Study objectives Zinc chloride smoke inhalation injury (ZCSII) is uncommon and has been rarely described in previous studies. We hypothesized that structural changes of the lung might correlate with pulmonary function. To answer this question, we correlated findings from high-resolution CT (HRCT) scan and the results of pulmonary function tests (PFTs) in patients with ZCSII. Design Retrospective cohort study. Setting University hospital. Patients Twenty patients who had been hospitalized with ZCSII-related conditions. Measurements The study included HRCT scan scores (0 to 100), static and dynamic lung volumes, and diffusing capacity of the lung for carbon monoxide (Dlco). Results HRCT scans and PFTs were performed initially after injury (range, 3 to 21 days) in all patients and during the follow-up period (range, 27 to 66 days) in 10 patients. The predominant CT scan findings were patchy or diffuse ground-glass opacities with or without consolidation. The majority of patients showed a significant reduction of FVC, FEV 1 , total lung capacity, and Dlco, but normal FEV 1 /FVC ratio values. Changes of functional parameters correlated well with HRCT scan scores. Substantial improvements in CT scan abnormalities and pulmonary function were observed at follow-up. Conclusions The majority of our patients with ZCSII presented with a predominant parenchymal injury of the lung that was consistent with a restrictive type of functional impairment and a reduction in Dlco rather than with obstructive disease. Our results suggest that HRCT scanning and pulmonary function testing may reliably predict the severity of ZCSII.

Background: Asthma has rarely been studied by evaluating all of its trigger factors in 1 study population. Thus, correlations between the concentration of allergen immunoglobulin (Ig) E antibodies and airway limitation or asthma severity remain unclear. Methods: Five hundred and seventy-nine asthmatic patients were enrolled, and serum specific IgE antibodies to allergens were analyzed. All suspected trigger factors were assessed by questionnaire, case histories over a 4-year period, and diary card recordings; possible trigger factors were then re-evaluated. Results: Antibodies to the following allergens were found: Dermatophagoides pteronyssinus (59.8% of patients), D. microceras (58.8%), D. farinae (56.8%), cockroach (38.3%), dog dander (26.3%), Candida albicans (13.3%), cat dander (10%), and Cladosporium herbarum (6.6%). A greater prevalence of allergy to dog and cat dander was found than previously. Younger patients were more often positive for mite allergens, and had higher titers of antibodies against such allergens, than older patients. Further, females had a lower concentration of mite allergen antibodies than males. No correlation between the concentration of allergen antibodies and forced expiratory volume in 1 second (FEV 1 ), or the ratio of FEV 1 :forced vital capacity (FEV 1 :FVC), was found. In addition, there was no significant change in antibody titers with varying asthma severity. Non-allergenic trigger factors were irritant air inhalants (94.6% of patients), respiratory infection (92.2%), exercise (75.2%), emotional factors (58.8%), drugs and chemical substances (16%). Conclusion: There are multiple trigger factors in asthma. Allergenic trigger factors are more common in younger than older patients, whereas non-allergenic trigger factors are more common in older patients. There was no linear correlation between the concentration of specific IgE antibodies and asthma severity or airway limitation; therefore, to prevent asthma attacks in individual asthmatic patients, greater attention should be paid to avoiding all potential trigger factors, and not just house dust mite allergens. [J Chin Med Assoc 2005;68(5):204‐209]

Objectives: Chest ultrasonography is a useful diagnostic tool for the detection of pleural effusions of different etiologies. Our purpose was to determine whether the echogenic swirling pattern identifiable on real-time chest ultrasonographic images is a predictor of malignant pleural effusions in patients with malignancies. Design: Medical records of patients undergoing chest ultrasonography in the Tri-Service General Hospital (Taiwan) between January 2000 and December 2002 were reviewed retrospectively. Patients with an echogenic swirling pattern in the pleural effusion, or with malignant diseases associated with pleural effusions, whose pleural fluids had been examined cytologically or whose pleural tissues had been examined pathologically, were enrolled in this study (n 140). Malignant pleural effusions were defined by the presence of malignant cells in the pleural fluid identified by thoracentesis or by pleural biopsy. The echogenic swirling pattern was defined as numerous echogenic floating particles within the pleural effusion, which swirled in response to respiratory movement or heartbeat. Correlation between malignant pleural effusions and the echogenic swirling pattern was compared in patients with an underlying malignant disease. Results: In patients with underlying malignancies, malignant pleural effusions were diagnosed in 81.8% of patients with a positive echogenic swirling pattern and in 48% of those with no echogenic swirling pattern. The presence of echogenic swirling was significantly more predictive of malignant pleural effusions than was the absence of echogenic swirling (p < 0.01). Conclusions: The echogenic swirling pattern is a useful predictor of possible malignant pleural effusions, and may be a good marker for malignant pleural effusions in patients with underlying malignancies. (CHEST 2004; 126:129 –134)

Pharmacological therapies targeting fulminant lung inflammation in acute lung injury (ALI) need to be improved. We evaluated the effect of thalidomide, a chemical modulating both acute and chronic inflammation, on ALI induced by intravenous administration of lipopolysaccharide (LPS) and zymosan in male Sprague-Dawley rats. Injection of LPS and zymosan induced significant lung inflammation, as evidenced by increased neutrophil sequestration in lung tissue as well as enhanced nitric oxide metabolite (NO(x)(-)) production in the serum and bronchoalveolar lavage (BAL) fluid. Lactate dehydrogenase (LDH) activity and protein concentration in BAL fluid were significantly increased after administration of LPS and zymosan. Pulmonary microvascular permeability was determined using the Evans blue retention method, which showed a significant increase in microvascular permeability after LPS and zymosan administration, indicating the development of ALI. Animals that received thalidomide (100 mg/kg) 2 h prior to LPS injection had significantly reduced pulmonary NO(x)(-) production, pulmonary microvascular permeability, and LDH activity and protein concentration in BAL fluid. We therefore conclude that thalidomide ameliorates lung inflammation and reduces ALI induced by combined LPS and zymosan administration in rats.

Oxygen therapy remains the main component of the ventilation strategy for treatment of patients with acute lung injury. Hyperbaric oxygen therapy (HBO(2)) is the intermittent administration of 100% oxygen at pressure greater than sea level and has been applied widely to alleviate a variety of hypoxia-related tissue injuries. The purpose of this study was to evaluate the effect of hyperbaric oxygen on acute lung injury induced by intratracheal spraying of lipopolysaccharide (LPS) in rats. Male Sprague-Dawley rats underwent implantation of a carotid artery catheter under general anesthesia. Aerosolized LPS was delivered twice into the lungs via intratracheal puncture. Animals were either breathing room air (n = 27) or subjected to hyperbaric oxygen (HBO(2)) exposure (n = 27) 1 h after LPS spraying. Acute lung injury was evaluated 5 h and 24 h later. Compared with the control group, intratracheal spraying of LPS caused profound hypoxemia, greater wet/dry weight ratio (W/D) of the lung (5.67 +/- 0.22 vs. 4.98 +/- 0.19), and higher protein concentration (1706 +/- 168 vs. 200 +/- 90 mg/L) and LDH activity (129 +/- 30 vs. 46 +/- 15, mAbs/min) in bronchoalveolar lavage (BAL) fluid. Intratracheal spraying of LPS also caused significant WBC sequestration in the lung tissue. HBO2 treatment significantly reverted hypoxemia, reduced lung injury measures evaluated at 5 and 24 h, and enhanced 24-h animal survival rate (chi = 5.08, P = 0.024). The malondialdehyde (MDA) concentrations in lung tissue and serum were both increased after LPS spraying. Neither single HBO(2) therapy nor five sequential daily treatments enhanced MDA production in lung tissue or serum. Our results suggested that hyperbaric oxygen might reduce acute lung injury caused by intratracheal spraying of LPS in rats. This treatment modality is not associated with enhancement of oxidative stress to the lung.