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Objective: The survival of prostate cancer (PC) patients after radiotherapy (RT) has improved over time, but it raises the debate of increased risk of secondary colorectal cancer (SCRC). This study aimed to assess whether RT for PC treatment increases the risk of SCRC in comparison with radical prostatectomy (RP). Methods: A population-based cohort of PC patients treated only with RT or only with RP between January 2007 and December 2015 was identified from the Taiwan Cancer Registry. The incidence rate of SCRC development was estimated using Cox regression model. Results: In this study, total 8,797 PC patients treated with either RT (n = 3,219) or RP (n =5,578). Patients subjected to RT were elder (higher percentage of 70≧years, p < 0.0001) and more advanced clinically (stage III: 22.90% vs. 11.87%; stage IV: 22.15% vs. 13.80%, p < 0.0001), compared to those subjected to RP. More patients subjected to RT had a much higher percentage of autoimmune disease (22.34% vs. 18.75%, p < 0.0001) and osteoarthritis and allied disorders (16.31% vs. 12.98%, p < 0.0001). Besides, RT patients had a higher percentage of underlying Crohn's disease (0.25% vs. 0.05%, p = 0.0230). Although almost all selected factors were not statistically significant, they presented the positive risk of SCRC for those under RP compared with those among RT. Besides, for PC patients in clinical stage I and II, patients with RP may have borderline significantly protective effects of SCRC compared with those under RT (stage I, HR: 0.14; 95% C.I.:0.01-1.39; p = 0.0929; stage II, HR: 1.92; 95% C.I.:0.93-3.95; p = 0.0775). Kaplan-Meier curves for a 3-year-period, which demonstrated no statistical difference in the risk of SCRC free between PC patients undergoing RT and RP (p = 0.9766). Conclusion: Whether or not pelvic RT for PC is associated with an increased risk for SCRC on a population-based level remains a matter of considerable debate. From a clinical perspective, these PC survivors should be counseled accordingly and received continued cancer surveillance with regular colonoscopy follow-up.

Background Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. Method This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH Results We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. Conclusions Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

It has been acknowledged that excess body weight increases the risk of colorectal cancer (CRC), however, there is little evidence on the impact of body mass index (BMI) on CRC patients’ long-term oncologic results in Asian populations. We studied the influence of BMI on overall survival (OS), disease-free survival (DFS), and CRC-specific survival rates in CRC patients from the administrative claims datasets of Taiwan using the Kaplan–Meier survival curves and the log-rank test to estimate the statistical differences among BMI groups. Underweight patients (&lt, 18.50 kg/m2) presented higher mortality (56.40%) and recurrence (5.34%) rates. Besides this, they had worse OS (aHR:1.61, 95% CI: 1.53–1.70, p-value: &lt, 0.0001) and CRC-specific survival (aHR:1.52, 95% CI: 1.43–1.62, 0.0001) rates compared with those of normal weight patients (18.50–24.99 kg/m2). On the contrary, CRC patients belonging to the overweight (25.00–29.99 kg/m2), class I obesity (30.00–34.99 kg/m2), and class II obesity (≥35.00 kg/m2) categories had better OS, DFS, and CRC-specific survival rates in the analysis than the patients in the normal weight category. Overweight patients consistently had the lowest mortality rate after a CRC diagnosis. The associations with being underweight may reflect a reverse causation. CRC patients should maintain a long-term healthy body weight.

Chronic obstructive pulmonary disease (COPD) is a chronic disease that burdens patients worldwide. This study aims to discover the burdens of health services among COPD patients who received palliative care (PC). Study subjects were identified as COPD patients with ICU and PC records between 2009 and 2013 in Taiwan&rsquo, s National Health Insurance Research Database. The burdens of healthcare utilization were analyzed using logistic regression to estimate the difference between those with and without cancer. Of all 1215 COPD patients receiving PC, patients without cancer were older and had more comorbidities, higher rates of ICU admissions, and longer ICU stays than those with cancer. COPD patients with cancer received significantly more blood transfusions (Odds Ratio, OR: 1.66, 95% C.I.: 1.11&ndash, 2.49) and computed tomography scans (OR: 1.88, 95% C.I.: 1.10&ndash, 3.22) compared with those without cancer. Bronchoscopic interventions (OR: 0.26, 95% C.I.: 0.07&ndash, 0.97) and inpatient physical restraints (OR: 0.24, 95% C.I.: 0.08&ndash, 0.72) were significantly more utilized in patients without cancer. COPD patients without cancer appeared to receive more invasive healthcare interventions than those without cancer. The unmet needs and preferences of patients in the life-limiting stage should be taken into consideration for the quality of care in the ICU environment.

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.

Kuang-Ming Liao,1 Yi-Chen Chen,2 Kuo-Chen Cheng,3 Jhi-Joung Wang,2 Chung-Han Ho2,4 1Department of Internal Medicine, ChiMei Medical Center, Chiali, Taiwan;2Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; 3Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; 4Department of Hospital and Health Care Administration, Chia Nan Universityof Pharmacy and Science, Tainan, Taiwan Objective: The objective of this study was to investigate the trends in COPD patients admitted to the intensive care unit (ICU) in Taiwan from 2003 to 2013. Patients and methods: A retrospective study was conducted to analyze the available data in the National Health Insurance Research Database compiled by the Taiwan Department of Health. We selected patients admitted to the ICU nationwide from 2003 to 2013. Patients older than 40years with a diagnosis of COPD were enrolled. The ICU admission date was used as the index date. Baseline comorbidities existing before the index date were identified. The comorbidities of interest included diabetes, hypertension, diabetes mellitus, coronary artery disease, stroke, dyslipidemia, cancer, and end-stage renal disease. Results: The number of COPD patients in the ICU increased from 12,384 in 2003 to 13,308 in 2013 (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.

The effect of early rehabilitation on the outcome of patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure (ARF) in intensive care units (ICUs) remains unclear. We examined the effect of early rehabilitation on the outcomes of COPD patients requiring mechanical ventilation (MV) in the ICU. This retrospective, observational, case–control study was conducted in a medical center with a 19-bed ICU. The records of all 105 ICU patients with COPD and ARF who required MV from January to December 2011 were examined. The outcomes (MV duration, rates of successful weaning and survival, lengths of ICU and hospital stays, and medical costs) were recorded and analyzed. During the study period, 35 patients with COPD underwent early rehabilitation in the ICU and 70 demographically and clinically matched patients with similar COPD stage, cause of intubation, type of respiratory failure, and levels of disease severity who had not undergone early rehabilitation in the ICU were selected as comparative controls. Multiple regression analysis showed that early rehabilitation was significantly negatively associated with MV duration. Early rehabilitation for COPD patients in the ICU with ARF shortened the duration of their MV.

The clinical impact of prior exposure to antibiotics on patients with tuberculosis (TB) is largely unknown. This study investigated the survival of patients with severe TB after exposure to a variety of antibiotics.A retrospective cohort study was conducted in TB patients with prior exposure to fluoroquinolones (FQs) (FQ group), to third-generation cephalosporins (CEPH group), and to third-generation penicillins (PCN group). To understand the impact of monotherapy with antibiotics on survival, patients with prior exposure to only moxifloxacin, ceftriaxone, or piperacillin were investigated.Patients in the FQ group (N= 401) had a significantly higher survival rate (82.5%) than patients in the CEPH (N = 210) and PCN (N = 172) groups (67.6% and 62.8%, respectively; both p 0.0001) at 180 d after TB diagnosis. Adjusted odds ratio (AOR) logistic regression analysis demonstrated that patients in the FQ group had significantly more favourable outcomes than those in the CEPH and PCN groups in terms of intensive care unit (ICU) admission rate (versus CEPH cohort: AOR, 1.70; 95% CI: 1.16-2.50; p = 0.0067, versus PCN cohort: AOR, 3.58; 95% CI: 2.42-5.29; both p 0.0001), mechanical ventilation rate (versus CEPH cohort: AOR, 1.70; 95% CI: 1.09-2.66; p = 0.0205, versus PCN cohort: AOR, 3.92; 95% CI: 2.54-6.05; both p 0.0001), and acute respiratory failure rate (versus CEPH cohort: AOR, 1.62; 95% CI: 1.07-2.45; p = 0.0223, versus PCN cohort: AOR, 4.29; 95% CI: 2.86-6.43; both p 0.0001). TB patients with prior exposure to moxifloxacin (N = 198) had a significantly higher survival rate (85.9%) than that of patients with exposure to ceftriaxone (N = 119) and piperacillin (N = 172) monotherapy (survival rates: 69.8% and 62.8%, respectively; both p 0.001).TB patients with prior exposure to FQs had more favourable outcomes compared with patients who had prior exposure to third-generation cephalosporins or third-generation penicillins. This study provides new insights into the impact of previous exposure to FQs on the survival of TB patients.

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

Background: This study aims to compare the impact of early and late post-discharge cardiopulmonary rehabilitation on the outcomes of intensive care unit (ICU) survivors. Methods: The retrospective, cohort study used a sub-database of the Taiwan National Health Insurance Research Database (NHIRD) that contains information of all patients had ICU admission between 2000 and 2012. Early group was defined if patients had received cardiopulmonary rehabilitation within 30 days after ICU discharge, and late group was define as if patients had received cardiopulmonary rehabilitation between 30 days and one year after ICU discharge. The end points were mortality and re-admission during the 3-year follow-up. Results: Among 2136 patients received cardiopulmonary rehabilitation after ICU discharge, 994 was classified early group and other 1142 patients were classified as late group. Overall, early group had a lower mortality rate (6.64% vs 10.86%, p = 0.0006), and a lower ICU readmission rate (47.8% vs 57.97%, p < 0.0001) than late group after 3-year follow-up. Kaplan-Meier analysis showed that early group had significantly lower mortality (p=0.0009) and readmission rate (p

Monitoring of trends in the use of the intensive care unit (ICU) and the outcomes of ICU patients is essential for the assessment of the effective use of ICU. This study aims to investigate the incidence and outcome of critical care admissions in Taiwan from 1997 to 2013.Patients18 years who had ICU admission between January 1997 and December 2013 were identified from the National Health Insurance Research Database in Taiwan. The main outcomes including ICU mortality and ICU length of stay (LOS) were measured.A total of 3,451,157 patients with ICU admission were identified during the study period. The mean ICU LOS was 5.9±9.0 days and the overall ICU-mortality rate was 19.8%. The mean age of the patients was 65.4 years old, 58.0% were elderly (≥65 years old), 61.1% were male. Annual incidence of ICU admissions increased from 115,754 in 1997 (age-adjusted incidence: 1,130/100,000 population) to 244,820 in 2013 (incidence: 1,483/100,000 population) (P0.0001). The admission rate was highest for patients 75-104 years old (8,074 per 100,000 population), and lowest for those 18-44 years old (298 per 100,000 population). Among ICU admission patients, the percentage of patients ≥75 years old significantly increased from 25.2% in 1997 to 38.3% in 2013 (P0.0001). ICU LOS remained stable during the study period, but the annual mortality rate significantly decreased from 23.0% in 1997 to 16.3% in 2013.ICU admissions significantly increased from 1997 to 2013, especially for elderly patients, in contrast, the mortality rate of ICU patients significantly declined with time. In addition, the ICU LOS did not change during the study period.

Adipokines play a role in carcinogenesis in a variety of malignancies. These findings were established with regard to serum adipokines and malignancies. However, the expression of adipokines in bone marrow fluid remains unclear, and an investigation of the correlation between bone marrow adipokines and hematological malignancy is needed. The present study was designed to detect adipokine concentrations, including adiponectin, leptin and resistin, in bone marrow interstitial fluid from patients with hematological malignancy and controlled counterparts. The correlations between adipokines, body mass index, clinical parameters, and hematological malignancy were assessed. A total of 80 bone marrow samples were assessed for values of adipokines, adiponectin, leptin and resistin. Patients with hematological malignancy had lower levels of adiponectin. Adiponectin from leukemia bone marrow expressed significantly low values. The adiponectin levels were inversely correlated with body mass index. In conclusion, adiponectin was decreased in bone marrow from patients with leukemia and negatively correlated with body mass index.

Background: Inhaled nitric oxide (iNO) is a potent selective pulmonary vasodilator, which is used in critically ill patients to improve oxygenation. It avoids systemic hypotension and ventilator-induced lung injury in patients using ventilators. This study explored the medical resource utilization and outcome, and predicted risk factors for mortality in patients using ventilators with iNO. Methods: The database was from the National Health Insurance hospital claims data in Taiwan from 2004 to 2009. The patients using ventilators with iNO were collected and stratified by age to 20–44 years, 45–64 years, 65–74 years, and ≥ 75 years. Results: Seven hundred and thirty ventilator patients with iNO were enrolled (63.15% male, mean age 60 years). Mechanical ventilation (MV) weaning rate was 18.25%, intensive care unit (ICU) readmission rate was 5.75%, and ICU mortality rate was 74.52%. ICU mortality rate was lower, case-mix index, MV weaning rate, and hospital costs were higher for patients aged 20–44 years and 45–64 years than in those aged 65–74 years and ≥ 75 years (p

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.

This retrospective, population-based cohort study aims to investigate the long-term risk of newly diagnosed dementia in patients discharged for acute respiratory failure that required mechanical ventilation (MV) and intensive care unit (ICU) admission. From the Taiwan National Health Insurance Research Database, first-time ICU patients using MV between June 1, 1998, and December 31, 2012, were enrolled, and they were followed-up until the earliest onset of one of our two endpoints: a new diagnosis of dementia (primary endpoint), or the end of the study. A total of 18,033 patients were enrolled and thirteen hundred eighty-seven patients had been newly diagnosed with dementia (mean onset: 3.2 years post-discharge). Patients ≥ 85 years old had the highest risk (multivariate analysis). Males had a lower risk than did females in both models (HR: 0.81, 95% CI: 0.72–0.9 in model 1; HR: 0.80, 95% CI: 0.72–0.89 in model 2). ICU stays > 5 days, hospital stays > 14 days, and more ICU readmissions were associated with a higher risk of developing dementia. In conclusion, the long-term risks of a subsequent diagnosis of dementia for acute respiratory failure with MV patients who survive to discharge increase with age and are higher in women than in men. Additionally, the longer the ICU or hospital stay is, and the more ICU readmissions a patient has, are both significantly associated with developing dementia.

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

We investigated whether N-terminal proB-type natriuretic peptide (NT-proBNP) predicts the prognosis of patients with acute respiratory distress syndrome (ARDS). Between December 1, 2012, and May 31, 2015, this observational study recruited patients admitted to our tertiary medical center who met the Berlin criteria for ARDS and who had their NT-proBNP measured. The main outcome was 28-day mortality. We enrolled 61 patients who met the Berlin criteria for ARDS: 7 were classified as mild, 29 as moderate, and 25 as severe. The median APACHE II scores were 23 (interquartile range [IQR], 18–28), and SOFA scores were 11 (IQR, 8–13). The median lung injury score was 3.0 (IQR, 2.50–3.25), and the median level of NT-proBNP was 2011 pg/ml (IQR, 579–7216). Thirty-four patients died during this study, and the 28-day mortality rate was 55.7%. Patients who die were older and had significantly (all p

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

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

This study aims to compare the impact of early and late post-discharge cardiopulmonary rehabilitation on the outcomes of intensive care unit (ICU) survivors. The retrospective, cohort study used a sub-database of the Taiwan National Health Insurance Research Database (NHIRD) that contained information of all patients had ICU admission between 2000 and 2012. Early group was defined if patients had received cardiopulmonary rehabilitation within 30 days after ICU discharge, and late group was define as if patients had received cardiopulmonary rehabilitation between 30 days and 1 year after ICU discharge. The end points were mortality and re-admission during the 3-year follow-up. Among 2136 patients received cardiopulmonary rehabilitation after ICU discharge, 994 was classified early group and other 1142 patients were classified as late group. Overall, early group had a lower mortality rate (6.64% vs. 10.86%, P = .0006), and a lower ICU readmission rate (47.8% vs. 57.97%, P

Summary Background The primary goal in critically ill patients who are mechanically ventilated is to wean from the ventilator. Higher weaning rates have been noted in patients undergoing mechanical ventilation following tracheostomy. The purpose of this study was to clarify the current status of tracheostomy execution in mechanically ventilated middle-aged and elderly patients. Methods Patients admitted to the intensive care unit (ICU) aged ≥ 45 years, mechanically ventilated on at least one occasion after undergoing tracheostomy, were included by using hospitalization registration records that had been submitted to the Bureau of National Health Insurance between March 2004 and February 2009. We analyzed the current status of tracheostomy execution and the risk factors for mortality. Results We enrolled a total of 453,939 patients ever using ventilators, with 29,128 of them (20,059 men and 9069 women) undergoing tracheostomies. The tracheostomy rate was 6.4% among patients who were mechanically ventilated. The mean age was 72 years. The mean RW value was 4.78. The mean ICU days, total hospital days, ventilator days, and mortality rate were highest in patients aged ≥ 75 years, followed by patients aged 65–74 years. The medical expenses were highest in patients aged 65–74 years, followed by those aged ≥ 75 years. The tracheostomy rate showed the strongest decline in patients aged ≥ 75 years, followed by patients aged 65–74 years. Sex, age, hospital level, the duration of mechanical ventilation, and medical and antibiotic expenses were identified as risk factors for mortality ( p Conclusions This study demonstrated that the utilization of medical resources and the decline in the number of tracheostomies performed were higher in patients aged ≥ 65 compared to patients under 65.

The aim of this study was to establish predictors for successfully planned extubation, which can be followed by medical personnel. The patients who were admitted to the adult intensive care unit of a tertiary hospital and met the following criteria between January 2005 and December 2014 were collected retrospectively: intubation > 48 hours; and candidate for extubation. The patient characteristics, including disease severity, rapid shallow breath index (RSBI), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), cuff leak test (CLT) before extubation, and outcome, were recorded. The CLT was classified as 2+ with audible flow without a stethoscope, 1+ with audible flow using a stethoscope, and negative (N) with no audible flow, even with a stethoscope. Failure to extubate was defined as reintubation within 48 hours. In total, 6583 patients were enrolled and 403 patients (6.1%) had extubation failures. Male patients dominated the patient cohort (4261 [64.7%]). The mean age was 64.5±16.3 years. The overall in-hospital mortality rate was 11.3%. The extubation failure rate for females was greater than males (7.7% vs 5.3%, P

The aims of this study were to investigate the outcomes of patients requiring prolonged mechanical ventilation (PMV) and to identify risk factors associated with its mortality rate. All patients admitted to the respiratory care centre (RCC) who required PMV (the use of MV ≥21 days) between January 2006 and December 2014 were enrolled. A total of 1,821 patients were identified; their mean age was 69.8 ± 14.2 years and 521 patients (28.6%) were aged >80 years. Upon RCC admission, the APACHE II scores were 16.5 ± 6.3 and 1,311 (72.0%) patients had at least one comorbidity. Pulmonary infection was the most common diagnosis (n = 770, 42.3%). A total of 320 patients died during hospitalization and the in-hospital mortality rate was 17.6%. A multivariate stepwise logistic regression analysis indicated that patients were more likely to die if they who were >80 years of age, had lower albumin levels (

The initial hypoxemic level of acute respiratory distress syndrome (ARDS) defined according to Berlin definition might not be the optimal predictor for prognosis. We aimed to determine the predictive validity of the stabilized ratio of partial pressure arterial oxygen and fraction of inspired oxygen (PaO2/FiO2 ratio) following standard ventilator setting in the prognosis of patients with ARDS. This prospective observational study was conducted in a single tertiary medical center in Taiwan and compared the stabilized PaO2/FiO2 ratio (Day 1) following standard ventilator settings and the PaO2/FiO2 ratio on the day patients met ARDS Berlin criteria (Day 0). Patients admitted to intensive care units and in accordance with the Berlin criteria for ARDS were collected between December 1, 2012 and May 31, 2015. Main outcome was 28-day mortality. Arterial blood gas and ventilator setting on Days 0 and 1 were obtained. A total of 238 patients met the Berlin criteria for ARDS were enrolled, and they were classified as mild (n = 50), moderate (n = 125), and severe (n = 63) ARDS, respectively. Twelve (5%) patients who originally were classified as ARDS did not continually meet the Berlin definition, and a total of 134 (56%) patients had the changes regarding the severity of ARDS from Day 0 to Day 1. The 28-day mortality rate was 49.1%, and multivariate analysis identified age, PaO2/FiO2 on Day 1, number of organ failures, and positive fluid balance within 5 days as significant risk factors of death. Moreover, the area under receiver-operating curve for mortality prediction using PaO2/FiO2 on Day 1 was significant higher than that on Day 0 (P = 0.016). PaO2/FiO2 ratio on Day 1 after applying mechanical ventilator is a better predictor of outcomes in patients with ARDS than those on Day 0.

This study investigated the outcomes and the prognostic factors among the very elderly (patients ≥80 years old) requiring prolonged mechanical ventilation (PMV). Between 2006 and 2014, all of the very elderly patients of age 80 or more transferred to respiratory care center (RCC) of a tertiary medical center were retrospectively identified, and only patients who used mechanical ventilation (MV) for >3 weeks were included in this study. A total of 510 very elderly patients undergoing PMV were identified. The mean age of the patients was 84.3 ± 3.3 years, and it ranged from 80 to 96 years. Male comprised most of the patients (n = 269, 52.7%), and most of the patients were transferred to RCC from medical ICU (n = 357, 70.0%). The APACHE II scores on RCC admission was 17.6 ± 6.0. At least 1 comorbidity was found in 419 (82.2%) patients. No significant differences of gender, disease severity, diagnosis, dialysis, laboratory examinations, comorbidities, and outcome were found between octogenarians (aged 80–89) and nonagenarians (aged ≥ 90). The overall in-hospital mortality rate was 21.8%. In the multivariate analysis, patients who had APACHE II score ≥ 15(odds ratio [OR], 2.30, 95% confidence interval [CI], 1.36–3.90), or albumin ≤ 2 g/dL (OR, 3.92, 95% CI, 2.17–7.01) were more likely to have significant in-hospital mortality (P

The emergence of multidrug-resistant Salmonella isolates has created the need for new therapeutic agents. We evaluated the intracellular activity of four carbapenem compounds against clinical nontyphoid Salmonella (NTS) isolates in vitro and ex vivo . Subsequently, the efficacy of carbapenem treatment against selected Salmonella isolates in vivo was assessed using a murine peritonitis model. The MIC 50 and MIC 90 for doripenem, ertapenem, imipenem, and meropenem against 126 NTS isolates were found to be 0.062 and 0.062, 0.015 and 0.015, 0.5 and 1, and 0.031 and 0.031 μg/ml, respectively. The intracellular killing effect of ertapenem was sustained for 24 h and was superior to that of imipenem, meropenem, and doripenem; its effect was comparable to that of ceftriaxone. Ertapenem demonstrated an excellent pharmacokinetic profile with a percent time above the MIC of 75.5% and an area under the concentration-time curve/MIC ratio of 20,733. When peritoneal exudate cells were examined directly ex vivo from mice with Salmonella -induced peritonitis, cells from mice treated with ertapenem and ceftriaxone had intracellular and extracellular bacterial counts reduced 10 2 - to 10 4 -fold and exhibited killing effects similar to each other. The survival rates of mice inoculated with 1 × 10 5 and 10 6 CFU of a ceftriaxone-susceptible Salmonella isolate that were subsequently treated with ertapenem or ceftriaxone were 100% and 90%, respectively. When mice were inoculated with 5 × 10 4 and 10 5 CFU of a ceftriaxone-resistant and ciprofloxacin-resistant Salmonella isolate, mice treated with ertapenem had a higher survival rate than mice treated with ceftriaxone (70% versus 0% and 50% versus 0%, respectively; P < 0.001). Our results suggest that ertapenem is at least as effective as ceftriaxone in treating murine Salmonella infections and show that further clinical investigations on the potential use of ertapenem in treatment of human Salmonella infections are warranted.

BACKGROUND: The effectiveness of noninvasive ventilation (NIV) after extubation in preventing post-extubation respiratory failure is still controversial. METHODS: We conducted a prospective, multicenter randomized controlled study involving patients on mechanical ventilation for > 48 hours who tolerated a 2-hour spontaneous breathing trial and were subsequently extubated. The patients were randomized to NIV or standard medical therapy. Re-intubation rate within 72 hours was the primary outcome measure. Multivariable logistic regression analysis was used to determine predictors for extubation failure. RESULTS: We randomized 406 patients to either NIV (no. = 202) or standard medical therapy (no. = 204). The 2 groups had similar baseline clinical characteristics. There were no differences in extubation failure (13.2% in control and 14.9% in NIV), intensive care unit or hospital mortality. Cardiac failure was a more common cause of extubation failure in control than in NIV. There was no difference in rapid shallow breathing index (RSBI) in extubation failure patients between control (80) and NIV (73). When using data from all patients, we found Acute Physiology and Chronic Health Evaluation (APACHE II) scores (odds ratio [OR] 1.13, 95% CI 1.07–1.20, P < .001), maximal inspiratory pressure (OR 1.04, 95% CI 1.00–1.08, P = .03), and RSBI (OR 1.03, 95% CI 1.02–1.05, P < .001) to be predictors of extubation failure. Abundant secretions were the most common reason (35.1%) for extubation failure identified by attending physicians. CONCLUSIONS: Preventive use of NIV after extubation in patients who passed spontaneous breathing trial did not show benefits in decreasing extubation failure rate or the mortality rate.

Summary Background Weaning off the ventilator and removal of the endotracheal tube requires appropriate timing and supportive care in order to avoid reintubation. In this study, the incidence, outcome, and factors predictive of failed extubation (reintubation within 48 hours), as well as the associated mortality in critically ill patients on mechanical ventilation in the adult intensive care unit (ICU), were studied. Methods The medical records of all patients who experienced planned extubation in the ICUs of Chi-Mei Medical Center in 2008 were reviewed. The primary endpoints were factors predicting failed extubation and mortality. The secondary endpoint was the outcome of failed extubation. Results Among the 1794 patients experiencing planned extubation, 167 patients (9.3%) required reintubation within 48 hours. The overall mortality rate was 8.1%. Using multivariate analyses, the factors predicting failed extubation were age ≥65 years and medical patients. The predictors of mortality included age ≥65 years, higher Acute Physiology and Chronic Health Evaluation II scores, and failed extubation. The patients with failed extubation had significantly longer ICU and hospital stays (15.2 vs. 6.6 days, and 40.3 vs. 24.0 days, respectively), increased incidence of tracheostomy (21.6% vs. 1.5%), a higher hospital mortality (45.5% vs. 4.2%), and higher hospital costs (52.3 vs. 30.4×10 4 New Taiwan dollars) when compared with patients who had successful extubation. Conclusion Our study indicated that patients with failed extubation experienced significantly increased admission expenditure, increased tracheostomy rate, and higher hospital mortality. Advanced age should be considered an important risk factor for failed extubation and overall mortality when planning extubation in critically ill ICU patients.

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)

The rapid shallow breathing index (RSBI) is commonly used clinically for predicting the outcome of weaning from mechanical ventilation. We compared the RSBI and its predictive accuracies measured under 5 ventilatory strategies before weaning trials. Ninety-eight patients were included and divided into successful (n=71) and failed (n=27) groups based on their weaning outcomes. The RSBI was randomly measured when patients spontaneously breathed 21% O2 with no ventilator support (the control strategy) or were connected to ventilator breathing with 21% or 40% O2 and 0 or 5 cm H2O of continuous positive airway pressure (CPAP). We found that the RSBI values did not exhibit significant differences among the 4 ventilator strategies, but all were higher than that of the control; this remained valid in the non-chronic obstructive pulmonary disease (COPD) subgroup, but not in the COPD subgroup. Values of the area under the receiver operating characteristic curve of the RSBI for the 5 strategies were 0.51-0.62 with no significant difference between any 2 strategies. The incidences of adverse reactions (respiratory rateor =35 breaths/min or oxygen saturationor =89% foror =1 min) were relatively high for the 21% O2-0 and 5 cm H2O CPAP groups (20 patients each) and low for the 40% O(2)-5 cmH2O CPAP group (2 patients). We concluded that RSBI values increased with the use of a ventilator, but not with additional applications of 40% 02 and/or 5 cm H2O CPAP. Their accuracies for predicting weaning outcome were unaltered by any of these interventions, but the incidence of adverse reactions increased with the use of the ventilator and decreased with additional 40% O2 supplementation.

We report a 45-year-old woman of systemic lupus erythematosus (SLE) with thoracic empyema that was unusually infected by Mycobacterium tuberculosis (MTB), Nontuberculosis mycobacteria (NTM) concomitant with Nocardia asteroides. After a combined treatment of cotrimoxazole, clarithromycin and anti-tuberculosis drugs with a short-term of intravenous immunoglobulin (IVIG), the patient recovered from the critical illness. On the basis of the results in this case, we recommend a thorough survey of the probably concomitant infections of MTB and NTM in an immunocompromised patient with a known N. asteroid infection. In addition, an adjuvant intravenous immunoglobulin therapy may have beneficial effect in the control of infections in an SLE patient.

To determine whether treatment with corticosteroids decreases the incidence of postextubation airway obstruction in an adult intensive care unit.Clinical experiment.Adult medical and surgical intensive care unit of a teaching hospital.One hundred twenty-eight patients who were intubated for24 hrs with a cuff leak volume24% of tidal volume and met weaning criteria.: Patients were randomized into a placebo group (control, n = 43) receiving four injections of normal saline every 6 hrs, a 4INJ group (n = 42) receiving four injections of methylprednisolone sodium succinate, or a 1INJ group (n = 42) receiving one injection of the corticosteroid followed by three injections of normal saline. Cuff volume was assessed 1 hr after each injection, and extubation was performed 1 hr after the last injection. Postextubation stridor was confirmed by examination using bronchoscopy or laryngoscopy.The incidences of postextubation stridor were lower both in the 1INJ and the 4INJ groups than in the control group (11.6% and 7.1% vs. 30.2%, both p.05), whereas there was no difference between the two treated groups (p = .46). The cuff leak volume increased after the second and fourth injection in the 4INJ group and after a second injection in the 1INJ group compared with the control group (both p.05).A reduced cuff leak volume is a reliable indicator to identify patients at high risk to develop stridor. Treatment with a single or multiple injections of methylprednisolone can effectively reduce the occurrence of postextubation stridor.

UNLABELLED We tested the hypothesis that, under relatively low tidal volume (VT) mechanical ventilation, continuing lung decruitment induced by negative end-expiratory pressure (NEEP) would increase the lung cytokine response, potentially contributing to lung injury. Mouse lungs were excised and randomly assigned to one of 3 different ventilatory strategies: 1) the zero end-expiratory pressure group served as a control, 2) the NEEP7 group received a NEEP of -7.5 cm H(2)O, and 3) the NEEP15 group received a NEEP of -15 cm H(2)O. In all 3 groups, a VT of 7 mL/kg was used. After 2 h of ventilation, lung lavage fluid was collected for measurements of tumor necrosis factor-alpha, monocyte chemoattractant protein-1, and lactate dehydrogenase. Increases in plateau pressure before and after mechanical ventilation were significantly greater in the NEEP15 group compared with the zero end-expiratory pressure group or NEEP7 group. Lung compliance was decreased in the NEEP15 compared with the other two groups. Concentrations of tumor necrosis factor-alpha, monocyte chemoattractant protein-1, and lactate dehydrogenase in lung lavage were larger in the NEEP15 group than in the other groups. Atelectatic lung during repeated collapse and reopening of lung units accentuates the lung cytokine response that may contribute to lung injury even during relatively low VT mechanical ventilation. IMPLICATIONS Repeated closing and reopening of lung units induced by negative end-expiratory pressure resulted in lung inflammation and cell injury even under mechanical ventilation using a normal tidal volume. This finding may have clinical relevance in certain patients who are prone to atelectasis during mechanical ventilation.

We investigated failure predictors for the planned extubation of overweight (body mass index [BMI] = 25.0–29.9) and obese (BMI ≥ 30) patients. All patients admitted to the adult intensive care unit (ICU) of a tertiary hospital in Taiwan were identified. They had all undergone endotracheal intubation for > 48 h and were candidates for extubation. During the study, 595 patients (overweight = 458 [77%]); obese = 137 [23%]) with planned extubation after weaning were included in the analysis; extubation failed in 34 patients (5.7%). Their mean BMI was 28.5 ± 3.8. Only BMI and age were significantly different between overweight and obese patients. The mortality rate for ICU patients was 0.8%, and 2.9% for inpatients during days 1–28; the overall in-hospital mortality rate was 8.4%. Failed Extubation group patients were significantly older, had more end-stage renal disease (ESRD), more cardiovascular system-related respiratory failure, higher maximal inspiratory pressure (MIP), lower maximal expiratory pressure (MEP), higher blood urea nitrogen, and higher ICU- and 28-day mortality rates than did the Successful Extubation group. Multivariate logistic regression showed that cardiovascular-related respiratory failure (odds ratio [OR]: 2.60; 95% [confidence interval] CI: 1.16–5.80), ESRD (OR: 14.00; 95% CI: 6.25–31.35), and MIP levels (OR: 0.94; 95% CI: 0.90–0.97) were associated with extubation failure. We conclude that the extubation failure risk in overweight and obese patients was associated with cardiovascular system-related respiratory failure, ESRD, and low MIP levels.

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.

AIM To assessed the effect of liver cirrhosis (LC) on the poorly understood long-term mortality risk after first-ever mechanical ventilation (1-MV) for acute respiratory failure. METHODS All patients in Taiwan given a 1-MV between 1997 and 2013 were identified in Taiwan’s Longitudinal Health Insurance Database 2000. Each patient with LC was individually matched, using a propensity-score method, to two patients without LC. The primary outcome was death after a 1-MV. RESULTS A total of 16653 patients were enrolled: 5551 LC-positive (LC[Pos]) patients, including 1732 with cryptogenic LCs and 11102 LC-negative (LC[Neg]) controls. LC[Pos] patients had more organ failures and were more likely to be admitted to medical department than were LC[Neg] controls. LC[Pos] patients had a significantly lower survival rate (AHR = 1.38, 95%CI: 1.32-1.44). Moreover, the mortality risk was significantly higher for patients with non-cryptogenic LC than for patients with cryptogenic LC (AHR = 1.43, 95%CI: 1.32-1.54) and patients without LC (AHR = 1.56, 95%CI: 1.32-1.54). However, there was no significant difference between patients with cryptogenic and without LC (HR = 1.05, 95%CI: 0.98-1.12). CONCLUSION LC, especially non-cryptogenic LC, significantly increases the risk of death after a 1-MV.

Chronic kidney disease increases the risk for hip fractures. Hip fractures are associated with increased mortality, decreased quality of life, and higher economic burden. To determine whether dialysis modality is associated with a higher incidence of hip fractures in patients with end-stage renal disease (ESRD), we used the Taiwan National Health Insurance Research Database to examine the records of 51,473 patients who began dialysis between 1999 and 2005. The patients were followed until death, transplantation, dialysis cessation, or 31 December 2008. The follow-up period was (mean±SD) 4.14±2.48 years. The cumulative incidence rate of hip fracture was calculated using Kaplan-Meier methods. Predictors of hip fracture were determined using Cox models. During the study period, 1903 patients had a hip fracture. The overall incidence rate of hip fracture was 89.21/10,000 patient-years. Patients on hemodialysis (HD) had a 31% higher incidence of hip fracture than those on peritoneal dialysis (PD) (HR 1.31, 95% CI: 1.01-1.70). Patients ≥65 years old had more than 13 times the risk of a hip fracture than did those 18-44 years old (HR: 13.65; 95% CI: 10.12-18.40). Other factors that increased the risk of a hip fracture were a prior hip fracture (HR: 1.44; 95% CI: 1.15-1.80), osteoporosis (HR: 1.24; 95% CI: 1.07-1.45), DM (HR: 1.66; 95% CI: 1.51-1.83), and liver cirrhosis (HR: 1.37, 95% CI: 1.15-1.64). The overall in-hospital mortality rate was 3.2%. The cumulative survival rates after a hip fracture were 74.6% at one year and only 29.6% at seven years. Our findings supported the notion that being on HD is a risk for hip fracture. Additionally, old age, female gender, a prior hip fracture, osteoporosis, DM and liver cirrhosis were also risk factors for hip fracture in patients with ESRD and undergoing dialysis.

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.

Objectives: To investigate the clinical features, especially cancer-related complications, and short-term outcome of critically ill patients with head and neck cancer (HNC) in the medical intensive care unit. Methods: We reviewed 57 patients with a diagnosis of HNC in the medical intensive care unit (≥24 hours) of a tertiary-care medical center between January 1999 and December 2005. Results: Thirty-two (56.1%) patients had advanced cancers (stage III/IV), and 21 (36.8%) remained uncontrolled (ie, relapsed or progressive). Twenty-five (43.9%) patients had cancer-related complications, including airway obstruction, tumor bleeding, or wound infection. Among 47 (82.4%) patients with acute respiratory failure, 25.5% of them were caused by cancer-related life-threatening airway complications. After excluding 5 already tracheos-tomized acute respiratory failure patients, difficult intubation was encountered in 26.2% (11/42); and 72.7% (8/11) of them required emergency tracheostomy. The 30-day mortality was 38.6%. Uncontrolled HNC (adjusted odds ratio [OR], 4.13; 95% confidence interval, 1.14-14.92) and Acute Physiology and Chronic Health Evaluation II score (adjusted OR 1.13; 95% confidence interval, 1.04-1.22) were found as the risk factors for 30-day mortality in multivariate analysis. Conclusions: Although critically ill patients with HNC usually had advanced cancers and carried a high rate of cancer-related life-threatening airway complications, their 30-day mortality was favorable and only independently associated with cancer status and Acute Physiology and Chronic Health Evaluation II score.

Objectives: Mechanical ventilation is associated with overwhelming inflammatory responses that are associated with ventilator-induced lung injury (VILI) in patients with acute respiratory distress syndrome. The activation of adenosine A 2A receptors has been reported to attenuate inflammatory cascades. Hypothesis: The administration of A 2A receptors agonist ameliorates VILI. Methods: Rats were subjected to hemorrhagic shock and resuscitation as a first hit to induce systemic inflammation. The animals randomly received the selective A 2A receptor agonist CGS-21680 or a vehicle control in a blinded fashion at the onset of resuscitation phase. They were then randomized to receive mechanical ventilation as a second hit with a high tidal volume of 20 mL/kg and zero positive end-expiratory pressure, or a low tidal volume of 6 mL/kg with positive end-expiratory pressure of 5 cm H 2 O. Results: The administration of CGS-21680 attenuated lung injury as evidenced by a decrease in respiratory elastance, lung edema, lung injury scores, neutrophil recruitment in the lung, and production of inflammatory cytokines, compared with the vehicle-treated animals. Conclusions: The selective A 2A receptor agonist may have a place as a novel therapeutic approach in reducing VILI.

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.

28-year-old man presented with syncope after passing ark-red stool several times in 24 hours. He had no ematemesis, nausea, vomiting, or epigastralgia. The abomen was soft without tenderness. His hemoglobin as 7.2 g/dL and hematocrit was 20.5%. Panendosopy did not reveal any abnormality. Colonoscopy failed ecause of a large amount of blood in the rectum. Aniography showed active extravasation of contrast media rom a distal branch of an ileal artery (A, black arrow). mergent laparotomy was performed because of persisent bleeding with unstable hemodynamics. Under light ranslumination, the entire colon and ileum were filled ith blood. A 0.4 0.5 0.8-cm mass over the ileum as palpated, with a marginal artery feeding this mass B). The rest of the bowel was unremarkable. Limited esection of the ileal lesion with primary end-to-end nastomosis was performed. The patient had a rapid and neventful recovery. The lesion looked crater-like on the mucosal side (C). icroscopically, a large-caliber artery was located within he submucosa. There was erosion on the mucosal surace without surrounding ulceration. A thrombus was resent in the vascular lumen (D). It was a typical picure of Dieulafoy’s lesion. Dieulafoy’s lesion is an important cause of gastrointestial hemorrhage and is potentially life-threatening. It can A