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Purpose We aimed to determine the clinical characteristics of patient self-inflicted lung injury (P-SILI)-associated pneumothorax/pneumomediastinum, explore its risk factors, and measure its impact on severe COVID-19 cases.Methods In total, 229 patients were included in this case-control study. They were divided into the case group and control group according to the inclusion criteria. Then, the two groups were compared to explore the risk factors of spontaneous pneumothorax/pneumomediastinum. Finally, we analyzed the risk factors of death in the case group and among all patients.Results The mean age of patients was 59.69 ± 17.01 years, most of them were male (74.2%), and 62.0% of them had comorbidities on admission. A respiratory rate higher than 30 was a risk factor for spontaneous pneumothorax/pneumomediastinum (OR = 7.186, 95% CI 2.414–21.391, P Conclusion P-SILI occurs in severe COVID-19 with acute respiratory failure. It is necessary to identify the risk factors of P-SILI, the indicators of severe P-SILI, and the preventive measures.

Previous studies and the concentration-dependent antibacterial actions of daptomycin suggested that a high dose would be needed for difficult-to-treat infections in burn patients. Here, we evaluated the effects of administration of low and high doses of daptomycin in patients with severe burn injuries. The study retrospectively analyzed 10 patients with severe burn injuries, using pharmacokinetic (PK) and pharmacodynamic (PD) evaluations of daptomycin doses given to combat serious infections. Daptomycin was administered as a single dose or by multiple doses intravenously at a standard dose of 6 mg/kg/d or a high dose of 12 mg/kg/d for 7 to 14 days. The serum concentrations of daptomycin from patients were analyzed by liquid chromatography–mass spectrometry/mass spectrometry (LC-MS/MS). Burn injury patients treated with high-dose daptomycin had a linear PK profile and a negative correlation between the AUC0–24 and Baux score (R2 = .953 and R2 = .801). The Cmax, AUC0–24, and t(h)½ increased significantly compared with patients given a standard dose. The efficacy of daptomycin against Staphylococcus aureus showed significantly higher rates of (AUC0–24)/MIC and Cmax/MIC after high-dose daptomycin compared with the standard dose, reflected in a significant correlation between a high dose and the Baux score (r = .976, P < .001). Positive S. aureus cultures from two of three high-dose and none of two daptomycin low-dose patients converted from positive to negative after therapy. No serious adverse events or discontinuation of the drug occurred during the treatment period. Daptomycin doses up to 12 mg/kg/d were well tolerated in Chinese patients with severe burn injuries, which were complicated by infections with S. aureus.

Background: Pneumocystis jirovecii pneumonia (PJP) is one of the main causes for acute respiratory failure (ARF) in immunocompromised hosts with non-HIV infection. Few studies focused on the effect of noninvasive ventilation (NIV) in non-HIV-related PJP (NH-PJP) patients, and the risk factors of NIV failure in these patients are still unclear. Methods: Data of all ARF patients with NH-PJP requiring NIV were retrospectively reviewed in a respiratory intensive care unit from January 2017 to December 2019, and information extracted for identifying the risk factors for NIV failure and mortality. Results: 38 patients were collected and NIV failed in 27 patients(71.1%). The hospital mortality of all PJP patients was 65.8%. PaO2/FiO2 in NIV failure group was significantly lower than that in NIV success group at 1h (103.58±40.73 vs 142.86±60.54, p=0.02) and 24h (94.87±40.19 vs 165.22±83.34, p=0.02) after NIV. The APACHE II score was significantly higher in NIV failure group when using NIV (16.59±3.31 vs 13.55±4.11, p=0.02). The mortality rate in NIV failure group was 88.9% compared with 9% in successful group. Risk factors associated with NIV failure included APACHE II score (Adj. OR: 1.351, 95% CI: 1-1.825, p=0.05) and PaO2/FiO2 at 24h after NIV (Adj. OR: 0.977, 95% CI: 0.961-0.994, p=0.009). NIV failure was significantly associated with hospital survival (Adj. OR: 10, 95% CI: 0.001-0.135, p=0.02). Conclusions: APACHE II score and PaO2/FiO2 at 24h after NIV might predict NIV failure in NH-PJP. The mortality rate of our NH-PJP patients was high, and NIV failure was associated with the higher hospital mortality.

Background There is a lack of large-scale epidemiological data on the clinical practice of enteral nutrition (EN) feeding in China. This study aimed to provide such data on Chinese hospitals and to investigate factors associated with EN delivery. Methods This cross-sectional study was launched in 118 intensive care units (ICUs) of 116 mainland hospitals and conducted on April 26, 2017. At 00:00 on April 26, all patients in these ICUs were included. Demographic and clinical variables of patients on April 25 were obtained. The dates of hospitalization, ICU admission and nutrition initiation were reviewed. The outcome status 28 days after the day of investigation was obtained. Results A total of 1953 patients were included for analysis, including 1483 survivors and 312 nonsurvivors. The median study day was day 7 (IQR 2–19 days) after ICU entry. The proportions of subjects starting EN within 24, 48 and 72 h after ICU entry was 24.8% (84/352), 32.7% (150/459) and 40.0% (200/541), respectively. The proportion of subjects receiving > 80% estimated energy target within 24, 48, 72 h and 7 days after ICU entry was 10.5% (37/352), 10.9% (50/459), 11.8% (64/541) and 17.8% (162/910), respectively. Using acute gastrointestinal injury (AGI) 1 as the reference in a Cox model, patients with AGI 2–3 were associated with reduced likelihood of EN initiation (HR 0.46, 95% CI 0.353–0.599; p

Background Nutrition therapy is recognized as one of the most significant treatment aspects for burn patients. However, data were limited regarding the actual nutrition practices in patients with severe burn injury. This study aims to explore the measured energy expenditure (MEE) changes in severe burn patients and to evaluate the precision of commonly used predictive formulas for estimating predictive energy expenditure (PEE) in burn patients. Methods A prospective multicenter trial was conducted in the intensive care units in the hospitals enrolling the severely burned patients. Data on MEE and PEE were collected and analyzed. Results Forty-three patients were enrolled from 3 hospitals. All the patients had severe burns. MEE was measured by metabolic cart, and the MEE on the seventh day after severe burns was as high as 65 kcal/kg, which was 267% of the basal metabolic rate. The presence of hypermetabolism was sustained throughout the 21-day afterburn and decreased gradually to 34 kcal/kg thereafter until 4 weeks after injury. Wound percentage after skin-grafting therapy, time course of burn injury, the existence of severe sepsis, and blood infection were significantly associated with higher MEE. Compared with PEE and MEE, Toronto formula could estimate patients' energy requirements with more accuracy; Curreri and Pennisi formula both significantly overestimated the patient's energy expenditure, whereas underestimation occurred with the Harris-Benedict formula. Conclusions Severe burn patients were hypermetabolic at the early stage and sustained this status over a long time. The Toronto formula was the unbiased method to predict energy expenditure.

BACKGROUND. Data are limited on the impact of neuraminidase inhibitor (NAI) treatment on avian influenza A(H7N9) virus RNA shedding. METHODS. In this multicenter, retrospective study, data were collected from adults hospitalized with A(H7N9) infection during 2013–2017 in China. We compared clinical features and A(H7N9) shedding among patients with different NAI doses and combination therapies and evaluated factors associated with A(H7N9) shedding, using Cox proportional hazards regression. RESULTS. Among 478 patients, the median age was 56 years, 71% were male, and 37% died. The median time from illness onset to NAI treatment initiation was 8 days (interquartile range [IQR], 6–10 days), and the median duration of A(H7N9) RNA detection from onset was 15.5 days (IQR, 12–20 days). A(H7N9) RNA shedding was shorter in survivors than in patients who died (P < .001). Corticosteroid administration (hazard ratio [HR], 0.62 [95% confidence interval {CI}, .50-.77]) and delayed NAI treatment (HR, 0.90 [95% CI, .91-.96]) were independent risk factors for prolonged A(H7N9) shedding. There was no significant difference in A(H7N9) shedding duration between NAI combination treatment and monotherapy (P = .65) or between standard-dose and double-dose oseltamivir treatment (P = .70). CONCLUSIONS. Corticosteroid therapy and delayed NAI treatment were associated with prolonged A(H7N9) RNA shedding. NAI combination therapy and double-dose oseltamivir treatment were not associated with a reduced A(H7N9) shedding duration as compared to standard-dose oseltamivir.

This study examines the clinical utility of plasma neutrophil gelatinase-associated lipocalin (NGAL) as an indicator of myocardial dysfunction and mortality in severe sepsis and septic shock.We designed a prospective cohort study in an intensive care unit, and 53 patients with severe sepsis or septic shock were included. Data were used to determine a relationship between NGAL and the development of myocardial dysfunction and mortality. These associations were determined by the Mann-Whitney test, multiple logistic regression, plotting the receiver operating characteristic (ROC) curve, Kaplan-Meier curves and Spearman test.The High NGAL group had higher need for inotropic/vasopressor support (92% vs. 52%, p=0.0186), higher incidence of regional wall motion abnormalities (46% vs. 13%, p=0.0093), higher B-type natriuretic peptide (BNP) level (p=0.0197), higher cardiac troponin I (cTnI) level (p=0.0016), lower ejection fraction (EF) (p0.0001) and higher mortality (p=0.0262) compared to the Low NGAL group. Patients with High NGAL were more likely to manifest electrocardiogram (ECG) abnormalities (p=0.042) and demonstrate clinical myocardial dysfunction (p=0.0186) as evidenced by clinical or radiological evidence of pulmonary edema as compared to those with Low NGAL group. NGAL, BNP, Acute Physiology and Chronic Health Evaluation (APACHE) II score, cTnI, and PaOHigh plasma NGAL correlates with high mortality and myocardial dysfunction in severe sepsis and septic shock.

Immune disorders are common in critically ill patients. Catecholamines play a crucial role in theimmune regulation and modulation. Immune cells can synthesize catecholamines and express adrenergic receptors. Catecholamine has a wide-ranging regulatory effect on innate immunity such as neutrophils, monocyte macrophages, dendritic cells, natural killer cells, and lymphocyte-mediated acquired immunity. Catecholamines exert different immunomodulatory effects by binding to α receptors, β receptors, and dopamine receptor subtypes on immune cells. In-depth study of the effect and mechanism of catecholamine on immune function in critically ill patients will provide new ideas for the prevention and treatment of immune dysfunction in critical illness.

Nutrition therapy is considered an important treatment of burn patients. The aim of the study was to delineate the nutritional support in severe burn patients and to investigate association between nutritional practice and clinical outcomes. Severe burn patients were enrolled (n 100). In 90 % of the cases, the burn injury covered above 70 % of the total body surface area. Mean interval from injury to nutrition start was 2·4 (sd 1·1) d. Sixty-seven patients were initiated with enteral nutrition (EN) with a median time of 1 d from injury to first feed. Twenty-two patients began with parenteral nutrition (PN). During the study, thirty-two patients developed EN intolerance. Patients received an average of about 70 % of prescribed energy and protein. Patients with EN providing

Background: Asthma is a complex and heterogeneous chronic inflammatory disorder which is characterized by airway remodeling and airway inflammation, including goblet cell and airway smooth muscle cell hyperplasia, mucus hypersecretion and eosinophils infiltration. Epidermal growth factor receptor (EGFR) plays an important role in goblet cell hyperplasia and mucus hypersecretion. We aimed to investigate the effects of gefitinib, an EGFR inhibitor, on ovalbumin (OVA)-induced airway remodeling and inflammation of a mouse model of asthma. Methods: Pathological changes of OVA sensitization of BALB/c mice were measured by H&E and PAS staining; pEGFR, Bcl-2 and Bax expression was measured by western blot; ELISA was used to measure the level of muc5ac, IL-13 and IFN-γ; TUNEL staining was used to detect goblet cell apoptosis. Results: At the present study, H&E and PAS staining showed that mice pretreated with gefinitib developed fewer pathological changes compared with asthmatic mice and gefinitib treatment asthmatic mice, such as a remarkable reduction in airway inflammation, goblet cell and airway smooth muscle cell hyperplasia. Chronic gefitinib treatment or short-term gefitinib treatment significant down-regulate the expression of pEGFR compared with asthma group. Also, chronic gefitinib treatment markedly decreased the levels of muc5ac and IL-13 in BALF, whereas the level of IFN-γ did not change obviously. TUNEL staining showed that the goblet cell apoptosis rate was much higher in the short-term gefinitib treatment group compared with the asthma and chronic gefitinib treatment group which was accompanied by a decrease in Bcl-2 levels and an increase in Bax expression in goblet cells. Conclusion: In summary, our results suggested that gefinitib may have a potential role in airway remodeling and inflammation, and may be an effective pharmacotherapy for asthma.

BACKGROUND: The aim of the study was to identify the clinical features and the factors associated with burn induced mortality among young adults after exposure to indoor explosion and fire. METHODS: This is an observational study which included burn patients who were admitted to eighteen ICUs after a fire disaster. Epidemiologic and clinical characteristics, as well as therapy were recorded. The primary outcome was 90-day mortality. The mortality-related factors were also analyzed. RESULTS: There were 167 burn patients enrolled in the study, the median age was 38 years, 62 (37.1%) patients died within 90 days. Seventy-one percent of patients had a burn size ≥90% TBSA, and 73.7% of patients had a full-thickness burn area above 50% TBSA. The survivors had lower Baux scores, and received earlier escharectomy and autologous skin grafts. The 50% mortality rates (LA50s) for burn size and full-thickness burn area were 95.8% and 88.6% TBSA, respectively. The multivariate analysis showed that full-thickness burn area over 50% TBSA and residual burned surface area (RBSA)/TBSA at 28 days were strong predictors of mortality among burn patients (odds ratio 2.55; 95% CI, 1.01 to 6.44, P=0.047; odds ratio 1.07; 95% CI, 1.04 to 1.09, P

Background Evidence concerning the efficacy and safety of extracorporeal membrane oxygenation (ECMO) in patients with influenza A (H7N9) has been was limited to case reports. Our study is aimed to investigate the current application, efficacy and safety of ECMO in for severe H7N9 pneumonia-associated acute respiratory distress syndrome (ARDS) in the Chinese population. Methods A multicentre retrospective cohort study was conducted at 20 hospitals that admitted patients with avian influenza A (H7N9) viral pneumonia patients’ admission from 9 provinces in China between October 1, 2016, and March 1, 2017. Data from the National Health and Family Planning Commission of China, including general conditions, outcomes and ECMO management, were analysed. Then, successfully weaned and unsuccessfully weaned groups were compared. Results A total of 35 patients, aged 57 ± 1 years, were analysed; 65.7% of patients were male with 63% mortality. All patients underwent invasive positive pressure ventilation (IPPV), and rescue ventilation strategies were implemented for 23 cases (65.7%) with an average IPPV duration of 5 ± 1 d, PaO2/FiO2 of 78 ± 23 mmHg, tidal volume (VT) of 439 ± 61 ml and plateau pressure (Pplat) of 29 ± 8 cmH2O pre-ECMO. After 48 h on ECMO, PaO2 improved from 56 ± 21 mmHg to 90 ± 24 mmHg and PaCO2 declined from 52 ± 24 mmHg to 38 ± 24 mmHg. Haemorrhage, ventilator-associated pneumonia (VAP) and barotrauma occurred in 45.7%, 60% and 8.6% of patients, respectively. Compared with successfully weaned patients (n = 14), the 21 unsuccessfully weaned patients had a longer duration of IPPV pre-ECMO (6 ± 4 d vs. 2 ± 1 d, P

Blood flow during ECMO, changes in IPPV parameters and physiological indicators pre-ECMO and during ECMO. (DOCX 107Â kb)

ECMO Cases Per Year for Each Hospital. (DOCX 60Â kb)

This study examines the clinical utility of the increased lactate/albumin ratio as an indicator of multiple-organ dysfunction syndrome (MODS) and mortality in severe sepsis and septic shock.We designed a prospective cohort study in an intensive care unit, and 54 patients with severe sepsis or septic shock were included. Data were used to determine a relationship between lactate/albumin ratio and the development of MODS and mortality. These associations were determined by the Mann-Whitney test, multiple logistic regression, plotting the receiver operating characteristic curve and Spearman test.Lactate/albumin ratio level was higher in MODS patients on day 1 (median [interquartile range, or IQR], 2.295 [1.818-3.065]; n = 30, P.0001) than in those without (median [IQR], 1.550 (1.428-1.685); n = 24), and on day 2, (median [IQR], 1.810 [1.377-2.448]; n = 26, P = .0022) it was higher than in those without (median [IQR], 1.172 (1.129-1.382); n = 23) on day 2. We found that lactate/albumin ratio was an independent predictor of the development of MODS (odds ratio, 5.5; P = .033; 95% confidence interval, 1.1-26.1) during intensive care unit stay. The area under the receiver operating characteristic curve showed that lactate/albumin ratio could predict MODS (0.8458) and mortality (0.8449). Furthermore, the higher the Acute Physiology and Chronic Health Evaluation II score, the more lactate/albumin ratio was discovered on day 1 (r = 0.5315, P.0001) and day 2 (r = 0.5408, P.0001), whereas the lower partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio, the more lactate/albumin ratio was illustrated on day 1 (r = -0.5143, P.0001) and day 2 (r = -0.5420, P.0001).Increased lactate/albumin ratio correlates with the development of MODS and mortality in patients with severe sepsis and septic shock.

This study examines the clinical utility of increased neutrophil gelatinase-associated lipocalin (NGAL) as an indicator of mortality and multiple organ dysfunction syndrome (MODS) in severe sepsis and septic shock.We designed a prospective cohort study in an intensive care unit, and 123 patients with severe sepsis or septic shock were included. Data were used to determine a relationship between NGAL and the development of MODS and mortality. These associations were determined by the Mann-Whitney U test, log-rank test, Cox proportional hazards regression analyses, and plotting the receiver operating characteristic curve.Patients with high NGAL (75th percentile) had increased risk of mortality and MODS compared with patients with low NGAL (log-rank test, P0.05). There were 39 patients (32%) with mortality during follow-up at 12 months, 10 patients (8%) with MODS on day 1, and 37 patients (30%) on day 7. The area under the receiver operating characteristic curve showed that high NGAL could predict mortality (0.6385) during intensive care unit stay. After adjustment for confounding risk factors chosen by backward elimination by Cox regression analysis, high NGAL remained an independent predictor of mortality and MODS (hazard ratios, 2.128 [95% confidence interval, 1.078-4.203; P = 0.030] and 1.896 [95% confidence interval, 1.012-3.552; P = 0.046], respectively).High plasma NGAL independently predicts mortality and MODS in severe sepsis and septic shock.

A 76-year-old man with a 30-year history of gout was admitted for chronic renal failure and the articular pain at the right foot. He was noted to have multiple hard swelling. The swelling developed over 10 years, progressively increasing in size. Physical examination revealed that there were multiple large firm tophi on the hands, both olecranon processes, and feet (Figure 1A). Figure 1. ( A ) Multiple large subcutaneous tophi are seen in the feet. ( B ) 3D CT images of the right foot demonstrating extensive tophi (dorsal view). Laboratory investigations showed: serum uric acid 728.0 μmol/l (155.0–428.0 μmol/l), urea 10.3 mmol/l (2.8–8.2 mmol/l) and creatinine 213.3 μmol/l (35.0–104.0 μmol/l). Three-dimensional computed tomography (3D CT) …

The objective was to analyze the clinical features of multiple organ dysfunction syndrome (MODS) induced by severe heat stroke, and to investigate the pathogenesis, diagnosis and prevention strategies in patients with MODS caused by severe heat stroke.