Abstract Background Acute exacerbation of interstitial lung disease (AE-ILD) significantly impacts prognosis, leading to high mortality rates. Although lung transplantation is a life-saving treatment for selected patients with ILD, its outcomes in those presenting with AE-ILD have yielded conflicting results compared with those with stable ILD. This study aims to investigate the impact of pre-existing AE on the prognosis of ILD patients who underwent lung transplantation. Method We conducted a single-center retrospective study by reviewing the medical records of 108 patients who underwent lung transplantation for predisposing ILD at Asan Medical Center, Seoul, South Korea, between 2008 and 2022. The primary objective was to compare the survival of patients with AE-ILD at the time of transplantation with those without AE-ILD. Results Among the 108 patients, 52 (48.1%) experienced AE-ILD at the time of lung transplantation, and 81 (75.0%) required pre-transplant mechanical ventilation. Although the type of ILD (IPF vs. non-IPF ILD) did not affect clinical outcomes after transplantation, AE-ILD was associated with worse survival outcomes. The survival probabilities at 90 days, 1 year, and 3 years post-transplant for patients with AE-ILD were 86.5%, 73.1%, and 60.1%, respectively, while those for patients without AE-ILD were higher, at 92.9%, 83.9%, and 79.6% (p = 0.032). In the multivariable analysis, pre-existing AE was an independent prognostic factor for mortality in ILD patients who underwent lung transplantation. Conclusions Although lung transplantation remains an effective treatment option for ILD patients with pre-existing AE, careful consideration is needed, especially in patients requiring pre-transplant mechanical respiratory support.
This study aimed to compare the prognostic value of lactate level and lactate clearance at 6 hours after septic shock recognition. And, we performed it to determine lactate kinetics in the Sepsis-3 defined septic shock.This retrospective study was performed from a prospective septic shock registry.This study was performed at single urban tertiary center. And, all patients were treated with protocol-driven resuscitation bundle therapy between 2010 and 2016.We included septic shock patients who met the Sepsis-3 definition, which involves lactate levels greater than or equal to 2 mmol/L and vasopressor use.Serum lactate levels were measured at initial and 6 hours from septic shock recognition.Lactate clearance was calculated as ([initial lactate - 6-hr lactate]/initial lactate) × 100. The prognostic value of measured lactate levels and lactate clearance for 28-day mortality was analyzed and compared with that of subsequent lactate levels greater than or equal to 2 mmol/L, greater than or equal to 3 mmol/L, and greater than or equal to 4 mmol/L and less than 10%, less than 20%, and less than 30% lactate clearance. A total of 1,060 septic shock patients by Sepsis-3, 265 patients died (28-d mortality: 25%). In survivor, groups had lower median 6-hour lactate level and higher lactate clearance than nonsurvivors (2.5 vs 4.6 mmol/L and 35.4% vs 14.8%; p < 0.01). Both lactate and lactate clearance were associated with mortality after adjusting for confounders (odd ratio, 1.27 [95% CI, 1.21-1.34] and 0.992 [95% CI, 0.989-0.995]), but lactate had a significantly higher prognostic value than lactate clearance (area under the curve, 0.70 vs 0.65; p < 0.01). The prognostic value of subsequent lactate levels (≥ 2, ≥ 3, and ≥ 4 mmol/L) and lactate clearances (< 10%, < 20%, and < 30%) was not significantly differed. However, lactate levels of greater than or equal to 2 mmol/L had the greatest sensitivity (85.3%).Our findings indicate lactate and lactate clearance are both useful targets in patients with septic shock defined by Sepsis-3. Serum lactate level at 6-hour can be an easier and more effective tool for prognosis of septic shock patients who were treated with protocol-driven resuscitation bundle therapy.
Background: Mesenchymal stem cells (MSCs) attenuate injury in various lung injury models through paracrine effects.We hypothesized that intratracheal transplantation of allogenic MSCs could attenuate lipopolysaccharide (LPS)-induced acute lung injury (ALI) in mice, mediated by anti-inflammatory responses.Methods: Six-week-old male mice were randomized to either the control or the ALI group.ALI was induced by intratracheal LPS instillation.Four hours after LPS instillation, MSCs or phosphate-buffered saline was randomly intratracheally administered.Neutrophil count and protein concentration in bronchoalveolar lavage fluid (BALF); lung histology; levels of interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α, and macrophage inflammatory protein-2; and the expression of proliferation cell nuclear antigen (PCNA), caspase-3, and caspase-9 were evaluated at 48 hours after injury.Results: Treatment with MSCs attenuated lung injury in ALI mice by decreasing protein level and neutrophil recruitment into the BALF and improving the histologic change.MSCs also decreased the protein levels of proinflammatory cytokines including IL-1β, IL-6, and TNF-α, but had little effect on the protein expression of PCNA, caspase-3, and caspase-9.Conclusions: Intratracheal injection of bone marrow-derived allogenic MSCs attenuates LPSinduced ALI via immunomodulatory effects.
Differential diagnosis of patients with bilateral lung infiltrates remains a difficult problem for intensive care clinicians. Here we evaluate the diagnostic role of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in bronchoalveolar lavage (BAL) specimens from patients with bilateral lung infiltrates.We conducted a prospective observational study on 80 patients with bilateral lung infiltrates with clinical suspicion of infectious pneumonia. Patients were categorized into three groups: bacterial or fungal infection, intracellular or viral infection, and noninfectious inflammatory disease. sTREM-1 concentrations were measured, and BAL fluid and Clinical Pulmonary Infection Score (CPIS) were analyzed.The sTREM-1 concentration was significantly increased in patients with bacterial or fungal pneumonia (n = 29, 521.2 +/- 94.7 pg/ml), compared with that in patients with viral pneumonia, atypical pneumonia or tuberculosis (n = 14, 92.9 +/- 20.0 pg/ml) or noninfectious inflammatory disease (n = 37, 92.8 +/- 10.7 pg/ml). The concentration of sTREM-1 in BAL fluid, but not CPIS, was an independent predictor of bacterial or fungal pneumonia, and a cutoff value of more than 184 pg/ml yielded a diagnostic sensitivity of 86% and a specificity of 90%.The sTREM-1 level in BAL fluid from patients with bilateral lung infiltrates is a potential marker for the differential diagnosis of pneumonia due to extracellular bacteria.
Some patients with Takayasu arteritis (TA) have aortic valve (AV) involvement, which can lead to aortic regurgitation (AR). However, data on the long-term outcomes, including survival of TA patients with AR, are lacking. Moreover, previous studies were limited to patients who underwent AV surgery.
Objectives
This study aimed to characterise the long-term outcomes and clinical characteristics of TA patients with AR regardless of whether they underwent surgical intervention.
Methods
Medical records of patients with TA between January 1995 and December 2015 were retrospectively reviewed. AR was diagnosed using transthoracic echocardiography. Poor outcomes were defined as all-cause death and major adverse cardiac and cerebrovascular events (MACCE). Multivariate analysis was performed to determine the factors affecting poor prognosis in the surgical group.
Results
Of the total 105 patients with TA and AR, 41 (39.0%) underwent AV surgery. Among patients who underwent AV surgery, inflammation values (Erythrocyte sedimentation rate, 62.07±31.8 mm/hr vs. 39.16±28.4 mm/hr; C-reactive protein, 3.66±4.1 mg/dL vs. 0.92±1.7 mg/dL), AR degree (3.56±0.7 grade vs. 2.08±1.0 grade), and sinus diameter (37.24±5.7 mm vs. 33.22±4.5 mm) were significantly higher than in those who did not undergo AV surgery. Long-term survival and freedom from MACCE were not significantly different between the groups (10 year survival, 84.3% vs. 79.4%; p=0.827; 10 year event-free survival, 51.8% vs. 71.2%; p=0.29). Twelve of the 41 patients who underwent AV surgery had a poor outcome during follow-up (median, 92.5 months; IQR, 54.5–183.5), and eight of them had a recurrence of AR requiring reoperation. Multivariate Cox analysis revealed that coronary disease [hazard ratio (HR), 4.234; 95% confidence interval (CI), 1.381–12.979; p=0.012], LV dysfunction (HR, 3.387; 95% CI, 1.143–10.042; p=0.028), and impaired renal function (HR, 19.983; 95% CI, 3.480–114.731; p=0.001) were significant risk factors associated with poor outcomes at follow-up (table 1).
Conclusions
In patients with TA with AV involvement, there were no significant differences between long-term survival rate and event-free survival (MACCE) among those who had or had not undergone AV surgery. In the surgical group, the prognosis was poor when coronary artery disease, LV dysfunction, and renal impairment were present at the time of surgery.
We investigated the effects of corticosteroids on the 90-day mortality outcomes in patients with pulmonary tuberculosis who were admitted to the intensive care unit (ICU) because of acute respiratory failure (ARF). The medical records of 124 patients who had pulmonary tuberculosis with ARF and were admitted to the ICU at our tertiary referral center in South Korea between March 1989 and December 2014 were retrospectively analyzed. The 90-day mortality rate in this population was analyzed after adjustments with the inverse probability of treatment weighted (IPTW) method. The mean patient age was 62 years, and the 90-day mortality rate was 49.2% (61/124). Adjuvant steroids were used in 70 (56.5%) patients. The 90-day mortality rate was similar irrespective of corticosteroid use (48.6%, steroid group; 50.0%, nonsteroid group). The use of adjuvant steroids was not associated with the unadjusted 90-day mortality (odds ratio [OR], 0.94; 95% confidence interval [CI], .46-1.92; P = .875). In a comparison using an adjusted IPTW approach of the 90-day mortality between the 2 groups, we found that corticosteroid use was independently associated with reduced 90-day mortality (OR, 0.47; 95% CI, .22-.98; P = .049). The study results showed that corticosteroids could reduce the 90-day mortality rate in critically ill pulmonary tuberculosis patients with ARF.
The use of extracorporeal membrane oxygenation (ECMO) has increased after the 2009 pandemic H1N1 infections, and the ECMO-related complications have also increased.Specifically, the mechanical vessel injury due to catheter cannulation seems to be less frequent than other complications, but there is a risk of hemorrhagic shock which requires special attention.We experienced a case of successful management with graft stenting during ECMO operation for iliac vein injury.A 56-year-old female patient with non-small cell lung cancer developed endobronchial obstruction, and ECMO was applied for the ECMO-assisted rigid bronchoscopy.During catheter cannulation, hypovolemic shock was developed due to her right external iliac vein injury.We detected the hemorrhage with bedside ultrasound at an early stage and the hemorrhage was effectively managed with graft stenting on ECMO.
BACKGROUND A rapid response system (RRS) contributes to the safety of hospitalized patients. Clinical deterioration may occur in the general ward (GW) or in non-GW locations such as radiology or dialysis units. However, there are few studies regarding RRS activation in non-GW locations. This study aimed to compare the clinical characteristics and outcomes of patients with RRS activation in non-GW locations and in the GW. METHODS From January 2016 to December 2017, all patients requiring RRS activation in nine South Korean hospitals were retrospectively enrolled and classified according to RRS activation location: GW vs non-GW RRS activations. RESULTS In total, 12,793 patients were enrolled; 222 (1.7%) were non-GW RRS activations. There were more instances of shock (11.6% vs. 18.5%) and cardiac arrest (2.7% vs. 22.5%) in non-GW RRS activation patients. These patients also had a lower oxygen saturation (92.6% ± 8.6% vs. 88.7% ± 14.3%, P < 0.001) and a higher National Early Warning Score 2 (7.5 ± 3.4 vs. 8.9 ± 3.8, P < 0.001) than GW RRS activation patients. Although non-GW RRS activation patients received more intubation (odds ratio [OR], 3.135; P < 0.001), advanced cardiovascular life support (OR, 3.912; P < 0.001), and intensive care unit transfer (OR, 2.502; P < 0.001), their hospital mortality (hazard ratio, 0.630; P = 0.013) was lower than GW RRS activation patients upon multivariate analysis. CONCLUSION Considering that there were more critically ill but recoverable cases in non-GW locations, active RRS involvement should be required in such locations.
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