A prospective study on the long-term storage of sputum and the recovery of nontuberculous mycobacteria

BACKGROUND

There is little information on the optimal storage conditions for recovery of nontuberculous Mycobacterium spp. (NTM) from refrigerated sputum.

OBJECTIVES

We investigated the storage duration that could increase the culture-positive rate of NTM isolates.

DESIGN

In this prospective study, we collected NTM isolates and clinical data from patients with repeated culture-positive NTM pulmonary disease (NTM-PD).

METHODS

From June 2020 to July 2021, the participants were instructed to randomly collect six sputum samples and immediately store them in a refrigerator at 4°C until the date of their clinic visit. At the outpatient visits, expectorated spot sputum samples were collected.

RESULTS

A total of 226 sputum samples were collected from 35 patients. The median duration of refrigeration was 6 days (maximum duration: 36 days). The overall culture-positive rate was 81.6%. While there was a trend for a higher culture positivity rate when stored for ⩽3 weeks, this was not significant compared with those stored for >3 weeks (p = 0.610). According to sputum microscopy, smear-positive sputum was 100% isolated, but smear-negative samples had a culture-positive rate of 77.5%. Similarly, there was no significant association between sputum storage duration and culture positivity (p = 0.511). In addition, the recovery rate of the refrigerated sputum was comparable with the collected spot expectorated sputum (82.6% versus 80.6%, p = 0.795), which is suggestive of the long-term viability of NTM in refrigerated sputum.

CONCLUSION

Our data demonstrated the long-term viability of refrigerated NTM, and the culture positivity rate of these samples was comparable with the spot expectorated sputum. These results suggest that implementing sputum refrigeration would enhance convenience in diagnosing and following patients with NTM-PD.

PLAIN LANGUAGE SUMMARY

Easy way to diagnose NTM lung diseasesUnder usual circumstances, most patients with suspected NTM submit spontaneously expectorated sputum rather than induced sputum for the purpose of testing the causative organism. By collecting and storing sputum specimens for a longer period than before, it is expected that more sufficient and adequate collection of sputum specimens will be possible.

Impact of body weight change on clinical outcomes in patients with idiopathic pulmonary fibrosis receiving pirfenidone

There have been limited studies on the association between prognosis and body weight change in patients with idiopathic pulmonary fibrosis (IPF). This single-center retrospective observational study evaluated the impact of weight loss on outcomes in Korean patients with IPF receiving pirfenidone at a tertiary medical institution. We analyzed 215 IPF patients prescribed pirfenidone from January 1st, 2015 to December 31st, 2019. The patients were categorized into maintained weight (MW; weight gain or loss < 5%/year) and reduced weight (RW; weight loss ≥ 5%/year) groups. The mean age was 71.8 years and 175 (81.4%) were male. There were 54 (25.1%) patients in the RW group. All patients showed a decrease in body weight (baseline vs. after 1 year; 64.1 kg vs. 62.8 kg, P < 0.001). Although baseline lung function showed a difference, there was no difference in the rate of change (forced vital capacity [% of predicted]; P = 0.221, diffusing capacity of the lung for carbon monoxide [% of predicted]; P = 0.973). The MW group had a lower risk of all-cause mortality (P < 0.001). Weight loss appeared to be a significant risk factor for mortality in patients with IPF. Not only disease control with antifibrotic agents, but also efforts to prevent weight loss may be necessary.

The significance of elevated tumor markers among patients with interstitial lung diseases

The clinical implication of using serum tumor markers in patients with interstitial lung disease (ILD) is inconclusive. In this retrospective study, we analyzed the data of 1176 subjects (294 with ILDs and 882 healthy controls). Eligible patients were who had at least one or more available tumor marker results [carbohydrate antigen (CA) 19-9, CA 125, and carcinoembryonic antigen (CEA)] with no evidence of malignancies or other benign diseases that could be related to the increasing concentration of the values. The healthy controls selected from a health screening program were also screened for the presence of active cancer, and matched at a ratio of 1:3 with age and sex. The proportion of patients with abnormal values in the ILD group (121, idiopathic pulmonary fibrosis (IPF); 173, non-IPF-ILDs) was higher than in the matched control group (CEA, 21.5% vs. 5.5%; CA 19-9, 27.9% vs. 4.0%; CA 125, 36.4% vs. 2.0%). In the multivariable analysis, higher CEA levels were associated with shorter survival after adjusting for age, sex, lung function, and ILD subtypes (hazard ratio: 2.323, 95% confidence interval: 1.271–4.248, P = 0.006). In subgroup analysis, CEA remained a prognostic factor in patients with non-IPF-ILDs, but not in those with IPF.

Liposomal docosahexaenoic acid halts atherosclerosis progression

Background

Atherosclerosis is the main cause underlying cardiovascular disease (CVD). Docosahexaenoic acid (DHA, 22:6n-3) is a hydrophobic polyunsaturated fatty acid that exerts anti-inflammatory and antioxidant activities. However, the beneficial effects of DHA on CVD have been controversial likely due to variations in bioavailability after oral intake.

Purpose

In this study, we aim to investigate the potential inhibiting properties of liposomal DHA on atherosclerosis progression upon intravenous administration.

Methods

Four weeks old ApoE−/− and LDLr−/− mice were fed on athero-inducing high fat diet for 4 weeks and then randomly divided into two groups. The mice received either control liposomes (control group) or liposomes containing DHA (liposomal DHA treatment group) via intravenous injection, twice a week for 8 weeks while still being fed on high fat diet. At the experiment endpoint, whole aortas were collected for Oil Red O staining to quantify plaque area or for biochemical analysis. Plasma was collected for total cholesterol measurement and lipidomic analysis. Aortic roots were used for histological analysis.

Results

Upon intravenous injection, as shown by IVIS imaging, DHA-containing liposomes accumulated preferentially in the atherosclerotic plaques. Compared to control liposomes, liposomal DHA treatment reduced the atherosclerotic plaque area in both atherosclerosis animal models, with the total plaque area decreased by 35.8% in ApoE−/− mice, (p&lt;0.001) and by 22.4% in LDLr−/− mice (p&lt;0.05). Plaque composition analysis revealed that liposomal DHA treatment increased collagen content and reduced the number of macrophages and neutral lipid within the plaques, resulting in a lower plaque vulnerability index (1.095 for liposomal DHA treated group vs. 1.692 for control group, p&lt;0.05). Among those plaque macrophages, as demonstrated by immunohistology, M2 (anti-inflammatory) macrophages accounted for 4.44% in liposomal DHA treated mice and 2.24% in control liposomes treated mice (p&lt;0.05). In agreement with the histology results, higher mRNA expression levels of anti-inflammatory markers (IL-10, CD206 and CD163) and collagen type 1 were determined in aortic tissue after liposomal DHA treatment. Moreover, liposomal DHA did not change total cholesterol level in the blood but significantly lowered plasma levels of several species of triglycerides. In vitro experiment with bone marrow derived macrophages showed that liposomal DHA was able to suppress lipopolysaccharide-induced inflammatory response and oxidative stress.

Conclusions

Our findings demonstrate that incorporation of DHA in injectable liposomes is an effective way to increase the inhibitory effects of DHA on halting the progression of atherosclerosis via lowering circulating triglycerides, reducing plaque inflammation, and enhancing plaque stability. Intravenous administration of liposomal DHA may become an efficacious strategy for the treatment of atherosclerosis.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): NUSMed Seed Fund

Mortality of patients with hospital-onset sepsis in hospitals with all-day and non-all-day rapid response teams: a prospective nationwide multicenter cohort study

Background

Hospital-onset sepsis is associated with a higher in-hospital mortality rate than community-onset sepsis. Many hospitals have implemented rapid response teams (RRTs) for early detection and timely management of at-risk hospitalized patients. However, the effectiveness of an all-day RRT over a non-all-day RRT in reducing the risk of in-hospital mortality in patient with hospital-onset sepsis is unclear. We aimed to determine the effect of the RRT’s operating hours on in-hospital mortality in inpatient patients with sepsis.

Methods

We conducted a nationwide cohort study of adult patients with hospital-onset sepsis prospectively collected from the Korean Sepsis Alliance (KSA) Database from 16 tertiary referral or university-affiliated hospitals in South Korea between September of 2019 and February of 2020. RRT was implemented in 11 hospitals, of which 5 (45.5%) operated 24-h RRT (all-day RRT) and the remaining 6 (54.5%) had part-day RRT (non-all-day RRT). The primary outcome was in-hospital mortality between the two groups.

Results

Of the 405 patients with hospital-onset sepsis, 206 (50.9%) were admitted to hospitals operating all-day RRT, whereas 199 (49.1%) were hospitalized in hospitals with non-all-day RRT. A total of 73 of the 206 patients in the all-day group (35.4%) and 85 of the 199 patients in the non-all-day group (42.7%) died in the hospital (P = 0.133). After adjustments for co-variables, the implementation of all-day RRT was associated with a significant reduction in in-hospital mortality (adjusted odds ratio 0.57; 95% confidence interval 0.35–0.93; P = 0.024).

Conclusions

In comparison with non-all-day RRTs, the availability of all-day RRTs was associated with reduced in-hospital mortality among patients with hospital-onset sepsis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04149-z.

Effect of a nutritional support protocol on enteral nutrition and clinical outcomes of critically ill patients: a retrospective cohort study

Background

Enteral nutrition (EN) supply within 48 hours after intensive care unit (ICU) admission improves clinical outcomes. The “new ICU evaluation & development of nutritional support protocol (NICE-NST)” was introduced in an ICU of tertiary academic hospital. This study showed that early EN through protocolized nutritional support would supply more nutrition to improve clinical outcomes.

Methods

This study screened 170 patients and 62 patients were finally enrolled; patients who were supplied nutrition without the protocol were classified as the control group (n=40), while those who were supplied according to the protocol were classified as the test group (n=22).

Results

In the test group, EN started significantly earlier (3.7±0.4 days vs. 2.4±0.5 days, P=0.010). EN calorie (4.0±1.0 kcal/kg vs. 6.7±0.9 kcal/kg, P=0.006) and protein (0.17±0.04 g/kg vs. 0.32±0.04 g/kg, P=0.002) supplied were significantly higher in the test group. Although EN was supplied through continuous feeding in the test group, there was no difference in complications such as feeding hold due to excessive gastric residual volume or vomit, and hyper- or hypo-glycemia between the two groups. Hospital mortality was significantly lower in the group that started EN within 1.5 days (42.9% vs. 11.8%, P=0.018). The proportion of patients who started EN within 1.5 days was higher in the test group (40.9% vs. 17.5%, P=0.044).

Conclusions

The NICE-NST may improve EN supply and mortality of critically ill patients without increasing complications.

Comprehensive Rehabilitation in Severely Ill Inpatients With COVID-19: A Cohort Study in a Tertiary Hospital

BACKGROUND

This study aimed to investigate the effects of comprehensive rehabilitation management on functional recovery and examine the correlation between clinical parameters and improvements in functional outcomes in severe-to-critical inpatients with coronavirus disease 2019 (COVID-19) in a tertiary hospital.

METHODS

Post-acute COVID-19 patients who had a World Health Organization (WHO) ordinal scale of 5-7, underwent intensive care, and received comprehensive rehabilitation management, including exercise programs, nutritional support, dysphagia evaluation, and psychological care were included. The appendicular skeletal muscle mass index (SMI), Medical Research Council sum score, handgrip strength, number of repetitions in the 1-minute sit-to-stand test, gait speed, Berg Balance Scale (BBS), and Functional Ambulation Classification (FAC) were evaluated at hospital stay, discharge, and 1-month follow-up. The correlation between the rehabilitation dose and improvement in each outcome measure was analyzed.

RESULTS

Overall, 37 patients were enrolled, of whom 59.5% and 32.4% had a score of 6 and 7 on the WHO ordinal scale, respectively. Lengths of stay in the intensive care unit and hospital were 33.6 ± 23.9 and 63.8 ± 36.5 days. Outcome measures revealed significant improvements at discharge and 1-month follow-up. The SMI was significantly increased at the 1-month follow-up (6.13 [5.24-7.76]) compared with that during the hospital stay (5.80 [5.39-7.05]). We identified dose-response associations between the rehabilitation dose and FAC (ρ = 0.46) and BBS (ρ = 0.50) scores. Patients with older age, longer hospitalization, longer stay at the intensive care unit, longer duration of mechanical ventilation, tracheostomy, a more depressive mood, and poorer nutritional status revealed poorer improvement in gait speed at the 1-month follow-up.

CONCLUSION

Comprehensive rehabilitation management effectively improved muscle mass, muscle strength, and physical performance in severe-to-critical COVID-19 patients. Dose-response relationship of rehabilitation and functional improvement emphasizes the importance of intensive post-acute inpatient rehabilitation in COVID-19 survivors.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05104411.

Evaluation of the synergistic impact of needle and forceps biopsy with electromagnetic navigation bronchoscopy: the CONFIDENT-ENB trial design

Background

Electromagnetic navigation bronchoscopy (ENB) is an emerging advanced imaging-guided bronchoscopy technique for diagnosing peripheral lung lesions. However, the selection strategy for the optimal biopsy device and whether adopting a multi-tool strategy increases the diagnostic yield remains undetermined. The CONFIDENT-ENB trial (NCT05110131) is a prospective randomized study on ENB, performed in a least-invasive setting. The primary aim is to evaluate whether a combination of needle aspiration and forceps biopsy improves the diagnostic performance, and assess the comparative diagnostic value and discordance of the two devices.

Methods

The trial will recruit 142 participants with lung lesions suspected of malignancy who are eligible for an elective ENB procedure under moderate sedation. Participants will undergo ENB-guided needle aspiration and forceps biopsy in a randomized order without the use of any complementary techniques. All participants will be followed up subsequently for up to 12 months to conclude the final diagnosis of the biopsied lesions. Primary outcomes include the diagnostic yield and sensitivity of each biopsy modality and the diagnostic yield of the combined modalities.

Discussion

The CONFIDENT-ENB trial will prospectively evaluate the synergistic effectiveness and comparative accuracy of ENB-guided needle aspiration and forceps biopsy in a least-invasive setting. The results are expected to improve our understanding of the optimal tool-selection strategy for ENB.

Trial registration: ClinicalTrials.gov (NCT05110131). Prospectively registered on 5 November 2021.

Incidence of preventable cardiopulmonary arrest in a mature part-time rapid response system: A prospective cohort study

Background

The purpose of a rapid response system (RRS) is to reduce the incidence of preventable cardiopulmonary arrests (CPAs) and patient deterioration in general wards. The objective of this study is to investigate the incidence and temporal trends of preventable CPAs and determine factors associated with preventable CPAs in a hospital with a mature RRS.

Methods

This was a single-center prospective cohort study of all CPAs occurring in the general ward between March 2017 and June 2020. The RRS operates from 07:00 to 23:00 on weekdays and from 07:00 to 12:00 on Saturdays. All CPAs were reviewed upon biweekly conference, and a panel of intensivists judged their preventability. Trends of preventable CPAs were analyzed using Poisson regression models and factors associated with preventable CPAs were analyzed using multivariable logistic regression.

Results

There were 253 CPAs over 40 months, and 64 (25.3%) of these were preventable. The incidence rate of CPAs was 1.07 per 1000 admissions and that of preventable CPAs was 0.27 per 1000 admissions. The number of preventable CPAs decreased by 24% each year (incidence rate ratio = 0.76; p = 0.039) without a change in the total CPA incidence. The most common contributor to the preventability was delayed response from physicians (n = 41, 64.1%). A predictable CPA with a pre-alarm sign had increased odds in the occurrence of preventable CPAs, while a cardiac cause of CPAs and RRS operating hours had decreased odds in terms of occurrence of preventable CPA.

Conclusion

Our study showed that one-fourth of all CPAs occurring in the general wards were preventable, and these arrests decreased each year. A mature RRS can evolve to reduce preventable CPAs with regular self-evaluation. Efforts should be directed at improving physicians’ response time since a delay in their response was the most common cause of preventable CPAs.

Time-to-antibiotics and clinical outcomes in patients with sepsis and septic shock: a prospective nationwide multicenter cohort study

Background

Timely administration of antibiotics is one of the most important interventions in reducing mortality in sepsis. However, administering antibiotics within a strict time threshold in all patients suspected with sepsis will require huge amount of effort and resources and may increase the risk of unintentional exposure to broad-spectrum antibiotics in patients without infection with its consequences. Thus, controversy still exists on whether clinicians should target different time-to-antibiotics thresholds for patients with sepsis versus septic shock.

Methods

This study analyzed prospectively collected data from an ongoing multicenter cohort of patients with sepsis identified in the emergency department. Adjusted odds ratios (ORs) were compared for in-hospital mortality of patients who had received antibiotics within 1 h to that of those who did not. Spline regression models were used to assess the association of time-to-antibiotics as continuous variables and increasing risk of in-hospital mortality. The differences in the association between time-to-antibiotics and in-hospital mortality were assessed according to the presence of septic shock.

Results

Overall, 3035 patients were included in the analysis. Among them, 601 (19.8%) presented with septic shock, and 774 (25.5%) died. The adjusted OR for in-hospital mortality of patients whose time-to-antibiotics was within 1 h was 0.78 (95% confidence interval [CI] 0.61–0.99; p = 0.046). The adjusted OR for in-hospital mortality was 0.66 (95% CI 0.44–0.99; p = 0.049) and statistically significant in patients with septic shock, whereas it was 0.85 (95% CI 0.64–1.15; p = 0.300) in patients with sepsis but without shock. Among patients who received antibiotics within 3 h, those with septic shock showed 35% (p = 0.042) increased risk of mortality for every 1-h delay in antibiotics, but no such trend was observed in patients without shock.

Conclusion

Timely administration of antibiotics improved outcomes in patients with septic shock; however, the association between early antibiotic administration and outcome was not as clear in patients with sepsis without shock.

Differences in detection patterns, characteristics, and outcomes of central and peripheral lung cancers in low-dose computed tomography screening

Background

Although low-dose computed tomography (LDCT) screening is known to be effective for the detection of lung cancers localized in peripheral lung regions at a curable stage, limited data is available regarding the characteristics and outcomes of central lung cancers diagnosed in a screening cohort. This study aimed to determine whether LDCT screening could effectively detect central lung cancers at an early stage and offer survival benefits.

Methods

We analyzed 52,615 adults who underwent lung cancer screening with LDCT between May 2003 and Dec 2019 at a tertiary center in South Korea. Characteristics and outcomes of those diagnosed with lung cancer, stratified by screen-detection status and cancer location, were evaluated.

Results

A total of 352 individuals (281 screen-detected, 71 non-screen-detected) were diagnosed with lung cancer. Compared to screen-detected cancers, non-screen-detected cancers tended to be centrally-located (11.4% vs. 64.8%, P<0.001). Most non-screen-detected central cancers (89.1%) had a negative result on prior LDCT screening. Multivariable regression analyses revealed that for peripheral cancers, screen-detection was associated with a significantly lower probability of diagnosis at an advanced stage [III/IV, odds ratio (OR) =0.15, 95% confidence interval (CI): 0.05-0.45] and mortality [hazard ratio (HR) =0.33, 95% CI: 0.13-0.84]; however, the association was insignificant for central cancers. For screen-detected cancers, central location, compared to peripheral location, was significantly associated with a higher risk of diagnosis at an advanced stage (OR =20.83, 95% CI: 6.67-64.98) and mortality (HR =4.98, 95% CI: 2.26-10.97).

Conclusions

Unlike for peripheral cancers, LDCT screening did not demonstrate an improvement in outcomes of central lung cancers, indicating an important limitation of LDCT screening and the need for developing novel modalities to screen and treat central lung cancer.

Compound heterozygosity for a variably penetrant variant and a variant of unknown significance in FLT4 causes fully penetrant Milroy's lymphedema

Milroy disease, known as primary congenital lymphedema, is characterized by chronic tissue swelling due to impaired lymphatic drainage and is inherited in an autosomal dominant manner. This study reports a rare case of Milroy disease affecting siblings from unaffected parents. A one-month-old female infant presented with swelling of the bilateral calf and the dorsum of the feet which had been present since birth. Her 14-month-old brother had a similar presentation since birth with swelling of the bilateral calf and the dorsum of the feet. Milroy disease was diagnosed based on the clinical findings of bilateral lower limb swelling and confirmed by molecular genetic testing. The patient and her family, including her brother, parents, and maternal grandfather, were genetically tested, and two novel missense mutations (NM_182925.4: c.2534T>C; p.Leu845Pro, c.4006G>A; p.Glu1336Lys) were found in the Fms-related tyrosine kinase (FLT4) gene. Mutations segregated by the parents who carried each mutation in the heterozygous state were identified in the patient and her brother. The present case report in which Milroy disease developed in all offspring of parents with a normal phenotype suggests the possibility of a compound heterozygous mutation or non-penetrance during the process of inheritance of Milroy disease.

Lung cancer probability and clinical outcomes of baseline and new subsolid nodules detected on low-dose CT screening

BACKGROUND

Limited data are available regarding the management of subsolid nodules detected on lung cancer screening with low-dose CT (LDCT). We aimed to determine the characteristics of screen-detected subsolid nodules, and to evaluate the probability of lung cancer and the clinical course of subsolid nodules detected at baseline and during follow-up screening.

METHODS

We evaluated 50 132 asymptomatic adults (22 631 never-smokers and 27 501 ever-smokers) who underwent LDCT screening for lung cancer between May 2003 and June 2019 at a tertiary centre in South Korea. The incidence, characteristics and clinical outcomes of the baseline and new screen-detected subsolid nodules were determined.

RESULTS

A total of 6725 subsolid nodules (5116 pure ground glass opacity nodules and 1609 part-solid nodules) were detected in 4545 participants (1484 new subsolid nodules detected in 937 (1.9%) participants; the overall incidence of subsolid nodules: 10.7% in never-smokers and 7.7% in ever-smokers, p<0.001). Among 4918 subsolid nodules that underwent follow-up with CT scans (the mean number of CT scans, including the baseline LDCT scan: 4.6), 2116 nodules (30.0% of baseline subsolid nodules and 78.9% of new subsolid nodules) resolved spontaneously. Among 293 biopsied subsolid nodules, 227 (77.5%) nodules were diagnosed as lung cancer, of which 226 (99.6%) were adenocarcinomas. No significant difference was observed in pathological invasiveness or the initial stage between the baseline and new cancerous subsolid nodules. Multivariable analyses revealed that new detection at follow-up screening was significantly associated with a lower probability of lung cancer (OR 0.26, 95% CI 0.14 to 0.49) and overall growth (OR 0.39, 95% CI 0.26 to 0.59), but with a higher probability of resolution (OR 6.30, 95% CI 5.09 to 7.81).

CONCLUSIONS

LDCT screening led to a considerably high rate of subsolid nodule detection, particularly in never-smokers. Compared with the baseline subsolid nodules, the new subsolid nodules were associated with a lower probability of lung cancer and higher probability of spontaneous resolution, indicating their more inflammatory nature. Less aggressive follow-up may be allowed for new subsolid nodules, particularly in screening programmes for Asian populations.

Renal outcomes of laparoscopic versus open surgery in patients with rectal cancer: a propensity score analysis

Background

A laparoscopic approach is widely used in abdominal surgery. Although several studies have compared surgical and oncological outcomes between laparoscopic surgery (LS) and open surgery (OS) in rectal cancer patients, there have been few studies on postoperative renal outcomes.

Methods

We conducted a retrospective cohort study involving 1,633 patients who underwent rectal cancer surgery between 2003 and 2017. Postoperative acute kidney injury (AKI) was diagnosed according to the serum creatinine criteria of the Kidney Disease: Improving Global Outcomes classification.

Results

Among the 1,633 patients, 1,072 (65.6%) underwent LS. After matching propensity scores, 395 patients were included in each group. The incidence of postoperative AKI in the LS group was significantly lower than in the OS group (9.9% vs. 15.9%; p = 0.01). Operation time, estimated blood loss, and incidence of transfusion in the LS group were significantly lower than those in the OS group. Cox proportional hazard models revealed that LS was associated with decreased risk of postoperative AKI (hazard ratio [HR], 0.599; 95% confidence interval [CI], 0.402–0.893; p = 0.01) and postoperative transfusion was associated with increased risk of AKI (HR, 2.495; 95% CI, 1.529–4.072; p < 0.001). In the subgroup analysis, the incidence of postoperative AKI in patients with middle or high rectal cancer who underwent LS was much lower than in those who underwent OS (HR, 0.373; 95% CI, 0.197–0.705; p = 0.002).

Conclusion

This study showed that LS may have a favorable effect on the development of postoperative AKI in patients with rectal cancer.

Clustering and multiple-spreading events of nosocomial severe acute respiratory syndrome coronavirus 2 infection

Background

There is growing evidence that super-spreading events (SSEs) and multiple-spreading events (MSEs) are a characteristic feature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, data regarding the possibility of SSEs or MSEs in healthcare settings are limited.

Methods

This study was performed at a tertiary-care hospital in Korea. We analysed the nosocomial COVID-19 cases that occurred in healthcare workers and inpatients and their caregivers between January and 20^th December 2020. Cases with two to four secondary cases were defined as MSEs and those with five or more secondary cases as SSEs.

Findings

We identified 21 nosocomial events (single-case events, N = 12 (57%); MSE + SSE, N = 9 (43%)) involving 65 individuals with COVID-19. Of these 65 individuals, 21 (32%) were infectors. The infectors tended to have a longer duration between symptom onset and diagnostic confirmation than did the non-infectors (median two days vs zero days, P=0.08). Importantly, 12 (18%) individuals were responsible for MSEs and one (2%) for an SSE, which collectively generated 35 (54%) secondary cases.

Conclusion

In a hospital with thorough infection-control measures, approximately 70% of the nosocomial cases of COVID-19 did not generate secondary cases, and one-fifth of the infectors were responsible for SSEs and MSEs, which accounted for approximately half of the total cases. Early case identification, isolation, and extensive contact tracing are important for the prevention of transmission and SSEs.

Pathophysiology of Cardiorenal Syndrome and Use of Diuretics and Ultrafiltration as Volume Control

Acute deterioration in kidney function in the setting of decompensated heart failure, known as cardiorenal syndrome, results from venous congestion. Although diuretics or ultrafiltration are effective measures in decreasing venous congestion and improving symptoms in patients with cardiorenal syndrome, the impact of decongestive therapy on kidney function or mortality remains uncertain. A precise assessment of venous congestion is required to assess the adequacy of patients' response to decongestive therapy and to guide therapeutic decision making.

Acute or chronic dysfunction of the heart or kidneys can cause dysfunction of other organs. This interaction between the heart and kidneys is characterized as cardiorenal syndrome (CRS). Recently, a preponderance of data indicated that venous congestion plays an important role in the combination of renal and cardiac diseases. This review aims to focus on the pathophysiology of venous congestion that leads to renal impairment in heart failure and the use of diuretics or ultrafiltration as decongestive therapy in CRS. We found that although clinical studies have confirmed that decongestive therapy has a definite role in decreasing volume overload and the consequent symptom improvement in patients with CRS, the impact of diuretics or ultrafiltration on the improvement of kidney function or mortality remains uncertain. A precise assessment of volume status is required to determine the adequacy of decongestion. Objective measures of renal venous congestion may be a future metric to assess the adequacy of the diuretic response in patients and guide therapeutic decision making.

368 Perioperative Outcomes in Open versus Laparoscopic Surgery in Elderly Patients Undergoing Right Hemicolectomy

Introduction

With the global aging population, elderly patients are increasingly undergoing colorectal surgery. This study aims to evaluate postoperative outcomes in open (OS) and laparoscopic surgery (LS) for right hemicolectomy in elderly patients.

Method

We retrospectively reviewed patients aged 70 and above undergoing right hemicolectomy for malignancies at our institution. Additionally, Embase and Medline databases were reviewed, and comparative meta-analysis was conducted.

Results

84 patients were included in our cohort (OS = 34; LS = 50). No significant difference in anastomotic leak (AL) (OS = 4; LS = 2; p = 0.176), surgical site infection (SSI) (OS = 4; LS = 2; p = 0.216), and ileus (OS = 10; LS = 16; p = 0.801) was observed. LS was associated with decreased postoperative stay (p = 0.001). Additionally, LS had faster return of bowel function (ROBF) (p = 0.068) and resumption of diet (p = 0.147), albeit without significance. Overall survival (p = 0.062), and disease-free survival (p = 0.067) did not significantly differ between LS and OS.

Pooled analysis of 463 patients yielded no significant difference in AL (OR:1.15; 95%CI: 0.17-8.01; p = 0.89), SSI (OR:0.88; 95%CI: 0.44-1.76; p = 0.71), and ileus (OR:1.42; 95%CI: 0.69 – 2.92; p = 0.35). Postoperative stay (WMD:1.90 days; 95%CI: -1.81–5.61 days; p = 0.31), and ROBF (WMD:14.49 hours; 95%CI: -4.07–33.05 hours; p = 0.13) were shortened in LS, although without significance.

Conclusions

LS is associated with improved functional outcomes without an increased risk of postoperative morbidity or mortality.

Reasons why patients with tuberculosis in South Korea stop anti-TB treatment: a cross-sectional study

BACKGROUND: As there had been no reduction in the TB burden in South Korea since 2000, a public-private mix (PPM) strategy was launched in 2011. The purpose of this study was to investigate the reasons for lost to follow-up (LTFU) among TB patients and their clinical characteristics.METHOD: A multicentre, cross-sectional study based on in-depth interviews with patients and their families by TB specialist nurses was conducted. Patients who were reported with a final outcome of LTFU in 2015-2017 at all PPM hospitals across the country were enrolled. Enrolled patients were classified into six subgroups by age and three major reasons for LTFU (adverse effects, refusal of treatment, marginalisation) and their clinical features were compared.RESULTS: Among 780 patients, those who were lost to follow-up due to adverse effects accounted for the largest proportion (n = 387). LTFU in those aged <65 years who refused treatment (n = 189) and those aged <65 years who were marginalised (n = 108) were related to having smear-positive TB and a previous history of unfavourable outcomes.CONCLUSION: To reduce LTFU in South Korea, comprehensive strategies, including management of adverse effects, systematic counselling and education, should be implemented.

Distinctive patterns of pulmonary function change according to baseline lung volume and diffusing capacity

SETTING: Multicentre retrospective study in South Korea.OBJECTIVE: To longitudinally evaluate changes in lung volume and diffusing capacity for carbon monoxide (DLCO) with forced expiratory volume in 1 sec (FEV₁).DESIGN: A total of 155 patients with chronic obstructive pulmonary disease (COPD), whose pulmonary function parameters were measured annually for 5 years, were selected from a prospective cohort in South Korea. A random coefficients model was used to estimate mean annual FEV₁, lung volume parameter and DLCO change rates.RESULTS: Patients were classified into four groups based on baseline DLCO and residual volume/total lung capacity (RV/TLC) measurements. The annual FEV₁ decline rate was greater in patients with low DLCO than in those with normal DLCO, with the greatest decline occurring in patients with low DLCO and normal RV/TLC. RV and RV/TLC declined in patients with high RV/TLC, whereas these increased in patients with normal RV/TLC. DLCO decreased longitudinally in all four groups, with the greatest decline occurring in patients with normal DLCO and normal RV/TLC.CONCLUSIONS: Different subgroups of patients with COPD exhibited distinctive pulmonary function change patterns. Baseline DLCO and RV/TLC may be used as physiological markers to predict long-term changes in pulmonary function.

Association of low fat mass with nontuberculous mycobacterial infection in patients with bronchiectasis

The incidence of pulmonary nontuberculous mycobacterial (NTM) infection is high in patients with underlying lung disease such as bronchiectasis. Although previous studies have reported many risk factors contributing to the development of NTM-lung disease (LD), only a few reports on the relationship of the characteristics of patients, such as body mass index (BMI), skeletal mass, and fat mass, with NTM-LD have been published. We aimed to investigate the association between these parameters and NTM-LD in patients with bronchiectasis.A monocentric retrospective study in a university hospital was conducted over 4 years (2013-2016). Parameters including BMI, skeletal mass, and fat mass were measured using bioelectrical impedance analysis in noncystic fibrosis bronchiectasis patients. Patients were grouped by the presence or absence of NTM-LD, and the differences in BMI, skeletal mass, and fat mass between the 2 groups were compared. In the NTM-LD group, the progression of disease was also followed.Two hundred forty-five patients with bronchiectasis were enrolled in the study. One hundred six subjects (48%) had NTM-LD. These patients with NTM-LD were predominantly female, and had a significantly lower body weight (58.20 ± 8.84 vs 54.16 ± 8.99, P < .001), BMI (22.67 ± 3.04 vs 21.20 ± 2.59 kg/m2, P < .001), fat mass (16.19 ± 6.60 vs 14.23 ± 5.79, P = .013), and fat mass index (FMI; 6.79 ± 2.70 vs 5.57 ± 2.27 kg/m2, P < .001). Multivariate regression analysis showed that both female sex and lower FMI but not skeletal muscle index were independent risk factors for NTM-LD after adjusting for age, bronchiectasis severity index, and BMI (odds ratio 3.86 (1.99-7.78); 0.72 (0.63-0.82), P < .001, respectively).Our results suggest that lower FMI may contribute to susceptibility to NTM infection in patients with bronchiectasis, independent of age or its severity.

Utility and safety of sole electromagnetic navigation bronchoscopy under moderate sedation for lung cancer diagnosis

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Profile of reticulated platelets in the early, subacute and late phases after transient ischemic attack or ischemic stroke

Information regarding the profile of reticulated platelets (RP) in ischemic cerebrovascular disease (CVD) patients is limited. Data from two prospective, observational, case-control studies were combined to compare the %RP using whole blood flow cytometry in patients ≤ 4 weeks of TIA/stroke onset (baseline, N = 210), and 14 ±7 days (14d, N = 182) and ≥ 90 days (90d, N = 145) after starting or changing antiplatelet therapy with healthy controls (N = 34). There were no differences in median %RP between the overall CVD patient population at baseline or 14d vs. controls (P ≥ 0.2). However, the median %RP was significantly higher in CVD patients overall at 90d (P = .036), and in the subgroup of patients with "lacunar" TIA/ischemic stroke at baseline (P = .04) and at 90d (P = .01), but not at 14d (P = .06) vs. controls. There were no significant differences in the median %RP between other TIA/stroke subgroups and controls (P ≥ 0.05). Elevated circulating reticulated platelets, as a marker of increased platelet production/turnover, may occur following an ischemic event in a well-phenotyped TIA/ischemic stroke population overall, but may precede symptom onset at least in the subgroup with small vessel occlusion. These data improve our understanding of the profile of reticulated platelets in CVD patients.