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Dolinay T, Hsu L, Maller A, Walsh BC, Szűcs A, Jerng JS, Jun D. Ventilator Weaning in Prolonged Mechanical Ventilation-A Narrative Review. J Clin Med 2024; 13:1909. [PMID: 38610674 PMCID: PMC11012923 DOI: 10.3390/jcm13071909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/11/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Patients requiring mechanical ventilation (MV) beyond 21 days, usually referred to as prolonged MV, represent a unique group with significant medical needs and a generally poor prognosis. Research suggests that approximately 10% of all MV patients will need prolonged ventilatory care, and that number will continue to rise. Although we have extensive knowledge of MV in the acute care setting, less is known about care in the post-ICU setting. More than 50% of patients who were deemed unweanable in the ICU will be liberated from MV in the post-acute setting. Prolonged MV also presents a challenge in care for medically complex, elderly, socioeconomically disadvantaged and marginalized individuals, usually at the end of their life. Patients and their families often rely on ventilator weaning facilities and skilled nursing homes for the continuation of care, but home ventilation is becoming more common. The focus of this review is to discuss recent advances in the weaning strategies in prolonged MV, present their outcomes and provide insight into the complexity of care.
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Affiliation(s)
- Tamás Dolinay
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Lillian Hsu
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Abigail Maller
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Brandon Corbett Walsh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Department of Medicine, Division of Palliative Care Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Attila Szűcs
- Department of Anesthesiology, András Jósa County Hospital, 4400 Nyíregyháza, Hungary;
| | - Jih-Shuin Jerng
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei 100, Taiwan;
| | - Dale Jun
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Medical Center, Los Angeles, CA 90073, USA
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Chung KP, Su JY, Wang YF, Budiarto BR, Yeh YC, Cheng JC, Keng LT, Chen YJ, Lu YT, Juan YH, Nakahira K, Ruan SY, Chien JY, Chang HT, Jerng JS, Huang YT, Chen SY, Yu CJ. Immunometabolic features of natural killer cells are associated with infection outcomes in critical illness. Front Immunol 2024; 15:1334882. [PMID: 38426112 PMCID: PMC10902670 DOI: 10.3389/fimmu.2024.1334882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/10/2024] [Indexed: 03/02/2024] Open
Abstract
Immunosuppression increases the risk of nosocomial infection in patients with chronic critical illness. This exploratory study aimed to determine the immunometabolic signature associated with nosocomial infection during chronic critical illness. We prospectively recruited patients who were admitted to the respiratory care center and who had received mechanical ventilator support for more than 10 days in the intensive care unit. The study subjects were followed for the occurrence of nosocomial infection until 6 weeks after admission, hospital discharge, or death. The cytokine levels in the plasma samples were measured. Single-cell immunometabolic regulome profiling by mass cytometry, which analyzed 16 metabolic regulators in 21 immune subsets, was performed to identify immunometabolic features associated with the risk of nosocomial infection. During the study period, 37 patients were enrolled, and 16 patients (43.2%) developed nosocomial infection. Unsupervised immunologic clustering using multidimensional scaling and logistic regression analyses revealed that expression of nuclear respiratory factor 1 (NRF1) and carnitine palmitoyltransferase 1a (CPT1a), key regulators of mitochondrial biogenesis and fatty acid transport, respectively, in natural killer (NK) cells was significantly associated with nosocomial infection. Downregulated NRF1 and upregulated CPT1a were found in all subsets of NK cells from patients who developed a nosocomial infection. The risk of nosocomial infection is significantly correlated with the predictive score developed by selecting NK cell-specific features using an elastic net algorithm. Findings were further examined in an independent cohort of COVID-19-infected patients, and the results confirm that COVID-19-related mortality is significantly associated with mitochondria biogenesis and fatty acid oxidation pathways in NK cells. In conclusion, this study uncovers that NK cell-specific immunometabolic features are significantly associated with the occurrence and fatal outcomes of infection in critically ill population, and provides mechanistic insights into NK cell-specific immunity against microbial invasion in critical illness.
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Affiliation(s)
- Kuei-Pin Chung
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Laboratory Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jia-Ying Su
- Institute of Molecular Biology, Academia Sinica, Taipei, Taiwan
- Institute of Statistical Science, Academia Sinica, Taipei, Taiwan
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Bioinformatics Program, Taiwan International Graduate Program, Academia Sinica, Taipei, Taiwan
| | - Yi-Fu Wang
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Bugi Ratno Budiarto
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
- Taiwan International Graduate Program in Molecular Medicine, National Yang Ming Chiao Tung University and Academia Sinica, Taipei, Taiwan
| | - Yu-Chang Yeh
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jui-Chen Cheng
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Ta Keng
- Department of Internal Medicine, National Taiwan University Hospital, Hsinchu, Taiwan
| | - Yi-Jung Chen
- Department of Laboratory Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ya-Ting Lu
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Yi-Hsiu Juan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kiichi Nakahira
- Department of Pharmacology, Nara Medical University, Kashihara, Nara, Japan
| | - Sheng-Yuan Ruan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jung-Yien Chien
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hou-Tai Chang
- Department of Critical Care Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan
- Department of Industrial Engineering and Management, Yuan Ze University, Taoyuan, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yen-Tsung Huang
- Institute of Statistical Science, Academia Sinica, Taipei, Taiwan
| | - Shih-Yu Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Hsinchu, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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Lin FC, Chen YH, Kuo YW, Ku SC, Jerng JS. Aerosol particle dispersion in spontaneous breathing training of oxygen delivery tracheostomized patients on prolonged mechanical ventilation. J Formos Med Assoc 2024:S0929-6646(24)00081-0. [PMID: 38336509 DOI: 10.1016/j.jfma.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/29/2023] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Tracheostomized patients undergoing liberation from mechanical ventilation (MV) are exposed to the ambient environment through humidified air, potentially heightening aerosol particle dispersion. This study was designed to evaluate the patterns of aerosol dispersion during spontaneous breathing trials in such patients weaning from prolonged MV. METHODS Particle Number Concentrations (PNC) at varying distances from tracheostomized patients in a specialized weaning unit were quantified using low-cost particle sensors, calibrated against a Condensation Particle Counter. Different oxygen delivery methods, including T-piece and collar mask both with the humidifier or with a small volume nebulizer (SVN), and simple collar mask, were employed. The PNC at various distances and across different oxygen devices were compared using the Kruskal-Wallis test. RESULTS Of nine patients receiving prolonged MV, five underwent major surgery, and eight were successfully weaned from ventilation. PNCs at distances ranging from 30 cm to 300 cm showed no significant disparity (H(4) = 8.993, p = 0.061). However, significant differences in PNC were noted among oxygen delivery methods, with Bonferroni-adjusted pairwise comparisons highlighting differences between T-piece or collar mask with SVN and other devices. CONCLUSIONS Aerosol dispersion within 300 cm of the patient was not significantly different, while the nebulization significantly enhances ambient aerosol dispersion in tracheostomized patients on prolonged MV.
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Affiliation(s)
- Feng-Ching Lin
- Division of Respiratory Therapy, Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan; School of Respiratory Therapy, Taipei Medical University, Taipei, Taiwan
| | - Yung-Hsuan Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Wen Kuo
- Division of Respiratory Therapy, Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan.
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Wu CH, Lin FC, Jerng JS, Shin MH, Wang YC, Lee CJ, Lin LM, Lin NH, Kuo YW, Ku SC, Wu HD. Automatic tube compensation for liberation from prolonged mechanical ventilation in tracheostomized patients: A retrospective analysis. J Formos Med Assoc 2023; 122:1132-1140. [PMID: 37169656 DOI: 10.1016/j.jfma.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 04/01/2023] [Accepted: 04/23/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND To analyze the predictability of an automatic tube compensation (ATC) screening test compared with the conventional direct liberation test performed before continuous oxygen support for MV liberation. METHODS This retrospective study analyzed tracheostomized patients with prolonged MV in a weaning unit of a medical center in Taiwan. In March 2020, a four-day ATC test to screen patient eligibility for ventilator liberation was implemented, intended to replace the direct liberation test. We compared the predictive accuracy of these two screening methods on the relevant outcomes in the two years before and one year after the implementation of this policy. RESULTS Of the 403 cases, 246 (61%) and 157 (39%) received direct liberation and ATC screening tests, respectively. These two groups had similar outcomes: successful weaning upon leaving the Respiratory Care Center (RCC), success on day 100 of MV, success at hospital discharge, and in-hospital survival. Receiver operating characteristic curve analysis showed that the ATC screening test had better predictive ability than the direct liberation test for RCC weaning, discharge weaning, 100-day weaning, and in-hospital survival. CONCLUSION This closed-circuit ATC screening test before ventilator liberation is a feasible and valuable method for screening PMV patients undergoing ventilator liberation in the pandemic era. Its predictability for a comparison with the open-circuit oxygen test requires further investigation.
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Affiliation(s)
- Chia-Hao Wu
- Department of Internal Medicine, National Taiwan University Hospital Hsin-chu Branch, Hsin-chu, Taiwan.
| | - Feng-Ching Lin
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Ming-Hann Shin
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Yi-Chia Wang
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Cheng-Jun Lee
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Li-Min Lin
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
| | - Nai-Hua Lin
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
| | - Yao-Wen Kuo
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Huey-Dong Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
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Huang HF, Jerng JS, Hsu PJ, Lin NH, Lin LM, Hung SM, Kuo YW, Ku SC, Chuang PY, Chen SY. Monitoring the performance of a dedicated weaning unit using risk-adjusted control charts for the weaning rate in prolonged mechanical ventilation. J Formos Med Assoc 2023; 122:880-889. [PMID: 37149422 DOI: 10.1016/j.jfma.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 04/05/2023] [Accepted: 04/23/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Weaning rate is an important quality indicator of care for patients with prolonged mechanical ventilation (PMV). However, diverse clinical characteristics often affect the measured rate. A risk-adjusted control chart may be beneficial for assessing the quality of care. METHODS We analyzed patients with PMV who were discharged between 2018 and 2020 from a dedicated weaning unit at a medical center. We generated a formula to estimate monthly weaning rates using multivariate logistic regression for the clinical, laboratory, and physiologic characteristics upon weaning unit admission in the first two years (Phase I). We then applied both multiplicative and additive models for adjusted p-charts, displayed in both non-segmented and segmented formats, to assess whether special cause variation existed. RESULTS A total of 737 patients were analyzed, including 503 in Phase I and 234 in Phase II, with average weaning rates of 59.4% and 60.3%, respectively. The p-chart of crude weaning rates did not show special cause variation. Ten variables from the regression analysis were selected for the formula to predict individual weaning probability and generate estimated weaning rates in Phases I and II. For risk-adjusted p-charts, both multiplicative and additive models showed similar findings and no special cause variation. CONCLUSION Risk-adjusted control charts generated using a combination of multivariate logistic regression and control chart-adjustment models may provide a feasible method to assess the quality of care in the setting of PMV with standard care protocols.
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Affiliation(s)
- Hsiao-Fang Huang
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Pei-Jung Hsu
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Nai-Hua Lin
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Min Lin
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Min Hung
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Wen Kuo
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Pao-Yu Chuang
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan; Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Shey-Ying Chen
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Chen DR, Jerng JS, Tsai DFC, Young Y. Gender differences in the intention to withhold life-sustaining treatments involving severe dementia for self and on behalf of parent or spouse. Palliat Care 2022; 21:171. [PMID: 36203170 PMCID: PMC9534740 DOI: 10.1186/s12904-022-01062-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/26/2022] [Accepted: 09/22/2022] [Indexed: 11/30/2022] Open
Abstract
Background Few studies have explored gender differences in the attitudes toward advanced care planning and the intention to withhold life-sustaining treatments (LSTs) involving severe dementia in Asian countries. We examined gender differences in the attitude toward the Patient Autonomy Act (PAA) in Taiwan and how the gender differences in these attitudes affect the intention to withhold LSTs for severe dementia. We also investigated self–other differences in the intention to withhold LSTs between genders. Methods Between March and October 2019, a structured questionnaire was distributed to hospitalized patients’ family members through face-to-face contact in an academic medical center. Exploratory factor analysis and independent and paired-sample t-tests were used to describe gender differences. Mediation analyses controlled for age, marital status, and education level were conducted to examine whether the attitude toward the PAA mediates the gender effect on the intention to withhold LSTs for severe dementia. Results Eighty respondents filled out the questionnaire. Exploratory factor analysis of the attitude toward the PAA revealed three key domains: regarding the PAA as (1) promoting a sense of abandonment, (2) supporting patient autonomy, and (3) contributing to the collective good. Relative to the men, the women had lower average scores for promoting a sense of abandonment (7.48 vs. 8.94, p = 0.030), higher scores for supporting patient autonomy (8.74 vs. 7.94, p = 0.006), and higher scores for contributing to the collective good (8.64 vs. 7.47, p = 0.001). Compared with the women, the men were less likely to withhold LSTs for severe dementia (15.84 vs. 18.88, p = 0.01). Mediation analysis revealed that the attitude toward the PAA fully mediated the gender differences in the intention to withhold LSTs for severe dementia. Both men and women were more likely to withhold LSTs for themselves than for their parents. Compared with the women, the men were more likely to withhold resuscitation for themselves than for their parents (p = 0.05). Women were more likely to agree to enteral tube feeding and a tracheotomy for their husbands than for themselves; men made consistent decisions for themselves and their wives in those LST scenarios. Conclusion Gender influences the attitude toward advanced care planning and consequently affects the intention to withhold LSTs, indicating that there may be a difference in how men and women perceive EOL decision-making for severe dementia in Taiwan. Further studies are warranted.
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Affiliation(s)
- Duan-Rung Chen
- Institute of Health Behaviors and Community Sciences, National Taiwan University, Taipei, Taiwan.
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Daniel Fu-Chang Tsai
- Department & Graduate Institute of Medical Education and Bioethics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yuchi Young
- Department of Health Policy, Management & Behavior, School of Public Health, New York State University,, Albany, USA
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Jerng JS, Chen LC, Chen SY, Kuo LC, Tsan CY, Hsieh PY, Chen CM, Chuang PY, Huang HF, Huang SF. Effect of Implementing Decision Support to Activate a Rapid Response System by Automated Screening of Verified Vital Sign Data: A Retrospective Database Study. Resuscitation 2022; 173:23-30. [DOI: 10.1016/j.resuscitation.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/23/2022] [Accepted: 02/04/2022] [Indexed: 11/16/2022]
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Cheng JC, Chen HC, Jerng JS, Kuo PH, Wu HD. End-Expiratory Lung Volumes During Spontaneous Breathing Trials in Tracheostomized Subjects on Prolonged Mechanical Ventilation. Respir Care 2021; 66:1704-1712. [PMID: 34465570 PMCID: PMC9993541 DOI: 10.4187/respcare.08957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The role of end-expiratory lung volume (EELV) during a spontaneous breathing trial (SBT) in patients who were tracheostomized and on prolonged mechanical ventilation is unclear. This study aimed to assess EELV during a 60-min SBT and its correlation with weaning success. METHODS Enrolled subjects admitted to a weaning unit were measured for EELV and relevant parameters before and after the SBT. RESULTS Of the 44 enrolled subjects, 29 (66%) were successfully liberated, defined as not needing mechanical ventilation for 5 d. The success group had fewer subjects with chronic kidney disease (41% vs 73%, P = .044), stronger mean ± SD maximum inspiratory pressure (41.6 ± 10.4 vs 34.1 ± 7.1 cm H2O; P = .02) and mean ± SD maximum expiratory pressure (46.9 ± 11.7 vs 35.3 ± 16.9 cm H2O; P = .01) versus the failure group. Toward the end of the SBT, the success group had a significant increase in the mean ± SD EELV (before vs after: 1,278 ± 744 vs 1,493 ± 867 mL; P = .040) and a decrease in the mean ± SD rapid shallow breathing index (83.8 ± 39.4 vs 66.3 ± 29.4; P = .02), whereas there were no significant changes in these 2 parameters in the failure group. The Cox regression analysis showed that, at the beginning of SBT, a greater difference between EELV with a PEEP of 0 cm H2O and with a PEEP of 5 cm H2O was significantly correlated to a higher likelihood of weaning success. Toward the end of the SBT, a greater EELV level at a PEEP of 0 cm H2O was also correlated with weaning success. Also, the greater difference of EELV at a PEEP of 0 cm H2O between the beginning and the end of the SBT was also correlated with a shorter duration to weaning success. CONCLUSIONS The change in EELV during a 60-min SBT may be of prognostic value for liberation from prolonged mechanical ventilation in patients who had a tracheostomy. Our findings suggest a model to understand the underlying mechanism of failure of liberation from mechanical ventilation in these patients.
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Affiliation(s)
- Jui-Chen Cheng
- Division of Respiratory Therapy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Hui-Chuan Chen
- Division of Respiratory Therapy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Ping-Hung Kuo
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Dong Wu
- Division of Respiratory Therapy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
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Lin SJ, Tsan CY, Su MY, Wu CL, Chen LC, Hsieh HJ, Hsiao WL, Cheng JC, Kuo YW, Jerng JS, Wu HD, Sun JS. Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness. BMJ Open Qual 2021; 9:bmjoq-2019-000698. [PMID: 32317274 PMCID: PMC7202726 DOI: 10.1136/bmjoq-2019-000698] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 01/24/2023] Open
Abstract
Aim Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation. Design and implementation We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including ‘VITAL’ (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, ‘STOP’ (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and ‘STOP’ (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme. Results The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001). Conclusion The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness.
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Affiliation(s)
- Shwu-Jen Lin
- Division of Respiratory Therapy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Yuan Tsan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Yuan Su
- Department of Radiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Ling Wu
- Division of Respiratory Therapy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Chin Chen
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Jung Hsieh
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Ling Hsiao
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Jui-Chen Cheng
- Division of Respiratory Therapy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Wen Kuo
- Division of Respiratory Therapy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan .,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Dong Wu
- Division of Respiratory Therapy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jui-Sheng Sun
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan.,Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
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Lin FC, Kuo YW, Jerng JS, Wu HD. Association of weaning preparedness with extubation outcome of mechanically ventilated patients in medical intensive care units: a retrospective analysis. PeerJ 2020; 8:e8973. [PMID: 32322446 PMCID: PMC7161570 DOI: 10.7717/peerj.8973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 03/24/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Assessment of preparedness of weaning has been recommended before extubation for mechanically ventilated patients. We aimed to understand the association of a structured assessment of weaning preparedness with successful liberation. METHODS We retrospectively investigated patients with acute respiratory failure who experienced an extubation trial at the medical intensive care units of a medical center and compared the demographic and clinical characteristics between those patients with successful and failed extubation. A composite score to assess the preparedness of weaning, the WEANSNOW score, was generated consisting of eight components, including Weaning parameters, Endotracheal tube, Arterial blood gas analysis, Nutrition, Secretions, Neuromuscular-affecting agents, Obstructive airway problems and Wakefulness. The prognostic ability of the WEANSNOW score for extubation was then analyzed. RESULTS Of the 205 patients included, 138 (67.3%) patients had successful extubation. Compared with the failure group, the success group had a significantly shorter duration of MV before the weaning attempt (11.2 ± 11.6 vs. 31.7 ± 26.2 days, p < 0.001), more with congestive heart failure (42.0% vs. 25.4%, p = 0.020), and had different distribution of the types of acute respiratory failure (p = 0.037). The failure group also had a higher WEANSNOW score (1.22 ± 0.85 vs. 0.51 ± 0.71, p < 0.001) and worse Rapid Shallow Breathing Index (93.9 ± 63.8 vs. 56.3 ± 35.1, p < 0.001). Multivariate logistic regression analysis showed that a WEANSNOW Score = 1 or higher (OR = 2.880 (95% CI [1.291-6.426]), p = 0.010) and intubation duration >21 days (OR = 7.752 (95% CI [3.560-16.879]), p < 0.001) were independently associated with an increased probability of extubation failure. CONCLUSION Assessing the pre-extubation status of intubated patients in a checklist-based approach using the WEANSNOW score might provide valuable insights into extubation failure in patients in a medical ICU for acute respiratory failure. Further prospective studies are warranted to elucidate the practice of assessing weaning preparedness.
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Affiliation(s)
- Feng-Ching Lin
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Nursing, Cardinal Tien Junior College of Healthcare and Management, New Taipei City, Taiwan
| | - Yao-Wen Kuo
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Dong Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
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Lin SJ, Jerng JS, Kuo YW, Wu CL, Ku SC, Wu HD. Maximal expiratory pressure is associated with reinstitution of mechanical ventilation after successful unassisted breathing trials in tracheostomized patients with prolonged mechanical ventilation. PLoS One 2020; 15:e0229935. [PMID: 32155187 PMCID: PMC7064239 DOI: 10.1371/journal.pone.0229935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/17/2020] [Indexed: 01/01/2023] Open
Abstract
Objective Reinstitution of mechanical ventilation (MV) for tracheostomized patients after successful weaning may occur as the care setting changes from critical care to general care. We aimed to investigate the occurrence, consequence and associated factors of MV reinstitution. Methods We analyzed the clinical data and physiological measurements of tracheostomized patients with prolonged MV discharged from the weaning unit to general wards after successful weaning to compare between those with and without in-hospital MV reinstitution within 60 days. Results Of 454 patients successfully weaned, 116 (25.6%) reinstituted MV at general wards within 60 days; at hospital discharge, 42 (36.2%) of them were eventually liberated from MV, 51 (44.0%) remained MV dependent, and 33 (28.4%) died. Of the 338 patients without reinstitution within 60 days, only 3 (0.9%) were later reinstituted with MV before discharge (on day 67, 89 and 136 at general wards, respectively), and 322 (95.2%) were successfully weaned again at discharge, while 13 (3.8%) died. Patients with MV reinstitution had a significantly lower level of maximal expiratory pressure (PEmax) before unassisted breathing trial compared to those without reinstitution. Multivariable Cox regression analysis showed fever at RCC discharge (hazard ratio [HR] 14.00, 95% confidence interval [CI] 3.2–61.9) chronic obstructive pulmonary disease (HR 2.37, 95% CI 1.34–4.18), renal replacement therapy at the ICU (HR 2.29, 95% CI 1.50–3.49) and extubation failure before tracheostomy (HR 1.76, 95% CI 1.18–2.63) were associated with increased risks of reinstitution, while PEmax > 30 cmH2O (HR 0.51, 95% CI 0.35–0.76) was associated with a decreased risk of reinstitution. Conclusions The reinstitution of MV at the general ward is significant, with poor outcomes. The PEmax measured before unassisted breathing trial was significantly associated with the risk of reinstituting MV at the general wards.
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Affiliation(s)
- Shwu-Jen Lin
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
| | - Yao-Wen Kuo
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Ling Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Dong Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
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Chen YY, Jerng JS, Chen JJ, Chang FC, Kuo YW, Wang HC, Wu HD. Changes in albuminuria during the spontaneous breathing trial: A prospective observational study. J Formos Med Assoc 2020; 119:488-495. [PMID: 31324438 DOI: 10.1016/j.jfma.2019.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 06/11/2019] [Accepted: 07/04/2019] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND We hypothesized urine albumin concentration may detect the early increasing cardiac load during the spontaneous breathing trial (SBT). The purpose of our study is to determine whether the changes in urine albumin concentration before and after the SBT correlate with SBT outcome. METHODS This prospective observational study was conducted from January 2013 to September 2013. Patients receiving endotracheal tube intubation due to acute respiratory failure were included. Urine albumin concentration was measured upon admission to the intensive care unit, before and after the SBT. RESULTS A total of 211 patients with respiratory failure were screened. Finally, 69 patients were included for analysis. Among the 69 patients received the SBT, 61 patients passed the SBT while 8 patients didn't. Urine albumin concentration upon admission was 251.00 ± 108.21 mg/g in the SBT success group and 260.87 ± 77.95 mg/g in the SBT failure group (p = 0.97). The mean percent change in urine albumin concentration during the SBT was significantly higher in the SBT failure group (+58.44%) than in the SBT success group (+13.11%) (p = 0.02). Univariable and multivariable logistic regression model showed that the difference of urine albumin concentration before and after the SBT correlated significantly with SBT failure (adjusted OR:1.04, p = 0.01). CONCLUSION This open label pilot study demonstrates the significant association of the changes in urine albumin concentration with SBT outcome. Further study is warranted to investigate the predictive value of urine albumin concentration.
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Affiliation(s)
- You-Yi Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Douliou, Taiwan
| | - Jih-Shuin Jerng
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jien-Jiun Chen
- Cardiovascular Center, National Taiwan University Hospital, Yun-Lin Branch, Douliou, Taiwan
| | - Fan-Chi Chang
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Wen Kuo
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Hao-Chien Wang
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Dong Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
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Liang HJ, Wu MJ, Jerng JS, Yang CH. Reinforcement of Tobacco Control and Reduction in Medical Utilization for Asthma in Taiwan: A Population-Based Study. Int J Environ Res Public Health 2019; 16:E3950. [PMID: 31627282 PMCID: PMC6844081 DOI: 10.3390/ijerph16203950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/26/2019] [Accepted: 10/15/2019] [Indexed: 11/21/2022]
Abstract
Environmental air quality can affect asthma control and the development of overt asthmatic manifestations. In this population-based study, we investigated the effect of reinforcing a smoking ban in Taiwan through the enactment of the Tobacco Hazards and Prevention Act (THPA) on healthcare utilization rate by asthmatics. Analysis was performed based on data relevant to non-hospitalized asthmatic patients with insurance claims between 2005 and 2013 from the National Health Insurance Research Database of Taiwan, reported data on Asian dust storms, and penalty rates for violations of the tobacco ban. Poisson regression showed that the risk for outpatient visits for asthma was lower after enactment of the THPA (RR = 0.98, 95% CI = 0.98-0.99), with a yearly trend of a reduced risk (RR = 0.99, 95% CI = 0.99-1.00), also lower in geographic regions with medium (RR = 0.79, 95% CI = 0.79-0.80) and high (RR = 0.91, 95% CI = 0.91-0.92) penalty rates. Subgroup analysis showed that asthma visit rates were reduced in both male and female groups after the enactment of the THPA. The risk of an asthma ER visit was increased after the enactment of the amended THPA (RR = 1.07, 95% CI = 1.05-1.09), although the yearly trend was not significant (RR = 1.00, 95% CI = 1.00-1.00). The risk of emergency room visits for asthma was significantly reduced in regions with medium (RR = 0.68, 95% CI = 0.68-0.69) and high (RR = 0.75, 95% CI = 0.74-0.76) penalty rates. Subgroup analysis showed that the visit rates were similar in both male and female groups. The effectiveness of reinforcing the smoking ban warrants further policies aimed at further reducing passive smoking.
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Affiliation(s)
- Huang-Ju Liang
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei 108, Taiwan.
- Center for Quality Management, National Taiwan University Hospital, Taipei 100, Taiwan.
| | - Ming-Jiuan Wu
- Department of Business and Management, Ming Chi University of Technology, New Taipei City 243, Taiwan.
| | - Jih-Shuin Jerng
- Center for Quality Management, National Taiwan University Hospital, Taipei 100, Taiwan.
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan.
| | - Chiang-Hsing Yang
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei 108, Taiwan.
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Jerng JS, Tang CH, Cheng RWY, Wang MYH, Hung KY. Healthcare utilization, medical costs and mortality associated with malnutrition in patients with chronic obstructive pulmonary disease: a matched cohort study. Curr Med Res Opin 2019; 35:1265-1273. [PMID: 30676096 DOI: 10.1080/03007995.2019.1574460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective: Although disease-related malnutrition has prognostic implications for patients with chronic obstructive pulmonary disease (COPD), its health-economic impact and clinical burdens are uncertain. We conducted a population-level study to investigate these questions. Methods: We excerpted data relevant to malnutrition, prolonged mechanical ventilation and medications from claims by 1,197,098 patients which were consistent with COPD and registered by the Taiwan National Health Insurance Administration between 2009 and 2013. These patients were separated into cohorts with or without respiratory failure requiring long-term mechanical ventilation, and each cohort was divided to compare cases who developed malnutrition after their first diagnosis consistent with COPD, versus non-malnourished propensity-score matched controls. Results: The prevalence of malnutrition was 3.8% overall (10,259/287,000 non-ventilator-dependent; 1198/15,829 ventilator-dependent). Propensity-score matched non-ventilator-dependent patients who became malnourished (N = 10,242) had comparatively more hospitalizations, emergency room and outpatient visits, longer hospitalization (all p < .01), and higher mortality (HR = 2.26, 95% CI 2.18-2.34) than non-malnourished controls (N = 40,968). Malnourished ventilator-dependent patients (N = 1197) had higher rates of hospitalization, emergency room and outpatient visits, but shorter hospitalization (all p < .001) and lower mortality (HR = 0.85, 95% CI 0.80-0.93) than matched non-malnourished controls (N = 4788). Total medical expenditure on malnourished non-ventilator-dependent COPD patients was 75% higher than controls (p < .001), whereas malnourished ventilator-dependent patients had total costs 7% lower than controls (p < .001). Conclusions: Malnourishment among COPD patients who were not dependent on mechanical ventilation was associated with greater healthcare resource utilization and higher aggregate medical costs.
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Affiliation(s)
- Jih-Shuin Jerng
- a Department of Internal Medicine , National Taiwan University Hospital , Taipei , Taiwan
| | - Chao-Hsiun Tang
- b School of Health Care Administration, College of Management , Taipei Medical University , Taipei , Taiwan
| | | | | | - Kuan-Yu Hung
- d Department of Internal Medicine , National Taiwan University Hospital Hsin-Chu Branch , Hsinchu , Taiwan
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Wu JH, Jerng JS, Su CC. Insidious-onset, non-wheezing carteolol-induced asthma in an atopic patient without asthma history. BMJ Case Rep 2019; 12:12/4/e229343. [PMID: 30948417 DOI: 10.1136/bcr-2019-229343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Carteolol, a non-selective beta-antagonist with a potential risk of severe bronchial constriction in patients with asthma, is one of the most commonly prescribed medication for managing ocular pressure in glaucoma. We present a case of a 24-year-old woman with a history of atopy but no known asthma who presented an insidious onset of clinical manifestations compatible with drug-induced asthma after the initiation of carteolol for ocular hypertension control. The patient developed progressive chest tightness and dyspnoea for 2 months before the pulmonary function test revealed a positive bronchoprovocation response. She reported significant improvement of respiratory symptoms within 2 weeks after the discontinuation of carteolol, and a negative provocation response was later confirmed by repeat pulmonary function test. In conclusion, eye drops with non-selective beta-antagonising effect can induce asthmatic symptoms in patients without a previous diagnosis of asthma and should be administered with caution in patients with associated risk factors.
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Affiliation(s)
- Jo-Hsuan Wu
- National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chia Su
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
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Chang HT, Jerng JS, Chen DR. Reduction of healthcare costs by implementing palliative family conference with the decision to withdraw life-sustaining treatments. J Formos Med Assoc 2019; 119:34-41. [PMID: 30876787 DOI: 10.1016/j.jfma.2019.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/14/2019] [Accepted: 02/21/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Evidence regarding the impact of early palliative family conferences (PFCs) and decision to withdraw life-sustaining treatment (DTW) on healthcare costs in an intensive care unit (ICU) setting is inconsistent. METHODS We retrospectively analyzed patients who died in an ICU from 2013 to 2016. PFCs held within 7 days after ICU admission and DTWs were verified by reviewing medical records and claims data. Comparisons were first made between patients with and without DTWs, and secondly, between DTW patients with and without PFCs within 7 days. Propensity score matching methods were used to examine the difference in costs between patients with and without DTWs and PFCs within 7 days. RESULTS Of the 579 patients included, those with DTWs (n = 73) had a longer ICU stay than those without (n = 506) (12.9 ± 7.1 vs. 8.4 ± 9.6 days, p < 0.001). The DTW patients were more likely to have a "do-not-resuscitate" order (p < 0.001) and PFCs within 7 days (p < 0.001) and had lower healthcare costs (USD 7358 ± 4116 vs. 8669 ± 9,535, p = 0.038). After matching, healthcare cost reduction for patients with DTWs, compared with those without DTWs, was USD 3467 [95% CI, 915-6019] (p < 0.001). Compared with DTW patients without PFCs within 7 days, the costs for DTW patients with PFCs within 7 days further reduced to USD 3042 [95%CI, 1358-4725] (p < 0.001). CONCLUSION Palliative family conferences held within 7 days after ICU admission with decisions to withdraw life-sustaining treatments significantly lowered healthcare costs.
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Affiliation(s)
- Hou-Tai Chang
- Department of Critical Care Medicine, Far Eastern Memorial Hospital, No. 21, Section 2, Nanya South Road, Banciao District, New Taipei City, 220, Taiwan; Department of Industrial Engineering and Management, Yuan-Ze University, 135 Yuan-Tung Road, Chung-Li, Taoyuan, 32003, Taiwan; Institute of Health Policy and Management, National Taiwan University, No. 17, Xu-Zhou Road, Taipei, 100, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, No. 7, Zhongshan South Road, Taipei, 100, Taiwan
| | - Duan-Rung Chen
- Institute of Health Policy and Management, National Taiwan University, No. 17, Xu-Zhou Road, Taipei, 100, Taiwan; Institute of Health Behavior and Community Sciences, National Taiwan University, College of Public Health, No. 17, Xu-Zhou Road, Taipei, 100, Taiwan.
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Jerng JS, Huang SF, Yu HY, Chan YC, Liang HJ, Liang HW, Sun JS. Comparison of complaints to the intensive care units and those to the general wards: an analysis using the Healthcare Complaint Analysis Tool in an academic medical center in Taiwan. Crit Care 2018; 22:335. [PMID: 30522508 PMCID: PMC6282256 DOI: 10.1186/s13054-018-2271-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 11/21/2018] [Indexed: 11/24/2022] Open
Abstract
Background The management of complaints in the setting of intensive care may provide opportunities to understand patient and family experiences and needs. However, there are limited reports on the structured application of complaint analysis tools and comparisons between healthcare complaints in the critical care setting and other settings. Methods From the complaint management database of a university-affiliated medical center in Taiwan, we retrospectively identified the records of healthcare complaints to the intensive care units (ICUs) from 2008 to 2016. Complaints to the general wards in the same period were randomly selected from the database with twice the number of that of the ICU complaints. We coded, typed, and compared the complaints from the two settings according to the Healthcare Complaint Analysis Tool. Results We identified 343 complaints to the ICUs and randomly selected 686 complaints to the general wards during the 9-year study period. Most (94.7%) of the complaints to the ICUs came from the family members, whereas more complaints to the general wards came from the patients (44.2%). A total of 1529 problems (441 from ICU and 818 from general wards) were identified. Compared with the general ward complaints, in the ICU there were more complaints with multiple problems (25.1% vs. 16.9%, p = 0.002), complaints were referred more frequently to the nurses (28.1% vs. 17.5%, p < 0.001), and they focused more commonly on the care on the ICU/ward (60.5% vs. 54.2%, p = 0.029). The proportions of the three domains (clinical, management, and relationship) of complaints were similar between the ICU and general ward complaints (p = 0.121). However, in the management domain, the problems from ICU complaints focused more on the environment than on the institutional processes (90.9% vs. 74.5%, p < 0.001), whereas in the relationship domain, the problems focused more on communication (17.9% vs. 8.0%) and less on listening (34.6% vs. 46.5%) (p = 0.002) than the general ward complaints. Conclusions A structured typing and systematic analysis of the healthcare complaints to the ICUs may provide valuable insights into the improvement of care quality, especially to the perceptions of the ICU environment and communications of the patients and their families. Electronic supplementary material The online version of this article (10.1186/s13054-018-2271-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Szu-Fen Huang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Yu Yu
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Chun Chan
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Huang-Ju Liang
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Wen Liang
- Department of Physical Medicine & Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Jui-Sheng Sun
- Department of Orthopedic Surgery, National Taiwan University Hospital, No. 7, Zhongshan South Road, Taipei, 100, Taiwan.
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Yang SH, Jerng JS, Chen LC, Li YT, Huang HF, Wu CL, Chan JY, Huang SF, Liang HW, Sun JS. Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system. BMJ Open 2017; 7:e017932. [PMID: 29101141 PMCID: PMC5695373 DOI: 10.1136/bmjopen-2017-017932] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. OBJECTIVE To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. SETTING A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan. PARTICIPANTS All eligible IHT-related patient safety events between January 2010 to December 2015 were included. MAIN OUTCOME MEASURES Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts. RESULTS There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm. CONCLUSIONS This study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted.
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Affiliation(s)
- Shu-Hui Yang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Chin Chen
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Tsu Li
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiao-Fang Huang
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Ling Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jing-Yuan Chan
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Szu-Fen Huang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Wen Liang
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
- Department of Physical Medicine & Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Jui-Sheng Sun
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
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Jerng JS, Huang SF, Liang HW, Chen LC, Lin CK, Huang HF, Hsieh MY, Sun JS. Workplace interpersonal conflicts among the healthcare workers: Retrospective exploration from the institutional incident reporting system of a university-affiliated medical center. PLoS One 2017; 12:e0171696. [PMID: 28166260 PMCID: PMC5293271 DOI: 10.1371/journal.pone.0171696] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 01/06/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE There have been concerns about the workplace interpersonal conflict (WIC) among healthcare workers. As healthcare organizations have applied the incident reporting system (IRS) widely for safety-related incidents, we proposed that this system might provide a channel to explore the WICs. METHODS We retrospectively reviewed the reports to the IRS from July 2010 to June 2013 in a medical center. We identified the WICs and typed these conflicts according to the two foci (task content/process and interpersonal relationship) and the three properties (disagreement, interference, and negative emotion), and analyzed relevant data. RESULTS Of the 147 incidents with WIC, the most common related processes were patient transfer (20%), laboratory tests (17%), surgery (16%) and medical imaging (16%). All of the 147 incidents with WIC focused on task content or task process, but 41 (27.9%) also focused on the interpersonal relationship. We found disagreement, interference, and negative emotion in 91.2%, 88.4%, and 55.8% of the cases, respectively. Nurses (57%) were most often the reporting workers, while the most common encounter was the nurse-doctor interaction (33%), and the majority (67%) of the conflicts were experienced concurrently with the incidents. There was a significant difference in the distribution of worker job types between cases focused on the interpersonal relationship and those without (p = 0.0064). The doctors were more frequently as the reporter when the conflicts focused on the interpersonal relationship (34.1%) than not on it (17.0%). The distributions of worker job types were similar between those with and without negative emotion (p = 0.125). CONCLUSIONS The institutional IRS is a useful place to report the workplace interpersonal conflicts actively. The healthcare systems need to improve the channels to communicate, manage and resolve these conflicts.
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Affiliation(s)
- Jih-Shuin Jerng
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Szu-Fen Huang
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Wen Liang
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
- Department of Physical Medicine & Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Chin Chen
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Kuei Lin
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiao-Fang Huang
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Yuan Hsieh
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
| | - Jui-Sheng Sun
- Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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Hsu NC, Huang CC, Jerng JS, Hsu CH, Yang MC, Chang RE, Ko WJ, Yu CJ. Influence of patient and provider factors on the workload of on-call physicians: A general internal medicine cohort observational study. Medicine (Baltimore) 2016; 95:e4719. [PMID: 27583910 PMCID: PMC5008594 DOI: 10.1097/md.0000000000004719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Factors associated with the physician workload are scarcely reported. The study aims to investigate the associated factors of on-call physician workload based on a published conceptual framework.The study was conducted in a general internal medicine unit of National Taiwan University Hospital. On-call physician workloads were recorded on a shift basis from 1198 hospitalized patients between May 2010 and April 2011. The proxy of on-call workloads included night calls, bedside evaluation/management (E/M), and performing clinical procedures in a shift. Multivariable logistic and negative binomial regression models were used to determine the factors associated with the workloads of on-call physicians.During the study period, 378 (31.6%) of patients had night calls with related workloads. Multivariate analysis showed that the number of patients with unstable conditions in a shift (odds ratio [OR] 1.89 and 1.66, respectively) and the intensive care unit (ICU) training of the nurse leader (OR 2.87 and 3.08, respectively) resulted in higher likelihood of night calls to and bedside E/M visits by the on-call physician. However, ICU training of nurses (OR = 0.37, 95% confidence interval: 0.16-0.86) decreased the demand of performing clinical procedures by the on-call physician. Moreover, number of patients with unstable conditions (risk ratio [RR] 1.52 and 1.55, respectively) had significantly increased the number of night calls and bedside E/M by on-call physicians by around 50%. Nurses with N1 level (RR 2.16 and 2.71, respectively) were more likely to place night calls and facilitate bedside E/M by the on-call physician compared to nurses with N0 level. In addition, the nurse leaders with ICU training (RR 1.72 and 3.07, respectively) had significant increases in night calls and bedside E/M by the on-call physician compared to those without ICU training.On-call physician workload is associated with patient factors and the training of nurses. Number of unstable patients in a shift may be considered in predicting workload. The training of nurses may improve patient safety and decrease demand for clinical procedure.
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Affiliation(s)
- Nin-Chieh Hsu
- Division of Hospital Medicine
- Department of Internal Medicine
- Department of Traumatology
| | - Chun-Che Huang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University
| | | | - Chia-Hao Hsu
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Chin Yang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University
- Correspondence: Ming-Chin Yang, Institute of Health Policy and Management, College of Public Health, National Taiwan University, Room 637, No. 17, Xu-Zhou Road, Taipei 100, Taiwan (e-mail: ); Ray-E Chang, Institute of Health Policy and Management, College of Public Health, National Taiwan University, Room 639, No. 17, Xu-Zhou Road, Taipei 100, Taiwan (e-mail: )
| | - Ray-E Chang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University
- Correspondence: Ming-Chin Yang, Institute of Health Policy and Management, College of Public Health, National Taiwan University, Room 637, No. 17, Xu-Zhou Road, Taipei 100, Taiwan (e-mail: ); Ray-E Chang, Institute of Health Policy and Management, College of Public Health, National Taiwan University, Room 639, No. 17, Xu-Zhou Road, Taipei 100, Taiwan (e-mail: )
| | - Wen-Je Ko
- Department of Surgery, National Taiwan University Hospital
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Lim CK, Ruan SY, Lin FC, Wu CL, Chang HT, Jerng JS, Wu HD, Yu CJ. Effect of Tracheostomy on Weaning Parameters in Difficult-to-Wean Mechanically Ventilated Patients: A Prospective Observational Study. PLoS One 2015; 10:e0138294. [PMID: 26379127 PMCID: PMC4574918 DOI: 10.1371/journal.pone.0138294] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/29/2015] [Indexed: 11/19/2022] Open
Abstract
Background and Objective Weaning parameters are commonly measured through an endotracheal tube in mechanically ventilated patients recovering from acute respiratory failure, however this practice has rarely been evaluated in tracheostomized patients. This study aimed to investigate changes in weaning parameters measured before and after tracheostomy, and to explore whether the data measured after tracheostomy were associated with weaning outcomes in difficult-to-wean patients. Methods In a two-year study period, we enrolled orotracheally intubated patients who were prepared for tracheostomy due to difficult weaning. Weaning parameters were measured before and after the conversion to tracheostomy and compared, and the post-tracheostomy data were tested for associations with weaning outcomes. Results A total of 86 patients were included. After tracheostomy, maximum inspiratory pressure (mean difference (Δ) = 4.4, 95% CI, 2.7 to 6.1, P<0.001), maximum expiratory pressure (Δ = 5.4, 95% CI, 2.9 to 8.0, P<0.001) and tidal volume (Δ = 33.7, 95% CI, 9.0 to 58.5, P<0.008) significantly increased, and rapid shallow breathing index (Δ = -14.6, 95% CI, -25.4 to -3.7, P<0.009) and airway resistance (Δ = -4.9, 95% CI, -5.8 to -4.0, P<0.001) significantly decreased. The patients who were successfully weaned within 90 days of the initiation of mechanical ventilation had greater increments in maximum inspiratory pressure (5.9 vs. 2.4, P = 0.04) and maximum expiratory pressure (8.0 vs. 2.0, P = 0.02) after tracheostomy than those who were unsuccessfully weaned. Conclusions In conclusion, the conversion from endotracheal tube to tracheostomy significantly improved the measured values of weaning parameters in difficult-to-wean patients who subsequently weaned successfully from the mechanical ventilator. The change was significant only for airway resistance in patients who failed weaning. Trial Registration ClinicalTrials.gov NCT01312142
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Affiliation(s)
- Chor-Kuan Lim
- Department of Internal Medicine, Division of Chest Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan (R.O.C)
| | - Sheng-Yuan Ruan
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei, Taiwan (R.O.C)
| | - Feng-Ching Lin
- Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan (R.O.C)
| | - Chao-Ling Wu
- Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan (R.O.C)
| | - Hou-Tai Chang
- Department of Internal Medicine, Division of Chest Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan (R.O.C)
| | - Jih-Shuin Jerng
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei, Taiwan (R.O.C)
- * E-mail:
| | - Huey-Dong Wu
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei, Taiwan (R.O.C)
- Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan (R.O.C)
| | - Chong-Jen Yu
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei, Taiwan (R.O.C)
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Chen YF, Lim CK, Ruan SY, Jerng JS, Lin JW, Kuo PH, Wu HD, Yu CJ. Factors associated with adherence to low-tidal volume strategy for acute lung injury and acute respiratory distress syndrome and their impacts on outcomes: an observational study and propensity analysis. Minerva Anestesiol 2014; 80:1158-1168. [PMID: 24569355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the factors affecting adherence to the low-tidal volume (LTV) strategy in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) and their impacts on outcomes. METHODS This prospective observational study included 111 patients with ALI/ARDS admitted to six intensive care units between March 2010 and February 2011. The patients were divided into the LTV group, which received a TV ≤7.5 mL/kg predicted body weight (PBW), and the non-LTV group, which received a TV >7.5 mL/kg PBW. We studied the association of selected clinical factors and adherence to the LTV strategy, and evaluated their impacts on 28-day mortality and 1-year mortality by the propensity-match process. RESULTS Adherence to the LTV strategy was only 44%, which was related to lung injury severity (odds ratio [OR]: 3.15, P=0.038), muscle relaxant use (OR: 3.28, P=0.031), and depth of sedation (OR: 0.65, P=0.008). Propensity score-based analysis showed that the LTV group had modestly better 28-day survival (P=0.081) and 1-year survival (P=0.067) than the non-LTV group. Moreover, muscle relaxant use was strongly associated with reducing the risk of death at both 28 days (hazard ratio [HR]: 0.122, 95% confidence interval [CI]: 0.027-0.542, P=0.006) and 1 year ([HR]: 0.111, 95% [CI]: 0.030-0.408, P=0.001). CONCLUSION Adherence to the LTV strategy was strongly associated with the lung injury score, muscle relaxant use, and depth of sedation. Propensity score-based analysis showed that the use of LTV ventilation and muscle relaxants reduced 28-day and 1-year mortality in ALI/ARDS patients.
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Affiliation(s)
- Y F Chen
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Douliou City, Yunlin County, Taiwan -
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Hung KY, Jerng JS. Time to have a paradigm shift in health care quality measurement. J Formos Med Assoc 2014; 113:673-9. [DOI: 10.1016/j.jfma.2014.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/14/2014] [Accepted: 06/19/2014] [Indexed: 01/21/2023] Open
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Hsu YC, Jerng JS, Chang CW, Chen LC, Hsieh MY, Huang SF, Liu YP, Hung KY. Integrating team resource management program into staff training improves staff's perception and patient safety in organ procurement and transplantation: the experience in a university-affiliated medical center in Taiwan. BMC Surg 2014; 14:51. [PMID: 25115403 PMCID: PMC4136399 DOI: 10.1186/1471-2482-14-51] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 08/05/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process. METHODS We implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes. RESULTS During the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records. CONCLUSION Implementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation.
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Affiliation(s)
- Ya-Chi Hsu
- Center for Quality Management, National Taiwan University, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Center for Quality Management, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Wen Chang
- Center for Quality Management, National Taiwan University, Taipei, Taiwan
| | - Li-Chin Chen
- Center for Quality Management, National Taiwan University, Taipei, Taiwan
| | - Ming-Yuan Hsieh
- Center for Quality Management, National Taiwan University, Taipei, Taiwan
| | - Szu-Fen Huang
- Center for Quality Management, National Taiwan University, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yueh-Ping Liu
- Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuan-Yu Hung
- Center for Quality Management, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, No. 7, Zhongshan South Road, Taipei 100, Taiwan
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Kuo YW, Chang HT, Wu PC, Chen YF, Lin CK, Wen YF, Jerng JS. Compliance and barriers to implementing the sepsis resuscitation bundle for patients developing septic shock in the general medical wards. J Formos Med Assoc 2012; 111:77-82. [PMID: 22370285 DOI: 10.1016/j.jfma.2011.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 10/07/2010] [Accepted: 01/05/2011] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND/PURPOSE This two-part study aimed to investigate compliance with the sepsis resuscitation bundle (SRB) and the barriers to its implementation for patients developing septic shock in the general medical wards. METHODS In the first part, medical records of patients who were admitted to the intensive care unit from the general medical wards due to septic shock were reviewed. Compliance rates with the six SRB components were assessed. In the second part, responsible junior physicians (first-year and second-year residents) in the general wards and senior physicians (third-year residents and fellows) were randomly invited for questionnaire-based interviews. RESULTS In the first part, during the 6-month study period, 40 patients were included. Overall compliance with the SRB within 6 h was only 2.5%, mainly due to femoral catheterization (42.5%) and the lack of measuring central venous oxygen saturation (ScvO₂). Delayed completion of SRB components contributed little to the low compliance rate. In the second part, based on the questionnaire results of 71 junior physicians and 64 senior physicians, the junior physicians were less familiar with the SRB guidelines, particularly regarding the meaning of ScvO₂ (p = 0.01) and management of low ScvO₂ (p = 0.04). Junior physicians were also more reluctant to measure the central venous pressure (CVP; p = 0.04) and the ScvO₂ (p = 0.01), and were also less confident with internal jugular vein or subclavian vein catheterization (p < 0.001). CONCLUSION Compliance with the SRB for patients developing septic shock in the general medical wards is very low. Besides providing educational programs to improve awareness and acceptance of the SRB, measures to help in central venous catheterization and completion of SRB may be considered.
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Affiliation(s)
- Yao-Wen Kuo
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
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Chang HT, Kuo YW, Lin CH, Jerng JS. The new nodular lesions at the brain base. Clin Infect Dis 2011; 53:295, 303-4. [PMID: 21765080 DOI: 10.1093/cid/cir303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hou-Tai Chang
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan
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Lin JW, Wang MJ, Yu HY, Wang CH, Chang WT, Jerng JS, Huang SC, Chou NK, Chi NH, Ko WJ, Wang YC, Wang SS, Hwang JJ, Lin FY, Chen YS. Comparing the survival between extracorporeal rescue and conventional resuscitation in adult in-hospital cardiac arrests: Propensity analysis of three-year data. Resuscitation 2010; 81:796-803. [DOI: 10.1016/j.resuscitation.2010.03.002] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Revised: 02/19/2010] [Accepted: 03/10/2010] [Indexed: 11/17/2022]
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Jan IS, Tsai TH, Chen JM, Jerng JS, Hsu HF, Hung PL, Hsueh PR, Lee LN. Hypoglycemia associated with bacteremic pneumococcal infections. Int J Infect Dis 2009; 13:570-6. [DOI: 10.1016/j.ijid.2008.08.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Revised: 08/22/2008] [Accepted: 08/28/2008] [Indexed: 10/21/2022] Open
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Affiliation(s)
- Nin-Chieh Hsu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Chen YS, Lin JW, Yu HY, Ko WJ, Jerng JS, Chang WT, Chen WJ, Huang SC, Chi NH, Wang CH, Chen LC, Tsai PR, Wang SS, Hwang JJ, Lin FY. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet 2008; 372:554-61. [PMID: 18603291 DOI: 10.1016/s0140-6736(08)60958-7] [Citation(s) in RCA: 794] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Extracorporeal life-support as an adjunct to cardiac resuscitation has shown encouraging outcomes in patients with cardiac arrest. However, there is little evidence about the benefit of the procedure compared with conventional cardiopulmonary resuscitation (CPR), especially when continued for more than 10 min. We aimed to assess whether extracorporeal CPR was better than conventional CPR for patients with in-hospital cardiac arrest of cardiac origin. METHODS We did a 3-year prospective observational study on the use of extracorporeal life-support for patients aged 18-75 years with witnessed in-hospital cardiac arrest of cardiac origin undergoing CPR of more than 10 min compared with patients receiving conventional CPR. A matching process based on propensity-score was done to equalise potential prognostic factors in both groups, and to formulate a balanced 1:1 matched cohort study. The primary endpoint was survival to hospital discharge, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00173615. FINDINGS Of the 975 patients with in-hospital cardiac arrest events who underwent CPR for longer than 10 min, 113 were enrolled in the conventional CPR group and 59 were enrolled in the extracorporeal CPR group. Unmatched patients who underwent extracorporeal CPR had a higher survival rate to discharge (log-rank p<0.0001) and a better 1-year survival than those who received conventional CPR (log rank p=0.007). Between the propensity-score matched groups, there was still a significant difference in survival to discharge (hazard ratio [HR] 0.51, 95% CI 0.35-0.74, p<0.0001), 30-day survival (HR 0.47, 95% CI 0.28-0.77, p=0.003), and 1-year survival (HR 0.53, 95% CI 0.33-0.83, p=0.006) favouring extracorporeal CPR over conventional CPR. INTERPRETATION Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin.
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Affiliation(s)
- Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
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Affiliation(s)
- Sheng-Yuan Ruan
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
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Shu CC, Lee CH, Wang JY, Jerng JS, Yu CJ, Hsueh PR, Lee LN, Yang PC. Nontuberculous mycobacteria pulmonary infection in medical intensive care unit: the incidence, patient characteristics, and clinical significance. Intensive Care Med 2008; 34:2194-201. [DOI: 10.1007/s00134-008-1221-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Accepted: 07/07/2008] [Indexed: 11/24/2022]
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Shih CL, Lu TC, Jerng JS, Lin CC, Liu YP, Chen WJ, Lin FY. A web-based Utstein style registry system of in-hospital cardiopulmonary resuscitation in Taiwan. Resuscitation 2007; 72:394-403. [PMID: 17161519 DOI: 10.1016/j.resuscitation.2006.07.020] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2006] [Revised: 07/19/2006] [Accepted: 07/20/2006] [Indexed: 11/26/2022]
Abstract
PURPOSE OF THE STUDY The Web-Based Registry System on In-hospital Resuscitation (WRSIR) is the first prospective, web-based, multi-site, and Utstein-based reporting system in Taiwan. This study was conducted to evaluate the feasibility of the system in one of the participating hospitals and identify prognostic factors associated with survival. MATERIAL AND METHODS The WRSIR is an on-line registry system coded with the active server page (ASP) programming method. Information was gathered and entered on-line by trained staff using spreadsheets that could be automatically created according to the updated Utstein in-hospital template. Through the implementation of the system, in a tertiary teaching hospital we evaluated all adults with in-hospital cardiac arrest receiving cardiopulmonary resuscitation between 1 October 2004 and 30 September 2005. The main outcome measures were return of spontaneous circulation (ROSC), survival to hospital discharge, and cerebral performance category score at the time of discharge. Logistic regression analysis was performed to determine independent predictors of survival. RESULTS A total of 330 cases experienced in-hospital resuscitation. ROSC occurred in 233 cases (71%) and 61 patients (18%) survived to hospital discharge. Thirty-five patients (58%) had a good neurological outcome with the cerebral performance category (CPC) score of 1 or 2 among survivors. The major predictor of ROSC was initial rhythm of VT/VF (adjusted OR 0.36, 95% CI 0.16-0.78). CONCLUSION This study examined the feasibility of a web-based registry system on in-hospital resuscitation using the Utstein style in an oriental country. It provides a comprehensive and standardised method for on-line registry of data collection, allowing individual hospitals to track each case for quality improvement. A further nationwide registry will enforce the possibility of data analysis and future perspective research of in-hospital resuscitation.
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Affiliation(s)
- Chung-Liang Shih
- Department of Emergency Medicine, National Taiwan University Hospital, Taiwan
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Jerng JS, Hsu YC, Wu HD, Pan HZ, Wang HC, Shun CT, Yu CJ, Yang PC. Role of the renin-angiotensin system in ventilator-induced lung injury: an in vivo study in a rat model. Thorax 2007; 62:527-35. [PMID: 17234658 PMCID: PMC2117227 DOI: 10.1136/thx.2006.061945] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Injurious mechanical ventilation can cause a pro-inflammatory reaction in the lungs. Recent evidence suggests an association of the renin-angiotensin system (RAS) with lung inflammation. A study was undertaken to investigate the pathogenic role of the RAS in ventilator-induced lung injury (VILI) and to determine whether VILI can be attenuated by angiotensin converting enzyme (ACE) inhibition. METHODS Male Sprague-Dawley rats were mechanically ventilated for 4 h with low (7 ml/kg) or high (40 ml/kg) tidal volumes; non-ventilated rats were used as controls. Lung injury and inflammation were measured by the lung injury score, protein leakage, myeloperoxidase activity, pro-inflammatory cytokine levels and nuclear factor (NF)-kappaB activity. Expression of the RAS components was also assessed. Some rats were pretreated with the ACE inhibitor captopril (10 mg/kg) for 3 days or received a concomitant infusion with losartan or PD123319 (type 1 or type 2 angiotensin II receptor antagonist) during mechanical ventilation to assess possible protective effects on VILI. RESULTS In the high-volume group (n=6) the lung injury score, bronchoalveolar lavage fluid protein concentration, pro-inflammatory cytokines and NF-kappaB activities were significantly increased compared with controls (n=6). Lung tissue angiotensin II levels and mRNA levels of angiotensinogen and type 1 and type 2 angiotensin II receptors were also significantly increased in the high-volume group. Pretreatment with captopril or concomitant infusion with losartan or PD123319 in the high-volume group attenuated the lung injury and inflammation (n=6 for each group). CONCLUSIONS The RAS is involved in the pathogenesis of ventilator-induced lung injury. ACE inhibitor or angiotensin receptor antagonists can attenuate VILI in this rat model.
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Affiliation(s)
- Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, No 7 Chung-Shan South Road, Taipei 100, Taiwan
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Jerng JS, Yu CJ, Wang HC, Chen KY, Cheng SL, Yang PC. Polymorphism of the angiotensin-converting enzyme gene affects the outcome of acute respiratory distress syndrome. Crit Care Med 2006; 34:1001-6. [PMID: 16484896 DOI: 10.1097/01.ccm.0000206107.92476.39] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE There has been increasing evidence that angiotensin II may play an important role in the pathogenesis and in the evolution of acute lung injury. It was therefore hypothesized that polymorphisms of the angiotensin-converting enzyme gene affects the risk and outcome of acute respiratory distress syndrome (ARDS). DESIGN Prospective, observational study. PATIENTS AND SETTINGS The ARDS group consisted of 101 patients treated at the medical intensive care unit; the control groups consisted of 138 "at-risk" patients treated at the medical intensive care unit due to acute respiratory failure but did not meet the ARDS criteria throughout the hospital course, and 210 non-at-risk subjects. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The ARDS patients and control subjects were genotyped for the insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme gene. Association of the polymorphism and the risk and the outcome of ARDS was analyzed. There was no significant difference in the frequencies of the genotypes between the ARDS, at-risk, and non-at-risk groups. The 28-day mortality rates were significantly different between the three angiotensin-converting enzyme genotypes (42%, 65%, and 75% for II, ID, and DD, respectively; p = .036). Survival analysis showed that the II genotype favorably affected 28-day survival (hazard ratio, 0.46; 95% confidence interval, 0.26-0.81; p = .007), whereas ARDS caused by hospital-acquired pneumonia had a negative effect (hazard ratio, 2.34; 95% confidence interval, 1.25-4.40; p = .008). The II genotype (hazard ratio, 0.53; 95% confidence interval, 0.32-0.87; p = .012) and ARDS caused by hospital-acquired pneumonia (hazard ratio, 2.13; 95% confidence interval, 1.24-3.68; p = .006) were also significant prognostic factors for the in-hospital mortality. CONCLUSIONS The angiotensin-converting enzyme I/D polymorphism is a significant prognostic factor for the outcome of ARDS. Patients with the II genotype have a significantly better chance of survival. This study did not show an increased risk for ARDS in Chinese patients with the D allele.
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Affiliation(s)
- Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei
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Wang CY, Jerng JS, Chen KY, Cheng KY, Lee LN, Yu CJ, Hsueh PR, Yang PC. Pandrug-resistant Pseudomonas aeruginosa among hospitalised patients: clinical features, risk-factors and outcomes. Clin Microbiol Infect 2006; 12:63-8. [PMID: 16460548 DOI: 10.1111/j.1469-0691.2005.01305.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Between 1 January 2003 and 31 December 2003, 37 patients had positive cultures of pandrug-resistant Pseudomonas aeruginosa (PDRPA) resistant to all commercially available anti-pseudomonal antimicrobial agents in Taiwan, including anti-pseudomonal penicillins, ceftazidime, fourth-generation cephalosporins, aztreonam, carbapenems, aminoglycosides and ciprofloxacin. Nineteen (51.4%) patients had PDRPA infections, including pneumonia (17 patients), catheter-related bacteraemia (one patient) and anal abscess (one patient). Eighteen patients were classified as having PDRPA colonisation, based on absence of clinical signs or symptoms of infection. In total, 92 isolates were recovered from various specimens, with the majority (85.9%) recovered from respiratory tract secretions (sputa, bronchial washings and pleural effusions), followed by urine (4.3%) and catheter tips (3.3%). Twenty-eight (75.7%) patients yielded cultures of non-PDR P. aeruginosa isolates before isolation of PDRPA, with a mean period between the first isolation of non-PDR P. aeruginosa and the isolation of PDRPA of 128.3 days. Most patients had received beta-lactam antibiotics, fluoroquinolones or carbapenems for prolonged periods. Univariate analysis showed that PDRPA infection, male gender and the presence of fever at the time of PDRPA isolation were associated with increased mortality.
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Affiliation(s)
- C Y Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Abstract
OBJECTIVE To assess the initial serum levels of lipids and lipoproteins and their correlations with the clinical outcome for patients with severe sepsis. The ability of high-density lipoprotein (HDL) to attenuate lipopolysaccharide (LPS)-induced cytokine production was also examined in vitro. DESIGN Prospective, observational cohort study. SETTING Medical intensive care unit (ICU) of a tertiary-level university hospital. PATIENTS Sixty-three consecutive patients with severe sepsis. INTERVENTIONS Blood samples were drawn within the first day of severe sepsis and the subsequent 14 days. Clinical outcome, including length of ICU stay, infection subsequent to hospital stay, and death, were monitored prospectively. MEASUREMENTS AND RESULTS Compared with the survivors, patients who died within 30 days had significantly lower levels of HDL cholesterol and apolipoprotein A-I during the first 4 days of severe sepsis. On day 1, HDL cholesterol levels correlated inversely with interleukin-6 (r = -0.72; p < .01) and tumor necrosis factor (TNF)-alpha (r = -0.70; p < .01) concentrations. Not only the overall and sepsis-attributable 30-day mortality rates but also the risk of prolonged ICU stay (>7 days) and the hospital-acquired infection rate were increased among patients with day 1 levels of HDL cholesterol of <20 mg/dL and apolipoprotein A-I of <100 mg/dL. Multivariate analysis identified an HDL cholesterol level of <20 mg/dL on day 1 (odds ratio, 12.92; 95% confidence interval, 2.73-61.29) and Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.15; 95% confidence interval, 1.04-1.26) as independent predictors of the overall 30-day mortality rate. In human macrophages, LPS-induced TNF-alpha release was attenuated by incremental doses of HDL cholesterol added simultaneously (p < .01). However, HDL failed to suppress LPS-induced TNF-alpha production when administered after macrophages were exposed to LPS. CONCLUSIONS A low HDL cholesterol level on day 1 of severe sepsis is significantly associated with an increase in mortality and adverse clinical outcomes. In cultured macrophages, HDL can attenuate LPS-induced TNF-alpha production only if added concomitantly with, but not after, LPS exposure.
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Affiliation(s)
- Jung-Yien Chien
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch , Douliu, Taiwan
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Abstract
OBJECTIVES To compare the clinical characteristics of community-acquired thoracic empyema in older and younger patients and to analyze the effect of various factors on outcome. DESIGN A retrospective, comparative observational study. SETTING A university-affiliated tertiary medical center. PARTICIPANTS Forty-six patients aged 65 and older (older group) and 86 patients aged 18 to 64 (younger group). MEASUREMENTS Demographic, clinical, and microbiological data were reviewed. RESULTS Older patients were more likely to have dyspnea but less likely to have chest pain or fever (P<.05 for all). The causative organisms were similar between the two groups, with anaerobes and facultative streptococci the most common pathogens. Older patients had increased morbidity and longer hospital stay (median 29.5 vs 20 days, P<.001), but the in-hospital mortality was not significantly different between the two groups (13% vs 8%, P=.37). Multivariate analysis showed that coexisting malignancy (odds ratio (OR)=10.33, P=.01), lack of fever higher than 38 degrees C (OR=17.97, P=.03), and isolation of fungi from pleural fluid (OR=32.66, P=.01) were independently and significantly associated with in-hospital deaths. CONCLUSION The microbiology and mortality of community-acquired thoracic empyema were similar between the two age groups. Difference in chronological age did not explain in-hospital death. This finding highlights the importance of effective treatment to obtain better outcomes for older patients.
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Affiliation(s)
- Tzu-Hsiu Tsai
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Affiliation(s)
| | | | | | | | | | - Li-Na Lee
- National Taiwan University Hospital, Taipei, Taiwan
| | - Po-Ren Hsueh
- National Taiwan University Hospital, Taipei, Taiwan
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Lee LN, Lo SC, Lau HP, Jerng JS, Lin FC, Yang PC. Hepatitis C‐associated cryoglobulinaemia presenting with refractory hypertensive crisis and acute pulmonary oedema. Med J Aust 2005; 182:38-40. [PMID: 15651947 DOI: 10.5694/j.1326-5377.2005.tb06554.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2004] [Accepted: 10/05/2004] [Indexed: 11/17/2022]
Abstract
We report two elderly women who presented with hypertensive crisis and acute pulmonary oedema, which responded poorly to antihypertensive therapy. The patients were later diagnosed as having hepatitis C virus-related cryoglobulinaemia.
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Affiliation(s)
- Li-Na Lee
- College of Medicine, National Taiwan University Hospital, Taipei.
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Hsu CL, Chen KY, Chang CH, Jerng JS, Yu CJ, Yang PC. Timing of tracheostomy as a determinant of weaning success in critically ill patients: a retrospective study. Crit Care 2004; 9:R46-52. [PMID: 15693966 PMCID: PMC1065112 DOI: 10.1186/cc3018] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2004] [Revised: 09/24/2004] [Accepted: 11/16/2004] [Indexed: 12/26/2022]
Abstract
Introduction Tracheostomy is frequently performed in critically ill patients for prolonged intubation. However, the optimal timing of tracheostomy, and its impact on weaning from mechanical ventilation and outcomes in critically ill patients who require mechanical ventilation remain controversial. Methods The medical records of patients who underwent tracheostomy in the medical intensive care unit (ICU) of a tertiary medical centre from July 1998 to June 2001 were reviewed. Clinical characteristics, length of stay in the ICU, rates of post-tracheostomy pneumonia, weaning from mechanical ventilation and mortality rates were analyzed. Results A total of 163 patients (93 men and 70 women) were included; their mean age was 70 years. Patients were classified into two groups: successful weaning (n = 78) and failure to wean (n = 85). Shorter intubation periods (P = 0.02), length of ICU stay (P = 0.001) and post-tracheostomy ICU stay (P = 0.005) were noted in patients in the successful weaning group. Patients who underwent tracheostomy more than 3 weeks after intubation had higher ICU mortality rates and rates of weaning failure. The length of intubation correlated with the length of ICU stay in the successful weaning group (r = 0.70; P < 0.001). Multivariate analysis revealed that tracheostomy after 3 weeks of intubation, poor oxygenation before tracheostomy (arterial oxygen tension/fractional inspired oxygen ratio <250) and occurrence of nosocomial pneumonia after tracheostomy were independent predictors of weaning failure. Conclusion The study suggests that tracheostomy after 21 days of intubation is associated with a higher rate of failure to wean from mechanical ventilation, longer ICU stay and higher ICU mortality.
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Affiliation(s)
- Chia-Lin Hsu
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuan-Yu Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Hsuin Chang
- Division of General Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Assistant Professor, Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Pan-Chyr Yang
- Professor, Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Abstract
INTRODUCTION The diaphragm plays a pivotal role in weaning and successful extubation. We hypothesized that ultrasonographic evaluation of the movements of the diaphragm by measuring liver/spleen displacement during spontaneous breathing trials is a good predictor for extubation outcome. PATIENTS AND METHODS The studied subjects were intubated patients receiving mechanical ventilation who were scheduled to be extubated. The displacement of liver/spleen was measured by ultrasonography before extubation. The patients were classified into a success group (SG) or failure group according to the extubation outcome. The baseline data and organ displacements in these two groups were analyzed. The sensitivity and specificity for the mean organ displacements and weaning parameters to predict successful extubation were calculated. RESULTS We included 55 patients, 32 of whom (58%) were in the SG. The baseline data are similar for these two groups, but the mean values of liver and spleen displacements were higher in the SG. Using a cutoff value of 1.1 cm, the sensitivity and specificity to predict successful extubation were 84.4% and 82.6%, respectively, better than traditional weaning parameters in this study. CONCLUSION The displacement of the liver/spleen, measured by ultrasonography, is a good predictor for extubation outcome.
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Affiliation(s)
- Jung-Rern Jiang
- Department of Internal Medicine, Yun Lin Hospital, Executive Yuan, Taiwan
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Abstract
STUDY OBJECTIVE To investigate the clinical features and prognosis of patients with coal worker's pneumoconiosis (CWP) requiring invasive mechanical ventilation (MV) in the ICU for their first episode of acute respiratory failure (ARF), with special attention to the prognostic implication of radiographic progressive massive fibrosis (PMF). DESIGN Retrospective study. SETTING A 16-bed medical ICU at a community hospital. PATIENTS AND METHODS We reviewed 53 patients with CWP and ARF requiring invasive MV in the ICU for the first time between August 1998 and March 2002. RESULTS Of the 53 patients with CWP, 28 patients (53%) with PMF had their first ARF at a younger age than those without PMF (69.1 +/- 7.9 years vs 74.8 +/- 7.2 years, p = 0.008 [mean +/- SD]). Pneumonia (49%) was the most common cause of ARF. The mean APACHE (acute physiology and chronic health evaluation) II score was 26.0 +/- 9.9, and the mean ICU stay was 14.7 +/- 16.1 days. Twenty-one patients (40%) were weaned successfully in the ICU, with mean ventilator time of 17.0 +/- 25.1 days. The ICU and in-hospital mortality rates were 40% and 43%, respectively. The median survivals for all patients and the ICU survivors were 2.6 months and 14.3 months, respectively. Multivariate analysis showed the following risk (or protective) factors for the ICU mortality: PaCO(2) > 45 mm Hg at the time of intubation (adjusted odds ratio [OR], 0.04; 95% confidence interval [CI], 0.003 to 0.44), PaO(2)/fraction of inspired oxygen ratio < 200 mm Hg at the time of intubation (OR, 8.78; 95% CI, 1.36 to 56.48), and APACHE II score >or= 25 (OR, 11.99; 95% CI, 1.49 to 96.78). PMF was not associated with the ICU mortality (OR, 1.18; 95% CI, 0.20 to 7.10). CONCLUSIONS Radiographic PMF was not associated with the ICU mortality in patients with CWP and ARF receiving invasive MV in the ICU. Although a substantial proportion of them could be weaned from the ventilator and discharged from the hospital, their long-term prognosis was poor.
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Affiliation(s)
- Hsiu-Nien Shen
- Department of Internal Medicine, En-Chu-Kong Hospital, Taiwan
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Lee PL, Jerng JS, Chang YL, Chen CF, Hsueh PR, Yu CJ, Yang PC, Luh KT. Patient mortality of active pulmonary tuberculosis requiring mechanical ventilation. Eur Respir J 2003; 22:141-7. [PMID: 12882464 DOI: 10.1183/09031936.03.00038703] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mortality remains high among patients with pulmonary tuberculosis requiring mechanical ventilation (TBMV). This study was carried out to establish the mortality rates of TBMV and to identify factors that contribute to in-hospital mortality. From January 1996-April 2001, there were 825 patients with active pulmonary tuberculosis at the National Taiwan University Hospital, Taipei, Taiwan. Of these, 41 suffered acute respiratory failure and required mechanical ventilation in the intensive care unit (ICU). Of these 41 patients, 38 were followed up for 180 days. In-hospital deaths were documented in the medical records and all possible parameters contributing to mortality were collected. Of the 41 patients, 27 died in the hospital and 14 were discharged alive (in-hospital mortality rate 65.9%), with (mean +/- SD) 40.7 +/- 35.4 admission days before death. Of the 27 that died, 25 died during ICU admission and two died after being transferred to the ward. The mortality rate for the 180-day monitoring period was 79%. Factors contributing to in-hospital mortality included consolidations on chest radiographs and multiple organ failure. The mortality rate in the patients with pulmonary tuberculosis requiring mechanical ventilation is very high, with two factors affecting in-hospital mortality. These factors were multiple organ failure and consolidation on chest radiographs.
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Affiliation(s)
- P L Lee
- Dept of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Oon PC, Jerng JS, Kao HL, Chang YL, Yu CJ, Yang PC. Diffuse alveolar damage associated with ticlopidine use: a case report. J Formos Med Assoc 2003; 102:262-5. [PMID: 12833191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
Ticlopidine-induced lung disease is rare. A 52-year-old man with acute myocardial infarction developed respiratory distress 2 days after receiving ticlopidine for coronary artery stenting. The dosage of ticlopidine was 500 mg orally followed by maintenance of 250 mg twice daily. Chest radiography revealed bilateral haziness predominantly over upper lung fields. He did not respond to treatment for suspected cardiogenic lung edema and mechanical ventilation was instituted. Open lung biopsy documented diffuse alveolar damage. After discontinuing ticlopidine and treatment with systemic corticosteroid, his pulmonary condition improved gradually. Within 2 weeks, the patient was successfully weaned from the ventilator. Although rare, diffuse alveolar damage is a potential side effect of ticlopidine treatment and should be included in the differential diagnoses of heart failure patients taking ticlopidine who respond poorly to optimal therapy.
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Affiliation(s)
- Pei-Ching Oon
- Department of Internal Medicine, En Chu Kung Hospital, Taipei, Taiwan
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Abstract
STUDY OBJECTIVE To identify the prognostic factors for pneumothorax in patients in the ICU. DESIGN Retrospective cohort study. SETTING ICU at a university-based teaching hospital. PATIENTS AND METHODS Sixty patients developed pneumothoraces in the ICU during a period of 36 months. Medical records relating to patients' age, sex, underlying diseases, associated medical conditions, reasons for admission, acute physiology and chronic health evaluation (APACHE) II scores, procedures performed before the development of pneumothorax, occurrences of tension pneumothorax, duration of chest tube placement, chest tube removal, duration of ICU stay, and patient outcomes all were analyzed. A multivariate logistic regression model was applied with variables that were significantly associated with survival in the univariate analysis. The probabilities of chest tube removal were calculated using the Kaplan-Meier method. RESULTS Thirty-five patients (58%) had procedure-related pneumothoraces. The procedure that most commonly caused pneumothoraces was thoracentesis (n = 19; 54%), followed by central vein/pulmonary artery catheterization (n = 14; 40%) and bronchoscopy/transbronchial lung biopsy (n = 8; 23%). A multivariate logistic regression analysis also showed that pneumothorax due to barotrauma (p = 0.001), tension pneumothorax (p = 0.0023), and concurrent septic shock (p = 0.0476) were significantly and independently associated with death. The log-rank test revealed that the success rate of chest tube removal was higher in patients with procedure-related pneumothoraces (p = 0.0055). CONCLUSIONS Patients with procedure-related pneumothoraces had better outcomes. Patients with pneumothoraces occurring in the ICU due to barotrauma, or a complicating tension pneumothoraces, carry a higher risk of mortality.
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Affiliation(s)
- Kuan-Yu Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Jerng JS, Yu CJ, Liaw YS, Wu HD, Wang HC, Kuo PH, Yang PC. Clinical spectrum of acute respiratory distress syndrome in a tertiary referral hospital: etiology, severity, clinical course, and hospital outcome. J Formos Med Assoc 2000; 99:538-43. [PMID: 10925563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND AND PURPOSE The clinical picture of patients with acute respiratory distress syndrome (ARDS) in Taiwan has seldom been reported, although new definitions of ARDS have been introduced over the past years. The purpose of this study was to investigate the clinical characteristics, modalities of management, and outcomes in patients with ARDS treated in a tertiary referral hospital. METHODS Case records were selected through a computerized search of diagnosis codified at discharge during the period from January 1995 to June 1997. Patients who met the criteria of the American-European Consensus Conference definition of ARDS were included and their medical records were retrospectively reviewed. RESULTS A total of 145 patients (91 men, 54 women; mean age, 58 years) who fulfilled the criteria for ARDS were identified. Malignancy (n = 53) and diabetes mellitus (n = 23) were the most common co-morbid conditions. Pneumonia (n = 90), including community-acquired pneumonia in 45 (31%) patients, was the most common risk factor. The lung injury score at the time of ARDS diagnosis was 2.89 +/- 0.40 (mean +/- standard error, SE). The worst value of PaO2/FIO2 was 86.8 +/- 3.8 mm Hg (mean +/- SE). Among the 145 patients, 130 (90%) received mechanical ventilation and 118 (81%) were treated in the intensive care unit. In-hospital mortality was 87%. Seventy (48%) patients received intensive treatment for ARDS, among whom 52 (74%) died; the most common causes of death were multiple organ failure (54%) and respiratory failure (23%). CONCLUSIONS The mortality in patients with ARDS was high in this tertiary referral institution. Our findings suggest that aggressive ventilatory, pharmacologic, and supportive therapy may be important to achieve a higher survival rate.
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Affiliation(s)
- J S Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Abstract
We retrospectively studied the bacteriology and clinical features of empyema thoracis and lung abscess caused by viridans streptococci in 72 patients seen from January 1984 to September 1996. A total of 76 strains of viridans streptococci were isolated, of which the most common isolates were Streptococcus constellatus (21 strains), S. intermedius (17), and S. sanguis (10). Species belonging to the S. milleri group accounted for the majority (68%) of isolates. In 38 (53%) patients these organisms were recognized as the sole pathogens. Of the 72 patients, 53 had empyema, 14 had lung abscesses, and five had both empyema and lung abscess. Forty-six (64%) patients had underlying diseases. Of these, malignancies were the most common (17 patients), followed by diabetes mellitus (12 patients) and central nervous system diseases (10 patients). Of the 48 patients who underwent chest-tube drainage, 27 (56%) received further treatments, including intrapleural streptokinase (18 cases), surgery (9), and both intrapleural streptokinase and surgery (3). Two (14%) of the patients with lung abscess alone underwent surgical treatment. Although all viridans streptococcal isolates were susceptible to penicillin, the patients in the study had a high mortality (21%). Univariate and multivariate analysis of data for patients with empyema alone (n = 53) showed a significantly increased risk of death in those with underlying malignancy (OR = 16.0, p = 0.023) and those with non-S. milleri-group isolates (OR = 3.72, p = 0.030). These data imply a strong clinical significance of viridans streptococci in the pathogenesis of empyema and lung abscess, as well as the need for species identification of viridans streptococci in patients with pleuropulmonary diseases.
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Affiliation(s)
- J S Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, R.O.C
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