Risk Factors for the Mortality of Patients With Coronavirus Disease 2019 Requiring Extracorporeal Membrane Oxygenation in a Non-Centralized Setting: A Nationwide Study

BACKGROUND

Limited data are available on the mortality rates of patients receiving extracorporeal membrane oxygenation (ECMO) support for coronavirus disease 2019 (COVID-19). We aimed to analyze the relationship between COVID-19 and clinical outcomes for patients receiving ECMO.

METHODS

We retrospectively investigated patients with COVID-19 pneumonia requiring ECMO in 19 hospitals across Korea from January 1, 2020 to August 31, 2021. The primary outcome was the 90-day mortality after ECMO initiation. We performed multivariate analysis using a logistic regression model to estimate the odds ratio (OR) of 90-day mortality. Survival differences were analyzed using the Kaplan-Meier (KM) method.

RESULTS

Of 127 patients with COVID-19 pneumonia who received ECMO, 70 patients (55.1%) died within 90 days of ECMO initiation. The median age was 64 years, and 63% of patients were male. The incidence of ECMO was increased with age but was decreased after 70 years of age. However, the survival rate was decreased linearly with age. In multivariate analysis, age (OR, 1.048; 95% confidence interval [CI], 1.010-1.089; P = 0.014) and receipt of continuous renal replacement therapy (CRRT) (OR, 3.069; 95% CI, 1.312-7.180; P = 0.010) were significantly associated with an increased risk of 90-day mortality. KM curves showed significant differences in survival between groups according to age (65 years) (log-rank P = 0.021) and receipt of CRRT (log-rank P = 0.004).

CONCLUSION

Older age and receipt of CRRT were associated with higher mortality rates among patients with COVID-19 who received ECMO.

Risk of tuberculosis after endoscopic resection and gastrectomy in gastric cancer: nationwide population-based matched cohort study

BACKGROUND

This study aimed to investigate the association between gastrectomy and endoscopic resection for gastric cancer and the subsequent tuberculosis incidence.

METHODS

We conducted a nationwide matched cohort study using data from the Korea National Health Insurance Service from 2013 to 2019. We created two cohorts: patients who underwent gastrectomy and those who had endoscopic resection. Each patient was matched 1:1 with an unexposed individual based on index year, age, sex, income, and various comorbidities. The primary outcome was the incidence of tuberculosis during the follow-up period.

RESULTS

Our study comprised 90,886 gastrectomy patients and 46,759 endoscopic resection patients. The tuberculosis incidence was significantly higher in the gastrectomy group compared to its matched non-gastrectomy group (IRR 1.69, 95% CI 1.43-1.99, p < .001). In contrast, there was no significant difference in tuberculosis incidence between the endoscopic resection group and its matched non-resection group (IRR 0.95, 95% CI 0.75-1.19, p = 0.627). The Kaplan-Meier cumulative incidence also did not differ between the two groups. However, tuberculosis incidence significantly increased in the first year after endoscopic resection.

CONCLUSION

Gastrectomy for gastric cancer is associated with a higher incidence of subsequent tuberculosis, while no significant association was observed for endoscopic resection. However, tuberculosis incidence increases significantly during the first year after endoscopic resection.

The Profile of Early Sedation Depth and Clinical Outcomes of Mechanically Ventilated Patients in Korea

BACKGROUND

Current international guidelines recommend against deep sedation as it is associated with worse outcomes in the intensive care unit (ICU). However, in Korea the prevalence of deep sedation and its impact on patients in the ICU are not well known.

METHODS

From April 2020 to July 2021, a multicenter, prospective, longitudinal, noninterventional cohort study was performed in 20 Korean ICUs. Sedation depth extent was divided into light and deep using a mean Richmond Agitation-Sedation Scale value within the first 48 hours. Propensity score matching was used to balance covariables; the outcomes were compared between the two groups.

RESULTS

Overall, 631 patients (418 [66.2%] and 213 [33.8%] in the deep and light sedation groups, respectively) were included. Mortality rates were 14.1% and 8.4% in the deep and light sedation groups (P = 0.039), respectively. Kaplan-Meier estimates showed that time to extubation (P < 0.001), ICU length of stay (P = 0.005), and death (P = 0.041) differed between the groups. After adjusting for confounders, early deep sedation was only associated with delayed time to extubation (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.55-0.80; P < 0.001). In the matched cohort, deep sedation remained significantly associated with delayed time to extubation (HR, 0.68; 95% CI, 0.56-0.83; P < 0.001) but was not associated with ICU length of stay (HR, 0.94; 95% CI, 0.79-1.13; P = 0.500) and in-hospital mortality (HR, 1.19; 95% CI, 0.65-2.17; P = 0.582).

CONCLUSION

In many Korean ICUs, early deep sedation was highly prevalent in mechanically ventilated patients and was associated with delayed extubation, but not prolonged ICU stay or in-hospital death.

Comparison of clinical characteristics and hospital mortality in critically ill patients without COVID-19 before and during the COVID-19 pandemic: a multicenter, retrospective, propensity score-matched study

Background

The high transmission and fatality rates of coronavirus disease 2019 (COVID-19) strain intensive care resources and affect the treatment and prognosis of critically ill patients without COVID-19. Therefore, this study evaluated the differences in characteristics, clinical course, and prognosis of critically ill medical patients without COVID-19 before and during the COVID-19 pandemic.

Methods

This retrospective cohort study included patients from three university-affiliated tertiary hospitals. Demographic data and data on the severity, clinical course, and prognosis of medical patients without COVID-19 admitted to the intensive care unit (ICU) via the emergency room (ER) before (from January 1 to May 31, 2019) and during (from January 1 to May 31, 2021) the COVID-19 pandemic were obtained from electronic medical records. Propensity score matching was performed to compare hospital mortality between patients before and during the pandemic.

Results

This study enrolled 1161 patients (619 before and 542 during the pandemic). During the COVID-19 pandemic, the Simplified Acute Physiology Score (SAPS) 3 and Sequential Organ Failure Assessment (SOFA) scores, assessed upon ER and ICU admission, were significantly higher than those before the pandemic (p < 0.05). The lengths of stay in the ER, ICU, and hospital were also longer (p < 0.05). Finally, the hospital mortality rates were higher during the pandemic than before (215 [39.7%] vs. 176 [28.4%], p < 0.001). However, in the propensity score-matched patients, hospital mortality did not differ between the groups (p = 0.138). The COVID-19 pandemic did not increase the risk of hospital mortality (odds ratio [OR] 1.405, 95% confidence interval [CI], 0.937–2.107, p = 0.100). SAPS 3, SOFA score, and do-not-resuscitate orders increased the risk of in-hospital mortality in the multivariate logistic regression model.

Conclusions

In propensity score-matched patients with similarly severe conditions, hospital mortality before and during the COVID-19 pandemic did not differ significantly. However, hospital mortality was higher during the COVID-19 pandemic in unmatched patients in more severe conditions. These findings imply collateral damage to non-COVID-19 patients due to shortages in medical resources during the COVID-19 pandemic. Thus, strategic management of medical resources is required to avoid these consequences.

Population-based study of the association between asthma and exogenous female sex hormone use

OBJECTIVES

Several studies have suggested the influence of exogenous hormones on asthma, but the results are still conflicting. Moreover, there has been little associated research on Asian population. This study aimed to assess the association between use of exogenous female sex hormones and asthma in Korean women.

DESIGN

Korea National Health and Nutrition Examination Survey (KNHANES) is a nationwide programme to assess national health and nutritional status in Korea. A population-based study was conducted to analyse the relationship between self-reported asthma and exogenous hormones using the KNHANES between 2007 and 2012.

PARTICIPANTS

The study sample included 6874 premenopausal and 4912 postmenopausal women aged 30-65.

OUTCOME MEASURES

KNHANES data comprised health interviews and physical examinations. Questionnaires regarding asthma, reproductive factors and exogenous hormones were included.

RESULTS

Among postmenopausal women, 3.4% reported doctor-diagnosed asthma. Hormone replacement therapy (HRT) was associated with increased odds of doctor-diagnosed asthma (OR 1.56; 95% CI 1.04 to 2.35), while the association between HRT and wheeze in the last 1 year was not significant (OR 1.37; 95% CI 0.95 to 1.96). In premenopausal women, the prevalence of asthma was 2.3%. Use of oral contraceptives (OCs) was associated with an increased odds of doctor-diagnosed asthma (OR 1.67; 95% CI 1.01 to 2.76) and wheeze in the last 1 year (OR 1.88; 95% CI 1.31 to 2.69). These associations were dominant among non-obese women (body mass index <25 kg/m²; OR 2.36; 95% CI 1.34 to 4.17 for asthma and OR 2.15; 95% CI 1.43 to 3.23 for wheeze).

CONCLUSIONS

HRT and OCs were associated with increased asthma in postmenopausal and premenopausal women, respectively. The association between OC use and asthma was strong in non-obese premenopausal women.

Korean Guidelines for Diagnosis and Management of Interstitial Lung Diseases: Part 4. Cryptogenic Organizing Pneumonia

Cryptogenic organizing pneumonia (COP) is a type of idiopathic interstitial pneumonia with an acute or subacute clinical course. Bilateral lung consolidations located in the subpleural area and bronchovascular bundle are the most common findings on chest high-resolution computed tomography. The pathologic manifestations include granulation tissue in the alveoli, alveolar ducts, and bronchioles. COP responds fairly well to glucocorticoid monotherapy with rapid clinical improvement, but recurrence is common. However, treatment with combined immunosuppressant agents is not recommended, even if the COP patient does not respond to glucocorticoid monotherapy with expert opinion.

Toll-like receptor expression in pulmonary sensory neurons in the bleomycin-induced fibrosis model

Airway sensory nerves are known to express several receptors and channels that are activated by exogenous and endogenous mediators that cause coughing. Toll-like receptor (TLR) s are expressed in nociceptive neurons and play an important role in neuroinflammation. However, there have been very few studies of TLR expression in lung-derived sensory neurons or their relevance to respiratory symptoms such as cough. We used the bleomycin-induced pulmonary fibrosis model to investigate the change in TLR expression in pulmonary neurons and the association of TLRs with transient receptor potential (TRP) channels in pulmonary neurons. After 2 weeks of bleomycin or saline administration, pulmonary fibrosis changes were confirmed using tissue staining and the SIRCOL collagen assay. TLRs (TLR 1-9) and TRP channel expression was analyzed using single cell reverse transcription polymerase chain reaction (RT-PCR) in isolated sensory neurons from the nodose/jugular ganglion and the dorsal root ganglion (DRG). Pulmonary sensory neurons expressed TLR2 and TLR5. In the bleomycin-induced pulmonary fibrosis model, TLR2 expression was detected in 29.5% (18/61) and 26.9% (21/78) of pulmonary nodose/jugular neurons and DRG neurons, respectively. TLR5 was also detected in 55.7% (34/61) and 42.3% (33/78) of pulmonary nodose/jugular neurons and DRG neurons, respectively, in the bleomycin-induced pulmonary fibrosis model. TLR5 was expressed in 63.4% of TRPV1 positive cells and 43.4% of TRPM8 positive cells. In conclusion, TLR2 and TLR5 expression is enhanced, especially in vagal neurons, in the bleomycin-induced fibrosis model group when compared to the saline treated control group. Co-expression of TLR5 and TRP channels in pulmonary sensory neurons was also observed. This work sheds new light on the role of TLRs in the control and manifestation of clinical symptoms, such as cough. To understand the role of TLRs in pulmonary sensory nerves, further study will be required.

Implications of Plasma Renin Activity and Plasma Aldosterone Concentration in Critically Ill Patients with Septic Shock

Background

The renin-angiotensin-aldosterone system is closely associated with volume status and vascular tone in septic shock. The present study aimed to assess whether plasma renin activity (PRA) and plasma aldosterone concentration (PAC) measurements compared with conventional severity indicators are associated with mortality in patients with septic shock.

Methods

We evaluated 105 patients who were admitted for septic shock. Plasma levels of the biomarkers PRA and PAC, the PAC/PRA ratio, C-reactive protein (CRP) level, and cortisol level on days 1, 3, and 7 were serially measured. During the intensive care unit stay, relevant clinical information and laboratory results were recorded.

Results

Patients were divided into two groups according to 28-day mortality: survivors (n = 59) and non-survivors (n = 46). The survivor group showed lower PRA, PAC, Acute Physiologic and Chronic Health Evaluation (APACHE) II score, and Sequential Organ Failure Assessment (SOFA) score than did the non-survivor group (all P < 0.05). The SOFA score was positively correlated with PRA (r = 0.373, P < 0.001) and PAC (r = 0.316, P = 0.001). According to receiver operating characteristic analysis, the areas under the curve of PRA and PAC to predict 28-day mortality were 0.69 (95% confidence interval [CI], 0.58 to 0.79; P = 0.001) and 0.67 (95% CI, 0.56 to 0.77; P = 0.003), respectively, similar to the APACHE II scores and SOFA scores. In particular, the group with PRA value ≥3.5 ng ml^-1 h^-1 on day 1 showed significantly greater mortality than did the group with PRA value <3.5 ng ml^-1 h^-1 (log-rank test, P < 0.001). According to multivariate analysis, SOFA score (hazard ratio, 1.11; 95% CI, 1.01 to 1.22), PRA value ≥3.5 ng ml^-1 h^-1 (hazard ratio, 3.25; 95% CI, 1.60 to 6.60), previous history of cancer (hazard ratio, 3.44; 95% CI, 1.72 to 6.90), and coronary arterial occlusive disease (hazard ratio, 2.99; 95% CI, 1.26 to 7.08) were predictors of 28-day mortality.

Conclusions

Elevated PRA is a useful biomarker to stratify the risk of critically ill patients with septic shock and is a prognostic predictor of 28-day mortality.

Value of Serum Cystatin C Measurement in the Diagnosis of Sepsis-Induced Kidney Injury and Prediction of Renal Function Recovery

PURPOSE

Acute kidney injury (AKI) is common in critically ill patients. Serum cystatin C has emerged as a reliable marker of AKI. We sought to assess the value of serum cystatin C for early detection and prediction of renal function recovery in patients with sepsis.

MATERIALS AND METHODS

Sepsis patients (113 AKI patients and 49 non-AKI patients) admitted to the intensive care unit (ICU) were included. Serum creatinine and cystatin C levels and glomerular filtration rate were measured on days 0, 1, 3, and 7.

RESULTS

Serum cystatin C levels were significantly higher in AKI patients than in non-AKI patients at all time points. Multivariate analysis showed that only serum cystatin C levels on day 0 were associated with AKI development [odds ratio (OR)=19.30; 95% confidence interval (CI)= 2.58-144.50, p<0.001]. Linear mixed model analysis showed significant variation in cystatin C levels between the recovery and non-recovery groups over time (p=0.001). High levels of serum cystatin C at day 0 (OR=1.64; 95% CI=1.00-2.68, p=0.048) were associated with recovery of AKI.

CONCLUSION

Serum cystatin C level was found to be associated with the development and worsening of AKI in ICU patients with sepsis.

Reactive Oxygen Species Modulator 1 (Romo1) Predicts Poor Outcomes in Advanced Non-small Cell Lung Cancer Patients Treated with Platinum-Based Chemotherapy

Purpose

Reactive oxygen species modulator 1 (Romo1) is a key mediator of intracellular reactive oxygen species production. However, examination of the clinical usefulness of Romo1 in cancers has been limited. We evaluated the association of Romo1 expression with clinical outcomes in advanced non-small cell lung cancer (NSCLC) patients treated with platinum-based chemotherapy.

Materials and Methods

Romo1 expression in tumor tissue was examined by immunohistochemistry and evaluated by histological score. Survival analyses were performed according to Romo1 expression and the association between Romo1 expression and clinical parameters was evaluated.

Results

A total of 88 tumor specimens were analyzed. Significantly shorter median progression-free survival (PFS) was observed in the high Romo1 group compared with the low Romo1 group (4.5 months vs. 9.8 months, p < 0.001), and the median overall survival (OS) of the high Romo1 group was also significantly shorter than that of the low Romo1 group (8.4 months vs. 15.5 months, p < 0.001). Results of multivariate analyses showed significant association of high Romo1 expression with both poor PFS (hazard ratio [HR], 2.75; 95% confidence interval [CI], 1.71 to 4.44) and poor OS (HR, 3.99; 95% CI, 2.36 to 6.74). Results of the subgroup analysis showed a similar association regardless of tumor histology. Romo1 expression showed no association with any clinical parameter including age, sex, smoking status, stage, differentiation, or tumor histology.

Conclusion

Romo1 overexpression was associated with poor response to treatment and shorter survival in advanced NSCLC patients treated with platinum-based chemotherapy. Romo1 could be a potential adverse predictive marker in this setting.

The effect of an IκB-kinase-β(IKKβ) inhibitor on tobacco smoke-induced pulmonary inflammation

PURPOSE OF THE STUDY

Inactivation of NF-κB with IKKβ knockout mice reduces tobacco smoke-induced pulmonary inflammation. In this study, we investigated whether the IKKβ inhibitor PS-1145 could attenuate the pulmonary inflammation induced by tobacco smoke.

MATERIALS AND METHODS

We divided 30 mice into three groups: a control group, a smoking group, and a PS-1145 group. Mice from the smoking and PS-1145 groups were exposed for 2 weeks to tobacco smoke. PS-1145 was injected intraperitoneally before every tobacco smoke exposure. After 2 weeks, bronchoalveolar lavage (BAL) was performed for cell counting and measuring of inflammatory chemokines. We analyzed the correlation between NF-κB and NF-κB-regulated chemokines in BAL fluid and measured the neutrophils and macrophages by immunostaining in lung tissues.

RESULTS

The PS-1145 group showed a significant reduction in the number of total cells, neutrophils, and macrophages, as well as the KC and MCP-1 level, in the BAL fluid compared to the smoking group. There was no significant difference in the level of MIP-1α. The level of NF-κB in BAL fluid was significantly positively correlated with KC and MCP-1 levels, but not with MIP-1α level. The PS-1145 group also showed a significant fewer neutrophils and macrophages in the lung tissue.

CONCLUSIONS

We conclude that the IKKβ inhibitor PS-1145 suppressed the NF-κB signaling pathway and reduced the recruitment of inflammatory cells and chemokines in pulmonary inflammation induced by tobacco smoke. IKKβ inhibition offers a potential therapeutic target for tobacco smoke-induced pulmonary inflammation.

Risk factors for tuberculosis after gastrectomy in gastric cancer

AIM: To examine incidence of tuberculosis (TB) in gastrectomy patients and investigate the risk factors for developing TB after gastrectomy in patients with gastric cancer.

METHODS: A retrospective cohort study of gastrectomy patients with gastric cancer was performed at a university-affiliated hospital in Seoul, South Korea between January 2007 and December 2009. We reviewed patient medical records and collected data associated with the risk of TB, surgery, and gastric cancer. Standardized incidence ratios (SIRs) of TB were calculated to compare the incidence of TB in gastrectomy patients with that in the general Korean population, and risk factors for TB after gastrectomies were analyzed.

RESULTS: Among the 1776 gastrectomy patients, 0.9% (16/1776) developed post-gastrectomy TB, with an incidence of 223.7 cases per 100000 patients per year. The overall incidence of TB in gastrectomy patients, adjusted by sex and age, was significantly higher than that in the general population (SIR = 2.22, 95%CI: 1.27-3.60). Previous TB infection [odds ratio (OR) = 7.1, P < 0.001], lower body mass index (BMI) (kg/m²; OR = 1.21, P = 0.043) and gastrectomy extent (total gastrectomy vs subtotal gastrectomy) (OR = 3.48, P = 0.017) were significant risk factors for TB after gastrectomy in a multivariate analysis.

CONCLUSION: TB incidence after gastrectomy is higher than that in the general population. Previous TB infection, lower BMI, and total gastrectomy are risk factors for TB after gastrectomy in patients with gastric cancer.

Association between interleukin-27 polymorphisms and pulmonary tuberculosis

OBJECTIVE

To investigate the effect of interleukin (IL) 27 -964A/G, 2095T/G, 4603G/A and 4730T/C gene polymorphisms on the development of pulmonary tuberculosis (PTB), radiographic characteristics and severity.

DESIGN

Differences in the allele and genotype distributions of the -964A/G, 2095T/G, 4603G/A and 4730T/C polymorphisms between 224 PTB patients and 233 healthy controls, between patients with single- and multi-lobe involvement, and between patients with and without cavitation, were investigated. Serum IL-27 concentration was measured using an enzyme-linked immunosorbent assay.

RESULTS

There were no significant differences in the allele or genotype distributions between PTB patients and healthy controls. However, the -964A/A genotype was more prevalent in patients with single-lobe involvement than the -964A/G or -964G/G genotype in patients with multi-lobe involvement (50.0% vs. 31.3%, P = 0.01). There was no difference between patients with and without cavitation (P > 0.05). Serum median IL-27 concentration was significantly higher in patients with single-lobe involvement than in those with multi-lobe involvement (P = 0.03) and in those with -964A/A genotypes than in those with -964A/G or -964G/G genotypes (P = 0.02).

CONCLUSIONS

In terms of serum IL-27 levels, the -964 A/A genotype may be associated with a protective role that prevents the intrapulmonary spread of PTB rather than its development.

Antibacterial activity of antagonistic bacterium Bacillus subtilis DJM-51 against phytopathogenic Clavibacter michiganense subsp. michiganense ATCC 7429 in vitro

To investigate antibacterial activity against the tomato pathogen Clavibacter michiganense subsp. michiganense ATCC 7429 (Cmm ATCC 7429), Bacillus subtilis DJM-51 was isolated from rhizosphere soil. For isolation of bacteria, samples were taken from rhizosphere soil. The isolate, DJA-51, had strong antagonistic ability against Tomato pathogen Cmm ATCC 7429 on nutrient-broth yeast extract agar (NBYA) as indicated by inhibition zones around colonies. On the basis of the nucleotide sequence of a conserved segment of the 16S rRNA gene, the bacterium has been identified as B. subtilis DJM-51. The growth of Cmm ATCC 7429 on NBYA plates was inhibited by culture broth of B. subtilis DJM-51 including cells, by the supernatant of culture broth of B. subtilis DJM-51, and by the liquid material resulting from butanol extract of bacterial cultures. The OD value in co-culture mixture was lower than the control throughout the entire incubation period. Antibiotics obtained from B. subtilis DJM-51 inhibited the growth of Tomato pathogen Cmm ATCC 7429. These results provide potentially information about the protection of tomato from pathogen Cmm ATCC 7429 under greenhouse conditions in Quebec.

Comparison of methicillin-resistant Staphylococcus aureus community-acquired and healthcare-associated pneumonia

PURPOSE

Methicillin-resistant Staphylococcus aureus (MRSA) is recognized as an important cause of not only healthcare-associated pneumonia (HCAP) but also community-acquired pneumonia (CAP). We determined the impact of MRSA on differences in clinical characteristics, courses, and outcomes between CAP and HCAP.

MATERIALS AND METHODS

We conducted a retrospective observational study on 78 adult patients admitted with MRSA pneumonia at a university-affiliated tertiary hospital between January 2008 and December 2011. We compared baseline characteristics, chest radiographs, treatment outcomes, and drug resistance patterns between the CAP and HCAP groups.

RESULTS

Of the 78 patients with MRSA pneumonia, 57 (73.1%) were HCAP and 21 (26.9%) were CAP. MRSA infection history in the previous year (29.8% vs. 14.3%, p=0.244) tended to be more common in HCAP than in CAP. Despite similar Pneumonia Severity Index scores (151 in CAP vs. 142 in HCAP), intubation rates (38.1% vs. 17.5%; p=0.072) and intensive care unit admission (42.9% vs. 22.8%; p=0.095) tended to be higher in the CAP group, while 28-day mortality was higher in the HCAP group (14.3% vs. 26.3%; p=0.368), although without statistical significance. All patients showed sensitivity to vancomycin and linezolid; meanwhile, HCAP patients showed greater resistance to gentamicin than CAP patients (58.3% vs. 16.6%; p=0.037). The median total hospital charges were 6899 American dollars for CAP and 5715 American dollars for HCAP (p=0.161).

CONCLUSION

MRSA pneumonia showed significantly differences in baseline characteristics, chest radiographs, treatment outcomes, and medical expenses between HCAP and CAP groups.

Prediction of methicillin-resistant Staphylococcus aureus in patients with non-nosocomial pneumonia

Background

Methicillin-resistant Staphylococcus aureus (MRSA) is recognized as an important cause of not only hospital acquired pneumonia, but also non-nosocomial pneumonia. However, the risk factors for non-nosocomial MRSA pneumonia are not clearly defined. Our objective was to identify risk factors at admission that were associated with non-nosocomial MRSA pneumonia.

Methods

We evaluated 943 patients admitted to a university-affiliated hospital with culture-positive bacterial pneumonia developed outside the hospital from January 2008 to December 2011. We compared the clinical characteristics between MRSA and non-MRSA pneumonia, and identified risk factors associated with MRSA pneumonia.

Results

Of 943 patients, MRSA was identified in 78 (8.2%). Higher mortality was observed in MRSA than in non-MRSA patients (33.3% vs. 21.5%; P = 0.017). In a logistic regression analysis, MRSA pneumonia was observed more frequently in patients with a previous history of MRSA infection (OR = 6.05; P < 0.001), a PSI score ≥120 (OR = 2.40; P = 0.015), intravenous antibiotic treatment within 30 days of pneumonia (OR = 2.23; P = 0.018). By contrast, non-MRSA pneumonia was observed more often in patients with a single infiltrate on chest radiography (OR = 0.55; P = 0.029).

Conclusions

Anti-MRSA antibiotics could be considered in hospitalized non-nosocomial patients with several risk factors identified herein. The presence or absence of these factors would provide useful guidance in selecting initial empirical antibiotics.

Two cases of humoral hypercalcemia of malignancy in metastatic cholangiocarcinoma

Humoral hypercalcemia of malignancy (HHM) is rarely associated with cholangiocarcinoma (CC), and represents dismal prognosis. A 63-year-old male was admitted for evaluation of an intrahepatic mass. He was diagnosed with HHM associated with locally advanced CC. As the tumor responded to the concurrent chemoradiotherapy with capecitabine and cisplatin, serum calcium level was normalized. However, according to the disease progression, he suffered recurrence of HHM and he expired approximately one year after initial diagnosis. A 68-year-old male who presented with abdominal pain was diagnosed with metastatic CC. After the eighth cycle of gemcitabine and cisplatin, progression of the disease was found with HHM. He was treated with the best supportive care, until his demise approximately one month after the diagnosis of HHM. We report on two cases of HHM associated with CC that demonstrate strong correlation between hypercalcemia and disease burden.

Two cases of Wernicke's encephalopathy in young age patients receiving allogeneic hematopoietic stem cell transplantation

Wernicke's encephalopathy is an acute neurolopsychiatric syndrome caused by thiamine deficiency, and classically presents with the triad of opthalmopathy, ataxia and altered mentality. Both prolonged total parenteral nutrition and reduced oral intake can induce Wernicke's encephalopathy during hematopoietic stem cell transplantation (HSCT). Although early treatment is important for recovery from Wernicke's encephalopathy, the vague symptoms and characteristics hinder early diagnosis. Furthermore, Wernicke's encephalopathy is not infrequent and can develop at any age during HSCT. Herein, we present two young patients developing Wernicke's encephalopathy during HSCT.

Delta neutrophil index as an early marker of disease severity in critically ill patients with sepsis

BACKGROUND

The immature granulocyte count has been reported to be a marker of infection and sepsis. The difference in leukocyte subfractions (delta neutrophil index, DNI) in ADVIA 2120 reflects the fraction of circulating immature granulocytes in the blood. This study evaluated the clinical utility of DNI as a severity and prediction marker in critically ill patients with sepsis.

METHODS

One hundred and three patients admitted to the medical intensive care unit with sepsis were studied. DNI (the difference in leukocyte subfractions identified by myeloperoxidase and nuclear lobularity channels) was determined using a specific blood cell analyzer.

RESULTS

Forty four patients (42.7%) were diagnosed with severe sepsis/septic shock. Overt disseminated intravascular coagulation (DIC) occurred in 40 (38.8%). DNI was significantly higher in patients with severe sepsis/septic shock and overt DIC than in patients without (p < 0.05). DNI correlated with DIC score (r = 0.54, p < 0.001). We observed a monotonic increase in the proportion of overt DIC and severe sepsis/septic shock associated with increasing quartiles of DNI (p < 0.001). A DNI value > 6.5% was a better indicator of severe sepsis/septic shock than C-reactive protein, lactate, white blood cell count, and absolute neutrophil count (sensitivity, 81.3%; specificity, 91.0%; positive predictive value, 88.6%; and negative predictive value, 84.7%). In 36 (82%) of the 44 patients with severe sepsis/septic shock, DNI values were already elevated up to 12 hours before the onset of organ/circulatory failure.

CONCLUSIONS

DNI may be used as a marker of disease severity in critically ill patients with sepsis. High levels of DNI may help to identify patients with an impending risk of developing severe sepsis/septic shock.

Extraction of chitin from red crab shell waste by cofermentation with Lactobacillus paracasei subsp. tolerans KCTC-3074 and Serratia marcescens FS-3

For one-step extraction of chitin from red crab shell waste, cofermentation with Lactobacillus paracasei subsp. tolerans KCTC-3074, a lactic-acid-producing bacterium, and Serratia marcescens FS-3, a protease-producing bacterium, was conducted. Fermentation with single strain (L. 3074 or FS-3) was also conducted. At day 7, the pH in L. 3074, FS-3, and L. 3074+FS-3 (1:1) treatment decreased from 6.90 to 3.30, 5.88, and 3.48, respectively. Ash content in the residue after fermentation treatment of crab shells in L. 3074 and L. 3074+FS-3 (1:1) treatment drastically decreased from 41.2% to 3.19 and 1.15%, respectively. In L. 3074+FS-3 (1:1) cofermentation, the level of demineralization was the highest value of 97.2%, but the level of deproteinization in the cofermentation was 52.6% at day 7. Protein content in the treatment of FS-3 alone reduced from 22.4 to 3.62%. These results indicate that cofermentation of the shells using the two strains is efficient and applicable for the one-step extraction of crude chitin from red crab shell waste.

Demineralization of red crab shell waste by lactic acid fermentation

Lactic acid fermentation was applied to demineralize red crab shell waste using Lactobacillus paracasei subsp. tolerans KCTC-3074. Various concentrations (0, 2.5, 5.0, 10.0%) of glucose were supplemented as an initial carbon source and various amounts (2.5, 5.0, 10.0%) of the bacterial culture were inoculated as a starter. Microbial growth was very dependent on glucose concentration but little dependent on inoculum level. The pH decreased rapidly from pH 8 to pH 6 during the first day, at all three inoculum levels. At day 5 of fermentation, the 2.5, 5.0, and 10.0% inoculum levels with 10% glucose supply gave pH 5.5, 5.1, and 4.6, respectively, i.e. a decrease in pH concomitant with an increase in the inoculum level. The total titratable acidities (TTA) at day 5 for 2.5, 5.0, and 10.0% inoculum levels with 10% glucose supplement were 3.1, 4.5, and 8.3%, and the relative residual ash contents were 26.6, 25.9, and 19.0%, respectively. A negative relationship was found between pH and demineralization level (r2 = 0.8571), but there was a positive relationship between TTA and demineralization level (r2 = 0.5532).

Production of N-acetyl-beta-D-glucosamine from chitin by Aeromonas sp. GJ-18 crude enzyme

A bacterium, GJ-18, having strong chitinolytic activity was isolated from coastal soil. The isolated strain was identified as Aeromonas sp. by morphological and biochemical properties along with 16S rRNA gene sequence. The crude chitinolytic activity of culture supernatants was maximal on the 5th day of culture. Below 45 degrees C, chitin was effectively hydrolyzed to N-acetyl-beta-D-glucosamine (GlcNAc) by Aeromonas sp. GJ-18 crude enzymes, but hydrolysis decreased markedly above 50 degrees C. The optimum pH for enzyme activity was 5.0. TLC and HPLC analysis revealed that, below 45 degrees C, the major reaction product was GlcNAc with a small amount of (GlcNAc)(2) and (GlcNAc)(3), whereas above 50 degrees C the major product was (GlcNAc)(2). When swollen chitin (100 mg) was incubated with crude enzyme preparations (10 U) at 40 degrees C, chitin was hydrolyzed to 83.0 and 94.9% yield of GlcNAc within 5 and 9 days, respectively.

Application of surface modified polypropylene membranes to an anaerobic membrane bioreactor

In order to increase hydrophilicity and thereby to reduce membrane fouling caused by hydrophobic adsorption, the surface of a hydrophobic 0.2 microm polypropylene (PP) membrane was modified by ozone treatment followed by graft polymerization with 2-hydroxy-ethyl methacrylate (HEMA). The modified PP (MPP) membranes were characterized in terms of contact angle, morphology and degree of grafting (DG). The contact angle was reduced from 112 degrees for a PP membrane to nearly 0 degrees for MPP membranes by introducing functional groups such as hydroxyl (-OH) and carbonyl groups (C=O) on the membrane surface. As the DG increased, the O/C ratio and membrane resistance of the MPP membrane increased. Using the MPP membrane in the crossflow operation of an anaerobic membrane bioreactor (MBR), the membrane permeability was enhanced although it was largely dependent on the DG of MPP.

Hepatic involvement in hypereosinophilia: sonographic findings

Hypereosinophilic syndrome may cause eosinophil-related tissue damage to various organs. The purpose of this paper is to describe sonographic findings in 13 patients with hypereosinophilia in whom the liver was involved. The diagnosis in these 13 patients was based on liver biopsy in seven patients with bone marrow biopsy in six patients. Eight patients had hypereosinophilic syndrome and five patients had clonorchiasis. All 13 patients had mild to marked hepatomegaly. Seven of 13 patients showed multiple round or oval hypoechoic (n = 6) or variably echogenic (n = 1) lesions measuring 1 to 2 cm with poorly defined margins in both lobes of the liver. Four patients had one or two hypoechoic lesions 3 to 4 cm in size, with geographic pattern and poorly defined margins. Two patients showed diffuse hepatomegaly with increased parenchymal echogenicity. The number of lesions and the extent of diffuse lesions seem to be proportional to the degree of eosinophilia. Hypereosinophilia may produce multiple small focal hepatic lesions or diffuse segmental or lobar echogenic lesions simulating primary or metastatic tumor of the liver.

Localization of mesial temporal lobe seizures with sphenoidal electrodes

Few studies have compared sphenoidal electrodes with scalp electrodes to determine their localizing value in temporal lobe seizures. We reviewed 76 ictal recordings with the standard International 10-20 System and T1/2 and sphenoidal electrodes from 31 patients whose subsequent intracranial EEG studies precisely localized seizures in one temporal lobe. Ictal EEGs were reviewed in a blinded fashion in both longitudinal bipolar and referential montages. Of the 23 seizures in 11 patients with mesial temporal lobe epilepsy (MTLE), all seven seizures in 3 patients were localized exclusively to one sphenoidal electrode, before involvement of T1/2 and temporal scalp electrodes. The remaining 16 seizures from 8 MTLE patients and all 53 seizures in the 20 patients with neocortical temporal lobe epilepsy (NTLE) had simultaneous involvement of sphenoidal, T1/2, and temporal scalp electrodes at seizure onset when analyzed with referential montages. Sphenoidal electrodes may provide valuable localization data for presurgical evaluation of patients with possible TLE. In particular, seizure rhythms confined to the sphenoidal electrode at ictal onset, without involvement of scalp electrodes, occurred only in patients with MTLE (p < 0.04). Further studies comparing these electrodes with other types of surface electrodes are needed.

Selection of a high affinity angiogenin-binding peptide from a peptide library displayed on phage coat protein

Although the phage-displayed peptide libraries have been widely used for the biopanning of peptide specific for various types of target molecules, the selected peptides often have affinities too low for practical purposes. In this report, selection of a high affinity peptide ligand specific for human angiogenin is described. We constructed a random dodecapeptide library displayed on the gene III protein of filamentous bacteriophage by use of a phagemid. The peptide insert was flanked by two cysteines to constrain the peptide structure by a disulfide bond. Phages were collected from 1.5 x 10(3) independent transformants. After the library phages were allowed to bind to the human angiogenin coated on a plate, the phages bound to the actin-binding site of angiogenin were selectively eluted with actin. The activity of each phage clone was estimated and three high affinity phage clones were identified. The peptides displayed by the three phage clones were synthesized as fusion proteins with Escherichia coli maltose-binding protein, and used for the quantitative estimation of their affinities. By this procedure, we were able to select a peptide having a dissociation constant of about 60 nM.