BackgroundThe clinical characteristics of Q fever are poorly identified in the tropics. Fever with pneumonia or hepatitis are the dominant presentations of acute Q fever, which exhibits geographic variability. In southern Taiwan, which is located in a tropical region, the role of Q fever in community-acquired pneumonia (CAP) has never been investigated.Methodology/Principal FindingsDuring the study period, May 2012 to April 2013, 166 cases of adult CAP and 15 cases of acute Q fever were prospectively investigated. Cultures of clinical specimens, urine antigen tests for Streptococcus pneumoniae and Legionella pneumophila, and paired serologic assessments for Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Q fever (Coxiella burnetii) were used for identifying pathogens associated with CAP. From April 2004 to April 2013 (the pre-study period), 122 cases of acute Q fever were also included retrospectively for analysis. The geographic distribution of Q fever and CAP cases was similar. Q fever cases were identified in warmer seasons and younger ages than CAP. Based on multivariate analysis, male gender, chills, thrombocytopenia, and elevated liver enzymes were independent characteristics associated with Q fever. In patients with Q fever, 95% and 13.5% of cases presented with hepatitis and pneumonia, respectively. Twelve (7.2%) cases of CAP were seropositive for C. burnetii antibodies, but none of them had acute Q fever. Among CAP cases, 22.9% had a CURB-65 score ≧2, and 45.8% had identifiable pathogens. Haemophilus parainfluenzae (14.5%), S. pneumoniae (6.6%), Pseudomonas aeruginosa (4.8%), and Klebsiella pneumoniae (3.0%) were the most common pathogens identified by cultures or urine antigen tests. Moreover, M. pneumoniae, C. pneumoniae, and co-infection with 2 pathogens accounted for 9.0%, 7.8%, and 1.8%, respectively.ConclusionsIn southern Taiwan, Q fever is an endemic disease with hepatitis as the major presentation and is not a common etiology of CAP.

ObjectiveOur population-based research aimed to clarify the association between chronic kidney disease (CKD) and mortality risk in patients with lung cancer.DesignRetrospective cohort studySettingNational health insurance research database in TaiwanParticipantsAll (n=1 37 077) Taiwanese residents who were diagnosed with lung cancer between 1997 and 2012 were identified. Eligible patients with baseline CKD (n=2269) were matched with controls (1:4, n=9076) without renal disease according to age, sex and the index day of lung cancer diagnosis.MethodsThe cumulative incidence of death was calculated by the Kaplan-Meier method, and the risk determinants were explored by the Cox proportional hazards model.ResultsMortality occurred in 1866 (82.24%) and 7135 (78.61%) patients with and without CKD, respectively (P=0.0001). The cumulative incidences of mortality in patients with and without chronic renal disease were 72.8% vs 61.6% at 1 year, 82.0% vs 76.6% at 2 years and 88.9% vs 87.2% at 5 years, respectively. After adjusting for multiple confounding factors including age and comorbidities, Cox regression analysis revealed that CKD was associated with an increased risk of mortality (adjusted HR 1.38; 95% CI 1.29 to 1.47). Stratified analysis further showed that the association was consistent across patient subgroups.ConclusionComorbidity associated with CKD is a risk factor for mortality in patients with lung cancer.

BackgroundIt is unknown whether clinically indicated replacement of peripheral intravenous catheters (PIVCs) increases the risks of PIVC-associated complications and infections compared to routine replacement of PIVCs.MethodsWe searched PubMed, the Web of Science, the Cochrane Library, Ovid MEDLINE, and Clinicaltrials.gov for randomized controlled trials (RCTs) that compare the safety outcomes of routine replacement and clinically indicated replacement of PIVCs were included for meta-analysis. The primary outcome was the incidence of phlebitis, and secondary outcomes included the risks of occlusion, local infection, infiltration, catheter-related bloodstream infection (CRBSI), and accidental removal of the PIVC.ResultsA total of 9 RCTs involving 10 973 patients were included in this meta-analysis, of whom 5,546 and 5,527 were assigned to the study group (clinically indicated replacement of PIVCs) and control group (routine replacement of PIVCs every 72–96 h), respectively. The incidence of phlebitis in the study group was significantly higher than that in the control group [risk ratio (RR), 1.20; 95% confidence interval (CI), 1.01–1.44, P = 0.04, I2 = 49%]. In addition, the study group was associated with a higher risk of occlusion (RR, 1.45; 95% CI, 1.08–1.95, P = 0.01, I2 = 82%) and infiltration (fluid leaks) (RR, 1.27; 95% CI, 1.06–1.53, P = 0.01, I2 = 72%) than the control group. However, no significant differences were observed in the risks of local infection (RR, 1.75; 95% CI, 0.38–8.16, P = 0.48, I2 = 0%) and CRBSI (RR, 0.61; 95% CI, 0.08–4.68, P = 0.64, I2 = 0%) between the study and control groups.ConclusionThe clinically indicated replacement of PIVCs may increase the risks of PIVC-associated phlebitis, infiltration, and occlusion compared to the routine replacement of PIVCs, but did not increase the risk of PIVC-associated infections. Based on these findings, routine replacement of PIVCs every 72–96 h maybe a preferred option than clinically indicated replacement of PIVCs.Systematic review registration[www.crd.york.ac.uk/prospero/], identifier [CRD42022302021].

Neoadjuvant immunotherapy and chemotherapy have improved the major pathological response (MPR) in patients with early-stage operable non-small cell lung cancer (NSCLC). This study aimed to assess whether the presence of targetable driver mutations affects the efficacy of the combination of immunotherapy and chemotherapy. We enrolled patients with early-stage operable NSCLC who received preoperative neoadjuvant therapy between January 1, 2017, and December 30, 2020. Neoadjuvant therapy was delivered with platinum-doublet chemotherapy; moreover, pembrolizumab was added at the attending physician’s discretion based on patient’s request. Pathological responses were assessed; moreover, disease-free survival was estimated. Next-generation sequencing was performed in case sufficient preoperative biopsy specimens were obtained. We included 23 patients; among them, 11 received a combination of neoadjuvant immunotherapy and chemotherapy while 12 received neoadjuvant chemotherapy alone. The MPR and pathological complete response rates were 54.5% and 27.3%, respectively, in patients who received a combination of neoadjuvant immunotherapy and chemotherapy. These rates were significantly higher than those in patients who only received neoadjuvant chemotherapy. Three patients in the combination group experienced disease recurrence during the follow-up period even though two of them showed an MPR. These three patients had targetable driver mutations, including an EGFR exon 20 insertion, EGFR exon 21 L858R substitution, and MET exon 14 skipping. Only one patient who remained disease-free had a targetable driver mutation. Among patients with early-stage operable NSCLC requiring neoadjuvant therapy, comprehensive genomic profiling is crucial before the administration of the combination of neoadjuvant immunotherapy and chemotherapy.

Myasthenia gravis (MG) can result in weakness of the respiratory muscles in 30% of patients. A life-threatening exacerbation, MG crisis can cause respiratory insufficiency requiring mechanical ventilation. Sleep disordered breathing (SDB) is seen in 40% to 60% of stable MG patients. Factors associated with SDB include age, male sex, obesity, and steroid use. Continuous positive airway pressure (CPAP) can reverse paradoxical weakness in MG patients with obstructive sleep apnea (OSA), but whether SDB can contribute to respiratory failure in MG and whether CPAP works in such patients remain unclear. This report presents a 54-year-old woman with MG with a history of 7 episodes of respiratory failure requiring mechanical ventilation. For each episode, she was treated for MG crisis using plasmapheresis and high-dose steroids. Later, OSA and obesity hypoventilation syndrome were confirmed by polysomnography with transcutaneous CO 2 monitoring. Thereafter, the patient had no further recurrence of MG crisis for 5 years, using pyridostigmine and CPAP only. I NTRO DUCTI O NMyasthenia gravis (MG) is an autoimmune disorder affecting the neuromuscular junction of skeletal muscle. It can result in weakness of respiratory muscles in 30% of patients. 1 A life-threatening exacerbation, MG crisis causes respiratory insufficiency, requiring mechanical ventilation (MV) with plasmapheresis, intravenous immunoglobulin, and high-dose steroids. Sleep disordered breathing (SDB) is common in MG, with obstructive sleep apnea (OSA) found in 36% to 41% of myasthenics. 1,2 Factors associated with SDB in MG include age, male sex, obesity, and steroid use. 1,3 Continuous positive airway pressure (CPAP) has been demonstrated to reverse paradoxical weakness in MG patients with OSA. 4,5 However, whether SDB can contribute to respiratory insufficiency in MG, especially in MG crisis, and whether CPAP works in such critical patients remain unclear.Here is a case of a woman with MG with a history of 7 episodes of respiratory failure requiring MV. She was treated for MG crisis with plasmapheresis and high-dose steroids. Her OSA and obesity hypoventilation syndrome (OHS) were confirmed by polysomnography (PSG) with transcutaneous CO 2 (PtcCO 2 ) monitoring. Thereafter, she remained well for 5 years using CPAP. 144.4 cm and 77.4 kg. Her symptoms included progressive weakness, nasal speech, dysarthria, dysphagia, and ptosis. Arterial blood gas (ABG) showed hypoxemia and hypercapnia (pH 7.31, PaCO 2 56.1 mm Hg, PaO 2 57.1 mm Hg, HCO 3 -27.5 mEq/L, at room air). She was intubated, and plasmapheresis, pyridostigmine (480 mg/day), and methylprednisolone were started for suspicion of MG crisis. The muscle power of her limbs fully recovered, while her vital capacity (VC) was 1.5 L and maximal inspiratory (Pimax) and expiratory (Pemax) pressures were −50 mm Hg and 52 mm Hg, respectively. The patient was extubated 9 days later. R EPO RT O F CASEAfter extubation, the patient suffered from wheeze and persistent hypercapnia (pH 7.41, PaCO 2 50.4 mm Hg, HCO 3 -31.5 ...

No abstract

No abstract

Background Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) are used as the standard first-line treatment for patients with advanced EGFR-mutated non-small cell lung cancer (NSCLC). However, the impact of clinical factors, including comorbidities and treatment-related adverse events (AEs), on quality of life (QoL) was seldom investigated. Objective We aimed to investigate the association of comorbidities, AEs, and QoL in treatment-naïve advanced NSCLC patients receiving EGFR-TKI treatments. Methods A multi-center prospective observational study was conducted to evaluate QoL and AEs at baseline, the 2nd, 4th, 12th, and 24th week. Clinical characteristics, comorbidities, and pre-treatment laboratory data were recorded. QoL was assessed by using the summary score of the EORTC QLQ-C30 and the dermatology life quality index. The impact of comorbidities, neutrophil-to-lymphocyte ratio (NLR), and AEs on QoL was analyzed by generalized estimating equations. Results A total of 121 patients were enrolled. Diarrhea (p = 0.033), anorexia (p < 0.001), and NLR ≥ 4 (p = 0.017) were significantly associated with a QoL impairment. Among skin toxicities, acneiform rash (p = 0.002), pruritus (p = 0.002), visual analogue scale for pruritus (≥ 3 and < 7, p = 0.006; ≥7, p = 0.001) and pain (1–3, p = 0.041) were associated with a QoL impairment. No significant association was found between comorbidities and QoL changes. Conclusion Diarrhea, anorexia, skin pain, and pruritus may cause a deterioration in QoL. NLR may be a potential predictive factor for QoL impairment. Aggressive management and close monitoring are crucial to improve QoL in patients receiving EGFR-TKI therapy.