Syndromic Recognition of Influenza A Infection in a Low Prevalence Community Setting

BACKGROUND: With epidemics of influenza A virus infection, people and medical professionals are all concerned about symptoms or syndromes that may indicate the infection with influenza A virus. METHODOLOGY/PRINCIPAL FINDINGS: A prospective study was performed at a community clinic of a metropolitan area. Throat swab was sampled for 3-6 consecutive adult patients with new episode (<3 days) of respiratory tract infection every weekday from Dec. 8, 2005 to Mar. 31, 2006. Demographic data, relevant history, symptoms and signs were recorded. Samples were processed with multiplex real time PCR for 9 common respiratory tract pathogens and by virus culture. Throat swab samples were positive for Influenza A virus with multiplex real time PCR system in 12 of 240 patients. The 12 influenza A positive cases were with more clusters and chills than the other 228. Certain symptoms and syndromes increased the likelihood of influenza A virus infection. The syndrome of high fever plus chills plus cough, better with clustering of cases in household or workplace, is with the highest likelihood (positive likelihood ratio 95; 95% CI 12-750). Absence of both cluster and chills provides moderate evidence against the infection (negative likelihood ratio 0.51; 95% CI 0.29-0.90). CONCLUSIONS/SIGNIFICANCE: Syndromic recognition is not diagnostic but is useful for discriminating between influenza A infection and common cold. In addition to relevant travel history, confirmatory molecular test can be applied to subjects with high likelihood when the disease prevalence is low

An agile approach for supply chain modeling

This paper proposes the generic label correcting (GLC) algorithm incorporated with the decision rules to solve supply chain modeling problems. The rough set theory is applied to reduce the complexity of data space and to induct decision rules. This proposed approach is agile because by combining various operators and comparators, different types of paths in the reduced networks can be solved with one algorithm. Furthermore, the four cases of the supply chain modeling are illustrated.Supply chain modeling Agility Generic label correcting algorithm Rough set

Inhalation of volatile anesthetics via a laryngeal mask is associated with lower incidence of intraoperative awareness in non-critically ill patients.

Increased incidence of intraoperative awareness was reported in critically ill patients during major operations, particularly under total intravenous (TIVA) or endotracheal general anesthesia (ETGA). However, the incidence and effect of anesthesia techniques on awareness in generally healthy, non-critically ill patients during operations have yet to receive significant attention.This retrospective matched case-control study was conducted between January 2009 to December 2014. Surgical patients (ASA physical status I-III) whom reported intraoperative awareness during this study period were interviewed and their medical records were reviewed. The potential risk factors for awareness were compared with the non-case matched controls, who were randomly selected from the database. A total of 61436 patients were included and 16 definite cases of intraoperative awareness were identified. Patients who received ETGA and TIVA had significantly higher incidence of developing awareness compared to those who were anesthetized using laryngeal masks (LMA) (P = 0.03). Compared with the matched controls (n = 80), longer anesthesia time was associated with increased incidence of awareness (odds ratio 2.04; 95% CI 1.30-3.20, per hour increase). Perioperative use of muscle relaxant was also associated with increased incidence of awareness, while significantly lower incidence of awareness was found in patients who were anesthetized with volatile anesthetics.The overall incidence of awareness was 0.023% in the ASA≤ III surgical patients who received general anesthesia. Anesthesia with a laryngeal mask under spontaneous ventilation and supplemented with volatile anesthetics may be the preferred anesthesia technique in generally healthy patients in order to provide a lower risk of intraoperative awareness

Characterizing post-extubation negative pressure pulmonary edema in the operating room—a retrospective matched case-control study

Abstract Background Post-extubation negative pressure pulmonary edema (NPPE) is an uncommon but important anesthesia-related emergency presenting with acute respiratory distress and hypoxemia after removal of airway devices. This study investigated the incidence and associated risk factors for post-extubation NPPE during emergence. Methods This retrospective, matched case-control study was conducted by reviewing the post-anesthesia records in Tzu Chi General Hospital, Taiwan. Patients reported of having acute hypoxemia (SpO2 < 92%) shortly after the removal of the endotracheal tube or supraglottic airway, associating with radiographic evidence of pulmonary edema and/or pink frothy sputum, were identified as definite NPPE cases. The potential risk factors were compared with the matched controls, who were randomly selected from the same database. Results A total of 85,561 patients received general anesthesia with airway instrumentation during the 8.5-year study period. A total of 16 patients were identified as definite cases of NPPE. Compared with the matched controls (n = 131), males, active smokers, emergency operation, endotracheal intubation, use of desflurane, and prolonged operation time carried significantly higher risks of developing NPPE (P < 0.05). Multivariate logistic regression analysis illustrated that active smoking (AOR 7.66, 95% CI 1.67–35.3; P = 0.009) and endotracheal intubation (AOR 10.87, 95% CI 1.23–100; P = 0.03) were the two most significant independent variables of post-extubation NPPE. Conclusion We present the first clinical comparative study demonstrating that the overall incidence of NPPE immediately after extubation in the operating room is 0.019%. Our results highlight that active smokers and patients receiving endotracheal intubation general anesthesia are associated with significantly higher risks of developing NPPE following extubation in the operating room

Inhalation of volatile anesthetics via a laryngeal mask is associated with lower incidence of intraoperative awareness in non-critically ill patients

<div><p>Background</p><p>Increased incidence of intraoperative awareness was reported in critically ill patients during major operations, particularly under total intravenous (TIVA) or endotracheal general anesthesia (ETGA). However, the incidence and effect of anesthesia techniques on awareness in generally healthy, non-critically ill patients during operations have yet to receive significant attention.</p><p>Methods and results</p><p>This retrospective matched case-control study was conducted between January 2009 to December 2014. Surgical patients (ASA physical status I-III) whom reported intraoperative awareness during this study period were interviewed and their medical records were reviewed. The potential risk factors for awareness were compared with the non-case matched controls, who were randomly selected from the database. A total of 61436 patients were included and 16 definite cases of intraoperative awareness were identified. Patients who received ETGA and TIVA had significantly higher incidence of developing awareness compared to those who were anesthetized using laryngeal masks (LMA) (P = 0.03). Compared with the matched controls (n = 80), longer anesthesia time was associated with increased incidence of awareness (odds ratio 2.04; 95% CI 1.30–3.20, per hour increase). Perioperative use of muscle relaxant was also associated with increased incidence of awareness, while significantly lower incidence of awareness was found in patients who were anesthetized with volatile anesthetics.</p><p>Conclusions</p><p>The overall incidence of awareness was 0.023% in the ASA≤ III surgical patients who received general anesthesia. Anesthesia with a laryngeal mask under spontaneous ventilation and supplemented with volatile anesthetics may be the preferred anesthesia technique in generally healthy patients in order to provide a lower risk of intraoperative awareness.</p></div

Characteristics and descriptions of intraoperative awareness.

<p>Characteristics and descriptions of intraoperative awareness.</p

Up-Regulation of Nerve Growth Factor in Cholestatic Livers and Its Hepatoprotective Role against Oxidative Stress

<div><p>The role of nerve growth factor (NGF) in liver injury induced by bile duct ligation (BDL) remains elusive. This study aimed to investigate the relationship between inflammation and hepatic NGF expression, to explore the possible upstream molecules up-regulating NGF, and to determine whether NGF could protect hepatocytes from oxidative liver injury. Biochemical and molecular detection showed that NGF was up-regulated in cholestatic livers and plasma, and well correlated with systemic and hepatic inflammation. Conversely, systemic immunosuppression reduced serum NGF levels and resulted in higher mortality in BDL-treated mice. Immunohistochemistry showed that the up-regulated NGF was mainly localized in parenchymal hepatocytes. In vitro mechanistic study further demonstrated that TGF-β1 up-regulated NGF expression in clone-9 and primary rat hepatocytes. Exogenous NGF supplementation and endogenous NGF overexpression effectively protected hepatocytes against TGF-β1- and oxidative stress-induced cell death in vitro, along with reduced formation of oxidative adducted proteins modified by 4-HNE and 8-OHdG. TUNEL staining confirmed the involvement of anti-apoptosis in the NGF-exhibited hepatoprotection. Moreover, NGF potently induced Akt phosphorylation and increased Bcl-2 to Bax ratios, whereas these molecular alterations by NGF were only seen in the H₂O₂-, but not TGF-β1-treated hepatocytes. In conclusion, NGF exhibits anti-oxidative and hepatoprotective effects and is suggested to be therapeutically applicable in treating cholestatic liver diseases.</p></div

Up-regulation of NGF expression in rodent hepatocytes by TGF-β1. Both clone-9 and primary rat hepatocytes were used for NGF induction experiments.

<p>Clone-9 cells (A, B) and primary hepatocytes isolated from rats (C, D) were grown on collagen I-coated dishes and treated with TGF-β1 at the indicated doses (ng/mL) for 6 h. Total RNA was extracted and subjected to qPCR analysis for <i>NGF</i> mRNA levels (A, C). Besides, conditioned media for 24 hrs of treatment were collected for NGF ELISA detection (B, D). Note that TGF-β1 at 10 ng/mL remarkably increased de novo synthesis of NGF in both cultured hepatocytes. Data are representative results from three independent experiments and shown in mean±SD. * indicates <i>P</i><0.05 compared to negative control group.</p

In vitro hepatoprotective effects of endogenous NGF overexpression on TGF-β1-induced and oxidative cell death.

<p>Clone-9 hepatocytes were transfected with either pCMS plasmid encoding EGFP (EGFP) or full-length NGF cDNA (NGF) using Lipofectamine reagent for 48 hrs, followed by morphological documentation (A, E, H) and viability determination (B, F, I). <i>Bar</i>  = 50 µm. ELISA showed that NGF gene transfection for 48 hrs significantly induced soluble NGF production in conditioned medium (D). The clone-9 hepatocytes transfected with plasmids were exposed to either TGF-β1 or H₂O₂ for 24 hrs. The MTT cell viability assay showed that NGF overexpression not only prevented transfection- induced cytotoxicity (B) but also reduced TGF-β1 (F) and H₂O₂ (I) cytotoxicity. # and * indicate <i>P</i><0.05 compared with negative control (NC) and between groups, respectively. Western blotting results showed that NGF overexpression attenuated the elevation of cellular oxidative adduct formation, including 4-HNE and 8-OHdG modified proteins, induced by plasmid transfection (C), TGF-β1 (G), and H₂O₂ insults (J). Data are representative results from three independent experiments, and normalized to NC. Density data are expressed as mean±SD. * indicates <i>P</i><0.05 compared with NC; # indicates <i>P</i><0.05 compared with corresponding EGFP- or NGF-transfected group.</p

Hypothetical scheme showing the regulatory mechanisms and hepatoprotective roles of NGF.

<p>When the liver encounters BDL-induced cholestatic injury, inflammatory signals will induce NGF up-regulation, which can be blocked by systemic MP administration. In vitro study shows that TGF-β1 may be one of the upstream molecules that induce NGF expression in parenchymal hepatocytes. NGF is able to (1) ameliorate hepatocyte cell death caused by exogenous hydrogen peroxide and TGF-β1, (2) enhance pro-survival pathways, including p-Akt and Bcl-2/Bax ratio, (3) decrease intracellular oxidative adduct formation.</p