The impact of COVID-19 epidemic on emergency department visits of older patients in Taiwan

BACKGROUND

The number of emergency department (ED) visits has significantly declined since the COVID-19 pandemic. In Taiwan, an aged society, it is unknown whether older adults are accessing emergency care during the COVID-19 epidemic. Therefore, this study aimed to investigate the impact of COVID-19 on the ED visits and triage, admission, and intensive care unit (ICU) hospitalization of the geriatric population in a COVID-19-dedicated medical center throughout various periods of the epidemic.

METHODS

A retrospective chart review of ED medical records from April 9 to August 31, 2021 were conducted, and demographic information was obtained from the hospital's computer database. The period was divided into pre-, early-, peak-, late-, and post-epidemic stages. For statistical analysis, one-way analysis of variance followed by multiple comparison tests (Bonferroni correction) were used.

RESULTS

A statistically significant decrease in the total number of patients attending the ED was noted during the peak-, late-, and post-epidemic stages. In the post-epidemic stage, the number of older patients visiting ED was nearly to that of the pre-epidemic stage, indicating that older adults tend to seek care at the ED earlier than the general population. Throughout the entire epidemic period, there was no statistically significant reduction in the number of the triage 1& 2 patients seeking medical attention at the emergency department. In the entire duration of the epidemic, there was no observed reduction in the admission of elderly patients to our hospital or ICU through the ED. However, a statistically significant decrease was observed in the admission of the general population during the peak epidemic stage.

CONCLUSIONS

During the peak of COVID-19 outbreak, the number of ED visits was significantly affected. However, it is noteworthy that as the epidemic was gradually controlled, the older patients resumed their ED visits earlier that the general population as indicated by the surge in their number. Additionally, in the patient group of triage 1& 2, which represents a true emergency, the number did not show a drastic change.

Percutaneous catheter drainage versus percutaneous needle aspiration for liver abscess: a systematic review, meta-analysis and trial sequential analysis

OBJECTIVE

To compare the effectiveness and safety of percutaneous catheter drainage (PCD) against percutaneous needle aspiration (PNA) for liver abscess.

DESIGN

Systematic review, meta-analysis and trial sequential analysis.

DATA SOURCES

PubMed, Web of Science, Cochrane Library, Embase, Airiti Library and ClinicalTrials.gov were searched from their inception up to 16 March 2022.

ELIGIBILITY CRITERIA

Randomised controlled trials that compared PCD to PNA for liver abscess were considered eligible, without restriction on language.

DATA EXTRACTION AND SYNTHESIS

Primary outcome was treatment success rate. Depending on heterogeneity, either a fixed-effects model or a random-effects model was used to derive overall estimates. Review Manager V.5.3 software was used for meta-analysis. Trial sequential analysis was performed using the Trial Sequential Analysis software. Certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation system.

RESULTS

Ten trials totalling 1287 individuals were included. Pooled analysis revealed that PCD, when compared with PNA, enhanced treatment success rate (risk ratio 1.16, 95% CI 1.07 to 1.25). Trial sequential analysis demonstrated this robust finding with required information size attained. For large abscesses, subgroup analysis favoured PCD (test of subgroup difference, p<0.001). In comparison to PNA, pooled analysis indicated a significant benefit of PCD on time to achieve clinical improvement or complete clinical relief (mean differences (MD) -2.53 days; 95% CI -3.54 to -1.52) in six studies with 1000 patients; time to achieve a 50% reduction in abscess size (MD -2.49 days; 95% CI -3.59 to -1.38) in five studies with 772 patients; and duration of intravenous antibiotic use (MD -4.04 days, 95% CI -5.99 to -2.10) in four studies with 763 patients. In-hospital mortality and complications were not different.

CONCLUSION

In patients with liver abscess, ultrasound-guided PCD raises the treatment success rate by 136 in 1000 patients, improves clinical outcomes by 3 days and reduces the need for intravenous antibiotics by 4 days.

PROSPERO REGISTRATION NUMBER

CRD42022316540.

Cognitive Screening via Comprehensive Geriatric Assessment of Older Patients for the Risk Factors of Hospital Revisit/Readmission after Emergency Department Visit at 3-Month Follow-Up

INTRODUCTION

Cognitive impairment (COIM) is a major challenge for healthcare systems and is associated with an increased risk of adverse outcomes in older people visiting emergency departments (EDs). Owing to global aging, both cognitive screening and comprehensive geriatric assessment (CGA) application in ED settings are developing areas of geriatric emergency medicine. Meanwhile, the association between clinical outcomes of COIM; cognitive impairment, no dementia (CIND); and dementia in the ED could be better investigated. Our study aims to identify individuals with COIM from older patients in the ED via CGA and to describe the association of CIND and dementia with prognosis in ED visits.

METHODS

A prospective cross-sectional study was conducted in the ED of the Taipei Veterans General Hospital, a medical center located in Taipei, Taiwan, from August 2018 to November 2020. Patients aged ≥75 years with and without COIM were compared using data obtained from the CGAs conducted by trained nurses.

RESULTS

A total of 823 older patients were enrolled in the study and underwent CGA. Of these, 463 (56.3%) were diagnosed with COIM, of which 292 (35.5%) were diagnosed with dementia; and 171 (20.8%), CIND. Between the no-COIM and COIM groups, the COIM group had a higher rate of hospital admission (p = 0.002) and mortality at 3 months (p < 0.05). Among the no-COIM, CIND, and dementia groups, ED disposition (p = 0.001) and the rate of revisit/readmission (p < 0.05) showed significant differences. In particular, the dementia group had a significantly higher rate of revisit/readmission as compared to the CIND group among the three groups.

DISCUSSION/CONCLUSION

Older patients with COIM had a higher rate of hospital admission and mortality at the 3-month follow-up than older patients without COIM. Among the no-COIM, CIND, and dementia groups, patients with dementia had significantly increased risks of hospital admission and revisit/readmission. The early detection of COIM, and even dementia, could help ED physicians formulate strategies with geriatric specialists to improve mortality outcomes and revisit/readmission.

Comprehensive Geriatric Assessment in the Emergency Department for Identifying Elderly Individuals at Risk of Hip Fracture

BACKGROUND

Hip fracture (HF) is a major challenge for healthcare systems in terms of increased costs and lengths of stay, and it has been estimated that by 2050, half of the projected 6.26 million global HFs will occur in Asia. Owing to the high morbidity and mortality associated with HF in elderly individuals, it is crucial to recognize at-risk elderly patients in the ED so that special precautions and preventive measures can be taken. While comprehensive geriatric assessment (CGA) has been shown to improve outcomes and prevent secondary fractures in elderly individuals with HF in outpatient settings, there is a lack of data to identify elderly Asian patients who are at risk of HF via using CGA in the emergency department (ED). The aim of this study is to identify the characteristics of elderly Asian patients in the ED who have an increased risk of HF via CGA.

METHODS

A case-control study was conducted in the ED at Taipei Veterans General Hospital, a medical center located in Taipei, Taiwan, from October 2018 to December 2019. Patients > 75 years old with and without HF were compared using data obtained from CGAs conducted by trained nurses.

RESULTS

A total of 85 HF patients (cases) and 680 non-HF patients were enrolled, among whom 340 non-HF control individuals (controls) were selected by simple random sampling. HF occurred more frequently in women and in patients with depressive symptoms. An association between decreased handgrip strength and HF risk, especially in men, was also identified ( p = 0.011). The variables independently associated with the presence of HF in the multivariate analysis were female sex (odds ratio [OR]: 2.229; 95% confidence interval [CI]: 1.332-3.728) and decreased handgrip strength (OR: 2.462; 95% CI: 1.155-5.247).

CONCLUSIONS

By performing CGAs in the ED, we found that female sex and decreased handgrip strength were associated with HF risk. Therefore, we propose that targeted assessment of handgrip strength in female patients aged > 75 years in the ED may identify those at greatest risk of HF, resulting in improved emergency care for geriatric patients.

Gastric Mobility and Gastrointestinal Hormones in Older Patients with Sarcopenia

Sarcopenia has serious clinical consequences and poses a major threat to older people. Gastrointestinal environmental factors are believed to be the main cause. The aim of this study was to describe the relationship between sarcopenia and gastric mobility and to investigate the relationship between sarcopenia and the concentration of gastrointestinal hormones in older patients. Patients aged ≥ 75 years were recruited for this prospective study from August 2018 to February 2019 at the emergency department. The enrolled patients were tested for sarcopenia. Gastric emptying scintigraphy was conducted, and laboratory tests for cholecystokinin(CCK), glucagon-like peptide-1 (GLP-1), peptide YY (PYY), nesfatin, and ghrelin were performed during the fasting period. We enrolled 52 patients with mean age of 86.9 years, including 17 (32.7%) patients in the non-sarcopenia group, 17 (32.7%) patients in the pre-sarcopenia group, and 18 (34.6%) in the sarcopenia group. The mean gastric emptying half-time had no significant difference among three groups. The sarcopenia group had significantly higher fasting plasma concentrations of CCK, GLP-1, and PYY. We concluded that the older people with sarcopenia had significantly higher plasma concentrations of CCK, GLP-1, and PYY. In the elderly population, anorexigenic gastrointestinal hormones might have more important relationships with sarcopenia than orexigenic gastrointestinal hormones.

Neutrophil-to-lymphocyte ratio in predicting neurologic outcome of patients with acute ischemic stroke treated with intravenous thrombolytics

BACKGROUND

Recombinant tissue plasminogen activator (rtPA) is currently the most standard treatment for patients with acute ischemic stroke (AIS). However, rtPA treatment may further enhance the immune response poststroke. This study is to investigate the clinical utility of white blood-based inflammatory biomarkers in predicting neurologic outcomes among AIS patients receiving rtPA.

METHODS

A retrospective observational cohort study of 100 patients with AIS treated with intravenous rtPA was conducted in an urban tertiary hospital in Taiwan. Favorable neurological outcome defined as modified Rankin Scale (mRS) score 0 to 2 in poststroke follow-up was the primary outcome measure. Baseline and post-rtPA neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were investigated for potential predictors.

RESULTS

These patients had a mean age of 71.3 ± 13.7 years and the average of initial National Institute of Health Stroke Scale was 12.7 ± 6.5. Using multiple regression analysis, PLR was not an independent factor; however, both baseline and post-rtPA NLR were independent factors predicting favorable neurological outcome at 3, 6, 12 months after a stroke. The area under the receiver operating characteristic curve for baseline and post-rtPA NLR were 0.645 (95% confidence interval [CI], 0.537-0.753) and 0.769 (95% CI, 0.676-0.862) (Z score = 2.086) in 3-month, 0.645 (95% CI, 0.537-0.752) and 0.791 (95% CI, 0.701-0.880) (Z score = 2.471) in 6-month, and 0.646 (95% CI, 0.538-0.754) and 0.813 (95% CI, 0.728-0.898) (Z score = 2.857) in 12-month poststroke follow-up.

CONCLUSION

For AIS patients treated with rtPA, both lower baseline and post-rtPA NLR levels were independently associated with a favorable neurologic outcome in serial mid- and long-term follow-up. Post-rtPA NLR was superior to baseline NLR in discriminative performance for neurologic prognosis.

Esophageal Cancer Stem-like Cells Resist Ferroptosis-Induced Cell Death by Active Hsp27-GPX4 Pathway

Cancer stem cells (CSCs), a subpopulation of cancer cells responsible for tumor initiation and treatment failure, are more susceptible to ferroptosis-inducing agents than bulk cancer cells. However, regulatory pathways controlling ferroptosis, which can selectively induce CSC death, are not fully understood. Here, we demonstrate that the CSCs of esophageal squamous carcinoma cells enriched by spheroid culture have increased intracellular iron levels and lipid peroxidation, thereby increasing exposure to several products of lipid peroxidation, such as MDA and 4-HNE. However, CSCs do not reduce cell viability until glutathione is depleted by erastin treatment. Mechanistic studies revealed that damage from elevated lipid peroxidation is avoided through the activation of Hsp27, which upregulates GPX4 and thereby rescues CSCs from ferroptosis-induced cell death. Our results also revealed a correlation between phospho-Hsp27 and GPX4 expression levels and poor prognosis in patients with esophageal cancer. Together, these data indicate that targeting Hsp27 or GPX4 to block this intrinsic protective mechanism against ferroptosis is a potential treatment strategy for eradicating CSC in esophageal squamous cell carcinoma.

Differences in Characteristics, Hospital Care, and Outcomes between Acute Critically Ill Emergency Department Patients Receiving Palliative Care and Usual Care

Background: The early integration of palliative care in the emergency department (ED-PC) provides several benefits, including improved quality of life with optimal comfort measures, and symptom control. Whether palliative care could affect the intensive care unit admissions, hospital care and resource utilization requires further investigation. Aim: To determine the differences in inpatient characteristics, hospital care, survival, and resource utilization between patients receiving palliative care (ED-PC) and usual care (UC). Design: Retrospective observational study. Setting/participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit at Taipei Veterans General Hospital from 1 February 2018 to 31 January 2020. Results: A total of 1273 patients were evaluated for unmet palliative care needs; 685 patients received ED-PC and 588 received UC. The palliative care patients were more severely frail (AOR 2.217 (1.295–3.797), p = 0.004), had functional deterioration with three ADLs (AOR 1.348 (1.040–1.748), p = 0.024), biopsychosocial discomfort (AOR 1.696 (1.315–2.187), p < 0.001), higher Taiwan Triage and Acuity Scale 1 (p = 0.024), higher in-hospital mortality (AOR 1.983 (1.540–2.555), p < 0.001), were four times more likely to sign an DNR (AOR 4.536 (2.522–8.158), p < 0.001), and were twice as likely to sign an DNR at admission (AOR 2.1331.619–2.811), p < 0.001). Palliative care patients received less epinephrine (AOR 0.424 (0.265–0.678), p < 0.001), more frequent withdrawal of an endotracheal tube (AOR 8.780 (1.122–68.720), p = 0.038), and more narcotics (AOR1.675 (1.132–2.477), p = 0.010). Palliative care patients exhibited lower 7-day, 30-day, and 90-day survival rates (p < 0.001). There was no significant difference in the hospital length of stay (LOS) (21.2 ± 26.6 vs. 21.7 ± 20.6, p = 0.709) nor total hospital expenses (293,169 ± 350,043 vs. 294,161 ± 315,275, p = 0.958). Conclusion: Acute critically ill patients receiving palliative care were more frail, more critical, and had higher in-hospital mortality. Palliative care patients received less epinephrine, more endotracheal extubation, and more narcotics. There was no difference in the hospital LOS or hospital costs between the palliative and usual care groups. The synthesis of ED-PC is new but achievable with potential benefits to align care with patient goals.

Comparison of colistin-induced nephrotoxicity between two different formulations of colistin in critically ill patients: a retrospective cohort study

Background

Colistin is widely used in the treatment of nosocomial infections caused by carbapenem-resistant gram-negative bacilli (CR-GNB). Colistin-induced nephrotoxicity is one of the major adverse reactions during colistin treatment. Comparisons of colistin-induced nephrotoxicity between different formulations of colistin are rarely reported.

Methods

In this retrospective cohort study, we enrolled intensive care unit–admitted patients if they had culture isolates of CR-GNB and underwent intravenous treatment with colistin. The occurrence of acute kidney injury (AKI) during intravenous treatment with colistin was recorded. The occurrence of colistin-induced nephrotoxicity was compared between two formulations of colistin, Locolin®, and Colimycin®. Treatment outcomes associated with the occurrence of colistin-induced nephrotoxicity were also investigated.

Results

Among 195 patients, 95 who were treated with Locolin® and 100 who were treated with Colimycin® were included for analysis. Patients treated with Locolin® had a higher rate of occurrence of stage 2 (46.3% vs. 32%, p = 0.040) and stage 3 (29.5% vs. 13%, p = 0.005) AKI than did those treated with Colimycin®. In multivariate analysis, the presence of septic shock (adjusted odds ratio [aOR] 2.17, 95% confidence interval [CI] 1.10–4.26) and inappropriate colistin dosage (aOR 2.52, 95% CI 1.00–6.33) were clinical factors associated with colistin-induced nephrotoxicity. Treatment with Colimycin® was an independent factor associated with a lower risk of colistin-induced nephrotoxicity (aOR 0.37, 95% CI 0.18–0.77). The mortality rate was comparable between patients with and without colistin-induced nephrotoxicity.

Conclusions

The risk of colistin-induced nephrotoxicity significantly varied in different formulations of colistin in critically ill patients. Colistin-induced nephrotoxicity was not associated with increased mortality rate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00977-w.

Differences in end-of-life care and outcomes in palliative consultation-eligible patients with and without do-not-resuscitate orders: A propensity score-matched study

BACKGROUND

The primary objective of palliative care, not synonymous with end-of-life (EOL) care, is to align care plans with patient goals, regardless of whether these goals include the pursuit of invasive, life-sustaining procedures, or not. This study determines the differences in EOL care, resource utilization, and outcome in palliative care consultation-eligible emergency department patients with and without do-not-resuscitate (DNR) orders.

METHODS

This is a retrospective observational study. We consecutively enrolled all the acutely and critically ill emergency department patients eligible for palliative care consultation at the Taipei Veterans General Hospital, a 3000-bed tertiary hospital, from February 1 to July 31, 2018. The outcome measures included in-hospital mortality and EOL care of patients with and without DNR.

RESULTS

A total of 396 patients were included: 159 with and 237 without DNR. Propensity score matching revealed that patients with DNR had significantly shorter duration of hospital stay (404.4 ± 344.4 hours vs 505.2 ± 498.1 hours; p = 0.037), higher in-hospital mortality (54.1% vs 34.6%; p < 0.001), and lower total hospital expenditure (191 239 ± 177 962 NTD vs 249 194 ± 305 629 NTD; p = 0.04). Among patients with DNR, there were fewer deaths in the intensive care unit (30.2% vs 37.0%), more deaths in the hospice ward (16.3% vs 7.4%), more critical discharge to home (9.3% vs 7.4%), more endotracheal removals (3.1% vs 0%; p = 0.024), and more narcotics use (32.7% vs 22.1%; p = 0.018).

CONCLUSION

The palliative care consultation-eligible emergency department patients with DNR compared with those without DNR experienced worse outcomes, greater pain control, more endotracheal extubations, shorter duration of hospital stay, more critical discharge to home, more hospice referrals, and 23.3% reduction in total expenditure. There were fewer deaths in the ICU among them as well.

Experience of resources management on coronavirus disease 2019 epidemic at a tertiary medical center in Northern Taiwan

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes infectious symptoms including fever, cough, respiratory and gastrointestinal symptoms, and even loss of smell/taste and to date had caused 489 000 people to be infected with 32 000 deaths. This article aims to develop some strategies in dealing with the COVID-19 epidemic to prevent nosocomial infection and ensure the safety of healthcare workforce and employees.

METHODS

This is a prospectively registered and retrospective descriptive study investigating the clinical characteristics, results of diagnostic tests, and patients' disposition from February 1, 2020, to April 30, 2020, at a tertiary medical center in Northern Taiwan.

RESULTS

There is no nosocomial spreading of SARS-CoV-2 in our facility. The following strategies were followed: information transparency; epidemic prevention resources planning by authorities; multidisciplinary cooperation; informative technologies; immigration quarantine policies; travel restrictions; management of diversion/subdivision; self-health monitoring; social distancing; screening of travel, occupation, contact, and cluster (TOCC) history; traffic control bundling (TCB); training of using personal protective equipment; real-name visiting management; and employee care. The patients' basic characteristics and diagnostic results were gathered. Of the 3832 cases, about 25.9% had travel history. Most of them were traveling to Asia (419 people/time, 10.9%) and from China (256 people/time, 6.7%). Meanwhile, healthcare personnel accounted for 316 people/time (8.3%) and cleaning personnel, 6 people/time (0.16%). The 36 cases who care or have contact with confirmed cases have negative results from the COVID-19 test. The most frequent symptoms were fever and upper respiratory infection followed by gastrointestinal symptoms.

CONCLUSION

The above strategies were followed. Patients were stratified based on the risk of TOCC history assessment to ensure the safety of healthcare personnel and patients' appropriate and timely medical services.

The Potential Risk Factors for Mortality in Patients After In-Hospital Cardiac Arrest: A Multicenter Study

Background and Purpose: In-hospital cardiac arrest (IHCA) has high mortality rate, which needs more research. This multi-center study aims to evaluate potential risk factors for mortality in patients after IHCA.

Methods: Data for this study retrospectively enrolled IHCA patients from 14 regional hospitals, two district hospitals, and five medical centers between 2013 June and 2018 December. The study enrolled 5,306 patients and there were 2,871 patients in subgroup of intensive care unit (ICU) and emergency room (ER), and 1,894 patients in subgroup of general wards.

Results: As for overall IHCA patients, odds ratio (OR) for mortality was higher in older patients (OR = 1.69; 95% CI:1.33–2.14), those treated with ventilator (OR = 1.79; 95% CI:1.36–2.38) and vasoactive agents (OR = 1.88; 95% CI:1.45–2.46). Whereas, better survival was reported in IHCA patients with initial rhythm as ventricular tachycardia (OR = 0.32; 95% CI: 0.21–0.50) and ventricular fibrillation (OR = 0.26; 95% CI: 0.16–0.42). With regard to ICU and ER subgroup, there was no mortality difference among different nursing shifts, whereas for patients in general wards, overnight shift (OR = 1.83; 95% CI: 1.07–3.11) leads to poor outcome.

Conclusion: For IHCA patients, old age, receiving ventilator support and vasoactive agents reported poor survival. Overnight shift had poor survival for IHCA patients in general wards, despite no significance in overall and ICU/ER subgroups.

Positive end-expiratory pressure titration with electrical impedance tomography and pressure-volume curve: a randomized trial in moderate to severe ARDS

OBJECTIVE

The aim of the study was to compare titration of positive end-expiratory pressure (PEEP) with electrical impedance tomography (EIT) and with ventilator-embedded pressure-volume (PV) loop in moderate to severe acute respiratory distress syndrome (ARDS).

APPROACH

Eighty-seven moderate to severe ARDS patients (arterial oxygen partial pressure to fractional inspired oxygen ratio, PaO₂/FiO₂ ≤ 200 mmHg) were randomized to either EIT group (n = 42) or PV group (n = 45). All patients received identical medical care using the same general support guidelines and protective mechanical ventilation. In the EIT group, the selected PEEP equaled the airway pressure at the intercept between cumulated collapse and overdistension percentages curves and in the PV group, at the pressure where maximal hysteresis was reached.

MAIN RESULTS

Baseline characteristics and settings were comparable between the groups. After optimization, PEEP was significantly higher in the PV group (17.4 ± 1.7 versus 16.2 ± 2.6 cmH₂O, PV versus EIT groups, p = 0.02). After 48 h, driving pressure was significantly higher in the PV group (12.4 ± 3.6 versus 10.9 ± 2.5 cmH₂O, p = 0.04). Lung mechanics and oxygenation were better in the EIT group but did not statistically differ between the groups. The survival rate was lower in the PV group (44.4% versus 69.0%, p = 0.02; hazard ratio 2.1, confidence interval 1·1-3.9). None of the other pre-specified exploratory clinical endpoints were significantly different.

SIGNIFICANCE

In moderate to severe ARDS, PEEP titration guided with EIT, compared with PV curve, might be associated with improved driving pressure and survival rate.

TRIAL REGISTRATION

NCT03112512, 13 April, 2017.

Prognostic significance of emergency department modified early warning score trend in critical ill elderly patients

OBJECTIVE

To explore the relationship between trends in emergency department modified early warning score (EDMEWS) and the prognosis of elderly patients admitted to the intensive care unit (ICU).

METHODS

Consecutive non-traumatic elderly ED patients (≥65 years old) admitted to the ICU between July 2018 and June 2019 were enrolled in this retrospective cohort study. The selected patients had at least 2 separate MEWS during their ED stay. Detailed patient information was retrieved initially from the ICU database of our hospital and then crosschecked with electronic medical recording system to confirm the completeness and correctness of the data. Patients who had do-not-resuscitate order and those with incomplete data of EDMEWS, acute physiology and chronic health evaluation (APACHE) II score, or survival information (7-day and 30-day mortality) were excluded. The trends in EDMEWS were determined using the regression line of multiple MEWS measured during ED stay, in which EDMEWS trend progression was defined as the slope of the regression line > zero. The relationship between EDMEWS trend and prognosis was assessed using univariate and multivariate analyses (multiple logistic regression analysis).

RESULTS

Of the 1423 selected patients, 499 (35.1%) had worsening 24-h APACHE II score, 110 (7.7%) died within 7 days, and 233 (16.4%) died within 30 days. Factors that were significantly associated with worsening 24-h APACHE II score, 7-day mortality, and 30-day mortality in univariate analysis were selected for inclusion into multiple logistic regression analyses. After adjusting for other covariates, EDMEWS trend progression was significantly associated with 24-h APACHE II score progression, 7-day mortality, and 30-day mortality.

CONCLUSIONS

EDMEWS trend progression was significantly associated with 24-h APACHE II score progression, 7-day mortality, and 30-day mortality in elderly ED patients admitted to the ICU. EDMEWS is a simple and useful tool for precisely monitoring patients' ongoing condition and predicting prognosis.

Effects of Sodium Silicate Complex against Hemorrhagic Activities Induced by Protobothrops mucrosquamatus Venom

Protobothrops mucrosquamatus poses a serious medical threat to humans in Southern and Southeastern Asia. Hemorrhage is one of the conspicuous toxicities related to the pathology of P. mucrosquamatus envenoming. Previous in vitro and in vivo studies showed that a silica-derived reagent, sodium silicate complex (SSC), was able to neutralize hemorrhagic and proteolytic activities induced by pit viper venoms, including Crotalus atrox, Agkistrodon contortrix contortrix and Agkistrodon piscivorus leucostoma. In this study, we validated that SSC could neutralize enzymatic and toxic effects caused by the venom of P. mucrosquamatus. We found that SSC inhibited the hemolytic and proteolytic activities induced by P. mucrosquamatus venom in vitro. In addition, we demonstrated that SSC could block intradermal hemorrhage caused by P. mucrosquamatus venom in a mouse model. Finally, SSC could neutralize lethal effects of P. mucrosquamatus venom in the mice. Therefore, SSC is a candidate for further development as a potential onsite first-aid treatment for P. mucrosquamatus envenoming.

Initial white blood cell count and revised Baux score predict subsequent bloodstream infection in burn patients: A retrospective analysis of severe burn patients from the Formosa color dust explosion of 2015

BACKGROUND

Infections are the most common complications among hospitalized severe burn patients. However, limited literature reports early effective predictors of bloodstream infections (BSI) among burn patients. This study aimed to identify cost-effective biomarkers and valuable clinical scoring systems in the emergency department (ED) for the prediction of subsequent BSI in mass burn casualties.

METHODS

In 2015, a flammable cornstarch-based powder explosion resulted in 499 burn casualties in Taiwan. A total of 35 patients were admitted at Taipei Veterans General Hospital. These severe burn patients (median total body surface area [TBSA] 54%) were young and previously healthy. We assessed the potential of various parameters to predict subsequent BSI, including initial laboratory tests performed at the ED, TBSA, and multiple scoring systems.

RESULTS

Fourteen patients (40.0%) had subsequent BSI. The most common causative pathogen was the Acinetobacter baumannii (Ab) group, mostly carbapenem resistant and associated with a poor outcome. The area under the receiver operating characteristic curve revealed that the revised Baux score, TBSA, and initial white blood cell count had excellent discrimination ability in predicting subsequent BSI (0.898, 0.889, and 0.821, respectively). The rate of subsequent BSI differed significantly at the cut-off points of revised Baux score >76, TBSA >55%, and WBC count >16,200/mm³.

CONCLUSION

The initial WBC count at the ED, TBSA, and revised Baux score were good and cost-effective biomarkers for predicting subsequent BSI after burn injuries.

Emergency department response to coronavirus disease 2019 outbreak with a fever screening station and "graded approach" for isolation and testing

BACKGROUND

Ever since coronavirus disease 2019 (COVID-19) emerged in Wuhan, China, in December 2019, it has had a devastating effect on the world through exponential case growth and death tolls in at least 146 countries. Rapid response and timely modifications in the emergency department (ED) for infection control are paramount to maintaining basic medical services and preventing the spread of COVID-19. This study presents the unique measure of combining a fever screening station (FSS) and graded approach to isolation and testing in a Taiwanese medical center.

METHODS

An FSS was immediately set up outside the ED on January 27, 2019. A graded approach was adopted to stratify patients into "high risk," "intermediate risk," and "undetermined risk" for both isolation and testing.

RESULTS

A total of 3755 patients were screened at the FSS, with 80.3% visiting the ED from home, 70.9% having no travel history, 21.4% having traveled to Asia, and 10.0% of TVGH staff. Further, 54.9% had fever, 35.5% had respiratory symptoms, 3.2% had gastrointestinal symptoms, 0.6% experienced loss of smell, and 3.1% had no symptoms; 81.3% were discharged, 18.6% admitted, and 0.1% died. About 1.9% were admitted to the intensive care unit, 10.3% to the general ward, and 6.4% were isolated. Two patients tested positive for COVID-19 (0.1%) and 127 (3.4%) tested positive for atypical infection; 1471 patients were tested for COVID-19; 583 were stratified as high-risk, 781 as intermediate-risk, and 107 as undetermined-risk patients.

CONCLUSION

Rapid response for infection control is a paramount in the ED to confront the COVID-19 outbreak. The FFS helped divide the flow of high- and intermediate-risk patients; it also decreased the ED workload during a surge of febrile patients. A graded approach to testing uses risk stratification to prevent nosocomial infection of asymptomatic patients. A graded approach to isolation enables efficient allocation of scarce medical resources according to risk stratification.

Handgrip strength, tumor necrosis factor-α, interlukin-6, and visfatin levels in oldest elderly patients with cognitive impairment

INTRODUCTION

Handgrip strength is associated with mild cognitive impairment. Tumor necrosis factor [TNF]-α and interleukin [IL]-6 were pro-inflammatory cytokines influencing the severity of initial neurological deficit. Visfatin is a novel adipokine and has a strong correlation with inflammation. The relationships of TNF-α, IL-6 and visfatin are not consistent, and no study has investigated them in the elderly patients with cognitive impairment.

METHODS

This study included patients aged ≥75 years at the emergency department from August 2018 to February 2019. All patients underwent comprehensive geriatric assessment and blood tests for fasting plasma TNF-α, IL-6 and visfatin levels.

RESULTS

We enrolled 106 elderly patients with a mean age of 87.3 years, including 62 (58.4%) patients in cognitive impairment group (Mini-Mental State Examination [MMSE] < 24) and 44 (41.5%) patients in the non-cognitive impairment group. Compared to the non-cognitive impairment group, the cognitive impairment group had significantly lower handgrip strength, and significantly higher TNF-α, IL-6 and visfatin levels. TNF-α positively correlated with IL-6. Both TNF-α and IL-6 negatively correlated with Barthel index and MMSE. Handgrip strength negatively correlated with TNF-α but positively correlated with Barthel index and MMSE scores. Backward and stepwise multiple logistic regression analyses showed that the independent predictor for cognitive impairment was handgrip strength and age.

CONCLUSION

The cognitive impairment group had significantly higher serum TNF-α, IL-6, and visfatin levels. The independent predictors of cognitive impairment were handgrip strength and age. Handgrip strength negatively correlated with TNF-α and IL-6 but positively with Barthel index and MMSE scores.

Comprehensive geriatric assessment in the emergency department for the prediction of readmission among older patients: A 3-month follow-up study

BACKGROUND

Older people present to the emergency department (ED) with distinct patterns and emergency care needs. This study aimed to use comprehensive geriatric assessment (CGA) surveying the patterns of ED visits among older patients and determine frailty associated with the risk of revisits/readmission.

METHODS

This prospective study screened 2270 patients aged ≥75 years in the ED from August 2018 to February 2019. All patients underwent CGA. A 3-months follow-up was conducted to observe the hospital courses of admission and revisit/readmission.

RESULTS

A total of 270 older patients were enrolled. The independent predictors of admission at initial ED visit were the risk of nutritional deficit and instrumental activities of daily living (IADL). In the admission group, the independent predictors of revisit/readmission were a fall in the past year and mobility difficulties. In the discharge group, the independent predictors of revisit/readmission were frailty and insomnia. Regardless if older patients were either admitted or discharged at the initial ED visit, the independent predictor of revisit/readmission for older patients was frailty.

CONCLUSION

Our study showed that frailty was the only independent predictor for revisit/readmission after ED discharge during the 3-month follow up. For ED physicians, malnutrition and IADL were independent predictors in recognizing whether the older patient should be admitted to the hospital. For discharged older ED patients, frailty was the independent predictor for the integration of community services for older patients to decrease the rate of revisit/readmission in 3 months.

Comparison of in-hospital and out-of-hospital cardiac arrest patients receiving targeted temperature management: A matched case-control study

BACKGROUND

Evidences that support the use of targeted temperature management (TTM) for in-hospital cardiac arrest (IHCA) are lacking. We aimed to investigate the hypothesis that TTM benefits for patients with IHCA are similar to those with out-of-hospital cardiac arrest (OHCA) and to determine the independent predictors of resuscitation outcomes in patients with cardiac arrest receiving subsequent TTM.

METHODS

This is a retrospective, matched, case-control study (ratio 1:1) including 93 patients with IHCA treated with TTM after the return of spontaneous circulation, who were admitted to Partners HealthCare system in Boston from January 2011 to December 2018. Controls were defined as the same number of patients with OHCA, matched for age, Charlson score, and sex. Survival and neurological outcomes upon discharge were the primary outcome measures.

RESULTS

Patients with IHCA were more likely to have experienced a witnessed arrest and receive bystander cardiopulmonary resuscitation, a larger total dosage of epinephrine, and extracorporeal membrane oxygenation. The time duration for ROSC was shorter in patients with IHCA than in those with OHCA. The IHCA group was more likely associated with mild thrombocytopenia during TTM than the OHCA group. Survival after discharge and favorable neurological outcomes did not differ between the two groups. Among all patients who had cardiac arrest treated with TTM, the initial shockable rhythm, time to ROSC, and medical history of heart failure were independent outcome predictors for survival to hospital discharge. The only factor to predict favorable neurological outcomes at discharge was initial shockable rhythm.

CONCLUSION

The beneficial effects of TTM in eligible patients with IHCA were similar with those with OHCA. Initial shockable rhythm was the only independent predictor of both survival and favorable neurological outcomes at discharge in all cardiac arrest survivors receiving TTM.

Initiating palliative care consultation for acute critically ill patients in the emergency department intensive care unit

BACKGROUND

Little is known about the characteristics of patients needing palliative care consultation in the emergency department (ED). This study aimed to investigate the impacts of initiating screening in acute critically ill patients needing palliative care on mortality, health care resources, and end-of-life (EOL) care in the intensive care unit in ED (EICU).

METHODS

We conducted an analysis study in Taipei Veterans General Hospital. From February 1 to July 31, 2018, acute critically ill patients in EICU were recruited. The primary outcomes were inhospital mortality and EOL care. The secondary outcomes included clinical characteristics and health care utilization.

RESULTS

A total of 796 patients were screened, with 396 eligible and 400 noneligible patients needing palliative care consultations. The mean age was 74.8 ± 17.1 years, and 62.6% of the patients were male. According to logistic regression analysis, clinical predictors, including age (adjusted odds ratio [AOR], 1.028; 95% CI, 1.015-1.042), respiratory distress and/or respiratory failure (AOR, 2.670; 95% CI, 1.829-3.897), the Acute Physiology and Chronic Health Evaluation II score (AOR, 1.036; 95% CI, 1.009-1.064), Charlson Comorbidity Index score (AOR, 1.212; 95% CI, 1.125-1.306), and Glasgow Coma Scale (AOR, 0.843; 95% CI, 0.802-0.885), were statistically more significant in eligible patients than in noneligible patients. The inhospital mortality rate was significantly higher in eligible patients than that in noneligible patients (40.7% vs 11.5%, p < 0.01). Eligible patients have a higher ratio in both vasopressor and narcotic use and withdrawal of endotracheal tube than noneligible patients (p < 0.05).

CONCLUSION

Our study results demonstrated that initiating palliative consultation for acute critically ill patients in ED had an impact on the utilization of health care resources and quality of EOL care. Further assessments of the viewpoints of ED patients and their family on palliative care consultations and hospice care are required.

Impact of a routine neurosurgical dispatch on emergency air medical transport and outcome of patients with intracranial hemorrhage

BACKGROUND/PURPOSE

Emergency air medical transport (EAMT) of patients in remote areas with neurological emergencies to higher-level facilities is an integral part of the regionalized healthcare system. EAMT is safe and feasible for head injuries. Debates persist on the high cost, safety, and risk of EAMT, thereby calling for alternatives.

METHODS

We conducted a retrospective cohort study by including all patients with intracranial hemorrhage (ICH) who visited the Kinmen Hospital from January 2006 to December 2016. Routine neurosurgical dispatch (RNSD) implemented since 2009, dispatches neurosurgeons to Kinmen. EAMT and 90-day mortality were assessed.

RESULTS

We enrolled 560 patients: 173 pre-stage and 387 post-stage. RNSD resulted in less EAMT deployment ([adjusted odds ratio AOR] = 0·23, p < 0·001) and lower 90-day mortality ([adjusted hazard ratio AHR] 0·66, p = 0·043). RNSD resulted in decreased EAMT among all subgroups, especially in age ≥81 years (AOR 0.03, p < 0.001), age 41-60 years (AOR 0.10, p < 0.001), traumatic intracranial hemorrhage (TICH) (AOR 0·11, p < 0·001), and Glasgow Coma Scale (GCS) 9-12 (AOR 0.14, p 0.001). The risk of 90-day mortality was higher in male (AHR 1.81, p = 0·006), GCS 3-8 (AHR 35.52, p < 0·001) and GCS 9-12 (AHR 7.46, p < 0·01) and lower in age 21-40 years (AHR 0.46, p = 0.034).

CONCLUSION

Incorporating RNSD with EAMT is a plausible alternative to EAMT with a significant decrease in EAMT and decreased 90-day mortality in patients with ICH compared with non-neurosurgical care with EAMT. Despite a 34% decrease in 90-day mortality after RNSD, patient characteristics such as disease severity, age, and sex still dictated patient outcomes.

High metabolic rate and stem cell characteristics of esophageal cancer stem-like cells depend on the Hsp27-AKT-HK2 pathway

Tumor progression with chemoresistance and local recurrence is commonly happened during treatment of esophageal squamous cell carcinoma (ESCC). Cancer stem cells (CSC) may respond for tumor progression. However, there are few reports regarding metabolism of esophageal CSCs with clinical correlation. In this work, we demonstrated that ESCC cell lines in spheroid culture display CSC phenotypes, including increased ALDH activity, chemoresistance and tumor initiation, which are dependent on Hsp27 activation. Esophageal CSCs also exhibit reprogrammed metabolic features particularly higher glycolysis and oxidative phosphorylation, which are regulated via the Hsp27-AKT-HK2 pathway. Moreover, HK2 is required for maintenance of CSC phenotypes. Inhibition of CSC metabolism reduces cell growth and tumor formation. Clinically, patients who underwent surgical resection for esophageal cancer, and displayed overexpression of both Hsp27 and HK2, had the worst prognosis of all expression types. In conclusion, stem cells features and aberrant metabolic reprogramming of esophageal CSCs depend on the Hsp27-AKT-HK2 pathway. Targeting Hsp27 and HK2 could be novel therapeutic strategy for treating esophageal cancer and warrants further investigation.

Protobothrops mucrosquamatus Bites to the Head: Clinical Spectrum from Case Series

Protobothrops mucrosquamatus (Trimeresurus mucrosquamatus) is a medically important species of pit viper with a wide geographic distribution in Southeast Asia. Bites by P. mucrosquamatus mostly involve the extremities. Little is known about the toxic effects of P. mucrosquamatus envenoming to the head because of the infrequency of such occurrence. To better delineate the clinical manifestations of envenoming to the head, we report three patients who suffered from P. mucrosquamatus bites to the head and were treated successfully. All three patients developed progressive soft tissue swelling extending from head to neck, with two patients expanding further onto the anterior chest wall. Mild thrombocytopenia was noted in two patients. One patient had transient acute renal impairment and airway obstruction, necessitating emergent intubation. All three patients received high doses of species-specific antivenom with recovery within 1 week. No adverse reactions to antivenom were observed.

Diabetes Shared Care Program (DSCP) and risk of infection mortality: a nationwide cohort study using administrative claims data in Taiwan

OBJECTIVE

The Diabetes Shared Care Program (DSCP) is an integrated care model in Taiwan that has been proven to improve the care quality of patients with diabetes. We aimed to evaluate the efficacy of DSCP in decreasing the hospital mortality of infectious diseases.

METHODS

From 1 662 929 patients with type 2 diabetes newly diagnosed between 1999 and 2013, we retrieved a total of 919 patients who participated in the DSCP with the first hospitalisation for an infectious disease as the study cohort and 9190 propensity score-matched patients with type 2 diabetes who did not participate as the comparison.The efficacy of DSCP was evaluated via the following comparisons between the DSCP and non-DSCP cohorts: hospital mortality, 1-year medical cost prior to and during the hospitalisation, and complications, such as receiving mechanical ventilation and intensive care unit admission. The ratio (OR) for hospital mortality of the DSCP participants was calculated by logistical regression. Further stratification analyses were conducted to examine which group of patients with type 2 diabetes benefited the most from the DSCP during hospitalisation for infectious diseases.

RESULTS

The DSCP cohort had a lower hospital mortality rate than the non-DSCP participants (2.18% vs 4.82%, p<0.001). The total medical cost during the hospitalisation was lower in the DSCP cohort than in the non-DSCP cohort (NT$72 454±30 429 vs NT$86 385±29 350) (p=0.006). In the logistical regression model, the DSCP participants exhibited a significantly decreased adjusted OR for hospital mortality (adjusted OR=0.42, 95% CI 0.26 to 0.66, p=0.0002). The efficacy of the DSCP was much more prominent in male patients with type 2 diabetes and in patients with lower incomes.

CONCLUSION

Participation in the DSCP was associated with a lower risk of hospital mortality for infectious diseases.

The Clinical Predictors of Shunt-Dependent Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage

AIM

Shunt-dependent hydrocephalus (SDH) is a relatively common complication following aneurysmal subarachnoid hemorrhage (aSAH). Delay in diagnosis and treatment may worsen neurological outcome. This study was conducted to identify early clinical factors associated with SDH following aSAH.

MATERIAL AND METHODS

Patients diagnosed with aSAH at our hospital from January 2010 through July 2014 were included. Patients aged ? 18 or ? 90 years, with concurrent arteriovenous malformation, treated with both clipping and coiling, or not receiving definitive treatment were excluded. Both clinical and radiological variables were analyzed by univariate and multivariate logistic model to identify factors independently associated with outcome of SDH following aSAH.

RESULTS

Overall, 33 patients (36.2%) developed SDH following aSAH after definitive treatment. Univariate analysis revealed age, emergency department (ED) white blood cell (WBC) count, hypernatremia, Hunt & Hess Grade, modified Fisher"s Grade, presentation of acute hydrocephalus, initial placement of external ventriculostomy, and post-operative central nervous system infection were clinically significant factors. Multivariate logistic regression showed ED WBC count > 14,500/?L (OR 5.096, 95% CI 1.332 to 19.499, p=0.017), poor Hunt&Hess Grade (III, IV & V) (OR 3.562, 95% CI 1.081 to 11.737, p=0.037), and initial placement of external ventriculostomy (OR 4.294, 95% CI 1.125 to 16.393, p=0.033) were independent factors. < p < CONCLUSION: Three early independent predictors of SDH were identified including poor Hunt&Hess Grade, initial placement of external ventriculostomy and ED leukocytosis. Early placement of a ventricular-peritoneal shunt after aSAH may shorten length of stay in hospital and in intensive care unit.

Pattern of non-trauma emergency department resource utilization in older adults: An 8-year experience in Taiwan

BACKGROUND

To describe the patterns of non-trauma emergency department (ED) resource utilization, cost of visit, acuity level, and admission rate in older adult patients in Taiwan.

METHODS

This is a retrospective observational cohort study conducted at the Taipei Veterans General Hospital with an annual ED population of 80,000 patients. Patients aged ≥20 years with non-trauma ED visits from 2005 to 2012 were included in the study.

RESULTS

We analyzed 441,665 ED visits. Older adult patients had higher ED usage, with the ratio of their ED visit and population being 3.56, 8.34, and 7.64 in the age groups 70-79, 80-89, and ≥90 years, respectively. ED cost, acuity level, and risks of intensive care unit (ICU) admission increased with increasing age. Compared with patients aged 20-29 years, patients aged ≥90 years required almost twice as much ED resources per visit [adjusted risk ratio (aRR), 1.98]. aRRs for high acuity in the age groups 70-79, 80-89, and ≥90 years were 1.96, 1.87, and 1.91, respectively. The risk of ICU admission in the age groups 40-49, 50-59, 70-79, and ≥90 years also increased by 3-fold (aRR, 2.99), 4-fold (aRR, 4.09), >6-fold (aRR, 6.66), and almost 10-fold (aRR, 9.84), respectively, compared with that in the age group 20-29 years. Among patients aged ≥90 years, 2.9% with low acuity still required ICU admission, whereas 25.1% with high acuity required ICU admission.

CONCLUSION

Our study shows that older adult patients are associated with more ED visits and higher acuity, higher ED costs, and higher risks of admission to both the ordinary ward and ICU than younger adult patients.

Changes of heart rate variability predicting patients with acute exacerbation of chronic obstructive pulmonary disease requiring hospitalization after Emergency Department treatment

BACKGROUND

Indexes of heart rate variability (HRV) appear to reflect severity and may have prognostic value in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We hypothesized that AECOPD without adequate treatment response would demonstrate impaired cardiac autonomic regulation and changes in HRV after emergency department (ED) treatment.

METHODS

A prospective study of measuring HRV in admitted and discharged patients with AECOPD shortly after ED arrival and again 24 h after treatment.

RESULTS

Total consecutive 33 patients (18 admitted and 15 discharged, age 77.1 ± 1.6 years) were enrolled. Among admitted patients, high frequency in normalized unit (HF%) was significantly lower (P < 0.001) while Ratio of LF to HF (LF/HF ratio) was significantly higher (P < 0.001) than discharged. 24 h after treatment, admitted patients had a significantly larger increase in HF% (P < 0.002) and larger decrease in LF/HF ratio (P < 0.05) than discharged. ROC curve analysis show the relative potential of the ΔHF% and ΔLF/HF% in the discrimination of groups. The area under the ROC curve between the 2 groups was 0.807 (P < 0.01) and 0.722 (P < 0.05), respectively. The best cut-off value for the admission between groups was ΔHF% >7.1 and ΔLF/HF% ≦-0.39.

CONCLUSION

Patients with AECOPD requiring admission after ED treatment had a greater increase in HF% and greater decrease in LF/HF ratio compared to those discharged. Our study demonstrates patient with ΔHF% was >7.1 or a ΔLF/HF% ≦-0.39 require admission despite 24 h of ED treatment.

Selective serotonin reuptake inhibitors and the risk of hepatocellular carcinoma in hepatitis B virus-infected patients

Background

This study aimed to investigate the association between the use of selective serotonin reuptake inhibitors (SSRIs) and the risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B virus (HBV) infection.

Methods

We conducted a population-based cohort study by using claims data from the Taiwan National Health Insurance Research Database (NHIRD). The study cohort comprised 1380 newly diagnosed HBV-infected patients with SSRI use who were frequency matched by age, sex, liver cirrhosis, and index year with HBV-infected patients without SSRI use in the comparison cohort. Each patient case was followed from 2000 to 2012 to identify incident HCC cases. Cox proportional hazards regression was performed to evaluate the association between SSRI use and HCC risk. The further sensitivity analysis used case-control study design. A total of 9070 HCC subjects retrieved from NHIRD, and equal non-HCC subjects were analyzed after matching for age and sex.

Results

We identified 9 and 24 HCC cases in the study and comparison cohorts during the follow-up period of 7056 and 6845 person-years, respectively. The incidence rate of HCC was 1.28 and 3.51 per 1000 person-years for SSRI and non-SSRI users, respectively. After adjusting for potential confounders, the adjusted hazard ratio (HR) for SSRI use was 0.28 (95% confidence interval [CI], 0.12–0.64; p = 0.0027). For SSRI users with a cumulative defined daily dose (cDDD) of 28–89, 90–364, and ≥365, the adjusted HRs were 0.51, 0.22, and 0.12, respectively, (95% CI, 0.21–1.25, 0.05–0.94, and 0.02–0.90, respectively) compared with non-SSRI users (<28 cDDD). The sensitivity analysis showed that the SSRI presented with a dose-response protective effect for HCC in the multivariate analysis.

Conclusion

SSRIs use may possibly reduce the risk of HCC in HBV-infected patients in a dose-responsive manner.

Clinical predictors of outcomes in patients undergoing emergency air medical transport from Kinmen to Taiwan

Emergency air medical transport (EAMT) is indispensable for acutely or critically ill patients in remote areas. We determined patient-level and transport-specific factors associated with all-cause mortality after EAMT.We conducted a population-based, retrospective cohort study using a prospective registry consisting of clinical/medical records. Study inclusion criteria consisted of all adults undergoing EAMT from Kinmen hospital to the ED of Taipei Veterans General Hospital (TVGH) between January 1, 2006 and December 31, 2012. The primary outcome assessments were 7-day and 30-day mortality.A total of 370 patients transported to TVGH were enrolled in the study with a mean age of 54.5 ± 21.5 (SD) years and with a male predominance (71.6%). The average in-transit time was 1.4 ± 0.4 hours. The 7-day, 30-day, and in-hospital mortality rates were 10.3%, 14.1%, and 14.9%. Among them 33.5% (124/370) were categorized under neurological etiologies, whereas 24.9% (90/370) cardiovascular, followed by 16.2% (60/370) trauma patients. Independent predictors associated with 7-day all-cause mortality were age (odds ratio [OR] 1.043, 95% confidence interval [CI] 1.016-1.070), Glasgow Coma Scale (GCS) (OR 0.730, 95% CI 0.650-0.821), and hematocrit level (OR 0.930, 95% CI 0.878-0.985). Independent predictors associated with 30-day all-cause mortality were age (OR 1.028, 95% CI 1.007-1.049), GCS (OR 0.686, 95% CI 0.600-0.785), hematocrit (OR 0.940, 95% CI 0.895-0.988), hemodynamic instability (OR 5.088 95% CI 1.769-14.635), and endotracheal intubation (OR 0.131 95% CI 0.030-0.569). The 7-day and 30-day mortality were not significantly related to transport-specific factors, such as length of flight, type of paramedic crew on board, or day and season of transport. Clinical patient-level factors, as opposed to transport-level factors, were associated with 7- and 30-day all-cause mortality in patients undergoing interfacility EAMT from Kinmen to Taiwan.

Rapid Emergency Medicine Score: A novel prognostic tool for predicting the outcomes of adult patients with hepatic portal venous gas in the emergency department

Objective

This study aims to evaluate the performance of Rapid Emergency Medicine Score (REMS), Rapid Acute Physiology Score (RAPS), and Modified Early Warning Score (MEWS) in ascertaining the severity of illness and predicting the mortality of adult hepatic portal venous gas (HPVG) patients presenting to the emergency department (ED). This will assist emergency physicians (EPs) in risk stratification.

Methods

Data for 66 adult HPVG patients who visited the EDs of 2 research hospitals between October 1999 and April 2016 were analyzed. REMS, RAPS, and MEWS were calculated based on data in the ED, and probability of death was calculated for each patient based on these scores. The ability of REMS, RAPS, and MEWS to predict group mortality was assessed by using receiver operating characteristic (ROC) curve analysis and calibration analysis.

Results

The sensitivity, specificity, and accuracy for each scoring system were 92.1%, 89.3%, and 90.9% for REMS, 86.8%, 82.1%, and 84.8% for RAPS, and 78.9%, 89.3%, and 83.3% for MEWS respectively. In the ROC curve analysis, the areas under the curve for REMS, RAPS, and MEWS were 0.929, 0.877, and 0.856 respectively.

Conclusion

Our study is the largest series performed in a population of adult HPVG patients in the ED. The results from this study demonstrate that REMS is superior in predicting the mortality of these patients compared to RAPS and MEWS. We therefore recommend that REMS be used for outcome prediction and risk stratification of adult HPVG in the ED.

Emergency department DNR order in patients with spontaneous intracerebral hemorrhage

OBJECTIVES

To explore the determinant factors and prognostic significance of emergency department do-not-resuscitate (ED-DNR) orders for patients with spontaneous intracerebral hemorrhage (SICH).

METHODS

Consecutive adult SICH patients treated in our ED from January 1, 2012 to December 31, 2016 were selected as the eligible cases from our hospital's stroke database. Patients' information was comprehensively reviewed from the database and medical and nursing charts. ED-DNR orders were defined as DNR orders written during ED stay. Multiple logistic regression analysis was used to identify significant determinants of ED-DNR orders. Thirty- and 90-day neurological outcomes were analyzed to test the prognosis impact of ED-DNR orders.

RESULTS

Among 835 enrolled patients, 112 (12.1%) had ED-DNR orders. Significant determinant factors of ED-DNR orders were age, ambulatory status before the event, brain computed tomography findings of midline shift, intraventricular extension, larger hematoma size, and ED arrival GCS ≤8. Patients with and without ED-DNR orders had a similar 30-day death rate if they had the same initial ICH score point. During 30 to 90days, patients with ED-DNR orders had a significantly increased mortality rate. However, the rate of improvement in neurological status between the two groups was not significantly different.

CONCLUSIONS

Older and sicker SICH patients had higher rate of ED-DNR orders. The mortality rates between patients with and without ED-DNR orders for each ICH score point were not significantly different. During the 30-to-90-day follow-up, the rates of neurological improvement in both groups were similar.

A new strategy for emergency department crowding: High-turnover utility bed intervention

BACKGROUND

This study applied a new strategy, termed high-turnover utility bed intervention, to offer early admission chances for emergency department (ED) patients and alleviate ED crowding.

METHODS

This before-and-after observational cohort study was conducted at the ED of an urban tertiary hospital. On January 1, 2012, 14 utility beds were prepared exclusively for ED patient use. A strict 48-hour course limit for each patient was formulated to govern these high-turnover beds. The primary outcome measure for this study was ED length of stay. Secondary outcome measures were the number of ED admissions, patients who left without being seen, and revisits within 72 hours of discharge, as well as the outcomes of cardiac arrest management and ambulance diversion hours.

RESULTS

There were 70,515 adult ED visits enrolled during the preintervention period (January-December 2011), and 69,706 during the postintervention period (July 2012-June 2013). In the postintervention period, this new strategy offered 1401 early admission opportunities. The ambulance diversion hours decreased prominently from 5.4 hours to 1.6 hours per day. A shortening in ED length of stay from 9.7 hours to 8.0 hours was achieved, mainly in cases of nontrauma. More patients (31.2% vs. 29.7%) were admitted to the wards with a lower discharge rate in the postintervention period. Additionally, there was no difference in ED revisit within 72 hours and cardiac arrest management.

CONCLUSION

The high-turnover ED utility bed intervention offered improved admission chance and alleviated ED crowding output. ED efficiency improved, with shortened ED length of stay and fewer ambulance diversion hours.

Emergency department critical care unit for critically ill cardiovascular patients: An observation study

BACKGROUND

We investigated an intensive care model for acute critically cardiovascular emergency patients in the emergency department (ED) as compared with those in the coronary care unit (CCU) after ED visits.

METHODS

We performed a retrospective cohort analysis of patients with acute cardiovascular emergency admitted to the intensive care unit in the ED (EICU) or CCU from January 1, 2010 to March 31, 2011 in an university-affiliated medical center. All clinical characteristics or predictors possibly related to in-hospital mortality were documented, completed, and measured via electronic medical records review. The clinical independent variables with p < 0.1 in univariate analysis were further analyzed by using multiple logistic regression. Survival analysis of the predictors for hospital mortality was assessed by Kaplan-Meier survival curves.

RESULTS

A total of 964 patients were recruited in this study. Of all patients, 328 were enrolled in the EICU group, whereas 636 were enrolled in the CCU group. Multiple regression analysis of both EICU and CCU mortality demonstrated that Acute Physiology and Chronic Health Evaluation II scores were common predictors of mortality in both groups of patients. Based on these scores, Kaplan-Meier survival curves showed no statistically significant differences of cumulative survival rates in both the 7-day and in-hospital survival between both groups.

CONCLUSION

Our study demonstrated a feasible and qualified model of intensive care delivery accomplished by collaboration of emergency physicians and cardiologists for acute critically ill cardiovascular emergency patients after initial ED management. Our results suggest that an expanded multicenter study should be conducted to further test and confirm this intriguing model.

Interhospital transfer neurological deterioration in patients with spontaneous intracerebral haemorrhage: incidence and risk factors

OBJECTIVE

To explore the incidence and risk factors for interhospital transfer neurological deterioration (IHTND) in patients with spontaneous intracerebral haemorrhage (SICH).

METHODS

Consecutive adult patients with first-ever SICH referred to our emergency department (ED) and transported by ambulance from July 2011 through June 2015 were eligible for this prospective observational study. Enrolled patients had SICH with elapsed time <12 hours and a nearly normal Glasgow Coma Scale (GCS) score (≥13) at presentation. IHTND was defined as GCS score drop ≥2 points during the time from last GCS measure in first ED (shortly before transport) and first measure in second ED (shortly after arrival), which was confirmed by the accompanying nurse practitioner. The potential risk factors for IHTND were screened by χ² test, unpaired t test (parametric data) or Mann-Whitney U test (non-parametric data) in univariate analysis. Multiple logistic regression analysis was used to adjust for other covariates.

RESULTS

Among 217 enrolled patients, 36 (16.6%) had IHTND. After adjustment for other covariates in multiple logistic regression analysis, the significant predictors of IHTND were arrival systolic blood pressure ≥180 mm Hg (p=0.026, OR=2.741, 95% CI 1.126 to 6.674), infratentorial ICH (p=0.015, OR=3.182, 95% CI 1.248 to 8.113), presence of intraventricular haemorrhage (p=0.023, OR=2.533, 95% CI 1.137 to 5.645) and larger ICH (by 1 mL increment of haematoma, p=0.013, OR=1.027, 95% CI 1.006 to 1.048).

CONCLUSIONS

About one-sixth of referred not comatose patients with SICH developed IHTND. Some risk factors were identified for the first time. Modifying procedures for proper transfer of patients at high-risk for IHTND might help in safely transferring patients with SICH.

Spontaneous Intramural Intestinal Hemorrhage versus Acute Mesenteric Ischemia by CT Evaluation

Objective The purpose of our study was to differentiate the imaging findings of patients with spontaneous intramural intestinal hemorrhage (SIIH) from those with acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department. Methods We retrospectively included 83 patients diagnosed with SIIH or AMI after abdominal CT. Results The mean ages of 30 SIIH patients and 53 AMI patients were 74.4±14.6 years and 75.8±11.2 years, respectively. Patients with SIIH had significantly thicker maximal intestinal wall thickening (14.8±3.9 vs. 10.9 ±4.1, p<0.001), a lower rate of ileum involvement (26.7% vs. 77.4%, p<0.001) and a higher rate of ascites (96.7% vs. 64.2%, p<0.001) compared with patients with AMI. Neither pneumatosis intestinalis (p<0.001) nor portomesenteric gas (p<0.01) were detected in SIIH patients but were observed in AMI patients. A receiver-operating characteristic (ROC) curve analysis showed that the optimal cut-off value for maximal intestinal wall thickening between groups was 10.4 mm and the area under the ROC curve between groups was 0.752 (p<0.0001). A multiple logistic regression analysis showed that the independent predictors of SIIH were non-involvement of the ileum (odds ratio, OR, 6.998; p=0.001), maximal intestinal wall thickening ≥10.4 mm (OR, 5.748; p=0.040) and ascites (OR, 13.348; p=0.023). The area under the ROC curve for the model was 0.854 (p<0.001). Conclusion The independent predictors of SIIH from AMI after abdominal CT in acute abdominal patients include non-involvement of the ileum, intestinal wall thickening ≥10.4 mm, and ascites.

Prognostic factors for survival outcome after in-hospital cardiac arrest: An observational study of the oriental population in Taiwan

BACKGROUND

In-hospital cardiac arrest (IHCA) is a catastrophic complication for patients while admitted in a medical institution. The outcome of IHCA remains poor, and understanding of the prognostic factors for survival outcome after IHCA is lacking, specifically in an oriental population.

METHODS

A retrospective observational cohort study of 382 patients with IHCA who required resuscitation was conducted in an urban tertiary hospital in Taiwan. Return of spontaneous circulation (ROSC) and survival to hospital discharge were the primary outcome measures.

RESULTS

The incidence of IHCA was 3.25 per 1000 admissions. These patients had a mean age of 67.2 ± 21.7 years and were mostly men (66.5%). The rate of successful ROSC was 66%, and the rate of survival to hospital discharge was 11.8%. A stepwise decrease in ROSC was observed with additional resuscitation efforts. Independent predictors for survival to hospital discharge were being female, a resuscitation duration of <20 minutes, and no use of epinephrine during resuscitation. A 68% ROSC success rate and an 84% survival to discharge rate was recorded in patients receiving resuscitation for <30 minutes. Young patients seemed the most likely to benefit from longer resuscitation attempts (>30 minutes), as observed in survival to hospital discharge.

CONCLUSION

Based on data from a single hospital registry in East Asia, a shorter duration of resuscitation was demonstrated to be a predictor of immediate survival with ROSC and survival to hospital discharge.

A novel endoscopic-assisted harvesting of pedicled freestyle fasciocutaneous flaps

The endoscopy-assisted technique has been demonstrated in harvesting muscle flaps; however, for pedicled freestyle fasciocutaneous flaps, few studies have applied this technique. We present a surgical procedure utilizing endoscopic-assisted method to identify the perforators of pedicled freestyle fasciocutaneous flaps for the reconstruction of soft tissue defects. From August to December 2012, 9 consecutive patients underwent endoscopic-assisted harvesting of fasciocutaneous flaps for the reconstruction of soft tissue defects. All of the defects were caused by trauma with tendon or bone exposure. Postoperatively, all patients were requested to return for outpatient follow-up visits for at least 3 months. The age of the 9 patients (8 men and 1 woman) ranged from 20 to 79 years (median 59 years). The defects ranged in size from 2 × 2 to 6 × 8 cm2. Two patients received anterolateral thigh transmuscular perforator flaps, 5 patients received fibular septocutaneous perforator flaps, and 2 patients received medial gastrocnemius transmuscular perforator flaps. The median incision length was 10 cm, and the median operative time was 120 minutes. None of the patients had intraoperative complications, and intraoperative bleeding was minimal (<50 mL). At the end of the 3-month follow-up period, none of the patients had any complications on either recipient or donor site, including total or partial necrosis of the flaps, flap dehiscence, hematomas, seromas, wound infections, or any conditions that indicated additional unplanned operative procedures. All of the patients had surviving flaps. Our results demonstrated that the endoscopic-assisted method could be a valuable and reliable alternative in harvesting pedicled freestyle fasciocutaneous flaps.

Comparing characteristics of adverse drug events between older and younger adults presenting to a Taiwan emergency department

To compare the proportion, seriousness, preventability of adverse drug events (ADEs) between the older adults (≥ 65 years old) and younger adults (<65 years old) presenting to the emergency department (ED), we conducted a prospective observational cohort study of patients 18 years and older presenting to the ED. For all ED visits between March 1, 2009, and Feb 28, 2010, investigators identified ADEs and assessed cases using the Naranjo adverse drug reaction probability scale. Outcomes (proportion, seriousness, and preventability of ADE, length of ED stay, and hospitalization) and associated variables were measured and compared between younger and older adults. The results showed that of 58,569 ED visits, 295 older adults, and 157 younger adults were diagnosed as having an ADE and included in our analysis. The proportion of ADEs leading to ED visits in the older group, 14.3 per 1000  (295/20,628), was significantly higher than the younger group of 4.1 per 1000  (157/37,941). The older group with ADE had a longer ED stay (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.9-6.4 for stay ≥ 24 hours) and larger proportion of preventable ADEs (OR 2.2, 95% CI 1.4-3.6) than the younger group, but there was no significant difference in terms of serious ADEs (OR 0.6, 95% CI 0.3-1.3 for fatal and life threatening) and hospitalization (OR 1.5, 95% CI 0.9-2.6) between the 2 groups. In addition, patients in the older group were more likely to be male, to have symptoms of fatigue or altered mental status, to involve cardiovascular, renal, and respiratory systems, and to have higher Charlson comorbidity index scores, higher number of prescription medications, and higher proportion of unintentional overdose. In conclusion, the proportion of ADE-related ED visits in older adults was higher than younger adults, and many of these were preventable. The most common drug categories associated with preventable ADEs in the older adults were antithrombotic agents, antidiabetic agents, and cardiovascular agents.

Performance assessment of the Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation II score, and the Sequential Organ Failure Assessment score in predicting the outcomes of adult patients with hepatic portal venous gas in the ED

OBJECTIVE

This study aims to evaluate the performance of Simplified Acute Physiology Score II (SAPS II), the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and the Sequential Organ Failure Assessment (SOFA) score for predicting illness severity and the mortality of adult hepatic portal venous gas (HPVG) patients presenting to the emergency department (ED). This will assist emergency physicians in risk stratification.

METHODS

Data for 48 adult HPVG patients who visited our ED between December 2009 and December 2013 were analyzed. The SAPS II, APACHE II score, and SOFA score were calculated based on the worst laboratory values in the ED. The probability of death was calculated for each patient based on these scores. The ability of the SAPS II, APACHE II score, and SOFA score to predict group mortality was assessed by using receiver operating characteristic curve analysis and calibration analysis.

RESULTS

The sensitivity, specificity, and accuracy were 92.6%,71.4%, and 83.3%, respectively, for the SAPS II method; 77.8%, 81%, and 79.2%, respectively, for the APACHE II scoring system, and 77.8%, 76.2%, and 79.2%, respectively, for the SOFA score. In the receiver operating characteristic curve analysis, the areas under the curve for the SAPS II, APACHE II scoring system, and SOFA score were 0.910, 0.878, and 0.809, respectively.

CONCLUSION

This is one of the largest series performed in a population of adult HPVG patients in the ED. The results from the present study showed that SAPS II is easier and more quickly calculated than the APACHE II and more superior in predicting the mortality of ED adult HPVG patients than the SOFA. We recommend that the SAPS II be used for outcome prediction and risk stratification in adult HPVG patients in the ED.

The prognostic factors of adult patients with hepatic portal venous gas in the ED

OBJECTIVES

This study aimed to investigate the prognostic factors of adult patients with hepatic portal venous gas (HPVG) in the emergency department (ED) to facilitate clinical decision making by emergency physicians.

METHODS

Data from adult patients with HPVG who visited our ED between December 2009 and December 2013 were analyzed. The computed tomographic scan images were reviewed, and the presence of HPVG with or without pneumatosis intestinalis (PI) was confirmed by a certified radiologist. The study end point was mortality or survival upon discharge. The factors associated with mortality were specifically analyzed with multiple logistic regression models.

RESULTS

Among the total of 50 HPVG patients, the overall mortality rate was 56%. No deaths were observed among the patients with neither shock nor PI in the ED. Shock (odds ratio, 17.02; 95% confidence interval, 3.36-86.22) and PI (odds ratio, 5.14; 95% confidence interval, 1.03-25.67) were determined to be significant predictors of patient mortality after adjusting for age and sex. The mortality of the patients with both shock and PI was very high (84%).

CONCLUSIONS

Early resuscitation should be initiated for the prevention of shock in adult patients with HPVG in the ED. To enhance the chance for survival, the prompt consultation of surgeons for emergency operations should be considered for adult ED patients exhibiting both shock and PI, which may indicate true ischemic bowel disease.

Bacteraemia caused by Mycobacterium abscessus subsp. abscessus and M. abscessus subsp. bolletii: clinical features and susceptibilities of the isolates

Mycobacterium abscessus complex (M. abscessus subsp. abscessus and M. abscessus subsp. bolletii) is an emerging pathogen causing various human infections. However, few studies have focused on M. abscessus complex bacteraemia with detailed species differentiation. The clinical characteristics of patients with bacteraemia due to M. abscessus complex treated at National Taiwan University Hospital from 2005-2012 were evaluated. Species identification was performed by molecular methods, and minimum inhibitory concentrations (MICs) were determined using a Sensititre RAPMYCO Panel Test for preserved M. abscessus complex isolates. During the study period, 15 patients with M. abscessus complex bacteraemia were found but only 14 isolates from 13 patients were preserved for analysis. One patient had two episodes of bacteraemia (one caused by M. abscessus subsp. bolletii and one by M .abscessus subsp. abscessus with a 9-month interval). Of the remaining 12 patients, 9 patients had M. abscessus subsp. bolletii bacteraemia and 3 had M .abscessus subsp. abscessus bacteraemia. Patients were mainly middle-aged adults with various co-morbidities. Steroid usage and malignancy (5/15) were the most common immunocompromised statuses, followed by diabetes mellitus (4/15). Surgical wound infection was the most common infection foci in all patients (5/15), particularly in M. abscessus subsp. bolletii bacteraemia patients. Clarithromycin and tigecycline exhibited good in vitro activities. Overall, the 14-day mortality was 20% (3/15). M. abscessus complex bacteraemia should be considered an emerging opportunistic infection in immunocompromised hosts. Clarithromycin and tigecycline have potent in vitro activities and are promising agents for treating infections due to M. abscessus complex.

Feasibility of using the predisposition, insult/infection, physiological response, and organ dysfunction concept of sepsis to predict the risk of deterioration and unplanned intensive care unit transfer after emergency department admission

BACKGROUND

Recognizing patients at risk for deterioration and in need of critical care after emergency department (ED) admission may prevent unplanned intensive care unit (ICU) transfers and decrease the number of deaths in the hospital. The objective of this research was to study if the predisposition, insult, response, and organ dysfunction (PIRO) concept of sepsis can be used to predict the risk of unplanned ICU transfer after ED admission.

METHODS

The ICU transfer group included 313 patients with unplanned transfer to the ICU within 48 hours of ED admission, and the control (non-transfer) group included 736 randomly sampled patients who were not transferred to the ICU. Two-thirds of the total 1049 patients in this study were randomly assigned to a derivation group, which was used to develop the PIRO model, and the remaining patients were assigned to a validation group.

RESULTS

Independent predictors of deterioration within 48 hours after ED admission were identified by the PIRO concept. PIRO scores were higher in the ICU transfer group than in the non-transfer group, both in the derivation group [median (mean ± SD), 5 (5.7 ± 3.7) vs. 2 (2.5 ± 2.5); p < 0.001], and in the validation group [median (mean ± SD), 6 (6.0 ± 3.4) vs. 2 (2.4 ± 2.6); p < 0.001]. The proportion of ICU transfer patients with a PIRO score of 0-3, 4-6, 7-9, and ≥10 was 14.1%, 46.5%, 57.3%, and 83.8% in the derivation group (p < 0.001) and 12.8%, 37.3%, 68.2%, and 70.0% in the validation group (p < 0.001), respectively. The proportion of inpatient mortality in patients with a PIRO score of 0-3, 4-6, 7-9, and ≥10 was 2.6%, 10.1%, 23.2%, and 45.9% in the derivation group (p < 0.001) and 3.3%, 12.0%, 18.2%, and 20.5% in the validation group (p < 0.001), respectively.

CONCLUSION

The PIRO concept of sepsis may be used in undifferentiated medical ED patients as a prediction system for unplanned ICU transfer after admission.

Risk factors associated with adverse drug events among older adults in emergency department

BACKGROUND

Little is known about the emergency department (ED) visits from drug-related injury among older adults in Taiwan. This study seeks to identify risk factors associated with adverse drug events (ADEs) leading to ED visits.

METHODS

We prospectively conducted a case-control study of patients 65years and older presenting to the ED. ED visits between March 1, 2009 and Feb 28, 2010 identified by investigators for suspected ADEs were further assessed by using the Naranjo Adverse Drug Reaction probability scale. For each patient with an ADE, a control was selected and time-matched from the ED population of the study hospital. The association between the risk of adverse drug events and triage, age, gender, serum alanine transaminase (ALT), serum creatinine, number of medications, and Charlson Comorbidity Index scores were analyzed using logistic regression.

RESULTS

Of 20,628 visits, 295 ADEs were physician-documented in older adults. Independent risk factors for ADEs included number of medications (adjusted odds ratio [OR]=4.1; 95% confidence interval [CI] 2.4-6.9 for 3-7 drugs; adjusted OR=6.4; 95% CI 3.7-11.0 for 8 or more drugs) and increased concentration of serum creatinine (adjusted OR=1.5; 95% CI 1.1-2.2). Diuretics, analgesics, cardiovascular agents, anti-diabetic agents and anticoagulants were the medications most commonly associated with an ADE leading to ED visits.

CONCLUSIONS

This study suggests that prevention efforts should be focused on older patients with renal insufficiency and polypharmacy who are using high risk medications such as anticoagulants, diuretics, cardiovascular agents, analgesics, and anti-diabetic agents.

The association between on-scene blood pressure and early neurological deterioration in patients with spontaneous intracerebral haemorrhage

OBJECTIVE

To determine whether on-scene BP is associated with early neurological deterioration (END) in patients with spontaneous intracerebral haemorrhage (SICH).

METHODS

This retrospective cohort study enrolled consecutive ambulance-transported adult SICH patients treated at our emergency department (ED) from January 2007 through December 2012. END was defined as a ≥2-point decrease in GCS within 24 h of ED arrival. The exact relationship between on-scene BP and END was assessed using multiple logistic regression analyses for adjusting age, gender, Charlson Index, aspirin use, smoking, elapsed time, consciousness level on ED arrival, haematoma size, intraventricular extension, midline shift and infratentorial ICH. We further calculated the -2 log-likelihood decrease for each regression model incorporated with the BP values measured at different times to compare model fitness.

RESULTS

After adjusting for the covariates, on-scene systolic BP (by 10 mm Hg incremental: OR = 1.126, 95% CI 1.015 to 1.265), diastolic BP (by 10 mm Hg incremental: OR=1.146, 95% CI 1.019 to 1.303) and mean arterial pressure (MAP) (by 10 mm Hg incremental: OR=1.225, 95% CI 1.057 to 1.443) were significantly associated with END; adding on-scene MAP into the regression model yielded the highest model fitness increase. Adding on-scene BPs into the regression model yielded higher model fitness increase than adding ED and admission BPs.

CONCLUSIONS

Few on-scene BP indices were associated with neuroworsening within 24 h after ED arrival in non-comatose SICH patients. Compared with BP measured on ED arrival or admission, on-scene BP had a stronger correlation with END.