Comparison of Two Scoring Systems in Predicting Outcomes in Non-Variceal Upper Gastrointestinal Bleeding in Taiwanese Population.

BACKGROUND: The role of scoring systems in detecting outcomes of non-variceal upper gastrointestinal bleeding in Taiwanese population remains uncertain. AIMS: The aim of our study was to compare Glasgow-Blatchford score with pre-endoscopic Rockall score in their utilities in predicting clinical outcomes in Taiwanese population. METHODS: We designed a prospective study to compare the performance of the Glasgow-Blatchford score and pre-endoscopic Rockall score in predicting endoscopic therapy, rebleeding and 30-day mortality in non-variceal upper gastrointestinal bleeding patients. The area under receiver operating characteristic curve was analyzed. 234 consecutive patients admitted during a 8-month period were enrolled. RESULTS: For prediction of therapeutic endoscopy, area under receiver operating characteristic curve was obtained for Glasgow-Blatchford score (0.629), and pre-endoscopic Rockall score (0.599). For prediction of rebleeding, area under receiver operating characteristic curve was obtained for Glasgow-Blatchford score (0.687), and pre-endoscopic Rockall score (0.581). For prediction of mortality, area under receiver operating characteristic curve was obtained for Glasgow-Blatchford score (0.505), and pre-endoscopic Rockall score (0.734). CONCLUSIONS: In detecting low risk patients requiring endoscopy therapy, the AUC for GBS shows that it is a poor stratification tool, and the AUC for PRS reveals that it is a worthless stratification test. In detecting rebleeding, Glasgow-Blatchford score has a better performance than pre-endoscopic Rockall score. In contrast, pre-endoscopic Rockall score has a better performance in predicting 30-day mortality than Glasgow-Blatchford score.

Factors associated with delayed recognition of pulmonary tuberculosis in emergency departments in Taiwan.

OBJECTIVE: To identify and evaluate factors associated with delayed recognition of pulmonary tuberculosis (TB) in the emergency department (ED). BACKGROUND: Delayed recognition of pulmonary TB in ED may precipitate mortality and morbidity. METHODS: Medical records of newly diagnosed TB patients admitted to four hospitals in Taiwan were retrospectively reviewed. Patients were divided into two groups based on ED physicians' recognition or not of TB and statistically compared to identify differences in their characteristics. RESULTS: 310 newly diagnosed TB patients were identified; 150 were unrecognized in the ED. Cough, chest tightness, general malaise, and body weight loss were more common for those with recognized TB. Older age (≥65 yrs, P = 0.035) and chronic renal insufficiency (P = 0.005) were associated with delayed TB recognition. CONCLUSION: Older age and chronic renal insufficiency are risk factors for delayed TB while in the ED. Typical symptoms should heighten alertness for recognizing TB.

The association between hypertension and traumatic intracranial haemorrhage.

BACKGROUND: Control of blood pressure is considered essential in the management of trauma patients. In patients with head injuries, both hypotension and hypertension are associated with poor outcomes. The present study was undertaken to ascertain whether hypertension at emergency triage is associated with traumatic intracranial haemorrhage. METHODS: From September 2012 to August 2013, data were collected prospectively for patients who presented with head injury and who received a brain CT examination at a university hospital. Factors associated with intracranial haemorrhage were identified, and logistic regression analysis was used to examine the association between hypertension at emergency department triage and traumatic brain haemorrhage. RESULTS: Of a total of 1457 patients enrolled in this study, 252 (17.3%) experienced traumatic intracranial haemorrhage. After controlling for factors associated with traumatic intracranial haemorrhage, an increased risk of intracranial haemorrhage following an initial brain CT scan was identified for patients presenting initially with a systolic blood pressure ≥ 180 mm Hg (odds ratio, 1.80; 95% confidence interval, 1.20-2.71, compared with those with 90-139 mm Hg). CONCLUSION: The presence of hypertension at emergency triage is associated with traumatic intracranial haemorrhage.

Hypertensive patients using thiazide diuretics as primary stroke prevention make better functional outcome after ischemic stroke.

BACKGROUND: Thiazides have been used for the control of blood pressure and primary prevention of ischemic stroke. No previous studies have assessed the influence of thiazides on functional prognosis after ischemic stroke. METHODS: Demographics, prestroke conditions, poststroke National Institutes of Health Stroke Scale score, and clinical and laboratory parameters were prospectively registered in 216 Taiwanese patients. One hundred forty patients who completed follow-up 3 months after experiencing ischemic stroke were assessed with the modified Rankin scale as functional prognoses. RESULTS: Twenty-one patients used thiazide to control hypertension before experiencing ischemic stroke. No differences of stroke subtypes and comorbidities before stroke were observed between the 2 groups. The emergency department National Institutes of Health Stroke Scale was lesser among thiazide users (4 [2-7] versus 6 [4-16], P = .02). Among 140 patients who completed follow-up in 90 days, thiazide users had more favorable functional status (modified Rankin scale ≤2: 42.4% versus 26.9%, P = .02, odds ratio 3.34, 95%, confidence interval .130-.862). CONCLUSION: Hypertensive patients treated with thiazides long term had a lesser severity of stroke and better functional outcomes after ischemic stroke.

Red cell distribution width is an independent predictor of mortality in necrotizing fasciitis.

INTRODUCTION: Necrotizing fasciitis (NF) is a rapidly progressing and potentially lethal infectious disease of the soft tissue. An elevated red blood cell distribution width (RDW) is associated with increased risk of death in patients with heart disease and infectious disease. We retrospectively assessed the association of elevated RDW with in-hospital mortality due to NF. METHODS: All patients had diagnoses of NF and were admitted to the emergency department of a single institution in Taiwan over a 4-year period. Demographics, comorbidities, clinical presentations, and laboratory parameters were retrospectively reviewed. Red blood cell distribution width was categorized as elevated (>14.5%) or not elevated. Multivariate regression analysis was used to identify risk factors associated with mortality. RESULTS: A total of 98 patients were enrolled, and the mortality rate was 23%. Univariate analysis indicated that advanced age, initial hypotension, low hemoglobin level, and elevated RDW (69.6% vs 20%, OR = 9.14, P < .001) were significantly associated with mortality. Multivariate analysis indicated that RDW was a significant and independent predictor of mortality in enrolled patients. CONCLUSIONS: Elevated RDW is a significant and independent predictor of in-hospital mortality for patients with NF.

Aortoiliac occlusive disease presenting as sudden onset paraplegia.

Thromboembolism and atherosclerotic stenosis both can cause arterial occlusion. Aortoiliac occlusive disease involving bifurcation of the aortoiliac artery induces symptoms of ischemia such as claudication and pain of buttocks and thighs, decreased bilateral femoral pulses, and impotence. Here, we describe a 58-year-old woman with a past history of atrial fibrillation and lacuna stroke with minimal right side weakness. She presented to our emergency department with sudden onset bilateral pain in the legs and paraplegia. A comprehensive examination revealed paresthesia and decreasing bilateral distal pulses. Computed tomographic imaging showed filling defects over the low abdominal aorta just above the bifurcation of the common iliac artery and bilateral femoral arteries. Acute aortic embolic occlusion was suspected. Her symptoms were resolved after emergent thrombectomy for acute limb ischemia. Physicians need to be aware of aortoiliac embolic occlusive disease which may present as acute paraplegia.

A prospective comparison of 3 scoring systems in upper gastrointestinal bleeding.

BACKGROUND: The clinical severities of upper gastrointestinal bleeding (UGIB) are of a wide variety, ranging from insignificant bleeds to fatal outcomes. Several scoring systems have been designed to identify UGIB high- and low-risk patients. The aim of our study was to compare the Glasgow-Blatchford score (GBS) with the preendoscopic Rockall score (PRS) and the complete Rockall score (CRS) in their utilities in predicting clinical outcomes in patients with UGIB. METHODS: We designed a prospective study to compare the performance of the GBS, PRS, and CRS in predicting primary and secondary outcomes in UGIB patients. The primary outcome included the need for blood transfusion, endoscopic therapy, or surgical intervention and was labeled as high risk. The secondary outcomes included rebleeding and 30-day mortality. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values for each system were analyzed. A total of 303 consecutive patients admitted with UGIB during a 1-year period were enrolled. RESULTS: For prediction of high-risk group, AUC was obtained for GBS (0.808), PRS (0.604), and CRS (0.767). For prediction of rebleeding, AUC was obtained for GBS (0.674), PRS (0.602), and CRS (0.621). For prediction of mortality, AUC was obtained for GBS (0.513), PRS (0.703), and CRS (0.620). CONCLUSIONS: In detecting high-risk patients with acute UGIB, GBS may be a useful risk stratification tool. However, none of the 3 score systems has good performance in predicting rebleeding and 30-day mortality because of low AUCs.

Facial palsy in children: emergency department management and outcome.

OBJECTIVE: To describe the characteristics of children who present to an emergency department (ED) with facial palsy and determine the association of outcome with etiology, degree of initial paralysis, and ED management. METHODS: This was a retrospective cohort study of children who presented to an ED with facial nerve paralysis (FNP). RESULTS: There were 85 patients with a mean age of 8.0 (SD, 6.1) years; 60% (n = 51) of the patients were male, and 65.9% (n = 56) were admitted to the hospital. Bell palsy (50.6%) was the most common etiology followed by infectious (22.4%), traumatic (16.5%), congenital (7.1%), and neoplastic etiologies (3.5%). Patients with Bell palsy had shorter recovery times (P = 0.049), and traumatic cases required a longer time for recovery (P = 0.016). Acute otitis media (AOM)-related pediatric FNP had shorter recovery times than non-AOM-related cases (P = 0.005) in infectious group. Patients given steroid therapy did not have a shorter recovery time (P = 0.237) or a better recovery (P = 0.269). There was no difference in recovery rate of pediatric patients with Bell palsy between hospitalization or not (P = 0.952). CONCLUSION: Bell palsy, infection, and trauma were most common etiologies of pediatric FNP. Recovery times were shorter in pediatric patients with Bell palsy and AOM-related FNP, whereas recovery took longer in traumatic cases. Steroid therapy did not seem beneficial for pediatric FNP. Hospitalization is not indicated for pediatric patients with Bell palsy.