A survey of the perception of well-being among emergency physicians in Taiwan.

OBJECTIVES: The objective of this study is to investigate the feelings (well-being) of emergency physicians in Taiwan regarding their job and the relationship between these feelings and the work environment. MATERIALS AND METHODS: A questionnaire was used to survey emergency physicians across Taiwan from January to June 2014. The questionnaire contents were categorized into five specific factors that could affect well-being, including "emergency quality, emergency safety, support environment, workload, and salary and benefits." Well-being was rated directly on a scale of 1-10, with 10 indicating the highest level of happiness. Physician retention was also surveyed. The correlations among the five factors, well-being, and physician retention were analyzed. The five factors were quantified as a "happiness index" and compared between religious and nonreligious hospitals and medical centers and regional hospitals. RESULTS: A total of 398 questionnaires were received, and the response rate was 39%. Of these, 42.7% of responders reported high ratings for well-being (scores of 7-10, 1 is the worse, and 10 is the best) and 40.3% felt neutral (scores of 5-6). Only 12.3% doctors did not think they would stay at the same position for the next 3 years. All five factors had moderately significant correlations with each other (γ = 0.195-0.534, P < 0.01). All five factors also significantly correlated with well-being. Emergency safety (γ = 0.121, P < 0.05), salary and benefits (γ = 0.143, P < 0.05), and well-being (γ = 0.189, P < 0.01) were correlated with physician retention. The happiness indices of emergency quality, support environment, and workload were significantly higher in regional hospitals than medical centers. CONCLUSIONS: All five indicators had impacts on well-being. The respondents reported heavy workloads, including high stress and even poorly met physiological needs. In addition, the threat of violence, salaries, and well-being correlated with physician retention. Hospital administrators can make efforts to improve the well-being of doctors and physician retention by adjusting environmental factors.

Prediction of Outcome of In-Hospital Mortality for Acute Heart Failure.

BACKGROUND: Prediction of in-hospital mortality in acute heart failure (AHF) is sought to evaluate the blood pressure and renal function. Acute heart failure with systolic pressure and impaired renal function is common but not well understood. METHODS: We reviewed 187 patients with acute heart failure from 2013-2014. Then we apply validation of a risk stratification tool to predict in-hospital mortality for acute HF group. The analysis of the inhospital mortality with acute heart failure group will based on BUN level, systolic blood pressure, and serum creatinine level. RESULTS: There were 23 patients in the in-hospital mortality group and 164 patients in the survived group after hospitalization. The 3 physiological parameters were compared between in-hospital mortality and survival group from the validation of a risk stratification tool: systolic blood pressure (123.7 ± 30.1 vs. 143.7 ± 34.2 mmHg, p value = 0.009), blood urea nitrogen (57.2 ± 27.7 vs. 38.7 ± 24.7 mg/dL, p value = 0.001), serum creatinine (2.38 ± 1.91 vs. 2.06 ± 1.62 mg/dL, p value = 0.390). Finding from NTUH compared with ADHERE was the group with blood urea nitrogen 43 mg/dL, systolic BP < 115 mmHg, and serum creatinine < 2.75 mg/dL will be high risk of in-hospital mortality (50% in NTUH vs. 12.42% in ADHERE). In our validation of a risk stratification tool, the accuracy was 77.8 % by receiver operator characteristic curve analysis. CONCLUSION: On the basis of these 3 variables- BUN level, systolic blood pressure, and serum creatinine level from the current analysis, the acute heart failure patient can be readily stratified into groups at high risk for in-hospital mortality.

Emergency Physician Compliance with Quality Indicators of Septic Shock and Severe Sepsis in Eastern Taiwanese Community Hospital.

BACKGROUND: A retrospective review was conducted, examining patient charts at a community hospital in Eastern Taiwan during a 2-year period, from April 2013 to March 2015. AIMS: The goal was assessment of adherence to quality indicators (QIs) in septic shock and severe sepsis (4S status) by emergency physicians (EPs). METHODS: Based on the Surviving Sepsis Campaign (SSC) guidelines, data was electronically retrieved from the Hospital Information System (HIS); and beginning in April 2014, our staff was regularly educated on this topic during monthly meetings. A Sepsis Bundle Care Set (SBCS) was also launched in September 2014. The Chi-square post hoc test was utilized in statistical analysis, setting signifi cance at p < 0.05. In patients with septic shock (n = 81) or severe sepsis (n = 572), QIs before and after educational initiatives were 36 vs. 45 and 259 vs. 313, respectively. RESULTS: In terms of septic shock, QIs that improved signifi cantly after education were C-reactive protein (CRP: 66.67% vs. 91.11%), arterial blood gas (ABG: 58.33% vs. 80.00%), and intravenous (IV)-fluid infusion rate (0.00% vs. 40.00%). QIs that significantly improved in the context of severe sepsis were CRP (59.46% vs. 84.66%), serum lactate (75.68% vs. 86.26%), intensive care unit (ICU) admission within 4 hours (72.97% vs. 81.79%), and IV-fluid infusion rate (0.00% vs. 18.85%). In comparing QI adherence rates by educational period subsets, two-set IV line showed signifi cant improvement after 7 months of education, and admission to ICU within 4 hours after 4 months of education. However, most QIs associated with severe sepsis (except serum lactate and antibiotic given in 1 hour) showed signifi cant improvement after 3 months of education. CONCLUSIONS: We concluded that there is much room to improve QI adherence rates in patients with 4S status, using educational initiatives.

Midgut volvulus induced extensive bowel infarction.

Midgut volvulus, mostly occurs due to congenital midgut malrotation, has been reported as a rare but lethal complication of some acquired medical conditions, such as postoperative adhesion bands, tumors, and mesenteric cysts. It is a surgical emergency to cause extensive bowel ischemia resulted from torsion of superior mesenteric artery. Early diagnosis and intervention is the only manner to prevent extended bowel necrosis. Here, we report a case of midgut volvulus with typical computed tomography features-the whirl sign, the transposition of the superior mesenteric artery and vein, and the ischemic change of bowel supplied by superior mesenteric artery. Early operation prevented the fate of extended bowel resection.

Angiotensin converting enzyme DD genotype is associated with acute coronary syndrome severity and sudden cardiac death in Taiwan: a case-control emergency room study.

BACKGROUND: Angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphisms have been associated with acute coronary syndrome (ACS); however, several controversial results have also been found in different studied populations. This hospital-based, emergency room, case-control study in Taiwan retrospectively investigated 111 ACS patients, and 195 non-coronary subjects as a control group, to study the effects of ACE I/D polymorphism in the most urgent ACS patients. ACE I/D polymorphisms were determined by polymerase chain reaction-based assays and their associations with ACS risk, severity, and sudden cardiac death were determined. RESULTS: The ACE DD genotype was associated with ACS incidence. The DD genotype was associated with a significant 4-fold higher risk of ACS in multivariate analysis (odds ratio (OR) = 4.295; 95% confidence interval (CI): 1.436-12.851, p = 0.009), and a 3.35-fold higher risk of acute myocardial infarction. DD genotype carriers also had more than 3-fold higher risks of stenosis in all the three coronary arteries, left anterior descending artery infarction, and anterior wall infarction. In addition, the DD genotype was also associated with a higher risk of sudden cardiac death (OR = 6.484, 95% CI: 1.036-40.598, p = 0.046). CONCLUSIONS: This study demonstrated that the ACE DD genotype is an independent risk factor for ACS, and in particular, for acute myocardial infarction. In addition, the ACE DD genotype is also associated with greater ACS severity and a higher risk of sudden cardiac death. ACE genotyping is recommended for patients with a history of ACS, and more intensive preventive care is suggested for patients with the DD genotype.

The toxic effect of Amiodarone on valve formation in the developing heart of zebrafish embryos.

BACKGROUND: Amiodarone is a class D drug given to treat arrhythmia, including pregnant women, but its effects on the developing heart have not been studied. Although some studies have suggested that this drug is safe for fetuses, they have been conducted on mothers with fetuses at or beyond six months of gestational age. RESULTS: The occurrence of valve defect was positively proportional to Amiodarone concentrations over 9 µM, but not lower than 6 µM. Ectopic overexpression of versican was observed at the atrioventricular canal of the Amiodarone-treated embryos at 15 µM (EC(50)). VE-cadherin (cdh5), normally downregulated at the endocardial cushion, was also ectopically overexpressed in the Amiodarone-treated embryos. Knockdown of either versican or cdh5 in the Amiodarone-treated embryos could rescue the valve defect caused by Amiodarone. CONCLUSIONS: By inducing versican ectopical overexpression, leading, in turn, to cdh5 ectopical overexpression, Amiodarone treatment causes failure of cardiac valve formation in zebrafish embryos.

Fin reduction is a novel and unexpected teratogenic effect of amikacin-treated zebrafish embryos.

We used zebrafish as a model to assess amikacin-induced embryotoxicity. We exposed zebrafish embryos to amikacin, using different amikacin doses (0-10 ppm), durations (12-48 h), and onsets (0, 24, 48 hpf). Amikacin-induced embryonic toxicity and reduced survival rate were found dependent on the exposure dose, duration and onset. Based on immunostaining with neuron-specific antibodies, amikacin reduced the number and size of zebrafish neuromasts. In addition, Amikacin caused pelvic, dorsal and anal fin defects in dose-dependent and duration-dependent manners. Proliferating cell nuclear antigen immunostaining revealed that amikacin-induced fin defects were not due to reduction of proliferating mesenchymal cells. TUNEL assay demonstrated that amikacin-induced fin defects might not associate with apoptosis. Therefore, further investigations are required to elucidate if other cell death pathways are involved in amikacin-induced fin defects.

Embryonic exposure to diclofenac disturbs actin organization and leads to myofibril misalignment.

The objective of this study was to investigate the embryotoxicity of diclofenac. Zebrafish (Danio rerio) embryos at 12 hpf were treated with different dosages of diclofenac (0-2,000 ppm) for different time courses (12-72 hr). Results showed no evident differences in survival rates or morphological changes between the mock-treated control (0 ppm) zebrafish embryos and those with 1-ppm diclofenac-exposure (12-24, 12-36 hpf). In contrast, after higher doses (5 and 10 ppm) of exposure, embryos displayed some defective phenotypes, including malformed somite boundary, a twisted body axis, and shorter body length. In addition, diclofenac-treated embryos exhibited significantly reduced frequencies of spontaneous in-chorion contractions in comparison with mock-control littermates (mock-control: 13.20 ± 2.24 vs. 5-10 ppm diclofenac: 6.66 ± 1.35-3.03 ± 1.84). Subtle changes were easily observed by staining with specific monoclonal antibodies F59 and phalloidin to detect morphological changes in muscle fibers and formation of F-actin, respectively. Our data show that diclofenac treatment disturbs actin organization and muscle fiber alignment, thus causing malformed somite phenotypes.

Can acute cholecystitis with gallbladder perforation be detected preoperatively by computed tomography in ED? Correlation with clinical data and computed tomography features.

PURPOSE: The purpose of this study is to determine which computed tomography (CT) findings and clinical data can help to diagnose gallbladder perforation in acute cholecystitis. MATERIALS AND METHODS: The medical records and CT findings of patients with surgically proven acute cholecystitis within the last recent 5 years were retrospectively reviewed and compared between 2 groups with and without gallbladder perforation. RESULTS: A total of 75 patients with acute cholecystitis were included in the study, and 16 patients were proven to have gallbladder perforation. Higher mortality rate was found in the perforation group (18.8% vs 1.7%; P = .029). Older age (>70 years; P = .004) and higher percentage of segmented neutrophil (>80%; P = .027) were significant clinical factors for predicting gallbladder perforation in acute cholecystitis. The significant CT signs related to gallbladder perforation included visualized gallbladder wall defect (P = .000), intramural gas (P = .043), intraluminal gas (P = .000), intraluminal membrane (P = .043), pericholecystic abscess or biloma formation (P = .009), intraperitoneal free air (P = .001), and presence of ascites in the absence of hypoalbuminemia or other intraabdominal malignancy (P = .017). In multivariate analysis, visualized gallbladder wall defect was the most significant predicting CT feature for diagnosing gallbladder perforation in acute cholecystitis. CONCLUSION: Elderly patients with higher segmented neutrophil and CT signs of gallbladder wall defect associated with acute cholecystitis may have high possibility of gallbladder rupture.

Immunotherapy: rAAV2 expressing interleukin-15 inhibits HeLa cell tumor growth in mice.

Human interleukin-15 (hIL15) has anti-tumor activities, but it is not convenient for tumor treatment because of its short half-life. A gene therapy for mouse lung cancer using an adenovirus vector expressing IL15 has been reported. However, adenovirus vector-mediated gene therapy can provoke cellular toxicity and inflammatory reactions. The recombinant adenovirus-associated vector 2 (rAAV2) is safer due to minimal cellular toxicity and immune response. In order to demonstrate that gene therapy can be used safely and successfully for human cancer treatment, the rAAV2 expressing hIL15 gene (rAAV2-hIL15) is applied for human cervical cancer, HeLa cell, in this study. This study successfully demonstrates that rAAV2-hIL15 can express IL15 with bioactivities in vitro and in vivo. In conclusion, our studies show that human cervical cancers are inhibited on animal model with rAAV2-hIL15 treatment and provide a safer and important reference for human cancer gene therapy.

Common toxidromes of plant poisonings in Taiwan.

OBJECTIVE: To describe the toxidromes associated with plant poisonings in Taiwan. METHODS: Retrospective review of acute single-plant exposures with clinical signs and symptoms reported between January 1987 and December 2006 by hospitals to the network of Taiwan Poison Control Centers. Recorded data included demographic data, intent of exposures, exposure routes, clinical findings, and therapeutic strategies. RESULTS: There were 389 cases that met the criteria. Each case was placed into one of the expected toxidromes: anticholinergic, mucosal inflammation, gastroenteritis, acute multisystem organ failure, delayed multisystem organ failure, cholinergic, cardiac dysrhythmia, hepatotoxicity, dermatitis, seizures, and dyspnea. Anticholinergic poisoning was the most common toxidrome. CONCLUSION: Plant poisonings can be classified into recognizable toxicologic syndromes. These toxidromes may guide a clinician's evaluation and management before a botanist can confirm the actual plant identity.

Epidemiology of organophosphate pesticide poisoning in Taiwan.

INTRODUCTION: The nationwide epidemiology of organophosphate pesticide (OP) poisoning has never been reported in detail for Taiwan. METHODS: This study retrospectively reviewed all human OP exposures reported to Taiwan's Poison Control Centers (PCCs) from July 1985 through December 2006. RESULTS: There were 4799 OP exposures. Most OP exposures were acute (98.37%) ingestions (74.50%) of a single OP (80.37%) to attempt suicide (64.72%) in adults (93.25%). Males were the most common gender (64.95%). Most patients (61.97%) received atropine and/or pralidoxime. The mortality rate for all 4799 OP exposures was 12.71%. Exposures to single OPs without co-intoxicants caused 524 deaths; of these, 63.36% were due to dimethyl OPs. CONCLUSION: Dimethyl OPs cause the majority of deaths in Taiwan.

PKC and MEK pathways inhibit caspase-9/-3-mediated cytotoxicity in differentiated cells.

Many studies have indicated that differentiated cells inhibit drug-induced cytotoxicity but undifferentiated cells do not, though the mechanisms are unclear. Currently, HL-60 cells are induced to differentiate into macrophage-like cells with Phorbol-12-myristate-13-acetate (TPA) treatment (TPA-differentiated cells). Our study shows that caspase-9/-3-mediated cytotoxicity can be induced in undifferentiated HL-60 cells but not in TPA-differentiated HL-60 cells. However, caspase-9/-3-mediated cytotoxicity can be induced in TPA-differentiated cells if they are pretreated with a protein kinase C (PKC) or a mitogen activated protein kinase (MEK) inhibitor. Taken together, this study demonstrates that TPA-differentiated HL-60 cells inhibit caspases-9/-3-mediated cytotoxicity through the PKC and MEK signaling pathways.

Alcohol-related Injuries at an emergency department in Eastern Taiwan.

BACKGROUND/PURPOSE: Injuries are major causes of mortality and morbidity in Taiwan. Alcohol involvement often plays a role in injuries. The purpose of this study was to determine the prevalence of alcohol-related injuries at an emergency department in Eastern Taiwan and their associated factors. METHODS: All injured patients who made emergency visits between October 2002 and September 2003 were enrolled. For each patient, the attending nurse completed an injury-coding sheet, which included the results of an assessment of whether the patient had an alcohol odor or alcohol consumption related behavior. Nurses recorded suspicion of alcohol consumption based on possible categories of "no alcohol odor", "alcohol odor", "intoxicated", "suspected" or "unknown". Blood alcohol testing was also performed based on the decision of the attending physician. Injuries were defined as alcohol-related based on the report of "alcohol odor" or "intoxicated" by the nurse or a positive blood alcohol test. Logistic regression was used to assess the significance of the association of possible related factors with alcohol-related injury. RESULTS: A total of 8822 eligible visits were studied and 14% were classified as alcohol-related. The proportion of alcohol-related injuries was 14.9% for vehicle-related injuries, and 51.3% for assaults. Male, young to middle aged, aboriginal ethnicity and visits after midnight were factors associated with increased likelihood of alcohol-related injuries. Multiple logistic regression analysis revealed that the three factors most significantly associated with alcohol-related injuries were visits after midnight (odds ratio, OR, 7.5; 95% confidence interval, CI, 6.4-8.9], assaults (OR, 3.4; 95% CI, 2.3-4.8), and head injuries (OR, 2.7; 95% CI, 2.3-3.2). CONCLUSION: Injuries were alcohol related in one out of seven patients this study from an emergency department in eastern Taiwan. Ongoing epidemiologic monitoring of the prevalence and nature of alcohol abuse among patients visiting the ED are urgently needed.

Alcohol intoxication increases morbidity in drivers involved in motor vehicle accidents.

We prospectively examined the correlation of alcohol intoxication with injury severity, morbidity, and mortality in drivers involved in motor vehicle accidents in a prospective cohort study. The study enrolled 923 injured patients, of whom 421 were legally intoxicated (blood alcohol concentration [BAC] > or = 50 mg/dL) and 502 were not intoxicated (BAC < 50 mg/dL). The intoxicated drivers had a significantly higher injury severity score (ISS), lower Glasgow Coma Score, lower systolic blood pressure; higher rate in old age, male sex, greater rate of habitual drinking, greater lack of use of safety gear, and greater accident-related morbidity. After logistic regression analysis, alcohol intoxication was not associated with severe injury (ISS > or = 9); however, alcohol intoxication analyzed either as a preinjury or postinjury risk factor, was one of the predictors for morbidity. Severe head injury was the only predictor of mortality. In conclusion, although alcohol intoxication is not associated with an increased incidence of severe injury or mortality in drivers involved in motor vehicle crashes, it is one of the significant predictors for morbidity after injury.

The feasibility of full computerization in the ED.

For understanding the feasibility of full computerization of an emergency department (ED), we investigated the completion rate performed by doctors, nurses, or registration clerks since the implementation of full computerization in our ED. We evaluated the changing style of chart-recording, from hand-writing pattern to full computer recording, by recording the execution rate of different information keyed by doctors, nurses, or registration clerks according to their work in ED. We recorded and analyzed different monthly reports of the execution rate in the 18-month period of study. Statistical analysis was performed using Wilcoxon rank-sum test or Kruskal-Wallis one-way ANOVA. The average monthly census was 4570.1 +/- 580.7 (95% confidence interval [CI] for mean: 4281.3, 4858.9). The average execution rate for mode of arrival and triage classification were 97.1 +/- 4.1% (95% CI for mean: 95.1%, 99.1%) and 97.2 +/- 4.1% (95% CI for mean: 95.2%, 99.2%), respectively. In comparison with the execution rate for disposition status between the period of the first 10 months (keying data by nurses) and the late 8 months (keying data by clerks), it showed 72.0 +/- 33.2% v 96.7 +/- 2.0%; 66.7 +/- 35.0% v 95.8 +/- 1.9%; 57.5 +/- 32.0% v 88.2 +/- 8.2% in nontrauma, trauma and pediatric section, respectively, with statistic significance (P <.01). To compare the rate of execution performed by physicians, we divided the study period into 3 phases (phase 1: first 6 months, phase 2: 7-12 months, phase 3: 13-18 months of the study period). The results were statistically significant (P =.004) in phase 3 (83.4 +/- 5.3%) with higher execution rate than phase 1 (69.7 +/- 7.7%) and phase 2 (75.2 +/- 4.9%) in trauma physician. In the pediatric section, it was also significantly higher in phase 3 than phase 2 (88.2 +/- 7.7% v 70.7 +/- 5.9%, P =.012). We concluded that it is efficient to key in data by registration clerks instead of nurses, and it takes time to persuade and educate most physicians to cooperate in using the computer while seeing patients.