Genome-wide association study of primary dysmenorrhea in the Taiwan Biobank validates associations near the NGF and IL1 gene loci.

Using the Taiwan Biobank, we aimed to identify traits and genetic variations that could predispose Han Chinese women to primary dysmenorrhea. Cases of primary dysmenorrhea included those who self-reported "frequent dysmenorrhea" in a dysmenorrhea-related Taiwan Biobank questionnaire, and those who have been diagnosed with severe dysmenorrhea by a physician. Controls were those without self-reported dysmenorrhea. Customized Axiom-Taiwan Biobank Array Plates were used to perform whole-genome genotyping, PLINK was used to perform association tests, and HaploReg was used to conduct functional annotations of SNPs and bioinformatic analyses. The GWAS analysis included 1186 cases and 24,020 controls. We identified 53 SNPs that achieved genome-wide significance (P < 5 × 10-8, which clustered in 2 regions. The first SNP cluster was on chromosome 1, and included 24 high LD (R2 > 0.88) variants around the NGF gene (lowest P value of 3.83 × 10-13 for rs2982742). Most SNPs occurred within NGF introns, and were predicted to alter regulatory binding motifs. The second SNP cluster was on chromosome 2, including 7 high LD (R2 > 0.94) variants around the IL1A and IL1B loci (lowest P value of 7.43 × 10-10 for rs11676014) and 22 SNPs that did not reach significance after conditional analysis. Most of these SNPs resided within IL1A and IL1B introns, while 2 SNPs may be in the promoter histone marks or promoter flanking regions of IL1B. To conclude, data from this study suggest that NGF, IL1A, and IL1B may be involved in the pathogenesis of primary dysmenorrhea in the Han Chinese in Taiwan.

Prospective health surveillance for COVID-19 among health care workers at a university medical center in Taiwan, January to June 2020.

BACKGROUND: Healthcare personnel (HCP) at the front line of care are exposed to occupational hazards that place them at risk for infection, which then endanger patient safety and compromise the capability of the healthcare workforce. As of March 8, 2021 more than 420,170 HCP in US had been infected with SARS CoV-2 with 1388 deaths. In two Taiwan hospitals COVID-19 outbreaks involved HCP and resulted in shutdown of service. This report describes our prospective health surveillance of the HCP and COVID-19 containment measures in a teaching hospital in Taiwan during Jan. 1 through June 30, 2020. METHODS: We prospectively monitored incidents, defined as an HCP with the predefined symptoms, reported by HCP through the web-based system. HCP were managed based on an algorithm that included SARS CoV-2 RNA PCR testing. Infection prevention and control policy/practice were reviewed. RESULTS: This hospital took care of 17 confirmed COVID-19 cases during the study period and the first Case was admitted on January 23, 2020. Among the 14,210 HCP, there were 367 incident events. Of 283 HCP tested for SARS CoV-2, 179 had predefined symptoms. These included 10 HCP who met the national case definition for COVID-19 infection and 169 based on Extended COVID-19 Community Screening program. The other 104 asymptomatic HCP were tested based on hospital policy. All of them had tested negative. CONCLUSION: We attribute our success in preventing COVID-19 infections among HCP to rapid, proactive, decisive, integrated national and institutional response in the early stages of the epidemic.

Neuroprognostic Accuracy of Quantitative Versus Standard Pupillary Light Reflex for Adult Postcardiac Arrest Patients: A Systematic Review and Meta-Analysis.

OBJECTIVES: An automated infrared pupillometer measures quantitative pupillary light reflex using a calibrated light stimulus. We examined whether the timing of performing quantitative pupillary light reflex or standard pupillary light reflex may impact its neuroprognostic performance in postcardiac arrest comatose patients and whether quantitative pupillary light reflex may outperform standard pupillary light reflex in early postresuscitation phase. DATA SOURCES: PubMed and Embase databases from their inception to July 2020. STUDY SELECTION: We selected studies providing sufficient data of prognostic values of standard pupillary light reflex or quantitative pupillary light reflex to predict neurologic outcomes in adult postcardiac arrest comatose patients. DATA EXTRACTION: Quantitative data required for building a 2 × 2 contingency table were extracted, and study quality was assessed using standard criteria. DATA SYNTHESIS: We used the bivariate random-effects model to estimate the pooled sensitivity and specificity of standard pupillary light reflex or quantitative pupillary light reflex in predicting poor neurologic outcome during early (< 72 hr), middle (between 72 and 144 hr), and late (≧ 145 hr) postresuscitation periods, respectively. We included 39 studies involving 17,179 patients. For quantitative pupillary light reflex, the cut off points used in included studies to define absent pupillary light reflex ranged from 0% to 13% (median: 7%) and from zero to 2 (median: 2) for pupillary light reflex amplitude and Neurologic Pupil index, respectively. Late standard pupillary light reflex had the highest area under the receiver operating characteristic curve (0.98, 95% CI [CI], 0.97-0.99). For early standard pupillary light reflex, the area under the receiver operating characteristic curve was 0.80 (95% CI, 0.76-0.83), with a specificity of 0.91 (95% CI, 0.85-0.95). For early quantitative pupillary light reflex, the area under the receiver operating characteristic curve was 0.83 (95% CI, 0.79-0.86), with a specificity of 0.99 (95% CI, 0.91-1.00). CONCLUSIONS: Timing of pupillary light reflex examination may impact neuroprognostic accuracy. The highest prognostic performance was achieved with late standard pupillary light reflex. Early quantitative pupillary light reflex had a similar specificity to late standard pupillary light reflex and had better specificity than early standard pupillary light reflex. For postresuscitation comatose patients, early quantitative pupillary light reflex may substitute for early standard pupillary light reflex in the neurologic prognostication algorithm.

Optimal initial antibiotic regimen for the treatment of acute appendicitis: a systematic review and network meta-analysis with surgical intervention as the common comparator.

BACKGROUND: The optimal antibiotic regimen for the medical management of acute appendicitis remains unknown due to a lack of head-to-head comparisons between different antibiotic regimens. METHODS: We systematically searched the PubMed, EMBASE, Scopus and Cochrane Central Register of Controlled Trials databases from their inception through to August 2020. We selected randomized controlled trials (RCTs) or observational studies comparing antibiotic therapy and appendectomy as the initial treatment for adult or paediatric patients with acute appendicitis. We performed a Bayesian network meta-analysis (NMA) to obtain the indirect comparison results between different antibiotic regimens by employing the group managed by surgery as a common comparator. Antibiotic regimens were classified into three categories: those including a carbapenem; those including a cephalosporin; and those including a ß-lactam/ß-lactamase inhibitor combination. RESULTS: A total of 9 RCTs (adults, n = 8; paediatrics, n = 1) and 12 observational studies (adults, n = 3; paediatrics, n = 9) were included in the NMA, with a total of 4551 patients. The most commonly administered regimen was a ß-lactam/ß-lactamase inhibitor combination (9/21; 43%), followed by a cephalosporin (7/21; 33%) or a carbapenem (5/21; 24%). The NMA indicated that surgery significantly increased 1 year treatment success, compared with cephalosporins [OR: 16.79; 95% credible interval: 3.8-127.64] or ß-lactam/ß-lactamase inhibitor combinations (OR: 19.99; 95% credible interval: 4.87-187.57), but not carbapenems (OR: 3.50, 95% credible interval: 0.55-38.63). In contrast, carbapenems were associated with fewer treatment-related complications compared with surgery (OR: 0.12; 95% credible interval: 0.01-0.85). CONCLUSIONS: Carbapenems might be recommended as the initial antibiotic regimen for the non-operative management of adult patients with acute appendicitis. Nevertheless, due to the imprecise estimates in our NMA, additional RCTs are needed to corroborate these findings, especially for paediatric patients.

Survival Impact and Clinical Predictors of Acute Gastrointestinal Bleeding in Patients With Bloodstream Infection.

PURPOSE: The impact of gastrointestinal bleeding (GIB) on outcomes of patients with bloodstream infection (BSI) has not been studied. We aim to evaluate the risk factors and survival impact of GIB on the outcome of BSI. MATERIALS AND METHODS: This study was conducted prospectively at National Taiwan University Hospital Yunlin Branch between January 1, 2015, and December 31, 2016. Patients aged ≥18 years for who BSI was confirmed by blood cultures were enrolled and followed for 90 days. Risk factors of GIB were identified by univariable and multivariable logistic regression models. The survival impact of GIB on BSI was evaluated with the Cox proportional hazards model with inverse probability of treatment weighting. RESULTS: Of the 1034 patients with BSI, 79 (7.64%) developed acute GIB. We identified 5 independent predictors of GIB. Patients with BSI complicated with GIB had an increased 90-day mortality compared to patients without GIB (hazard ratio 1.74, 95% confidence interval: 1.14, 2.65). CONCLUSIONS: Gastrointestinal bleeding had an adverse impact on the short-term survival in patients with BSI. The clinical predictors may help identify patients who may benefit from active prevention and treatment of GIB.

Comparing Effectiveness of Initial Airway Interventions for Out-of-Hospital Cardiac Arrest: A Systematic Review and Network Meta-analysis of Clinical Controlled Trials.

STUDY OBJECTIVE: We compare effectiveness of different airway interventions during cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest. METHODS: We systematically searched the PubMed and EMBASE databases from their inception through August 2018 and selected randomized controlled trials or quasi randomized controlled trials comparing intubation, supraglottic airways, or bag-valve-mask ventilation for treating adult out-of-hospital cardiac arrest patients. We performed a network meta-analysis along with sensitivity analyses to investigate the influence of high intubation success rate on meta-analytic results. RESULTS: A total of 8 randomized controlled trials and 3 quasi randomized controlled trials were included in the network meta-analysis: 7,361 patients received intubation, 7,475 received supraglottic airway, and 1,201 received bag-valve-mask ventilation. The network meta-analysis indicated no differences among these interventions for survival or neurologic outcomes at hospital discharge. Rather, network meta-analysis suggested that supraglottic airway improved the rate of return of spontaneous circulation compared with intubation (odds ratio 1.11; 95% confidence interval 1.03 to 1.20) or bag-valve-mask ventilation (odds ratio 1.35; 95% confidence interval 1.11 to 1.63). Furthermore, intubation improved the rate of return of spontaneous circulation compared with bag-valve-mask ventilation (odds ratio 1.21; 95% confidence interval 1.01 to 1.44). The sensitivity analyses revealed that the meta-analytic results were sensitive to the intubation success rates across different out-of-hospital care systems. CONCLUSION: Although there were no differences in long-term survival or neurologic outcome among these airway interventions, these system-based comparisons demonstrated that supraglottic airway was better than intubation or bag-valve-mask ventilation and intubation was better than bag-valve-mask ventilation in improving return of spontaneous circulation. The intubation success rate greatly influenced the meta-analytic results, and therefore these comparison results should be interpreted with these system differences in mind.

A Double Triage and Telemedicine Protocol to Optimize Infection Control in an Emergency Department in Taiwan During the COVID-19 Pandemic: Retrospective Feasibility Study.

BACKGROUND: Frontline health care workers, including physicians, are at high risk of contracting coronavirus disease (COVID-19) owing to their exposure to patients suspected of having COVID-19. OBJECTIVE: The aim of this study was to evaluate the benefits and feasibility of a double triage and telemedicine protocol in improving infection control in the emergency department (ED). METHODS: In this retrospective study, we recruited patients aged ≥20 years referred to the ED of the National Taiwan University Hospital between March 1 and April 30, 2020. A double triage and telemedicine protocol was developed to triage suggested COVID-19 cases and minimize health workers' exposure to this disease. We categorized patients attending video interviews into a telemedicine group and patients experiencing face-to-face interviews into a conventional group. A questionnaire was used to assess how patients perceived the quality of the interviews and their communication with physicians as well as perceptions of stress, discrimination, and privacy. Each question was evaluated using a 5-point Likert scale. Physicians' total exposure time and total evaluation time were treated as primary outcomes, and the mean scores of the questions were treated as secondary outcomes. RESULTS: The final sample included 198 patients, including 93 cases (47.0%) in the telemedicine group and 105 cases (53.0%) in the conventional group. The total exposure time in the telemedicine group was significantly shorter than that in the conventional group (4.7 minutes vs 8.9 minutes, P<.001), whereas the total evaluation time in the telemedicine group was significantly longer than that in the conventional group (12.2 minutes vs 8.9 minutes, P<.001). After controlling for potential confounders, the total exposure time in the telemedicine group was 4.6 minutes shorter than that in the conventional group (95% CI -5.7 to -3.5, P<.001), whereas the total evaluation time in the telemedicine group was 2.8 minutes longer than that in the conventional group (95% CI -1.6 to -4.0, P<.001). The mean scores of the patient questionnaire were high in both groups (4.5/5 to 4.7/5 points). CONCLUSIONS: The implementation of the double triage and telemedicine protocol in the ED during the COVID-19 pandemic has high potential to improve infection control.

Early percutaneous cholecystostomy versus antibiotic treatment for mild and moderate acute cholecystitis: A retrospective cohort study.

BACKGROUND: Percutaneous cholecystostomy (PC) is an effective treatment for severe acute cholecystitis (AC). Guidelines recommend PC as rescue therapy for patients with mild or moderate AC who do not receive emergent cholecystectomy. This study aims to investigate whether PC could be a first-line treatment for these patients. METHODS: Adult patients admitted through the emergency department between October 2004 and December 2013 were retrospectively reviewed. Patients with mild or moderate AC who did not undergo emergent cholecystectomy were included. Early PC was defined as a PC tube inserted within 24 h of diagnosis. The outcomes were compared between patients who received antibiotics plus early PC (early PC group) and those who received antibiotic treatment alone (antibiotic group). RESULTS: A total of 698 patients were included. The mean age was 63.4 years. There were 171 patients in the early PC group and 527 patients in the antibiotic group. Multivariable logistic regression analyses indicated that early PC was significantly associated with a decreased rate of prolonged fever (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.16-0.57; p < 0.001). Early PC also correlated with both increased short-term (OR, 15.95; 95% CI, 5.73-44.38; p < 0.001) and long-term treatment success (OR, 4.27; 95% CI, 2.55-7.15; p < 0.001). CONCLUSION: For patients with mild/moderate AC without emergent cholecystectomy, early PC might expedite sepsis resolution and improve the treatment success rate compared with antibiotic treatment alone. This result should be deemed as hypothesis-generating and should be examined in a randomized controlled trial.

Administration of Hypertonic Solutions for Hemorrhagic Shock: A Systematic Review and Meta-analysis of Clinical Trials.

BACKGROUND: Several clinical trials on hypertonic fluid administration have been completed, but the results have been inconclusive. The objective of this study is to summarize current evidence for treating hypovolemic patients with hypertonic solutions by performing a systematic review and meta-analysis. METHODS: Major electronic databases were searched from inception through June 2014. We included only randomized controlled trials involving hemorrhagic shock patients treated with hypertonic solutions. After screening 570 trials, 12 were eligible for the final analysis. Pooled effect estimates were calculated with a random effect model. RESULTS: The 12 studies included 6 trials comparing 7.5% hypertonic saline (HS) with 0.9% saline or Ringer's lactate solution and 11 trials comparing 7.5% hypertonic saline with dextran (HSD) with isotonic saline or Ringer's lactate. Overall, there were no statistically significant survival benefits for patients treated with HS (relative risk [RR], 0.96; 95% confidence interval [CI], 0.82-1.12) or HSD (RR, 0.92; 95% CI, 0.80-1.06). Treatment with hypertonic solutions was also not associated with increased complications (RR, 1.03; 95% CI, 0.78-1.36). Subgroup analysis on trauma patients in the prehospital or emergency department settings did not change these conclusions. There was no evidence of significant publication bias. Meta-regression analysis did not find any significant sources of heterogeneity. CONCLUSIONS: Current evidence does not reveal increased mortality when the administration of isotonic solutions is compared to HS or HSD in trauma patients with hemorrhagic shock. HS or HSD may be a viable alternative resuscitation fluid in the prehospital setting. Further studies are needed to determine the optimum volume and regimen of intravenous fluids for the treatment of trauma patients.

Statin treatment is associated with a decreased risk of active tuberculosis: an analysis of a nationally representative cohort.

BACKGROUND: Epidemiological data suggest that statins improve the clinical outcome of respiratory infections. We sought to examine whether statin therapy decreases the risk of active TB. METHODS: We conducted a nested case-control study on data obtained from a national health insurance claims database between 1999 and 2011. The use of statins was classified as current, recent, past or chronic use. Three conditional logistic regression models were used to estimate the incidence rate ratios (RRs). The first assessed the effect of statin use without further adjustment; the second adjusted (individually) for 75 potential confounders; and the third adjusted for the Disease Risk Score (DRS). RESULTS: A total of 8098 new TB cases and 809 800 control patients were examined. All four types of statin users showed a decreased risk of active TB. Chronic use (>90 days in a calendar year) of statins was associated with the lowest unadjusted risk of TB (RR 0.74; 95% CI 0.63 to 0.87). The protective effect of active TB remained after adjusting for individual confounders (RR 0.66; 95% CI 0.56 to 0.78) and after DRS adjustment (RR 0.62; 95% CI 0.53 to 0.72). The effect estimates obtained for chronic and current use of statins were very similar. We also found that the active TB protection increased with increasing length of statin prescription. CONCLUSIONS: We found that statin therapy was associated with a decreased risk of active TB, and the length of statin therapy affected the TB protection. Given the observational nature of this study, the protective effect against active TB must be confirmed in future randomised trials.

Periarrest Modified Early Warning Score (MEWS) predicts the outcome of in-hospital cardiac arrest.

BACKGROUND/PURPOSE: The Modified Early Warning Score (MEWS) reflects the physiological changes of cardiac arrest and has been used in identifying patient deterioration. Physiological reserve capacity is an important outcome predictor, but is seldom reported due to recording limitations in cardiac arrest patients. The aim of the study was to evaluate whether periarrest MEWS could be a further prognostic factor in in-hospital cardiac arrest. METHODS: This was a retrospective cohort study of nontrauma adult patients who had experienced in-hospital cardiac arrest during emergency department stays at an urban, 2600-bed tertiary medical center in Taiwan from February 2011 to July 2013. Data regarding patients' characteristics, Charlson Comorbidity Score, MEWS score before events, mode of arrest, and outcome details were extracted following the Utstein guidelines for uniform reporting of cardiac arrest. RESULTS: During the 30-month period, 234 patients suffered in-hospital cardiac arrest during emergency department stays, and 99 patients with periarrest MEWS were included in the final analysis. The MEWS at triage did not differ significantly between survival-to-discharge and mortality groups (3.42 ± 2.2 vs. 4.02 ± 2.65, p = 0.811). Periarrest MEWS was lower in the survival-to-discharge group (4.41 ± 2.28 vs. 5.82 ± 2.84, p = 0.053). In multivariate logistic regression analysis, periarrest MEWS was an independent predictors for survival to discharge. A rise in periarrest MEWS reduced the chance of survival to discharge by 0.77-fold (95% confidence interval: 0.60-0.97, p = 0.028). CONCLUSION: The simplest MEWS system not only can be used as a prevention measure, but the periarrest MEWS could also be considered as an independent predictor of mortality after in-hospital cardiac arrest.

Active compression-decompression resuscitation and impedance threshold device for out-of-hospital cardiac arrest: a systematic review and metaanalysis of randomized controlled trials.

OBJECTIVE: Active compression-decompression resuscitation and impedance threshold device are proposed to improve survival of patients of cardiac arrest by lowering intrathoracic pressure and increasing cardiac output. The results of clinical studies of active compression-decompression resuscitation or impedance threshold device were controversial. This metaanalysis pooled results of randomized controlled trials to examine whether active compression-decompression resuscitation or impedance threshold device would improve outcomes of out-of-hospital cardiac arrest in comparison with standard cardiopulmonary resuscitation and to explore factors modifying these effects. DATA SOURCES: Medline and Embase were searched from inception to September 2013. STUDY SELECTION: Randomized controlled trials comparing active compression-decompression resuscitation or impedance threshold device with standard cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients were selected. There were no restrictions for language, population, or publication year. DATA EXTRACTION: Data on study characteristics, including patients, intervention details, and outcome measures, were independently extracted. DATA SYNTHESIS: Fifteen trials, including 16,088 patients, were identified from 331 potentially relevant references. Return of spontaneous circulation was designated as the primary outcome. The pooled result showed no significant improvement in return of spontaneous circulation by active compression-decompression resuscitation or impedance threshold device in comparison with standard cardiopulmonary resuscitation (risk ratio, 1.04; 95% CI, 0.93-1.16; I, 46%). There was also no significant difference in survival or neurologic outcome at hospital discharge between active compression-decompression resuscitation or impedance threshold device and standard cardiopulmonary resuscitation. The meta-regression indicated that this minimal effect might be modified by two important prognostic factors, that is, witnessed status and response time. After adjustment of these two factors, impedance threshold device appeared to improve return of spontaneous circulation, which could be further augmented by advanced airway use. CONCLUSIONS: Active compression-decompression resuscitation or impedance threshold device seemed not to improve return of spontaneous circulation in out-of-hospital cardiac arrest patients. The meta-regression indicated two probable prognostic factors causing this minimal effect. Nonetheless, these findings referred to differences between trials and could not necessarily be extrapolated to individual patients. The individual patient-level extrapolation may need to be solved by a future randomized controlled trial.

Liberal versus restricted fluid resuscitation strategies in trauma patients: a systematic review and meta-analysis of randomized controlled trials and observational studies*.

OBJECTIVE: Hemorrhage is responsible for most deaths that occur during the first few hours after trauma. Animal models of trauma have shown that restricting fluid administration can reduce the risk of death; however, studies in patients are difficult to conduct due to logistical and ethical problems. To maximize the value of the existing evidence, we performed a meta-analysis to compare liberal versus restricted fluid resuscitation strategies in trauma patients. DATA SOURCES: Medline and Embase were systemically searched from inception to February 2013. STUDY SELECTION: We selected randomized controlled trials and observational studies that compared different fluid administration strategies in trauma patients. There were no restrictions for language, population, or publication year. DATA EXTRACTION: Four randomized controlled trials and seven observational studies were identified from 1,106 references. One of the randomized controlled trials suffered from a high protocol violation rate and was excluded from the final analysis. DATA SYNTHESIS: The quantitative synthesis indicated that liberal fluid resuscitation strategies might be associated with higher mortality than restricted fluid strategies, both in randomized controlled trials (risk ratio, 1.25; 95% CI, 1.01-1.55; three trials; I(2), 0) and observational studies (odds ratio, 1.14; 95% CI, 1.01-1.28; seven studies; I(2), 21.4%). When only adjusted odds ratios were pooled for observational studies, odds for mortality with liberal fluid resuscitation strategies increased (odds ratio, 1.19; 95% CI, 1.02-1.38; six studies; I(2), 26.3%). CONCLUSIONS: Current evidence indicates that initial liberal fluid resuscitation strategies may be associated with higher mortality in injured patients. However, available studies are subject to a high risk of selection bias and clinical heterogeneity. This result should be interpreted with great caution.

Prognostic determinants of community-acquired bloodstream infection in type 2 diabetic patients in ED.

OBJECTIVES: The objective of the study is to describe the epidemiology and outcome of community-acquired bloodstream infection (BSI) in type 2 diabetic patients in emergency department (ED). METHODS: All patients admitted to the ED of the university hospital from June 2010 to June 2011 with a history of type 2 diabetes mellitus and microbiologically documented BSI were retrospectively enrolled. Demographic characteristics, Charlson comorbidity index, antibiotic therapy, clinical severity, microbiological etiology, and diabetes-related complications were recorded in a standardized form. The major outcome measure was 30-day survival. χ2 Or Student t test was used for univariate analysis, and Cox proportional hazards models were used for multivariate analysis. RESULTS: Among 250 enrolled emergency patients with BSI, the overall 30-day mortality rate was 15.5%. Twenty-seven patients (10.7%) developed diabetic ketoacidosis (DKA), and 22 patients (8.8%) developed hyperosmolar hyperglycemic state. On univariate analysis, DKA rather than hyperosmolar hyperglycemic state was associated with adverse outcome. Other risk factors include higher mean glycated hemoglobin level, presence of underlying malignancy, long-term use of steroids, lower respiratory tract infection, and higher Charlson scores. Multivariate analysis identified 3 independent risk factors for early mortality when severity, comorbidity, age, and sex were under control: DKA (hazard ratio, 3.89; 95% confidence interval, 1.6-8.9), inappropriate antibiotics (2.25, 1.05-4.82), and chronic use of steroid (3.89, 1.1-13.2). CONCLUSION: In type 2 diabetic patients with BSI, a substantial proportion of patients developed DKA. This condition was probably underrecognized by clinicians and constituted an independent risk factor for short-term mortality. Other identified risk factors are potentially correctable and may allow preventive efforts to individuals at greatest potential benefit.

An observational study of extracorporeal CPR for in-hospital cardiac arrest secondary to myocardial infarction.

OBJECTIVE: To determine the effects of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with in-hospital cardiac arrest (IHCA) due to acute myocardial infarction (AMI). METHODS: IHCA patients due to AMI undergoing CPR between 1 January 2006 and 1 July 2010 were analysed retrospectively. We compared the survival outcome of 43 patients who received ECPR with that of 23 patients who underwent conventional CPR. RESULTS: The survival rate was 34.9% for patients who received ECPR and 21.8% for those who received conventional CPR (p=0.4). Increased survival rates to hospital discharge were seen in patients with ST segment elevation (p<0.01), or had initial rhythm of ventricular tachycardia/ventricular fibrillation (VT/VF) during resuscitation (p=0.031). CONCLUSIONS: ECPR may improve survival in cardiac arrest patients who have a ST segment elevation or initial rhythm of VT/VF myocardial infarction.

Preliminary experience of sandwich repair technique: a new method of laparoscopic splenorraphy for high-grade splenic injuries.

BACKGROUND: Laparoscopic splenectomy has been used safely for patients with blunt splenic trauma and failed nonoperative management. Reports of using laparoscopic splenorraphy for spleen salvage were fewer and mainly limited to lower grades of injuries. No study has focused on the role of laparoscopic splenorraphy in the treatment of patients with high grades of splenic injuries. METHODS: Medical records of 15 patients with high grades of splenic injuries that required an operation for failed nonoperative management were retrospectively reviewed. They underwent a new technique of sandwich repair laparoscopically for spleen salvage by 3 surgeons who had adequate training in laparoscopy for trauma. Preoperative parameters, sandwich repair technique, perioperative parameters, and postoperative outcomes were evaluated. RESULTS: Fourteen of the 15 (93.3%) patients underwent the technique successfully with 1 patient converting to laparotomy. The median (interquartile range) time to reach hemostasis was 30.0 (26.0-40.0) minutes, and the median overall operation time was 135.0 (120.0-165.0) minutes. Median blood loss amount was 1300.0 (750.0-2300.0) mL. The median length of hospital stay was 8.0 (7.0-11.0) days, and the intensive care unit stay was 2.0 (0.0-4.0) days. No mortality was noted. No rebleeding, total splenic infarction, or intra-abdominal abscess was noted during 3-month follow-up after the operation. CONCLUSIONS: The preliminary results show that laparoscopic splenorraphy by the "sandwich repair technique" is feasible and safe for patients with high-grade splenic injuries.

Sepsis increases the risk of in-hospital cardiac arrest: a population-based analysis.

Sepsis patients have a high risk of developing in-hospital cardiac arrest (IHCA), which portends poor survival. However, little is known about whether the increased incidence of IHCA is due to sepsis itself or to comorbidities harbored by sepsis patients. We conducted a retrospective population-based cohort study comprising 20,022 patients admitted with sepsis to hospitals in Taiwan using the National Health Insurance Research Database (NHIRD). We constructed three non-sepsis comparison cohorts using risk set sampling and propensity score (PS) matching. We used univariate conditional logistic regression to evaluate the risk of IHCA and associated mortality. We identified 12,790 inpatients without infection (matched cohort 1), 12,789 inpatients with infection but without sepsis (matched cohort 2), and 10,536 inpatients with end-organ dysfunction but without sepsis (matched cohort 3). In the three PS-matched cohorts, the odds ratios (OR) for developing ICHA were 21.17 (95% CI 17.19, 26.06), 18.96 (95% CI: 15.56, 23.10), and 1.23 (95% CI: 1.13, 1.33), respectively (p < 0.001 for all ORs). In conclusion, in our study of inpatients across Taiwan, sepsis was independently associated with an increased risk of IHCA. Further studies should focus on identifying the proxy causes of IHCA using real-time monitoring data to further reduce the incidence of cardiopulmonary insufficiency in patients with sepsis.

The impact of adding clinical assistants on patient waiting time in a crowded emergency department.

BACKGROUND: Emergency department (ED) crowding causes prolonged waiting times. OBJECTIVE: To evaluate the potential benefit of introducing clinical assistants to a busy and crowded ED. METHODS: This was a retrospective cohort study at an urban, academic tertiary medical centre. We introduced one clinical assistant to each ED shift. The main task of clinical assistants was managing the flow of incoming ED patients. The case group consisted of all adult non-trauma emergency patients during the case period from 1 September to 30 November 2008. The first control group consisted of all adult non-trauma emergency patients between 1 June and 31 August 2008 and the second control group consisted of all patients treated between 1 September and 30 November 2007. The primary outcome was the 'waiting time', defined as the time from triage to the time of the first medical order entered into the computer system. The secondary outcome was the number of adult non-trauma emergency patients who left the ED without being seen. RESULTS: There were 12 257 cases and 25 950 controls. The mean and median waiting times were significantly shorter in the case group. The mean waiting time of the case group was 20.86 min, which was 4.51 min (17.8%) shorter than that of the first control group and 7.41 min (26.2%) shorter than that of the second control group. The median waiting time of the case group was also significantly shorter than those of the control groups. The number of the patients who left without being seen was significantly smaller in the case period. CONCLUSIONS: In a busy and crowded ED, the introduction of clinical assistants to an existing emergency health service effectively reduces patient waiting times and decreases the number of patients leaving without being seen.