Early Identification of Sepsis-Induced Acute Kidney Injury by Using Monocyte Distribution Width, Red-Blood-Cell Distribution, and Neutrophil-to-Lymphocyte Ratio.

Sepsis-induced acute kidney injury (AKI) is a common complication in patients with severe illness and leads to increased risks of mortality and chronic kidney disease. We investigated the association between monocyte distribution width (MDW), red-blood-cell volume distribution width (RDW), neutrophil-to-lymphocyte ratio (NLR), sepsis-related organ-failure assessment (SOFA) score, mean arterial pressure (MAP), and other risk factors and sepsis-induced AKI in patients presenting to the emergency department (ED). This retrospective study, spanning 1 January 2020, to 30 November 2020, was conducted at a university-affiliated teaching hospital. Patients meeting the Sepsis-2 consensus criteria upon presentation to our ED were categorized into sepsis-induced AKI and non-AKI groups. Clinical parameters (i.e., initial SOFA score and MAP) and laboratory markers (i.e., MDW, RDW, and NLR) were measured upon ED admission. A logistic regression model was developed, with sepsis-induced AKI as the dependent variable and laboratory parameters as independent variables. Three multivariable logistic regression models were constructed. In Model 1, MDW, initial SOFA score, and MAP exhibited significant associations with sepsis-induced AKI (area under the curve [AUC]: 0.728, 95% confidence interval [CI]: 0.668-0.789). In Model 2, RDW, initial SOFA score, and MAP were significantly correlated with sepsis-induced AKI (AUC: 0.712, 95% CI: 0.651-0.774). In Model 3, NLR, initial SOFA score, and MAP were significantly correlated with sepsis-induced AKI (AUC: 0.719, 95% CI: 0.658-0.780). Our novel models, integrating MDW, RDW, and NLR with initial SOFA score and MAP, can assist with the identification of sepsis-induced AKI among patients with sepsis presenting to the ED.

Predictors of 72-h unscheduled return visits with admission in patients presenting to the emergency department with abdominal pain.

BACKGROUND: Unscheduled return visits (URVs) to the emergency department (ED) constitute a crucial indicator of patient care quality. OBJECTIVE: We aimed to analyze the clinical characteristics of patients who visited the ED with abdominal pain and to identify the risk of URVs with admission (URVAs) from URVs without admission (URVNAs). METHODS: This retrospective study included adult patients who visited the ED of Taipei Medical University Hospital because of abdominal pain and revisited in 72 h over a 5-year period (January 1, 2014, to December 31, 2018). Multivariable logistic regression analysis was employed to identify risk factors for URVAs and receiver operating characteristic (ROC) curve analysis was performed to determine the efficacy of variables predicting URVAs and the optimal cut-off points for the variables. In addition, a classification and regression tree (CART)-based scoring system was used for predicting risk of URVA. RESULTS: Of 702 eligible patients with URVs related to abdominal pain, 249 had URVAs (35.5%). In multivariable analysis, risk factors for URVAs during the index visit included execution of laboratory tests (yes vs no: adjusted odds ratio [AOR], 4.32; 95% CI 2.99-6.23), older age (≥ 40 vs < 40 years: AOR, 2.10; 95% CI 1.10-1.34), Level 1-2 triage scores (Levels 1-2 vs Levels 3-5: AOR, 2.30; 95% CI 1.26-4.19), and use of ≥ 2 analgesics (≥ 2 vs < 2: AOR, 2.90; 95% CI 1.58-5.30). ROC curve analysis results revealed the combination of these 4 above variables resulted in acceptable performance (area under curve: 0.716). The above 4 variables were used in the CART model to evaluate URVA propensity. CONCLUSIONS: Elder patients with abdominal pain who needed laboratory workup, had Level 1-2 triage scores, and received ≥ 2 doses of analgesics during their index visits to the ED had higher risk of URVAs.

Periappendiceal fat-stranding models for discriminating between complicated and uncomplicated acute appendicitis: a diagnostic and validation study.

BACKGROUND: Recent studies have reported promising outcomes of non-operative treatment for uncomplicated appendicitis; however, the preoperative prediction of complicated appendicitis is challenging. We developed models by incorporating fat stranding (FS), which is commonly observed in perforated appendicitis. MATERIAL AND METHODS: We reviewed the data of 402 consecutive patients with confirmed acute appendicitis from our prospective registry. Multivariate logistic regression was performed to select clinical and radiographic factors predicting complicated acute appendicitis in our model 1 (involving backward elimination) and model 2 (involving stepwise selection). We compared c statistics among scoring systems developed by Bröker et al. (in J Surg Res 176(1):79-83. https://doi.org/10.1016/j.jss.2011.09.049 , 2012), Imaoka et al. (in World J Emerg Surg 11(1):1-5, 2016), Khan et al. (in Cureus. https://doi.org/1010.7759/cureus.4765 , 2019), Kim et al. (in Ann Coloproctol 31(5):192, 2015), Kang et al. (in Medicine 98(23): e15768, 2019), Atema et al. (in Br J Surg 102(8):979-990. https://doi.org/10.1002/bjs.9835 , 2015), Avanesov et al. (in Eur Radiol 28(9):3601-3610, 2018), and Kim et al. (in Abdom Radiol 46:1-12, 2020). Finally, we examined our models by performing the integrated discrimination improvement (IDI) test. RESULTS: Among enrolled patients, 64 (15.9%) had complicated acute appendicitis. We developed new 10-point scoring models by including the following variables: C-reactive protein, neutrophil to lymphocyte ratio, and computed tomography features of FS, ascites, and appendicolith. A cutoff score of ≥ 6 exhibited a high sensitivity of 82.8% and a specificity of 82.8% for model 1 and 81.3% and 82.3% for model 2, respectively, with c statistics of 0.878 (model 1) and 0.879 (model 2). Compared with the model developed by Bröker et al. which included C-reactive protein and the abdominal pain duration (c statistic: 0.778), the models developed by Atema et al. (c statistic: 0.826, IDI: 5.92%, P = 0.0248), H.Y Kim et al. (c statistics: 0.838, IDI: 13.82%, P = 0.0248), and our two models (IDI: 18.29%, P < 0.0001) demonstrated a significantly higher diagnostic accuracy. CONCLUSION: Our models and the scoring systems developed by Atema et al. and Kim et al. were validated to have a high diagnostic accuracy; moreover, our models included the lowest number of variables.

Efficacy of gabexate mesilate in preventing post endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis of randomized clinical trials.

BACKGROUND/PURPOSE: The evidence provided by syntheses of the preventative effects of gabexate mesilate against pancreatitis among patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is limited and highly heterogeneous. To enhance the understanding of this topic, this study aimed to provide overview of gabexate mesilate on preventing post ERCP pancreatitis (PEP) by synthesizing all relevant randomized controlled trials (RCTs). METHODS: We searched three databases for relevant RCTs. Two authors independently extracted data of pancreatitis incidence after ERCP, abdominal pain within 48 hours, and hyperamylasemia for quality assessment and meta-analysis. RESULTS: Thirteen RCTs with 3718 patients undergoing ERCP met the eligibility criteria and were included. The results revealed that the use of gabexate mesilate led to lower PEP (Peto odds ratio: 0.66, 95% confidence interval [CI]: 0.49 to 0.89), especially in the subgroup of gabexate mesilate infusion starting more than 30 min (Risk ratio: 0.45, 95% CI: 0.29 to 0.72). CONCLUSION: The present synthesis found that gabexate mesilate could be an option of prophylactic treatment of pancreatitis for patients undergoing ERCP, and reveals that it is favorable to administer it starting 30 min before the ERCP. This evidence may improve the clinical prevention of PEP.

Locational effect on automated external defibrillator use and association of age with on-site return of spontaneous circulation.

BACKGROUND: Emergency medical services (EMSs) are used by approximately 383,000 patients with out-of-hospital sudden cardiac arrest (SCA) in the United States. Hence, it is crucial to implement automated external defibrillator (AED) programs to prepare responders for an SCA emergency. Taiwanese pass legislature to enforce AED installation in 8 mandatory areas since 2013. Our study investigated the efficacy of the policy regarding AED installation. MATERIALS AND METHODS: We collected data of patients who had sudden cardiac arrest (SCA) in pre-hospital settings, and received resuscitative efforts, including cardiopulmonary resuscitation or defibrillation with AEDs. The data were from July 11, 2013 to July 31, 2015. In total, 209 adult patients were documented by on-site caregivers of different facilities, and a report was mailed to the central health and welfare unit. RESULTS: Schools, large-scale gathering places, and special institutions used AEDs the most, accounting for 33 (15.3%) cases. From non-mandatory AED areas, long-term care facilities had the maximum cases of AED use (32 cases; 14.9%). With commuting stations as a reference, long-distance transport had the lowest odds ratio (OR) of 0.481 (95% confidence interval [CI], 0.24-0.962). The OR for schools, large-scale gathering places, and special institutions was 4.474 (95% CI: 2.497-8.015). Regarding failure of return of spontaneous circulation (ROSC), the OR for the ≥80-year age group was higher than that for the 20-39-year age group. CONCLUSIONS: The policy regarding the legislation to install AEDs in mandatory areas improved AED accessibility. Elderly patients aged ≥80 years have a higher rate of ROSC failure.

Impact of a 3-Day High-Altitude Trek on Xue Mountain (3886 m), Taiwan, on the Emotional States of Children: A Prospective Observational Study.

AIMS: Changes in emotions associated with mountain treks have rarely been reported. This study examined emotional state changes in sixth-grade elementary school students before and after a 3-day high-altitude mountain trek from the trailhead (2140 m) to Xue Mountain (3886 m) in Taiwan. METHODS: In June 2011, 201 students participated in the trek. The round-trip distance was 21.8 km. The age, gender, blood group, and family configuration of the participants were documented before the trek. A 36-item short-form survey instrument, including the Mood and Anxiety Symptom Questionnaire and the Positive and Negative Affect Scale for Children, was used to evaluate the participants' emotional states (happiness, anticipation, sadness, and anger). The participants answered the questionnaires 1 month before and 1 week after the trek. A Likert scale was used to evaluate individual items (range 1-4; from strongly disagree to strongly agree). We calculated scores for each index before and after the trek. The incidence and presentation of acute mountain sickness (AMS) among the participants was also studied and published previously. RESULTS: In total, 187 (112 boys and 75 girls) participants (mean age 11.9 ± 0.4 years) completed the trek and the survey. The sadness and anger scores (negative emotions) were significantly lower after than before the trek (39.5 vs. 36.6; p < 0.01). The happiness and anticipation scores (positive emotions) before and after the trek did not differ significantly (49.9 vs. 48.9; p = 0.11). No participant used AMS prophylaxis, while 78 participants met the AMS criteria. Negative emotions decreased more in those with AMS than without AMS (-4.6 vs. -1.8; p = 0.04), and the use of medications or acetazolamide did not alter the emotions. CONCLUSIONS: A 3-day high-altitude mountain trek can reduce children's negative emotions. Negative emotions decreased more in those with AMS, whereas medications or acetazolamide did not alter their emotions.

Assessment of the clinical efficacy of the heart spectrum blood pressure monitor for diagnosis of atrial fibrillation: An unblinded clinical trial.

Atrial fibrillation (AF) is the most common arrhythmia. The most common diagnostic method, 12-lead electrocardiogram (ECG), can record episodes of arrhythmia from which the type and severity can be determined. The Heart Spectrum Blood Pressure Monitor (P2; OSTAR Meditech Corp., New Taipei City, Taiwan) is used to measure cardiovascular pressure change with fast Fourier transform (FFT) analysis to obtain heart rate frequency variability and accurate blood pressure data. We compared the diagnostic efficacy of the Heart Spectrum Blood Pressure Monitor to a 12-lead ECG (gold standard) for patients with AF. Three measurement methods were used in this study to analyze the heart index and compare the results with simultaneous 12-lead ECG: blood pressure; mean arterial pressure, which was calculated from individual blood pressure as a constant pressure; and a constant pressure of 60 mmHg. The physician used a 12-lead ECG and the Heart Spectrum Blood Pressure Monitor simultaneously. The Heart Spectrum Blood Pressure Monitor used FFT analysis to diagnose AF, and the findings were compared to the 12-lead ECG readings. This unblinded clinical trial was conducted in the emergency department of Taipei Medical University Hospital. Twenty-nine subjects with AF and 33 without AF aged 25 to 97 y (mean, 63.5 y) were included. Subjects who were exposed to high-frequency surgical equipment during testing, those with cardiac pacemakers or implantable defibrillators, and pregnant women were excluded. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 97%, 97%, 97%, and 97%, respectively, for method 1; 90%, 100%, 100%, and 91%, respectively, for method 2; and 100%, 94%, 94%, and 100%, respectively, for method 3. The sensitivity, specificity, PPV, and NPV for both methods ranged between 90% and 100%, indicating that the Heart Spectrum Blood Pressure Monitor can be effectively applied for AF detection.

Smartphone transmission of electrocardiography images to reduce time of cardiac catheterization laboratory activation.

BACKGROUND: This retrospective study evaluated the use of a smartphone application to facilitate communication between the emergency physician (EP) and the interventional cardiologist in order to minimize the time to cardiac catheterization laboratory (CCL) activation and time to percutaneous coronary intervention (PCI). METHODS: We retrospectively collected pertinent time-points in the management of patients diagnosed with STEMI in the emergency department and their outcome. The primary outcome was the reduction in the time from ECG interpretation to CCL activation after the implementation of a smartphone application. A total of 84 patients were enrolled. Patients' electrocardiography (ECG) were described by traditional verbal communication via telephone (group 1, n = 40) and by additional smartphone transmission of ECG images to an interventional cardiologist (group 2, n = 44). Relevant time-points were recorded for analysis. RESULTS: The time from ECG interpretation to CCL activation was reduced from 28.3 ± 4.1 in group 1 to 17.6 ± 2.3 min in group 2 (p = 0.03). Similarly, the time from ECG interpretation to balloon inflation time (D2B) decreased from 93.1 to 73.4 min (p = 0.025). Comparing group 2 with group 1, the door to balloon (D2B) time improved to 90.4 ± 9.8 from 119.3 ± 16.3 min (p = 0.23), the proportion of patients with a D2B time less than 90 min increased to 70.5% from 52.5% (p = 0.09), and the mortality rate decreased to 2.2% from 12.5% (p = 0.07). CONCLUSION: The additional use of a smartphone application to transmit ECG information to interventional cardiologists by EPs facilitated communication and reduced the decision time to CCL activation and percutaneous intervention.

Development of single-vector Tet-on inducible systems with high sensitivity to doxycycline.

Single-vector Tet-on systems were developed to enable the tight regulation of transgenes in mammalian cells with a low dosage of doxycycline. Both the regulatory and the responsive units were integrated in a single vector and separated by a short DNA segment (214 bp). In the developed single-vector Tet-on systems, a high level of expression of the transgene can be induced by doxycycline at a concentration of as low as 1 ng/ml, which is 500-1,000 times lower than that usually utilized in other Tet-on systems. The single-vector Tet-on system developed here exhibited 3.5-10.8 times greater inducibility of the transgene in response to doxycycline than did a dual-vector system from a commercial source. Further studies indicate that the basal activity of Tet-on systems depends greatly on the strength of the promoter that controls the transactivator. The basal activity of Tet-on systems was high when the transactivator that was directed by the human cytomegalovirus promoter, and it was almost undetectable when the transactivator was placed under the control of a moderate strength mouse mammary tumor virus promoter. Moreover, the introduction of selectable markers allows the developed single-vector Tet-on systems to facilitate the generation of conditional transgenic cells and animals with high inducibility, low basal activity and detrimental effects of the long-term administration of doxycycline.

Prognostic value of QT parameters in patients with acute hemorrhagic stroke: a prospective evaluation with respect to mortality and post-hospitalization bed confinement.

BACKGROUND: This prospective study was performed to evaluate the prognostic prediction value of QT parameters and clinical characteristics exhibited by patients with acute hemorrhagic stroke at the time of presenting to the emergency department (ED). METHODS: One hundred and sixty-six patients admitted to the ED of Taipei Veterans General Hospital from January 2006 to October 2006 because of acute hemorrhagic stroke were enrolled. Glasgow Coma Scale (GCS) scores between 3 and 8 were taken to indicate severe neurologic deficits. QT parameters (QT max, QT min, QT dispersion, QTc max, QTc min, QTc dispersion) and other pertinent clinical variables were determined on admission. Logistic regression model was applied to evaluate prognostic prediction values. RESULTS: Mortality was higher among stroke patients with low GCS scores (p < 0.01). Leukocyte counts and systolic blood pressures were significantly higher among non-surviving patients (p = 0.04). No association was found between QT parameters and mortality (all p > 0.05). Among survivors, post-hospitalization bed confinement was required for those significantly older (p = 0.01) and those with higher QT max and QTc max values in multivariate analyses (p = 0.04 and p < 0.01, respectively). CONCLUSION: Low GCS scores, increased leukocyte counts, and elevated systolic blood pressures predict increased mortality for subjects with acute hemorrhagic stroke. Advanced age and prolongations in QTc and QT max at the time of stroke predicted poor functional recovery for these subjects.

The effect of different relieving methods on the outcome of out-of-hospital cardiac arrest patients with nontraumatic hemopericardium in the ED.

AIMS: This study aimed to assess the impact of different methods of draining nontraumatic hemopericardium on outcome from patients with out-of-hospital cardiac arrest (OHCA), identify independent predictors of return of spontaneous circulation (ROSC), and examine the ineffective rate of decompression based on subxiphoid pericardiotomy (SP) and percutaneous pericardial catheter drainage (PCD). METHODS: Adult patients with OHCA who presented to the ED between May 1, 2000, and October 30, 2006, with moderate to massive nontraumatic hemopericardium were recruited and stratified into 4 groups according to the relieving methods of hemopericardium. Charts were reviewed for various demographic data, resuscitation records, management, and outcome. Patient outcome was recorded as survival to hospital discharge and ROSC, as primary end points. Effective decompression was recorded as a secondary end point. We compared the outcome between the groups. RESULTS: A total of 1491 OHCA resuscitation records were prospective collected. There were 23 OHCA patients with moderate to massive nontraumatic hemopericardium. The overall ROSC rate was 39.1% (9/23). There was a clear difference in the ROSC rate between 4 groups (P < .05). The overall rate of survival to hospital discharge was 4.3% (1/23). There was no significant difference in the rate of survival to hospital discharge between the groups. Relieving methods was an independent predictor of ROSC in OHCA patients with nontraumatic hemopericardium (odds ratio, 0.17; 95% confidence interval, 0.4-0.70). There was a significant statistical difference in adequate relief of hemopericardium based on SP and PCD (P < .01). CONCLUSION: The early effective decompression method is associated with an increased rate of ROSC for OHCA patients with nontraumatic hemopericardium. Subxiphoid pericardiotomy has a better effective decompression of hemopericardium than PCD.

A differential diagnosis in postural headache: herniation of a giant posterior fossa arachnoid cyst.

The causes of postural headache are usually associated with low intracranial pressure. However, there are still rare causes of posture-related headaches that are not associated with low intracraninal pressure and caused by pathologic processes. Herein, we report a patient with giant posterior fossaarachnoid cyst herniating below the level of foramen magnum presenting with postural headache, which has not been described previously in the literature. Emergency physicians should be aware that posterior fossa arachnoid cysts should be considered one of the differential diagnoses in patients with postural headache.

Photophysical and electrochemical properties of 1,7-diaryl-substituted perylene diimides.

Substituent effects on the photophysical and electrochemical properties of 1,7-diaryl-substituted perylene diimides (1,7-Ar(2)PDIs) have been carefully explored. Progressive red-shifts of the absorption and emission maxima were observed when the electron-donating ability of these substituents was increased. Linear Hammett correlations of 1/lambda(max) versus sigma(+) were observed in both spectral analyses. The positive slopes of the Hammett plots suggested that the electronic transitions carry certain amounts of photoinduced intramolecular charge-transfer (PICT) character from the aryl substituents to the perylene diimide core which leads to the reduction of the electron density on the substituents. The substituent electronic effects originated mainly from the perturbation of the core PDI HOMO energy level by the substituents. This conclusion was supported by PM3 analyses and confirmed by cyclic voltammetry experiments. More interestingly, the Ph(2)NC(6)H(4)-substituted PDI, 4i, showed an unusual dual-band absorption that spans from 450 to 750 nm. We tentatively assigned these two bands as the charge-transfer band and the PDI core absorption, respectively.