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

INTRODUCTION: Cognitive impairment (COIM) is a major challenge for healthcare systems and is associated with an increased risk of adverse outcomes in older people visiting emergency departments (EDs). Owing to global aging, both cognitive screening and comprehensive geriatric assessment (CGA) application in ED settings are developing areas of geriatric emergency medicine. Meanwhile, the association between clinical outcomes of COIM; cognitive impairment, no dementia (CIND); and dementia in the ED could be better investigated. Our study aims to identify individuals with COIM from older patients in the ED via CGA and to describe the association of CIND and dementia with prognosis in ED visits. METHODS: A prospective cross-sectional study was conducted in the ED of the Taipei Veterans General Hospital, a medical center located in Taipei, Taiwan, from August 2018 to November 2020. Patients aged ≥75 years with and without COIM were compared using data obtained from the CGAs conducted by trained nurses. RESULTS: A total of 823 older patients were enrolled in the study and underwent CGA. Of these, 463 (56.3%) were diagnosed with COIM, of which 292 (35.5%) were diagnosed with dementia; and 171 (20.8%), CIND. Between the no-COIM and COIM groups, the COIM group had a higher rate of hospital admission (p = 0.002) and mortality at 3 months (p < 0.05). Among the no-COIM, CIND, and dementia groups, ED disposition (p = 0.001) and the rate of revisit/readmission (p < 0.05) showed significant differences. In particular, the dementia group had a significantly higher rate of revisit/readmission as compared to the CIND group among the three groups. DISCUSSION/CONCLUSION: Older patients with COIM had a higher rate of hospital admission and mortality at the 3-month follow-up than older patients without COIM. Among the no-COIM, CIND, and dementia groups, patients with dementia had significantly increased risks of hospital admission and revisit/readmission. The early detection of COIM, and even dementia, could help ED physicians formulate strategies with geriatric specialists to improve mortality outcomes and revisit/readmission.

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

BACKGROUND: Infections are the most common complications among hospitalized severe burn patients. However, limited literature reports early effective predictors of bloodstream infections (BSI) among burn patients. This study aimed to identify cost-effective biomarkers and valuable clinical scoring systems in the emergency department (ED) for the prediction of subsequent BSI in mass burn casualties. METHODS: In 2015, a flammable cornstarch-based powder explosion resulted in 499 burn casualties in Taiwan. A total of 35 patients were admitted at Taipei Veterans General Hospital. These severe burn patients (median total body surface area [TBSA] 54%) were young and previously healthy. We assessed the potential of various parameters to predict subsequent BSI, including initial laboratory tests performed at the ED, TBSA, and multiple scoring systems. RESULTS: Fourteen patients (40.0%) had subsequent BSI. The most common causative pathogen was the Acinetobacter baumannii (Ab) group, mostly carbapenem resistant and associated with a poor outcome. The area under the receiver operating characteristic curve revealed that the revised Baux score, TBSA, and initial white blood cell count had excellent discrimination ability in predicting subsequent BSI (0.898, 0.889, and 0.821, respectively). The rate of subsequent BSI differed significantly at the cut-off points of revised Baux score >76, TBSA >55%, and WBC count >16,200/mm3. CONCLUSION: The initial WBC count at the ED, TBSA, and revised Baux score were good and cost-effective biomarkers for predicting subsequent BSI after burn injuries.

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

BACKGROUND/PURPOSE: Emergency air medical transport (EAMT) of patients in remote areas with neurological emergencies to higher-level facilities is an integral part of the regionalized healthcare system. EAMT is safe and feasible for head injuries. Debates persist on the high cost, safety, and risk of EAMT, thereby calling for alternatives. METHODS: We conducted a retrospective cohort study by including all patients with intracranial hemorrhage (ICH) who visited the Kinmen Hospital from January 2006 to December 2016. Routine neurosurgical dispatch (RNSD) implemented since 2009, dispatches neurosurgeons to Kinmen. EAMT and 90-day mortality were assessed. RESULTS: We enrolled 560 patients: 173 pre-stage and 387 post-stage. RNSD resulted in less EAMT deployment ([adjusted odds ratio AOR] = 0·23, p < 0·001) and lower 90-day mortality ([adjusted hazard ratio AHR] 0·66, p = 0·043). RNSD resulted in decreased EAMT among all subgroups, especially in age ≥81 years (AOR 0.03, p < 0.001), age 41-60 years (AOR 0.10, p < 0.001), traumatic intracranial hemorrhage (TICH) (AOR 0·11, p < 0·001), and Glasgow Coma Scale (GCS) 9-12 (AOR 0.14, p 0.001). The risk of 90-day mortality was higher in male (AHR 1.81, p = 0·006), GCS 3-8 (AHR 35.52, p < 0·001) and GCS 9-12 (AHR 7.46, p < 0·01) and lower in age 21-40 years (AHR 0.46, p = 0.034). CONCLUSION: Incorporating RNSD with EAMT is a plausible alternative to EAMT with a significant decrease in EAMT and decreased 90-day mortality in patients with ICH compared with non-neurosurgical care with EAMT. Despite a 34% decrease in 90-day mortality after RNSD, patient characteristics such as disease severity, age, and sex still dictated patient outcomes.

Atrioventricular conduction abnormality and hyperchloremic metabolic acidosis in toluene sniffing.

Toluene is an aromatic hydrocarbon with widespread industrial use as an organic solvent. As a result of the euphoric effect and availability of these substances, inhalation of toluene-based products is popular among young adults and children. Chronic or acute exposure is known to cause acid-base and electrolyte disorders, and to be toxic to the nervous and hematopoietic systems. We report a 38-year-old man who suffered from general muscular weakness of all extremities after toluene sniffing, which was complicated with hypokalemic paralysis, atrioventricular conduction abnormality, and normal anion gap hyperchloremic metabolic acidosis. Renal function, serum potassium and acid-base status normalized within 3 days after aggressive potassium chloride and intravenous fluid replacement. Electrocardiography showed regression of first-degree atrioventricular block. Exposure to toluene can lead to cardiac arrhythmias and sudden sniffing death syndrome. Tachyarrhythmia is the classical manifestation of toluene cardiotoxicity. Atrioventricular conduction abnormalities have been rarely mentioned in the literature. Knowledge of the toxicology and medical complications associated with toluene sniffing is essential for clinical management of these patients.

Spontaneous Intramural Intestinal Hemorrhage versus Acute Mesenteric Ischemia by CT Evaluation.

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

Severe bleeding after antithrombotic therapy in urosepsis masquerading as myocardial infarction.

Cardiac dysfunction is common in patients with severe sepsis and septic shock. We present a 71-year-old woman with Escherichia coli urosepsis and sepsis-induced myocardial injury masquerading as non-ST elevated myocardial ischemia. Spontaneous psoas hematoma requiring blood transfusion and intracranial hemorrhage developed after antiplatelet and anticoagulant therapies, even in therapeutic doses. The patient was managed conservatively and recovered well with minor residual hemiparesis. Bleeding complications are a common risk of antithrombotic therapy. It is therefore crucial to weigh the impact of efficacy against safety. Old age, female gender, renal insufficiency and sepsis character increased the risk of bleeding in this patient. A misinterpretation of elevated cardiac troponin I may give rise to a diagnostic dilemma and cause unnecessary morbidity.