Association between Time to Emergent Surgery and Outcomes in Trauma Patients: A 10-Year Multicenter Study.

Background: Research on the impact of reduced time to emergent surgery in trauma patients has yielded inconsistent results. Therefore, this study investigated the relationship between waiting emergent surgery time (WEST) and outcomes in trauma patients. Methods: This retrospective, multicenter study used data from the Tzu Chi Hospital trauma database. The primary clinical outcomes were in-hospital mortality, intensive care unit (ICU) admission, and prolonged hospital length of stay (LOS) of ≥30 days. Results: A total of 15,164 patients were analyzed. The median WEST was 444 min, with an interquartile range (IQR) of 248-848 min for all patients. Patients who died in the hospital had a shorter median WEST than did those who survived (240 vs. 446 min, p < 0.001). Among the trauma patients with a WEST of <2 h, the median time was 79 min (IQR = 50-100 min). No significant difference in WEST was observed between the survival and mortality groups for patients with a WEST of <120 min (median WEST: 85 vs. 78 min, p < 0.001). Multivariable logistic regression analysis revealed that WEST was not associated with an increased risk of in-hospital mortality (adjusted odds ratio [aOR] = 1.05, 95% confidence interval [CI] = 0.17-6.35 for 30 min ≤ WEST < 60 min; aOR = 1.12, 95% CI = 0.22-5.70 for 60 min ≤ WEST < 90 min; and aOR = 0.60, 95% CI = 0.13-2.74 for WEST ≥ 90 min). Conclusions: Our findings do not support the "golden hour" concept because no association was identified between the time to definitive care and in-hospital mortality, ICU admission, and prolonged hospital stay of ≥30 days.

Risk analysis of breast cancer and breast fibrocystic change in female primary Sjögren's syndrome patients.

Sjögren's syndrome is an autoimmune disease with the chronic inflammation of glandular tissues, typically salivary and lacrimal glands. Since mammary tissue shares the glandular structure, Sjögren's syndrome may also target mammary tissue to cause breast diseases. We therefore determined whether primary Sjögren's syndrome (pSS) is associated with the increased risk of breast cancer (BC) and breast fibrocystic change (FC). Total 282 female patients with pSS were recruited from a medical center in Taiwan, and patients' medical records were reviewed to identify BC and ultrasonographic breast FC. The prevalence, incidence and risk factors for BC and breast FC in pSS patients were determined, and the risk factors for these breast diseases were subsequently analyzed. Our results showed that pSS patients had the increased prevalence and incidence of BC, and high anti-SSA(Ro) antibody titers were found to be associated with the increased risk of BC. Breast FC was also found highly prevalent in these patients. Comorbidity analysis as risk factor for BC in pSS patients showed diabetes mellitus was strongly associated with the increased risk of BC (odds ratio = 10.4, P = .0006), whereas breast FC was inversely associated with the risk of BC (odds ratio = 0.077 P = .0158). These data indicated that pSS is association with the increased risk of BC and with the high prevalence of ultrasonographic breast FC. Our results also suggest that, in pSS patients, the high anti-SSA(Ro) antibody titers and diabetes mellitus confer the increased risk of BC, whereas the absence of ultrasonographic breast FC predicts the higher risk of BC.

Klebsiella pneumoniae invasive syndrome with liver abscess and purulent meningitis presenting as acute hemiplegia: a case report.

BACKGROUND: Klebsiella pneumoniae can infect a variety of sites, with the risk of infection being higher in the immunocompromised state such as diabetes mellitus. A distinct invasive syndrome has been detected mostly in Southeast Asia in the past two decades. A common destructive complication is pyogenic liver abscess that can be complicated by metastatic endophthalmitis as well as the involvement of the central nervous system, causing purulent meningitis or brain abscess. CASE PRESENTATION: We report a rare case of an invasive liver abscess caused by K. pneumoniae, with metastatic infections of meninges. A 68-year-old man with type 2 diabetes mellitus presented to our emergency department as sepsis. Sudden disturbed consciousness was noticed with presentation of acute hemiplegia and gaze preference mimicking a cerebrovascular accident. CONCLUSIONS: The above case adds to the scarce literature on K. pneumoniae invasive syndrome with liver abscess and purulent meningitis. K. pneumoniae is a rare cause of meningitis and should raise suspicions about the disease in febrile individuals. In particular, Asian patients with diabetes presenting with sepsis and hemiplegia prompt a more thorough evaluation with aggressive treatment.

Thyroid Cancer With Cardiac Metastasis Presented With New Onset of Atrial Fibrillation.

Atrial fibrillation (Af) is frequently seen in the emergency department (ED), and the main concern of which is the potential to lead to blockage of blood flow. Cardiac tumors can also present with Af, which are often overlooked due to the rarity but clinically significant. A 70-year-old woman presented at our ED with intermittent palpitation and dizziness for several weeks. She has an underlying disease of right thyroid follicular carcinoma status-post surgery many years ago, but no history of heart disease. Her electrocardiogram (ECG) showed Af, and the transthoracic echocardiography showed a huge mass occupying the left atrium. The patient underwent an open-heart surgery with tumor excision. The pathology revealed metastatic thyroid follicular carcinoma. The patient recovered smoothly, and her ECG showed normal sinus rhythm after the operation. Most cardiac secondary tumors remain clinically silent and are often diagnosed postmortem. These conditions are rare but clinically significant; therefore, the physician should always raise suspicion of metastatic cardiac tumor as the differential diagnosis when patient presents with an unexplained Af.

A Rare Case of Spontaneous Pseudo-Aneurysm Rupture of an Extra-Anatomical Axillo-Femoral Bypass Graft: A Case Report.

BACKGROUND: Sudden onset of chest wall bulging is a rare chief symptom in the emergency department (ED). However, it may represent life-threatening diseases, such as tumor bleeding, aneurysm rupture, or subcutaneous emphysema. CASE REPORT: We present an 89-year-old woman who visited our ED with a chief symptom of abrupt bulging of the right chest wall accompanied with severe pain. The patient had a history of peripheral artery disease and 10-year post-extra-anatomical axillo-femoral bypass (AxFB) status. After several examinations, the patient was diagnosed as having spontaneous pseudo-aneurysm rupture of an extra-anatomical AxFB graft. Emergency endovascular intervention with stent insertion was performed immediately, and the patient was eventually discharged successfully. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Although spontaneous pseudo-aneurysm rupture of an extra-anatomical AxFB graft is rare, the disease may consequently lead to a fatal outcome once misdiagnosed, and prompt intervention is warranted. Therefore, we should always consider the differential diagnosis of this disease in patients with a bulging chest wall and history of AxFB graft placement.

A Case of Right Renal Arteriovenous Malformation Mimicking the Symptoms of Urinary Tract Infection in the Emergency Department.

BACKGROUND: Renal arteriovenous malformation (AVM) is a rare cause of massive hematuria, and patients with renal AVM may present with symptoms like urinary tract infections in the emergency department. CASE REPORT: A 37-year-old woman presented to the emergency department with symptoms of hematuria, urinary hesitancy, and severe suprapubic pain that had been present for a few hours. A urine examination revealed no pyuria, but urine occult blood for 3+ and a red blood cell count of >100 per high-power field. Bedside echocardiography revealed right kidney hydronephrosis and a distended bladder with a blood clot. A 3-way Foley catheter was inserted and drained 800 mL of bloody urine. A contrast-enhanced computed tomography scan was ordered that showed a 1.1-cm hypervascular tumor in the lower pole of right kidney, with active bleeding and rupture into the adjacent collecting system. Active renal tumor bleeding or renal AVM was suspected. The patient was transferred to a tertiary medical center where right renal artery angiography was arranged and disclosed an AVM with aneurysm formation at the right renal lower pole. Transarterial embolization was performed immediately to embolize the 3 feeders of the AVM. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Renal AVM is a rare but potentially life-threatening cause of massive hematuria. Delayed or missed diagnosis is possible because renal AVM may present with symptoms like urinary tract infection, especially in young females. Renal artery angiography is the diagnosis of choice, and emergent transarterial embolization is now the standard of treatment.

Risk of diabetes mellitus in physicians: a nationwide study in Taiwan.

BACKGROUND: The heavy workload of physicians in Taiwan may contribute to poor lifestyles and increased risk for diabetes mellitus (DM). We conducted this study to determine the risk for DM among physicians in Taiwan. METHODS: We used the Taiwan National Health Insurance Research Database to identify 28,440 physicians and 56,880 comparisons (general population) matched at a ratio of 1:2 by age and sex. Participants who had been diagnosed with DM before 2007 were excluded. We compared the risk for DM between physicians and comparisons by following up since 2007 to 2013. Comparisons among physician subgroups were also performed. RESULTS: After adjustment for hypertension, hyperlipidemia, hyperuricemia, coronary artery disease, congestive heart failure, hyperthyroidism, hypothyroidism, and polycystic ovary syndrome, physicians had a lower risk for DM than the comparisons (adjusted odds ratio [AOR]: 0.75; 95% confidence interval [CI]: 0.68-0.82). In comparisons among physicians, emergency physicians (AOR: 2.21; 95% CI: 1.44-3.40) and surgeons (AOR: 1.26; 95% CI: 1.05-1.52) had a higher risk for DM than other specialists. CONCLUSIONS: This study found that physicians have a lower risk for DM than the general population and emergency physicians and surgeons have a higher risk for DM than other specialists. Thus, more attention should be paid to the occupational health of these doctors.

Association between acute methanol poisoning and subsequent mortality: a nationwide study in Taiwan.

BACKGROUND: Methanol poisoning (MP) often causes acute mortality and morbidities; however, the association between MP and subsequent mortality has not been well studied. METHODS: We conducted a nationwide population-based cohort study by identifying 621 participants with MP from the Nationwide Poisoning Database and 6210 participants without MP from the Longitudinal Health Insurance Database 2000 by matching the index date at a 1:10 ratio between 1999 and 2012. Comparison of the mortality rate between the two cohorts was performed by following up until 2013. RESULTS: A total of 249 (40%) participants with MP and 154 (2.5%) participants without MP died during the follow-up (p < 0.001). Statistic analysis showed that participants with MP had a higher risk for mortality than did the participants without MP (adjusted hazard ratio [AHR]: 13.48; 95% confidence interval [CI]: 10.76-16.88). The risk of mortality was highest in the first 6 months after MP (AHR: 480.34; 95% CI: 117.55-1962.75). Hypertension, chronic obstructive pulmonary disease, liver disease, malignancy, drug abuse, and lower monthly income also predicted mortality. CONCLUSIONS: MP was associated with increased subsequent mortality. Close follow-up for comorbidity control and socioeconomic assistance are suggested for patients with MP.

Geriatric influenza death (GID) score: a new tool for predicting mortality in older people with influenza in the emergency department.

Although influenza may cause death in the geriatric population, the best method for predicting mortality in this population is still unclear. We retrospectively recruited older people (≥65 yr) with influenza visiting the emergency department (ED) of a medical center between January 1, 2010, and December 31, 2015. We performed univariate and multivariate logistic regression to identify independent mortality predictors and then developed a prediction score. Four hundred nine older ED patients with a nearly equal sex ratio were recruited. Five independent mortality predictors were identified: severe coma (Glasgow Coma Scale score ≤8), past histories of cancer and coronary artery disease, elevated C-reactive protein levels (>10 mg/dl), and bandemia (>10% band cells). We divided the patients into three mortality risk and disposition groups: (1) low risk (1.1%; 95% confidence interval [CI], 0.5-3.0%); (2) moderate risk (16.7%; 95% CI, 9.3-28.0%); and (3) high risk (40%; 95% CI, 19.8-64.2%). The area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness of fit of the GID score were 0.86 and 0.578, respectively. The GID score is an efficient and simple tool for predicting mortality in older ED patients with influenza. Further studies are warranted to validate its use.