A novel scale for triage assessment of frailty in the emergency department (ED-FraS): a prospective videotaped study.

BACKGROUND: Rapid recognition of frailty in older patients in the ED is an important first step toward better geriatric care in the ED. We aimed to develop and validate a novel frailty assessment scale at ED triage, the Emergency Department Frailty Scale (ED-FraS). METHODS: We conducted a prospective cohort study enrolling adult patients aged 65 years or older who visited the ED at an academic medical center. The entire triage process was recorded, and triage data were collected, including the Taiwan Triage and Acuity Scale (TTAS). Five physician raters provided ED-FraS levels after reviewing videos. A modified TTAS (mTTAS) incorporating ED-FraS was also created. The primary outcome was hospital admission following the ED visit, and secondary outcomes included the ED length of stay (EDLOS) and total ED visit charges. RESULTS: A total of 256 patients were included. Twenty-seven percent of the patients were frail according to the ED-FraS. The majority of ED-FraS was level 2 (57%), while the majority of TTAS was level 3 (81%). There was a weak agreement between the ED-FraS and TTAS (kappa coefficient of 0.02). The hospital admission rate and charge were highest at ED-FraS level 5 (severely frail), whereas the EDLOS was longest at level 4 (moderately frail). The area under the Receiver Operating Characteristic curve (AUROC) in predicting hospital admission for the TTAS, ED-FraS, and mTTAS were 0.57, 0.62, and 0.63, respectively. The ED-FraS explained more variation in EDLOS (R2 = 0.096) compared with the other two methods. CONCLUSIONS: The ED-Fras tool is a simple and valid screening tool for identifying frail older adults in the ED. It also can complement and enhance ED triage systems. Further research is needed to test its real-time use at ED triage internationally.

The incidence, predictors, and causes of cardiac arrest in United States emergency departments.

Background: Emergency department cardiac arrest (EDCA) is a global public health challenge associated with high mortality rates and poor neurological outcomes. This study aimed to describe the incidence, risk factors, and causes of EDCA during emergency department (ED) visits in the U.S. Methods: This retrospective cohort study used data from the 2019 Nationwide Emergency Department Sample (NEDS). Adult ED visits with EDCA were identified using the cardiopulmonary resuscitation code. We used descriptive statistics and multivariable logistic regression, considering NEDS's complex survey design. The primary outcome measure was EDCA incidence. Results: In 2019, there were approximately 232,000 ED visits with cardiac arrest in the U.S. The incidence rate of EDCA was approximately 0.2%. Older age, being male, black race, low median household income, weekend ED visits, having Medicare insurance, and ED visits in non-summer seasons were associated with a higher risk of EDCA. Hispanic race was associated with a lower risk of EDCA. Certain comorbidities (e.g., diabetes and cancer), trauma centers, hospitals with a metropolitan and/or teaching program, and hospitals in the South were associated with a higher risk of EDCA. Depression, dementia, and hypothyroidism were associated with a lower risk of EDCA. Septicemia, acute myocardial infarction, and respiratory failure, followed by drug overdose, were the predominant causes of EDCA. Conclusions: Some patients were disproportionately affected by EDCA. Strategies should be developed to target these modifiable risk factors, specifically factors within ED's control, to reduce the subsequent disease burden.

The outcomes of right-sided and left-sided colonic diverticulitis following non-operative management: a systematic review and meta-analysis.

BACKGROUND: There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was conducted to evaluate the recurrence/treatment failure in right-sided and left-sided CD. METHODS: A systematic review was conducted following PRISMA guidelines. MEDLINE, Embase, and Cochrane Library from inception to Dec 2021 were searched. The study characteristics, recurrence/treatment failure, and risk factors for recurrence/treatment failure were extracted. Proportional meta-analyses were performed to calculate the pooled recurrent/treatment failure rate of right-sided and left-sided CD using the random effect model. Logistic regression was applied for the factors associated with the recurrence/treatment failure. RESULTS: Thirty-eight studies with 10,129 patients were included, and only two studies comprised both sides of CD. None of the studies had a high risk of bias although significant heterogeneity existed. The pooled recurrence rate was 10% (95% CI 8-13%, I2 = 86%, p < 0.01) in right-sided and 20% (95% CI 16-24%, I2 = 92%, p < 0.01) in left-sided CD. For the uncomplicated CD, the pooled recurrence rate was 9% (95% CI 6-13%, I2 = 77%, p < 0.01) in right-sided and 15% (95% CI 8-27%, I2 = 97%, p < 0.01) in the left-sided. Age and gender were not associated with the recurrence of both sides. The treatment failure rate was 5% (95% CI 2-10%, I2 = 84%, p < 0.01) in right-sided and 4% (95% CI 2-7%, I2 = 80%, p < 0.01) in left-sided CD. The risk factors for recurrence and treatment failure were limited. CONCLUSION: Non-operative management is effective with low rates of recurrence and treatment failure for both right-sided and left-sided CD although left-sided exhibits a higher recurrence. The recurrence rates did not differ between patients receiving antibiotics or not in uncomplicated CD. Age and sex were not associated with the recurrence although other risk factors were dispersing. Further risk factors for recurrence and treatment failure would be investigated for precise clinical decision-making and individualized strategy.

High-risk Return Visits to United States Emergency Departments, 2010-2018.

INTRODUCTION: Although factors related to a return visit to the emergency department (ED) have been reported, only a few studies have examined "high-risk" ED revisits with serious adverse outcomes. In this study we aimed to describe the incidence and trend of high-risk ED revisits in United States EDs and to investigate factors associated with these revisits. METHODS: We obtained data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010-2018. Adult ED revisits within 72 hours of a previous discharge were identified using a mark on the patient record form. We defined high-risk revisits as revisits with serious adverse outcomes, including intensive care unit admissions, emergency surgery, cardiac catheterization, or cardiopulmonary resuscitation (CPR) during the return visit. We performed analyses using descriptive statistics and multivariable logistic regression, accounting for NHAMCS's complex survey design. RESULTS: Over the nine-year study period, there were an estimated 37,700,000 revisits, and the proportion of revisits in the entire ED population decreased slightly from 5.1% in 2010 to 4.5% in 2018 (P for trend = 0.02). By contrast, there were an estimated 827,000 high-risk ED revisits, and the proportion of high-risk revisits in the entire ED population remained stable at approximately 0.1%. The mean age of these high-risk revisit patients was 57 years, and 43% were men. Approximately 6% of the patients were intubated, and 13% received CPR. Most of them were hospitalized, and 2% died in the ED. Multivariable analysis showed that older age (65+ years), Hispanic ethnicity, daytime visits, and arrival by ambulance during the revisit were independent predictors of high-risk revisits. CONCLUSION: High-risk revisits accounted for a relatively small fraction (0.1%) of ED visits. Over the period of the NHAMCS survey between 2010-2018, this fraction remained stable. We identified factors during the return visit that could be used to label high-risk revisits for timely intervention.

Factors associated with a high-risk return visit to the emergency department: a case-crossover study.

BACKGROUND AND IMPORTANCE: Although factors related to a return emergency department (ED) visit have been reported, few studies have examined 'high-risk' return ED visits with serious adverse outcomes. Understanding factors associated with high-risk return ED visits may help with early recognition and prevention of these catastrophic events. OBJECTIVES: We aimed to (1) estimate the incidence of high-risk return ED visits, and (2) to investigate time-varying factors associated with these revisits. DESIGN: Case-crossover study. SETTINGS AND PARTICIPANTS: We used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 651 815 ED visits over a 6-year period. Patient demographics and computerized triage information were extracted. OUTCOME MEASURE AND ANALYSIS: A high-risk return ED visit was defined as a revisit within 72 h of the index visit with ICU admission, receiving emergency surgery, or with in-hospital cardiac arrest during the return ED visit. Time-varying factors associated with a return visit were identified. MAIN RESULTS: There were 440 281 adult index visits, of which 19 675 (4.5%) return visits occurred within 72 h. Of them, 417 (0.1%) were high-risk revisits. Multivariable analysis showed that time-varying factors associated with an increased risk of high-risk revisits included the following: arrival by ambulance, dyspnea, or chest pain on ED presentation, triage level 1 or 2, acute change in levels of consciousness, tachycardia (>90/min), and high fever (>39°C). CONCLUSIONS: We found a relatively small fraction of discharges (0.1%) developed serious adverse events during the return ED visits. We identified symptom-based and vital sign-based warning signs that may be used for patient self-monitoring at home, as well as new-onset signs during the return visit to alert healthcare providers for timely management of these high-risk revisits.

Association of interleukin-6 gene polymorphisms and glaucoma: Systematic review and meta-analysis.

AIM: To conduct a systematic review and meta-analysis to explore the association between IL-6 gene polymorphisms (rs1800795 and rs1524107) and glaucoma. METHODS: A comprehensive search was performed to select eligible studies regarding IL-6 polymorphisms and glaucoma. The effect sizes in the fixed-effects model were calculated using odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Four eligible studies comprising 762 cases and 799 controls were selected for meta-analysis. Regarding the association between the IL-6 rs1800795 polymorphism and glaucoma, those who carried the G/G+G/C genotypes had a non-significant higher risk of glaucoma (OR = 1.29, 95% CI = 0.76-2.19) in the dominant model. However, no obvious association (OR = 0.97, 95% CI = 0.68-1.37) was found for the recessive model (G/G vs G/C+C/C). In the subgroup analysis stratified by ethnicity, no significant associations were observed in populations of Asian or European heritage. Significantly higher glaucoma risks of 15.9 and 99.0 were observed for the dominant (C/C+C/T vs T/T) and recessive (C/C vs C/T+T/T) models, respectively. CONCLUSION: No statistically significant glaucoma risks were observed for the rs1800795 except rs1524107 polymorphism of IL-6. Further studies with a larger sample size are required to validate the effects of IL-6 polymorphisms on glaucoma risk.

Measurement of subglottic diameter and distance to pre-epiglottic space among Chinese adults.

Proper endotracheal tube (ETT) size selection and identification of potentially difficult airways are important to reduce laryngeal injury during intubation. However, controversies exist concerning transverse subglottic diameter-the narrowest part of the airway-and the distance to pre-epiglottic space. Because few studies have reported the distance from skin to the midpoint of the epiglottis (DSE) among normal individuals, whether the DSE varies between individuals and by ethnicity remains uncertain. The present study aims to investigate the sonographic subglottic diameter and DSE among healthy Chinese adults. Healthy volunteers were recruited at National Taiwan University Hospital between October and November 2019. Exclusion criteria included pre-existing airway or respiratory diseases, neck tumors, and a history of neck operation. Age, sex, height, weight, body mass index (BMI), sonographic DSE, and transverse subglottic diameter were recorded. A total of 124 participants were enrolled. The average age was 32.5 ± 10.4 years and 63 participants (51%) were males. The subglottic diameter was positively associated with sex (males, 14.40 mm; females, 11.10 mm, p < 0.001) and BMI (underweight, 12.13 mm; normal weight, 12.47 mm; overweight, 13.80 mm; obese, 13.67 mm, p = 0.007). Moreover, the DSE was shorter in males (male, 16.18 mm; females, 14.54 mm, p < 0.001) and participants with increased BMI (underweight, 13.70 mm; normal weight, 15.06 mm; overweight, 16.58 mm; obese, 18.18 mm, p < 0.001). As compared with other ethnicity, a smaller size of subglottic diameter and a shorter DSE were noted among Chinese participants, and we suggest that a relatively smaller size of endotracheal tube selection should be considered in tracheal intubations.

A primary meningioma of the lumbar spine with neck metastasis.

Context: Approximately 25% of all primary spinal cord tumors are meningiomas, and 80% of these tumors occur in the thoracic region. Few meningiomas of the lumbar spine have been presented. Extracranial metastasis of meningioma occurs extremely rare, only in about 0.1% of meningiomas. Even metastasis, the sites are seldom seen in deep soft tissue. We reported a woman original meningioma in the lumbar spine with distal deep neck metastasis. Findings: A 59-year-old patient suffered from severe right drop foot, numbness, and radicular pain for the previous 6 months. Computed tomography (CT) disclosed a huge, macrolobulated retroperitoneal soft-tissue lesion with a size of 14.9 × 10.8 × 17.7 cm. Magnetic resonance imaging (MRI) further revealed a solid spinal intracanal tumor with moderate enhancement involving the right paraspinal region at the L2∼L5 level and the right iliac fossa. A meningioma was diagnosed with histological proof. Four months later, another metastatic meningioma in her left neck. She was managed conservatively without neurologic dysfunction. Conclusions: To the best of our knowledge, such a large meningioma of the lumbar spine has not previously been reported in the literature. In this study, we demonstrated a rare spinal meningioma located in the lumbar spine primarily with secondary soft tissue metastasis.

Serum lipids and risk of atherosclerosis in xanthelasma palpebrarum: A systematic review and meta-analysis.

BACKGROUND: The association between dyslipidemia and xanthelasma palpebrarum (XP) remains controversial, and no definite evidence has indicated atherosclerosis risk in patients with XP. OBJECTIVE: The present study was a systematic review and meta-analysis to elucidate the association of serum lipid profiles and risk of atherosclerotic diseases with XP. METHODS: We systematically searched for the eligible comparative studies published before April 15, 2019, in the databases of PubMed, Web of Science, Embase, and Cochrane Library. A random-effects model was used to calculate the standard mean difference with 95% confidence interval for each pooled estimate. RESULTS: The qualitative analyses included 15 case-control studies with 854 patients with XP. Compared with the controls, the patients with XP had significantly higher serum levels of total cholesterol and low-density lipoproteins, significantly higher apolipoprotein B levels, and relatively lower apolipoprotein A1 levels, and the carotid intima-media thickness was significantly higher. CONCLUSION: Patients with XP had significantly higher serum levels of atherogenic low-density lipoproteins and bore significantly higher risk of atherosclerosis than the controls. Careful monitoring and targeted intervention for prevention of cardiovascular diseases is essential for these patients.

Efficacy of Autologous Platelet-Rich Plasma Combined With Ablative Fractional Carbon Dioxide Laser for Acne Scars: A Systematic Review and Meta-Analysis.

BACKGROUND: Acne scars are common and challenging clinical complications of acne vulgaris. Ablative fractional carbon dioxide (CO2) laser is a well-established treatment for acne scars; however, some postlaser adverse effects have been noted. Autologous platelet-rich plasma (PRP) can improve tissue regeneration. Several studies have investigated the efficacy of combination therapy of CO2 laser and PRP for acne scars. OBJECTIVES: The authors sought to conduct a meta-analysis of the efficacy of PRP combined with ablative fractional CO2 laser for treating acne scars by examining clinical trial results. METHODS: A systematic review was performed by searching PubMed, Embase, Cochrane Library, and Web of Science, and a meta-analysis was conducted to assess the clinical outcomes after combination therapy of PRP and ablative fractional CO2 laser compared with laser alone. RESULTS: We identified 4 eligible studies for the meta-analysis, including 3 randomized controlled trials. Our results demonstrated that clinical improvement after combination therapy was significantly higher than that after laser alone (odds ratio = 2.992, P = 0.001). Regarding major side effects, patients who underwent combination therapy experienced significantly shorter duration of crust compared with CO2 laser alone (standard mean difference = -1.140, P < 0.001); relatively shorter durations of erythema and edema were also noted after combination therapy. Furthermore, patient satisfaction rates were significantly higher after combination therapy than after laser alone (odds ratio = 3.169, P = 0.002). CONCLUSIONS: The combination of autologous PRP and ablative fractional CO2 laser has synergistic positive effects on the clinical outcomes for acne scars and can accelerate the recovery of laser-damaged skin.

Association between the rs1800795G>C polymorphism in the promoter of interleukin-6 gene and bladder cancer.

Interleukin-6 (IL-6) is an inflammatory cytokines that plays a role in the development of cancer. Several studies have examined the relationship between the IL-6 -174G>C polymorphism and bladder cancer, but these results are inconclusive. Therefore, we conducted a meta-analysis to explore the association between IL-6 -174G>C polymorphism and bladder cancer risk. A comprehensive literature search was performed to identify eligible studies regarding the IL-6 -174G>C polymorphism and bladder cancer. Effect sizes under fixed- and random-effects models were calculated using odds ratios (ORs) with 95% confidence intervals (CIs). Finally, five case-control studies were included in the subsequent analyses. In the fixed-effect analysis, significantly higher bladder cancer risks of 1.20 (95% CI = 1.07-1.36) and 1.30 (95% CI = 1.08-1.56) were found for the dominant model (C/C+G/C vs. G/G) and recessive model (C/C vs. G/C+G/G), respectively. Especially for the Asian population, significantly greater bladder cancer risks of 1.63 (95% CI = 1.32-2.00) and 1.54 (95% CI = 1.07-2.21) were observed for the dominant model (C/C+G/C vs. G/G) and the recessive model (C/C vs. G/C+G/G), respectively. Non-significantly increased risks of bladder cancer were observed for the dominant and recessive models under the random-effects analysis. The major findings of this meta-analysis suggest that IL-6 -174G>C polymorphism is significantly associated with bladder cancer risk in the Asian population. Further studies with a larger sample size are needed to validate the effects of IL-6 polymorphisms on bladder cancer risk.

Outcome Analysis of Patients with Gallstone Disease Receiving Cholecystectomy: A Population-Based Cohort Study.

BACKGROUND/AIMS: Cholecystectomy is generally performed to treat patients with gallstone disease (GSD) in clinical practice. The present study aimed to investigate whether type 2 diabetes mellitus (T2DM) may influence the overall survival of GSD patients. METHODS: The National Health Insurance Research Database, a population-based registry data in Taiwan, was used to identify GSD patients from 2001 to 2008. The risk of cancers and effects of T2DM on the overall survival of GSD patients receiving cholecystectomy were estimated by hazards ratios (HRs) and 95% CIs using the Cox proportional hazard model. RESULTS: Among 392,028 eligible GSD patients, 81,971 underwent cholecystectomy, whereas 310,057 did not. After cholecystectomy, the HR for developing cancer was 1.14. The HR for the overall survival was 0.74-fold lower for patients who underwent cholecystectomy than that for patients who did not. GSD patients without T2DM who underwent cholecystectomy (0.78-fold lower risk) had a longer survival, whereas those with T2DM had shorter survival (1.64-fold higher risk without cholecystectomy and 1.13-fold higher risk with cholecystectomy) compared with those without T2DM who did not undergo cholecystectomy. CONCLUSIONS: Our major findings suggest that T2DM may worsen the prognosis of GSD patients after cholecystectomy, which provides useful insight into the treatment of T2DM among GSD patients in clinical settings.

Serous degeneration of bone marrow mimics spinal tumor.

OBJECTIVE: To present a rare case of serous degeneration of bone marrow which resembles primary spinal tumor or bony metastasis to spine. Serous degeneration of bone marrow or gelatinous marrow transformation is a rare disease characterized by focal marrow hypoplasia, fat atrophy, and accumulation of extracellular mucopolysaccharides abundant in hyaluronic acid. Few literature was reviewed and few clinical case was presented. METHODS: Two cases of serous marrow transformation were reported. RESULTS: In the first case, a 29-year-old man suffered from severe left buttock pain. Bone metastasis was impressed in radiology examinations. Percutaneous endoscopic lumbar discectomy was performed along with bone biopsy. In the second case, a 49-year-old man presented lower back pain with radiation to bilateral lower legs. Magnetic resonance imaging revealed a water-like signal lesion in sacrum. Serous marrow transformation was confirmed pathologically in both cases. CONCLUSION: To the best of our knowledge, a case of serous degeneration of bone marrow resembling malignancy has not been reported in the literature. In this report, two cases demonstrate serous transformation of bone marrow mimics spinal tumor.

Therapeutic Potential of Drugs Targeting Pathophysiology of Intracerebral Hemorrhage: From Animal Models to Clinical Applications.

BACKGROUND: Intracerebral hemorrhage (ICH) is one of the most common forms of cerebral hemorrhage, the morbidity and death of ICH is high worldwide. ICH can be spontaneous or caused by hypertension, coagulopathy, angiopathy, head trauma, bleeding disorders, tumors, or drug usage. ICH is the most serious and least treatable form of hemorrhagic stroke, with rapidly increasing hematoma size and often resulting in significant brain injury and long term neurological deficits. Surgical hematoma evacuation remains controversial. The currently therapy is mainly supportive with limited benefit. New therapeutic approaches are desperately needed. METHODS: In this review, we provide an overview of the published literature concerning the pathophysiology leading to the ongoing neurologic damage, Emerging information of the physio-pathologic mechanisms of injury that occur after ICH is available from current animal models. Ideal therapeutic strategies should target on the pathophysiology of ICH. This review summarizes the recent advances in developing pharmaceutical agents in terms of therapeutic targets and effects in pre-clinical and clinical studies. RESULTS: Recent animal and clinical studies have provided important information about the parallel and sequential deleterious mechanisms underlying ICH-induced brain injury and pharmacological agents targeting on these mechanisms. Neuroscientists have paid more attention to novel drug development that target on antioxidants, antiinflammatory, and anti-apoptosis for neuroprotection after ICH. CONCLUSION: Although ICH remains without an approved treatment proven to decrease morbidity and mortality, notable advances in the understanding of ICH pathophysiology and new drug development have been made in the last decade.