Can different physicians providing urgent and non-urgent treatment improve patient flow in emergency department?

BACKGROUND: Emergency Department (ED) overcrowding is a worldwide problem, and it might be caused by prolonged patient stay in the ED. This study tried to analyze if different practice models influence patient flow in the ED. MATERIALS AND METHODS: A retrospective, 1-year cohort study was conducted across two EDs in the largest healthcare system in Taiwan. A total of 37,580 adult non-trauma patients were involved in the study. The clinical practice between two ED practice models was compared. In one model, urgent and non-urgent patients were treated by different emergency physicians (EPs) separately (separated model). In the other, EPs treated all patients assigned randomly (merged model). The ED length of stay (LOS), diagnostic tool use (including laboratory examinations and computed tomography scans), and patient dispositions (including discharge, general ward admission, intensive care unit (ICU) admissions, and ED mortality) were selected as outcome indicators. RESULT: Patients discharged from ED had 0.4h shorter ED LOS in the separated model than in merged model. After adjusting for the potential confounding factors through regression model, there was no difference of patient disposition of the two practice models. However, the separated model showed a slight decrease in laboratory examination use (adjusted odds ratio, 0.9; 95% confidence interval, 0.83-0.96) compared with the merged model. CONCLUSION: The separated model had better patient flow than the merged model did. It decreased the ED LOS in ED discharge patients and laboratory examination use.

The characteristics and prognostic predictors of unplanned hospital admission within 72 hours after ED discharge.

OBJECTIVES: The aims of this study were (1) to identify the characteristics of patients who return to the emergency department (ED) within 72 hours and are admitted to the hospital and (2) to identify the characteristics and predictors of in-hospital mortality subgroup. METHODS: This study was conducted in a tertiary teaching hospital to identify characteristics of adult nontraumatic revisit-admission patients from January 1 to December 31, 2011. Demographic data, cause of revisit, and the underlying diseases as well as the in-hospital complications were reviewed. RESULTS: Of the 72188 ED discharged patients, 690 revisit-admission patients were enrolled. The top 3 disease classifications were infection (38.7%), neurology (11.3%), and gastroenterology (11.2%). The etiology of the revisit included recurrent symptoms (72%), disease complications (15.8%), and inadequate diagnosis (12.1%). A total of 150 patients (21.7%) had complications, including receiving operation (17.2%), intensive care unit admission (4.2%), and cardiovascular conditions (2.5%). Forty-nine patients (7.1%) died during hospitalization owing to sepsis (57.1%), malignancy (34.7%), cardiogenic diseases (4.1%), and cerebrovascular conditions (4.1%). The nonsurvival group was older (64.1 ± 15.3 vs 55.7 ± 17.8; P < .001), had more patients with a diagnosis of moderate to severe liver disease (18.4% vs 4.8%; P < .001), malignancy (69.3% vs 20.1%; P < .001), and metastatic solid tumor (38.8% vs 6.2%; P < .001). CONCLUSIONS: Age and diagnosis with malignancy, metastatic tumors, or moderate-to-severe liver disease were predictors of in-hospital mortality among 72-hour revisit-admission patients.

Plasma nuclear and mitochondrial DNA levels as predictors of outcome in severe sepsis patients in the emergency room.

BACKGROUND AND AIM: The sensitivity and specificity of biomarkers and scoring systems used for predicting fatality of severe sepsis patients remain unsatisfactory. This study aimed to determine the prognostic value of circulating plasma DNA levels in severe septic patients presenting at the Emergency Department (ED). METHODS: Sixty-seven consecutive patients with severe sepsis and 33 controls were evaluated. Plasma DNA levels were estimated by real-time quantitative polymerase chain reaction assay using primers for the human ß-hemoglobin and ND2 gene. The patients' clinical and laboratory data on admission were analyzed. RESULTS: The median plasma nuclear and mitochondria DNA levels for severe septic patients on admission were significantly higher than those of the controls. The mean plasma nuclear DNA level on admission correlated with lactate concentration (γ = 0.36, p = 0.003) and plasma mitochondrial DNA on admission (γ = 0.708, p < 0.001). Significant prognostic factors for fatality included mechanical ventilation within the first 24 hours (p = 0.013), mean sequential organ failure assessment (SOFA) score on admission (p = 0.04), serum lactate (p < 0.001), and both plasma nuclear and mitochondrial DNA on admission (p < 0.001). Plasma mitochondrial DNA was an independent predictor of fatality by stepwise logistic regression such that an increase by one ng/mL in level would increase fatality rate by 0.7%. CONCLUSION: Plasma DNA has potential use for predicting outcome in septic patients arriving at the emergency room. Plasma mitochondrial DNA level on admission is a more powerful predictor than lactate concentration or SOFA scores on admission.

The Impact of Do-Not-Resuscitate Order in the Emergency Department on Respiratory Failure after ICU Admission.

(1) Background: It has been hypothesized that a discrepancy exists in the understanding of a do-not-resuscitate (DNR) order among physicians. We hypothesized that a DNR order signed in the emergency department (ED) could influence the patients' prognosis after intensive care unit (ICU) admission. (2) Methods: We included patients older than 17 years, who visited the emergency department for non-traumatic disease, who had respiratory failure, required ventilator support, and were admitted to the ICU between January 2010 and December 2016. The associations between DNR and mortality, hospital length of stay (LOS), and medical fees were analyzed. Prolonged hospital LOS was defined as hospital stay ≥75th percentile (≥26 days for the study). Patients were classified as those who did and did not sign a DNR order. A 1:4 propensity score matching was conducted for demographics, comorbidities, and etiology. (3) Results: The study enrolled a total of 1510 patients who signed a DNR and 6040 patients who did not sign a DNR. The 30-day mortality rates were 47.4% and 28.0% among patients who did and did not sign a DNR, respectively. A DNR order was associated with mortality after adjusting for confounding factors (hazard ratio, 1.9; confidence interval, 1.70−2.03). It was also a risk factor for prolonged hospital LOS in survivors (odds ratio, 1.2; confidence interval, 1.02−1.44). Survivors who signed a DNR order were charged higher medical fees than those who did not sign a DNR (217,159 vs. 245,795 New Taiwan Dollars, p < 0.001). (4) Conclusions: Signing a DNR order in the ED increased the ICU mortality rate among patients who had respiratory failure and needed ventilator support. It increased the risk of prolonged hospital LOS among survivors. Finally, signing a DNR order was associated with high medical fees among survivors.

Donor age and body weight determine the effects of fecal microbiota transplantation on growth performance, and fecal microbiota development in recipient pigs.

BACKGROUND: The application of fecal microbiota transplantation (FMT) to improve swine growth performance has been sporadically studied. Most of these studies used a single microbiota source and thus the effect of donor characteristics on recipient pigs' fecal microbiota development and growth performance is largely unknown. RESULTS: In this study, we collected feces from six donors with heavy (H) or light (L) body weight and different ages (d 42, nursery; d 96, growing; and d 170, finisher) to evaluate their effects on the growth performance and fecal microbiota development of recipient pigs. Generally, recipients that received two doses of FMT from nursery and finisher stages donor at weaning (21 ± 2 days of age) inherited the donor's growth pattern, while the pigs gavaged with grower stage material exerted a numerically greater weight gain than the control pigs regardless of donor BW. FMT from heavier donors (NH, GH, and FH) led to the recipients to have numerically increased growth compared to their lighter counterparts (NL, GL, and FL, respectively) throughout the growing and most finishing stages. This benefit could be attributed to the enrichment of ASV25 Faecalibacterium, ASV61 Faecalibacterium, ASV438 Coriobacteriaceae_unclassified, ASV144 Bulleidia, and ASV129 Oribacterium and decrease of ASV13 Escherichia during nursery stage. Fecal microbiota transplantation from growing and finishing donors influenced the microbial community significantly in recipient pigs during the nursery stage. FMT of older donors' gut microbiota expedited recipients' microbiota maturity on d 35 and 49, indicated by increased estimated microbiota ages. The age-associated bacterial taxa included ASV206 Ruminococcaceae, ASV211 Butyrivibrio, ASV416 Bacteroides, ASV2 Streptococcus, and ASV291 Veillonellaceae. The body weight differences between GL and GH pigs on d 104 were associated with the increased synthesis of the essential amino acid, lysine and methionine, mixed acid fermentation, expedited glycolysis, and sucrose/galactose degradation. CONCLUSIONS: Overall, our study provided insights into how donor age and body weight affect FMT outcomes regarding growth performance, microbiota community shifts, and lower GI tract metabolic potentials. This study also provided guidance to select qualified donors for future fecal microbiota transplantation.

Weaning Induced Gut Dysfunction and Nutritional Interventions in Nursery Pigs: A Partial Review.

Weaning is one of the most stressful events in the life of a pig. Unsuccessful weaning often leads to intestinal and immune system dysfunctions, resulting in poor growth performance as well as increased morbidity and mortality. The gut microbiota community is a complex ecosystem and is considered an "organ," producing various metabolites with many beneficial functions. In this review, we briefly introduce weaning-associated gut microbiota dysbiosis. Then, we explain the importance of maintaining a balanced gut microbiota. Finally, we discuss dietary supplements and their abilities to restore intestinal balance and improve the growth performance of weaning pigs.

Comprehensive Cultivation of the Swine Gut Microbiome Reveals High Bacterial Diversity and Guides Bacterial Isolation in Pigs.

Despite the substantial progress made in human gut culturomics, little is known about the culturability of the swine gut microbiota. In this study, we cultured swine gut microbiota using 53 bacterial cultivation methods with different medium and gas combinations from three pigs at four different growth stages. Both culture-dependent (CD; colony mixtures from each method) and culture-independent (CI; original fecal suspensions) samples were subjected to 16S rRNA gene amplicon sequencing. Increasing microbial diversities were observed in both CI and CD samples from successive growth stages. While a total of 378, 482, 565, and 555 bacterial amplicon sequence variants (ASVs) were observed in the CI samples, higher microbial diversities (415, 675, 808, and 823 observed ASVs) were detected using the CD methods at the lactation, nursery, growing, and finishing stages, respectively. We constructed reference culture maps showing the preferred cultivation conditions for specific bacterial taxa and examined the effects of culturing factors such as oxygen, medium, donor pig age, antibiotics, and blood culture preincubation on swine gut microbiota cultivation. We focused on a wide range of beneficial bacteria, chose 1,299 colonies based on the reference map, and Sanger sequenced their 16S rRNA genes. These isolates clustered into 148 different bacterial taxa covering 28 genera. We observed 11, 19, 33, and 25 pairs of cooccurring ASVs in both CD and CI samples at four successive growth stages. This study provides guidance in culturing the swine gut microbiota of interest, which is critical when characterizing their functions in this important animal species. IMPORTANCE The swine gut microbiome has been the focus of many investigations due to the fact that pigs serve as both an excellent biomedical model for human diseases and an important protein source. Substantial progress has been made in swine gut microbiome studies using next-generation sequencing-based culture-independent approaches, but little is known about the culturability of the swine gut microbiota. To understand their roles in swine production, it is critical to culture bacterial strains of interest. In this study, we cultured the gut microbiota from pigs at different growth stages using 53 bacterial cultivation methods with different medium and gas combinations. This study provides evidence that the swine gut microbiota is much more diverse based on a culture-dependent approach than previously known. It provides preliminary guidance for isolating certain bacteria of interest from pigs, which is critical in establishing causal relationships between the gut microbiota and the health status of pigs.

Dietary Organic Acids Modulate Gut Microbiota and Improve Growth Performance of Nursery Pigs.

Feed additives have been suggested to improve animal growth performance through modulating the gut microbiota. The hypothesis of this study was that the combination of two organic acids would exert synergistic effects on the growth performance and gut microbiota of weaning pigs. To test this hypothesis, we followed 398 weaning pigs from two university experiment stations (University of Illinois at Urbana-Champaign (UIUC) and University of Arkansas (UA)) to determine the effects of increasing levels (0%, 0.035%, 0.070%, and 0.105%) of sodium butyrate combined with 0.5% benzoic acid on the growth performance of nursery pigs. At the UA, an additional negative control diet was included and the gut microbiota analysis was carried out. At both universities, increasing levels of sodium butyrate in a diet containing 0.5% benzoic acid improved growth performance, which reached a plateau in the pigs fed 0.035% (SBA0.035) or 0.070% (SBA0.070) butyrate. Gut microbiota analysis revealed that pigs fed the SBA0.035 diet had more diverse microbiota and contained more potentially beneficial bacteria such as Oscillospira, Blautia, and Turicibacter and reduced levels of Veillonella and Sarcina. Results of the present study indicated that the inclusion of sodium butyrate at moderate levels in a diet containing 0.5% benzoic acid improved growth performance of weaning pigs and established potential health benefits on gut microbiota.

Effect of Lactylate and Bacillus subtilis on Growth Performance, Peripheral Blood Cell Profile, and Gut Microbiota of Nursery Pigs.

To evaluate the effects of lactylate and Bacillus subtilis on growth performance, complete blood cell count, and microbial changes, 264 weaning pigs were assigned to four treatments (1) control (Con) basal diets that met the nutrient requirement for each phase, (2) 0.2% lactylate (LA), (3) 0.05% Bacillus subtilis strains mixtures (BM), or (4) the combination of LA and BM (LA+BM) added to the control basal diet at their respective inclusion rates in each of the three phases. Dietary lactylate tended to increase weight gain, significantly increased feed intake, and reduced fecal total E. coli and enterotoxigenic E. coli counts during Phase 1. Pigs fed Bacillus subtilis had a greater gain to feed ratio (G:F) during Phases 1 and 2. Pigs fed lactylate had an increased peripheral absolute neutrophil count on D14 but a decreased eosinophil percentage. Pigs fed Bacillus subtilis had an elevated peripheral total white blood cell count at study completion. The addition of lactylate increased microbiota richness, reduced E. coli, and increased Prevotella, Christensenellaceae, and Succinivibrio. Bacillus subtilis supplementation-enriched f_Ruminococcaceae_unclassified and S24-7_ unclassified had positive relationships with feed efficiency. Collectively, these findings suggested that lactylate can be added to diets to balance gut microbiota and improve growth performance during the early postweaning period. The combination of lactylate and Bacillus subtilis strains exerted a synergic effect on the growth performance of nursery pigs.

ZnO Modulates Swine Gut Microbiota and Improves Growth Performance of Nursery Pigs When Combined with Peptide Cocktail.

Zinc has been very efficacious in reducing post-weaning diarrhea, whereas animal-derived peptides are suggested to improve the growth performance of weaned piglets. However, the combined effect of zinc and peptides on swine production and swine gut microbiota is still largely unknown. In this study, we followed 288 nursery pigs from the age of d30 to d60 to evaluate the growth performance and gut microbiota of weanling pigs subjected to different levels of a fish-porcine-microbial peptide cocktail (0.05%, 0.25%, and 0.5%) with or without the pharmaceutical level of zinc oxide (ZnO) (2500 ppm) supplementation in a nutrient-deficient diet. Rectal swab samples were collected from pigs with body weight (BW) approach average at each pen on d30, d42, and d60 to determine gut microbiota. Average daily gain (ADG) and BW in piglets fed high zinc (HZ) increased with increasing levels of peptide. The microbiota of the HZ group also diverged from those of the standard zinc (SZ) group from d30 to d60. Adding peptide did not alter community structure regardless of zinc supplementation. Collectively, these findings demonstrated that the pharmaceutical level of zinc as ZnO conditioned the gut community to the point where peptide could effectively restore growth performance in nursery pigs fed nutrient-deficient diets.

Liver Cirrhosis Predisposes One to Complicated Deep Neck Infection: Retrospective Analysis of 161 Cases.

INTRODUCTION: Without appropriate and prompt diagnosis and treatment, life-threatening complications may occur in patients with deep neck infection. Liver cirrhosis occurs more common in Asians and few studies mention if it predisposes to complicated deep neck infection. We aimed to identify predisposing factors of complications to reduce morbidity and mortality. MATERIALS AND METHODS: A retrospective analysis of 161 patients with deep neck infection at emergency department of Kaohsiung Chang Gung Memorial Hospital between 2010 and 2012 was performed. We also analyzed the differences between patients with complicated and non-complicated deep neck infection. RESULTS: One hundred and twenty-two patients were men (75.8%). The most common past medical history was diabetes mellitus, followed by liver cirrhosis, which occurs more commonly in Asians. The most common site of involvement was the peritonsillar space (42.9%). The most common pathogen was Streptococcus viridans (23.1%). Fourteen patients (8.7%) had complications and six (3.7%) died during hospitalization. Complicated cases had significantly lower heart rate and mean arterial pressure but higher blood sugar level. They also had higher opportunity to have liver cirrhosis, multiple sites and mediastinum involvement, resulting in longer duration of hospitalization and higher mortality rate. Logistic regression analysis determined that liver cirrhosis was the only predisposing factor for life-threatening complications. CONCLUSION: People with liver cirrhosis have higher occurrence of complication if they suffered from deep neck infection. Adequate treatment including airway maintenance, appropriate antibiotics, intravenous fluid support and surgical intervention should be provided as soon as possible to decrease complications and mortality.

Influence of a whole yeast product (Pichia guilliermondii) fed throughout gestation and lactation on performance and immune parameters of the sow and litter.

A study was conducted using 3 groups of gestating gilts and sows (n = 98) to determine the effects of Pichia guilliermondii (Pg), a whole cell-inactivated yeast product (CitriStim; ADM Alliance Nutrition), on performance and immune parameters of dams and litters. Within 24 h of breeding, gilts and sows were allotted to 1 of 3 treatments consisting of a control (SC) diet or SC diet supplemented with 0.1 (S1) or 0.2% (S2) Pg. Dietary treatments were maintained through lactation. Colostrum and milk (day 14) samples were collected for IgA, IgG, and IgM analysis. Blood samples were collected from sows on day 110 of gestation (group 3 only), while at weaning for all 3 groups, and from piglets at 14 d of age for peripheral white blood cell counts and serum IgA, IgG, and IgM analysis. Inclusion of Pg resulted in an increase in number born alive as the level of Pg increased (12.49, 13.33, and 13.43 born alive per litter for SC, S1, and S2, respectively; linear effect [LS], P = 0.003). Additionally, the percentage of piglets weighing less than 0.9 kg at birth was reduced in sows provided Pg at 0.1% or 0.2% compared with control (LS, P = 0.006). Sows receiving Pg during gestation and lactation also weaned a greater number of piglets (10.31, 10.55, and 10.60 weaned per litter in control, 0.1% and 0.2% Pg, respectively; LS, P = 0.02). However, percent preweaning mortality was 17.58%, 19.38%, and 19.61% for control, 0.1%, and 0.2% Pg, respectively (LS, P = 0.02). There were no differences in gestation BW gain, farrowing (days 110 to 48 h postfarrowing) or lactation (day 110 to weaning) BW loss, number of mummies or stillborn, or piglets' individual birth or weaning weight. On day 110 of gestation, the neutrophil concentration (quadratic effect [QS], P = 0.03) and neutrophil:lymphocyte ratio (QS, P = 0.04) in peripheral blood were greater in S1 than SC, with S2 being intermediate. At weaning there was a linear increase in neutrophil concentration (P = 0.03), neutrophil:lymphocyte ratio (P = 0.01), and percentage of neutrophils in the leukocyte population (P = 0.01) as level of Pg increased in sow diets. In conclusion, Pg inclusion in sow diets linearly increased total number born alive and weaned, with no change in average birth or weaning weight, and decreased the number of lightweight pigs at birth. However, inclusion of Pg had no effect on immune parameters measured in milk, colostrum, or day 14 piglet serum, but increased the peripheral blood neutrophil concentration of gilts and sows.

Longitudinal investigation of the swine gut microbiome from birth to market reveals stage and growth performance associated bacteria.

BACKGROUND: Despite recent advances in the understanding of the swine gut microbiome at different growth stages, a comprehensive longitudinal study of the lifetime (birth to market) dynamics of the swine gut microbiome is lacking. RESULTS: To fill in this gap of knowledge, we repeatedly collected a total of 273 rectal swabs from 18 pigs during lactation (day (d) 0, 11, 20), nursery (d 27, 33, 41, 50, 61), growing (d 76, 90, 104, 116), and finishing (d 130, 146, 159, 174) stages. DNA was extracted and subjected to sequencing with an Illumina Miseq sequencer targeting the V4 region of the 16S rRNA gene. Sequences were analyzed with the Deblur algorithm in the QIIME2 package. A total of 19 phyla were detected in the lifetime pig gut microbiome with Firmicutes and Bacteroidetes being the most abundant. Alpha diversity including community richness (e.g., number of observed features) and diversity (e.g., Shannon index) showed an overall increasing trend. Distinct shifts in microbiome structure along different growth stages were observed. LEfSe analysis revealed 91 bacterial features that are stage-specific. To validate these discoveries, we performed fecal microbiota transplantation (FMT) by inoculating weanling pigs with mature fecal microbiota from a growing stage pig. Similar stage-specific patterns in microbiome diversity and structures were also observed in both the FMT pigs and their littermates. Although FMT remarkably increased growth performance, it did not change the overall swine gut microbiome. Only a few taxa including those associated with Streptococcus and Clostridiaceae were enriched in the FMT pigs. These data, together with several other lines of evidence, indicate potential roles these taxa play in promoting animal growth performance. Diet, especially crude fiber from corn, was a major factor shaping the swine gut microbiome. The priority effect, i.e., the order and timing of species arrival, was more evident in the solid feed stages. CONCLUSIONS: The distinct stage-associated swine gut microbiome may be determined by the differences in diet and/or gut physiology at different growth stages. Our study provides insight into mechanisms governing gut microbiome succession and also underscores the importance of optimizing stage-specific probiotics aimed at improving animal health and production.

Metformin Affects Serum Lactate Levels in Predicting Mortality of Patients with Sepsis and Bacteremia.

This study determined if the use of metformin affected the prognostic value of hyperlactatemia in predicting 28-day mortality among patients with sepsis and bacteremia. We enrolled adult diabetic patients with sepsis and bacteremia. Of 590 patients, 162 and 162 metformin users and nonusers, respectively, were selected in propensity matching. The mean serum lactate levels in metformin users were higher than those in nonusers (4.7 vs. 3.9 mmol/L, p = 0.044). We divided the patients into four groups based on quick Sepsis-related Organ Failure Assessment (qSOFA) scores. No significant difference was found among nonusers with qSOFA score <2, nonusers with qSOFA score ≥2, and metformin users with qSOFA score <2. The lactate levels in metformin users with qSOFA score ≥2 were higher than those in other groups, and significant differences were found in both nonsurvivors (8.9 vs. 4.6 mmol/L, p = 0.027) and survivors (6.4 vs. 3.8 mmol/L, p = 0.049) compared with metformin users with qSOFA score <2. The best cut-off point to predict 28-day mortality in metformin users (5.9 mmol/L; area under the receiver operating characteristic curve (AUROC), 0.66; 95% confidence interval (CI), 0.55⁻0.77) was higher than that in nonusers (3.6 mmol/L; AUROC 0.63; 95% CI, 0.56⁻0.70). Metformin users had higher lactate levels than nonusers in increasing sepsis severity. Serum lactate levels could be useful in predicting mortality in patients using metformin, but higher levels are required to obtain more precise results.

Quick Sepsis-related Organ Failure Assessment predicts 72-h mortality in patients with suspected infection.

OBJECTIVE: The aim of this study was to compare quick Sepsis-related Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) scores for predicting mortality. PATIENTS AND METHODS: A single-center, retrospective study of adult patients with suspected infection was conducted. Area under the curve (AUC) and multivariate analyses were used to explore associations between the qSOFA and SIRS scores and mortality. RESULTS: Of the 69 115 patients enrolled, 1798 died within 72 h and 5640 within 28 days. The qSOFA scores were better than SIRS scores at predicting 72-h mortality (AUC: 0.77 vs. 0.64). However, the discriminatory power of both scores was low in terms of 28-day mortality (AUC: 0.69 vs. 0.60). Patients with qSOFA score of at least 2 had a higher hazard ratio for 72-h mortality than for 28-day mortality (2.64 vs. 1.91). CONCLUSION: The qSOFA scores are more accurate than SIRS scores for predicting 72-h mortality and are better at predicting 72-h mortality than 28-day mortality.

An electron-transporting host material compatible with diverse triplet emitters used for highly efficient red- and green-electrophosphorescent devices.

A bifluorene analogue, T2N, containing a pyridyl moiety serves as both a host and an efficient electron-transporting material that is compatible with various heavy metal-containing red (Ir, Ru, Os, and Pt) and green (Ir) phosphors for highly efficient phosphorescent OLEDs possessing simple device architectures.

Delayed diagnosis of active pulmonary tuberculosis in emergency department.

BACKGROUND AND PURPOSE: Tuberculosis (TB) is a worldwide health challenge. Emergency department (ED) is the major public access to the health care system. Delayed diagnosis of active pulmonary TB was believed to precipitate mortality and morbidity. The study was designed to investigate clinical characteristics and factors in patients with delayed diagnosis of active TB in ED. METHODS: We used a retrospective chart review. PATIENTS: A total of 103 patients were enrolled between December 2003 and March 2006. RESULTS: Typical chest radiographic findings were noted in 79.8% of nondelayed TB group and 31.6% of delayed TB group (P < .001). Diagnosis of pneumonia was made at ED in 22.6% of nondelayed TB group and 68.4% of delayed TB group (P < .001). Length of initiation of TB treatment intervention was 0 days (0-1 days) and 9 days (6-16 days), respectively (P < .001). In-hospital mortality rate was 15.5% and 47.4%, respectively (P < .01). Age (odds ratio, 1.07; 95% confidence interval, 1.01-1.1) and intensive care unit admission (odds ratio, 5.01; 95% confidence interval, 1.18-21.3) were associated with lower in-hospital survival. Delayed ED diagnosis of TB was associated with mortality in results of univariate analysis (P = .002), but no statistical significance was noted in the final result of stepwise logistic regression analysis. CONCLUSION: Intensive care unit admission and age are associated with mortality. Awareness of varying features of pulmonary TB by physicians is important.

Isolated Rearing at Lactation Increases Gut Microbial Diversity and Post-weaning Performance in Pigs.

Environment and diet are two major factors affecting the human gut microbiome. In this study, we used a pig model to determine the impact of these two factors during lactation on the gut microbiome, immune system, and growth performance. We assigned 80 4-day-old pigs from 20 sows to two rearing strategies at lactation: conventional rearing on sow's milk (SR) or isolated rearing on milk replacer supplemented with solid feed starting on day 10 (IR). At weaning (day 21), SR and IR piglets were co-mingled (10 pens of 4 piglets/pen) and fed the same corn-soybean meal-dried distiller grain with solubles- and antibiotic-free diets for eight feeding phase regimes. Fecal samples were collected on day 21, 62, and 78 for next-generation sequencing of the V4 hypervariable region of the bacterial 16S rRNA gene. Results indicate that IR significantly increased swine microbial diversity and changed the microbiome structure at day 21. Such changes diminished after the two piglet groups were co-mingled and fed the same diet. Post-weaning growth performance also improved in IR piglets. Toward the end of the nursery period (NP), IR piglets had greater average daily gain (0.49 vs. 0.41 kg/d; P < 0.01) and average daily feed intake (0.61 vs. 0.59 kg/d; P < 0.01) but lower feed efficiency (0.64 vs. 0.68; P = 0.05). Consequently, IR piglets were heavier by 2.9 kg (P < 0.01) at the end of NP, and by 4.1 kg (P = 0.08) at market age compared to SR piglets. Interestingly, pigs from the two groups had similar lean tissue percentage. Random forest analysis showed that members of Leuconostoc and Lactococcus best differentiated the IR and SR piglets at weaning (day 21), were negatively correlated with levels of Foxp3 regulatory T cell populations on day 20, and positively correlated with post-weaning growth performance. Our results suggest that rearing strategies may be managed so as to accelerate early-life establishment of the swine gut microbiome to enhance growth performance in piglets.

Difference between elderly and non-elderly patients in using serum lactate level to predict mortality caused by sepsis in the emergency department.

Elderly people are more susceptible to sepsis and experience more comorbidities and complications than young adults. Serum lactate is a useful biomarker to predict mortality in patients with sepsis. Lactate production is affected by the severity of sepsis, organ dysfunction, and adrenergic stimulation. Whether the predictive ability of serum lactate will be different between non-elderly and elderly patients is unknown.A retrospective cohort study was conducted to compare the prognostic value of hyperlactatemia in predicting the mortality between elderly (≥65 years) and non-elderly (<65 years) patients with sepsis.This is a single-center retrospective observational cohort study conducted from January 2007 to December 2013 in southern Taiwan. All patients with sepsis, who used antibiotics, with blood culture collected, and with available serum lactate levels in the emergency department, were included in the analysis. We evaluated the difference in serum lactate level between the elderly and non-elderly septic patients by using multiple regression models.A total of 7087 patients were enrolled in the study. Elderly and non-elderly patients accounted for 62.3% (4414) and 40.2% (2673) of all patients, respectively. Statistically significant difference of serum lactate levels was not observed between elderly and non-elderly survivors (2.9 vs 3.0 mmol/L; P = .57); however, elderly patients had lower lactate levels than those within the 28-day in-hospital mortality (5.5 vs 6.6 mmol/L, P < .01). Multiple logistic regression revealed higher adjusted mortality risk in elderly and non-elderly patients with lactate levels of ≥4.0 mmol/L (odds ratio [OR], 4.98 and 5.82; P < .01, respectively), and lactate level between 2 and 4 mmol/L (OR, 1.57 and 1.99; P < .01, respectively) compared to that in the reference group with lactate levels of <2.0 mmol/L in each group. In receiver operating characteristic curve analysis, sensitivity rates for predicting mortality were 0.80 and 0.77 for non-elderly and elderly patients, respectively, by using serum lactate levels higher than 2.0 mmol/L.Septic elderly non-survivors had 1 mmol/L lower serum lactate level than those of the non-elderly non-survivors. Lactate >2 mmol/L still could provide enough sensitivity in predicting sepsis mortality in elder patients.

How Does the Severity of Injury Vary between Motorcycle and Automobile Accident Victims Who Sustain High-Grade Blunt Hepatic and/or Splenic Injuries? Results of a Retrospective Analysis.

BACKGROUND: High-grade blunt hepatic and/or splenic injuries (BHSI) remain a great challenge for trauma surgeons. The main aim of this study was to investigate the characteristics, mortality rates, and outcomes of high-grade BHSI in motorcyclists and car occupants hospitalized for treatment of traumatic injuries in a Level I trauma center in southern Taiwan. METHODS: High-grade BHSI are defined as grade III-VI blunt hepatic injuries and grade III-V blunt splenic injuries. This retrospective study reviewed the data of 101 motorcyclists and 32 car occupants who experienced a high-grade BHSI from 1 January 2011 to 31 December 2013. Two-sided Fisher's exact or Pearson's chi-square tests were used to compare categorical data, unpaired Student's t-test was used to analyze normally distributed continuous data, and Mann-Whitney's U test was used to compare non-normally distributed data. RESULTS: In this study, the majority (76%, 101/133) of high-grade BHSI were due to motorcycle crashes. Car occupants had a significantly higher injury severity score (ISS; 26.8 ± 10.9 vs. 20.7 ± 10.4, respectively, p = 0.005) and organ injured score (OIS; 3.8 ± 1.0 vs. 3.4 ± 0.6, respectively, p = 0.033), as well as a significantly longer hospital length of stay (LOS; 21.2 days vs. 14.6 days, respectively, p = 0.038) than did motorcyclists. Car occupants with high-grade BHSI also had worse clinical presentations than their motorcyclist counterparts, including a significantly higher incidence of hypotension, hyperpnea, tube thoracostomy, blood transfusion >4 units, LOS in intensive care unit >5 days, and complications. However, there were no differences in the percentage of angiography or laparotomy performed or mortality rate between these two groups of patients. CONCLUSIONS: This study demonstrated that car occupants with high-grade BHSI were injured more severely, had a higher incidence of worse clinical presentation, had a longer hospital LOS, and had a higher incidence of complications than motorcyclists. The results also implied that specific attention should be paid to those car occupants with high-grade BHSI, whose critical condition should not be underestimated because of the concept that the patients within in a car are much safer.