A-qCPR risk score screening model for predicting 1-year mortality associated with hospice and palliative care in the emergency department.

BACKGROUND: Evaluating the need for palliative care and predicting its mortality play important roles in the emergency department. AIM: We developed a screening model for predicting 1-year mortality. DESIGN: A retrospective cohort study was conducted to identify risk factors associated with 1-year mortality. Our risk scores based on these significant risk factors were then developed. Its predictive validity performance was evaluated using area under receiving operating characteristic analysis and leave-one-out cross-validation. SETTING AND PARTICIPANTS: Patients aged 15 years or older were enrolled from June 2015 to May 2016 in the emergency department. RESULTS: We identified five independent risk factors, each of which was assigned a number of points proportional to its estimated regression coefficient: age (0.05 points per year), qSOFA ⩾ 2 (1), Cancer (4), Eastern Cooperative Oncology Group Performance Status score ⩾ 2 (2), and Do-Not-Resuscitate status (3). The sensitivity, specificity, positive predictive value, and negative predictive value of our screening tool given the cutoff larger than 3 points were 0.99 (0.98-0.99), 0.31 (0.29-0.32), 0.26 (0.24-0.27), and 0.99 (0.98-1.00), respectively. Those with screening scores larger than 9 points corresponding to 64.0% (60.0-67.9%) of 1-year mortality were prioritized for consultation and communication. The area under the receiving operating characteristic curves for the point system was 0.84 (0.83-0.85) for the cross-validation model. CONCLUSIONS: A-qCPR risk scores provide a good screening tool for assessing patient prognosis. Routine screening for end-of-life using this tool plays an important role in early and efficient physician-patient communications regarding hospice and palliative needs in the emergency department.

Clinicopathological differences in signet ring cell adenocarcinoma between early and advanced gastric cancer.

BACKGROUND: Signet ring cell adenocarcinoma is a histological classification based on the WHO classification. The presence of this specific histological type is associated with a worse pathological appearance. The prognosis of signet ring cell adenocarcinoma in gastric cancer patients after curative surgery is still under debate. METHODS: From January 1988 to December 2012, a total of 2971 patients, including 819 early and 2152 advanced gastric cancer patients underwent curative resection for gastric cancer. Among them, there were 185 cases of signet ring cell adenocarcinoma in early gastric cancer patients, while there were 570 cases in advanced gastric cancer patients. RESULTS: The overall incidence of signet ring cell adenocarcinoma was 25.4%. Our results showed that the 5-year overall survival rates of early gastric cancer patients with signet ring cell adenocarcinoma and non-signet ring cell adenocarcinoma were 90.7 and 83.2%, respectively (P = 0.001). The 5-year disease-free survival rates of early gastric cancer patients with signet ring cell adenocarcinoma and non-signet ring cell adenocarcinoma were 87.4 and 81.6%, respectively (P = 0.003). The 5-year overall survival rates of advanced gastric cancer patients with signet ring cell adenocarcinoma and non-signet ring cell adenocarcinoma were 32.1 and 37.9%, respectively (P = 0.041). The 5-year disease-free survival rates of advanced gastric cancer patients with signet ring cell adenocarcinoma and non-signet ring cell adenocarcinoma were 28.6 and 35.2%, respectively (P = 0.037). Signet ring cell adenocarcinoma was an independent predictor for overall survival in advanced gastric cancer (P = 0.017). CONCLUSION: The clinical features and prognosis of signet ring cell adenocarcinoma are different between early and advanced gastric cancer. Signet ring cell adenocarcinoma is a poor prognostic factor in advanced gastric cancer after curative resection.

Advanced gastric cancer patients with lymphoid stroma have better survival than those without.

BACKGROUND: Lymphoid stroma is a specific pathologic appearance in gastric cancer. This study aims to compare the clinicopathological characteristics of gastric cancer patients with and without lymphoid stroma. METHODS: From January 1988 to February 2009, 222 out of 1,959 patients with lymphoid stroma of gastric cancer received gastrectomy at the Department of Surgery, Taipei Veterans General Hospital. Clinicopathological characteristics and survival rates were analyzed and compared among the gastric cancer patients with and without lymphoid stroma. For patients with lymphoid stroma, CD20 expression of B lymphocytes and CD3 expression of T lymphocytes were examined using immunohistochemical stains. RESULTS: Advanced gastric cancer patients with lymphoid stroma had better 5-year survival status than those without lymphoid stroma (44.5% vs. 20.5%, P < 0.001). Univariate and multivariate analyses showed that male gender (P = 0.034), tumor invasion depth (P = 0.001), pathological staging (P = 0.006), and Ming's histological classification (P = 0.041) were significantly correlated with patients with lymphoid stroma. B lymphocytes appeared more in Borrmann type III and IV, diffuse Lauren's histological type, and lymph nodes metastases. CONCLUSION: Advanced gastric cancer patients with lymphoid stroma had better prognosis than those without lymphoid stroma. B lymphocytes appeared more in aggressive gastric cancer tissues with lymphoid stroma.

Transient hyperammonemia in seizures: a prospective study.

PURPOSE: To investigate the incidence and duration of transient hyperammonemia in seizures and to verify the significant confounders related to transient hyperammonemia in seizures. METHODS: One hundred twenty-one noncirrhotic adult patients with seizures admitted to the emergency department were enrolled in the study. Laboratory examination was performed, including plasma ammonia level assessment. In addition, the basic parameters, underlying systemic diseases, and seizure-related conditions were assessed. The patients were classified into a group with hyperammonemia on arrival and a group without, in order to compare seizure-related adverse events that occurred during a 9-month period. KEY FINDINGS: The incidence of hyperammonemia in patients with seizures was 67.77%. Plasma ammonia levels in patients with generalized tonic-clonic (GTC) seizures were significantly higher than those in patients in the non-GTC seizure group (median 174.5 vs. 47 µg/dl; proportion 76.5% vs. 21.1%; p < 0.001). Median plasma ammonia levels decreased spontaneously from 250 to 54 µg/dl (p < 0.00001) in an average interval of 466.79 min. GTC seizures (p < 0.0001), male gender (p < 0.0001), bicarbonate (p < 0.0001), diabetes (p = 0.0139), and alcohol-related seizures (p = 0.0002) were significant factors associated with hyperammonemia on arrival. No significant differences related to admission rates or mortalities were found between the two groups. SIGNIFICANCE: The presence of transient hyperammonemia in patients with seizures is significantly related to GTC seizures, male gender, bicarbonate, diabetes, and alcohol-related seizures. The appropriate period to study ammonia levels following a seizure event is within 8 h. Because these phenomena are self-limited, ammonia-lowering management are not necessary. Hyperammonemia on arrival is not necessarily related to adverse outcomes.

Palliative resection in noncurative gastric cancer patients.

BACKGROUND: Palliative resection for noncurable gastric cancer remains controversial, especially in the elderly. This retrospective study was designed to elucidate the clinicopathological factors and operative outcome in patients undergoing palliative gastric resection. METHODS: From January 1988 to December 2008, 365 patients received palliative gastrectomy while 151 underwent exploratory laparotomy or gastrojejunostomy for noncurative gastric cancer at the Department of Surgery, Taipei Veterans General Hospital. Among the 365 patients, 182 patients (Group A) were aged 70 or less and 183 patients (Group B) were older than 70 years of age. Clinicopathological characteristics and surgical morbidity and mortality were analyzed. RESULTS: The overall survival of patients who underwent resection was 10.2 months and that of patients without resection 4.48 months (p < 0.001). Compared to Group B, Group A patients were predominantly female (p < 0.001), had more advanced Borrmann-type tumors (p = 0.004), more diffuse type of Lauren classification (p < 0.001), and poorer cell differentiation (p < 0.001). The median overall survival was 10.5 months in Group A and 9.7 months in Group B (p = 0.854). The surgical morbidity was significant higher if the patients had comorbidity (p = 0.028). Both surgical morbidity (13.8% vs. 26.8%, p = 0.028) and mortality (0.5% vs. 6.0%, p < 0.0001) were significantly higher in Group B. CONCLUSIONS: Gastric cancer is less aggressive in the elderly. Palliative gastrectomy can be performed in both younger and older patients, but younger patients tolerate surgery better. More attention should be paid to the perioperative care of the elderly.

Extensor digitorum brevis manus is uncommon but can easily be misinterpreted during wrist ultrasound examination.

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Quantifying Dynamic Flow of Emergency Department (ED) Patient Managements: A Multistate Model Approach.

BACKGROUND: Emergency department (ED) crowding and prolonged lengths of stay continue to be important medical issues. It is difficult to apply traditional methods to analyze multiple streams of the ED patient management process simultaneously. The aim of this study was to develop a statistical model to delineate the dynamic patient flow within the ED and to analyze the effects of relevant factors on different patient movement rates. METHODS: This study used a retrospective cohort available with electronic medical data. Important time points and relevant covariates of all patients between January and December 2013 were collected. A new five-state Markov model was constructed by an expert panel, including three intermediate states: triage, physician management, and observation room and two final states: admission and discharge. A day was further divided into four six-hour periods to evaluate dynamics of patient movement over time. RESULTS: A total of 149,468 patient records were analyzed with a median total length of stay being 2.12 (interquartile range = 6.51) hours. The patient movement rates between states were estimated, and the effects of the age group and triage level on these movements were also measured. Patients with lower acuity go home more quickly (relative rate (RR): 1.891, 95% CI: 1.881-1.900) but have to wait longer for physicians (RR: 0.962, 95% CI: 0.956-0.967) and admission beds (RR: 0.673, 95% CI: 0.666-0.679). While older patients were seen more quickly by physicians (RR: 1.134, 95% CI: 1.131-1.139), they spent more time waiting for the final state (for admission RR: 0.830, 95% CI: 0.821-0.839; for discharge RR: 0.773, 95% CI: 0.769-0.776). Comparing the differences in patient movement rates over a 24-hour day revealed that patients wait longer before seen by physicians during the evening and that they usually move from the ED to admission afternoon. Predictive dynamic illustrations show that six hours after the patients' entry, the probability of still in the ED system ranges from 28% in the evening to 38% in the morning. CONCLUSIONS: The five-state model well described the dynamic ED patient flow and analyzed the effects of relevant influential factors at different states. The model can be used in similar medical settings or incorporate different important covariates to develop individually tailored approaches for the improvement of efficiency within the health professions.

An emerging and devastating acute abdomen in a patient under peritoneal dialysis: encapsulating peritoneal sclerosis.

Peritoneal dialysis (PD) has been applied to patients with end-stage renal disease for more than 2 decades. It should raise physicians' concern about the serious complications of prolonged PD therapy, particularly encapsulating peritoneal sclerosis (EPS), the most potentially life-threatening one. The prevalence and mortality rate of EPS increase as PD duration increases. We report a case of EPS presented with blood-tinged effluents and abdominal pain.

Central cyanosis due to severe pulmonary hypertension combined with pericarditis as the initial manifestation of systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disorder. The initial manifestation complicating any organ system either singly or in combination is protean. Herein we report a 26-year-old female patient with fresh SLE whose initial manifestation was central cyanosis caused by severe pulmonary hypertension and acute pericarditis. The symptoms were relieved dramatically after treatment with steroid and bosentan. Accurate and timely diagnosis in SLE-associated pulmonary hypertension may be life saving.

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.

Clinicopathological Variation of Lauren Classification in Gastric Cancer.

The investigation of prognostic factor for gastric cancer is still desirable because of dismal prognosis in gastric cancer. Lauren's classification is currently a useful histological classification. There are few large series evaluating the prognostic significance of Lauren's classification in gastric cancer. From January 1987 to December 2013, a total of 3071 patients received gastrectomy for gastric cancer. According Lauren's classification, 1423(46.3%) patients were intestinal type, 1000 patients (32.6%) were diffuse type, and 648 patients (21.1%) were mixed type. The clinicopathological characteristics and prognosis in Lauren's classification were analyzed in these patients. Our results showed that patients with intestinal type gastric cancer (57.7%) had a better 5-year overall survival than diffuse type (45.6%) and mixed type (43.4%, P < 0.001). The clinicopathological characteristics showed that gastric cancer patients with intestinal type were older (P < 0.001), male predominant (P < 0.001), smaller tumor size (P < 0.001), distal stomach predominant (P < 0.001), relative well differentiated (P < 0.001), less advanced Borrmann type (P < 0.001), less scirrhous type stromal reaction(P < 0.001), less infiltrating type of Ming's histology type(P < 0.001), less tumor invasion depth and less lymphovascular invasion (P < 0.001). Multivariate analysis with overall survival as an endpoint showed that age (P = 0.005), Borrmann classification (P < 0.001), pathological T category (P = 0.023), pathological N category (P < 0.001) and Lauren's classification (P = 0.003) were significant correlated in gastric cancer. Lauren's classification is an independent prognostic factor in gastric cancer patient undergoing gastrectomy. Lauren's classification can serve as a prognostic marker for gastric cancer patient receiving gastrectomy. The clinicopathological appearance and prognosis of mixed type gastric cancer is similar to diffuse type gastric cancer.

Primary small cell carcinoma of the pancreas with an unusual sonographic appearance.

We present a case of primary pancreatic small cell carcinoma with an unusual sonographic feature. A 75-year-old woman presented with poor appetite and weight loss. Abdominal sonographic examination revealed a diffusely enlarged pancreas with relative increased echogenicity and smooth contour. CT also confirmed the diffuse infiltrative pattern of the tumor. The diagnosis was confirmed via sonographically guided biopsy. The tumor was composed of small cells with hyperchromatic nuclei and scanty cytoplasm infiltrating the pancreatic tissue, consistent with small cell carcinoma of the pancreas. Primary pancreatic small cell carcinoma rarely presents as the diffuse infiltrating type. These unusual sonographic features must be differentiated from other pancreatic tumors presenting as diffuse pancreatic enlargement.