A feasibility study of a handmade ultrasound-guided phantom for paracentesis.

BACKGROUND: Simulation-based training is effective for ultrasound (US)-guided procedures. However, commercially developed simulators are costly. This study aims to evaluate the feasibility of a hand-made phantom for US-guided paracentesis. METHODS: We described the recipe to prepare an agar phantom. We collected the US performance data of 50 novices, including 22 postgraduate-year (PGY) residents and 28 undergraduate-year (UGY) students, who used the phantom for training, as well as 12 emergency residents with prior US-guided experience. We obtained the feedback after using the phantom with the Likert 5-point scale. The data were presented with medians and interquartile ranges (IQRs) and analyzed by the Wilcoxon rank sum test. RESULTS: While emergency residents demonstrated superior performance compared to trainees, all trainees exhibited acceptable proficiency (global rating of ≥ 3, 50/50 vs. 12/12, p = 1.000) and comparable needle steadiness [5 (5) vs. 5 (5), p = 0.223]. No significant difference in performance was observed between PGYs [5 (4-5)] and UGYs [5 (4-5), p = 0.825]. No significant differences were observed in terms of image stimulation, puncture texture, needle visualization, drainage simulation, and endurance of the phantom between emergency residents and trainees. However, experienced residents rated puncture texture and draining fluid as "neutral" (3/5 on the Likert scale). The cost of the paracentesis phantom is US$16.00 for at least 30 simulations, reducing it to US$6.00 without a container. CONCLUSIONS: The paracentesis phantom proves to be a practical and cost-effective training tool. It enables novices to acquire paracentesis skills, enhances their US proficiency, and boosts their confidence. Nevertheless, further investigation is needed to assess its long-term impact on clinical performance in real patients. TRIAL REGISTRATION: NCT04792203 at the ClinicalTrials.gov.

Submandibular Sialolithiasis Mimicking Ludwig's Angina: A Case Report and Brief Clinical Review.

The "double tongue sign" is a characteristic finding in patients with Ludwig's angina, a potentially life-threatening infection due to airway compromise. Management primarily focuses on early airway protection and antibiotic administration. Submandibular sialolithiasis, on the other hand, could present with the double tongue sign without symptoms suggestive of airway involvement. Unlike Ludwig's angina, conservative treatment is usually the first-line approach for sialolithiasis. The importance of rapidly recognizing and distinguishing between the 2 conditions is emphasized through effective triage and risk stratification, particularly in rural areas where physicians are not readily available.

The effect of point-of-care ultrasound on length of stay and mortality in patients with chest pain/dyspnea.

PURPOSE: This study aims to investigate the effects of point-of-care ultrasound (PoCUS) on length of stay (LOS) and mortality in hemodynamically stable patients with chest pain/dyspnea. MATERIALS AND METHODS: The prospective study was conducted from June 2020 to May 2021. A convenience sample of adult non-traumatic patients with chest pain/dyspnea was included and evaluated by PoCUS. The primary outcome was the relationship between the door-to-PoCUS time and LOS/mortality categorized by the ST-segment elevation (STE) and non-STE on the initial electrocardiogram. The diagnostic accuracy of PoCUS was computed, compared to the final diagnosis. RESULTS: A total of 465 patients were included. 3 of 18 patients with STE had unexpected cardiac tamponade and 1 had myocarditis with pulmonary edema. PoCUS had a minimal effect on LOS and mortality in patients with STE. In the non-STE group, the shorter door-to-PoCUS time was associated with a shorter LOS (coefficient, 1.26±0.47, p=0.008). After categorizing the timing of PoCUS as 30, 60, 90, and 120 minutes, PoCUS had a positive effect, especially when performed within 90 minutes of arrival, on LOS of less than 360 minutes (OR, 2.42, 95% CI, 1.61-3.64) and patient survival (OR, 3.32, 95% CI, 1.14-9.71). The overall diagnostic performance of PoCUS was 96.6% (95% CI, 94.9-98.2%), but lower efficacy occurred in pulmonary embolism and myocardial infarction. CONCLUSION: The use of PoCUS was associated with a shorter LOS and less mortality in patients with non-STE, especially when performed within 90 minutes of arrival. Although the effect on patients with STE was minimal, PoCUS played a role in discovering unexpected diagnoses.

Clinical Features and Outcomes of Immune Checkpoint Inhibitor-Associated Cardiovascular Toxicities.

BACKGROUND: Despite the increasing prevalence of therapies utilizing immune checkpoint inhibitors (ICIs), the associated cardiovascular complications have been poorly reported. Given the fatality of ICI-related complications, especially myocarditis, optimal risk stratification to predict major adverse cardio- and cerebrovascular events (MACCEs) in patients receiving ICIs is mandatory. METHODS: We collected clinical data from patients receiving ICIs, and the primary outcomes were MACCEs, including myocarditis, heart failure, and ischemic stroke. Other systemic immune responses relating to ICIs were also recorded. The median follow-up duration was 3 years. RESULTS: Among 580 patients, the incidence of MACCEs was 3.9%. Older patients, male patients, and patients with lung cancer, liver cirrhosis, or diabetes had higher risks of MACCEs. There was no significant difference between the use of PD-1/PD-L1 inhibitors or CTLA inhibitors in terms of developing cardiovascular toxicities. The development of ICI-related MACCEs was associated with worse survival. Notably, after re-review by specialists, three patients eventually diagnosed with ICI-related myocarditis had not previously been identified. Only one was treated with pulse steroids, and none survived. The most common concomitant extracardiac immune-related adverse events were myositis/dermatitis, endocrine toxicity and hepatitis. CONCLUSIONS: Collectively, ICIs may lead to severe cardiovascular toxicities and require more attention. Early identification, proper diagnosis, and prompt treatment are pivotal for improving survival.

Association between pre-arrest left ventricular ejection fraction and survival in nontraumatic out-of-hospital cardiac arrest.

BACKGROUND AND IMPORTANCE: Out-of-hospital cardiac arrest (OHCA) poses major public health issues. Pre-arrest heart function is a prognostic factor, but the specific contribution of pre-arrest echocardiographic evaluation in predicting OHCA outcome remains limited. OBJECTIVE: The primary objective was to investigate the association between left ventricular ejection fraction (LVEF) measured in echocardiography prior to OHCA and survival to hospital discharge. DESIGN, SETTINGS, AND PARTICIPANTS: This multicenter retrospective cohort study analyzed data from the National Taiwan University Hospital and its affiliated hospitals. We included adult nontraumatic OHCA patients who were treated by the emergency medical services (EMS) and underwent echocardiography within 6 months prior to the OHCA event from January 2016 to December 2022. Data included demographics, preexisting diseases, resuscitation events, and echocardiographic reports. OUTCOMES MEASURE AND ANALYSIS: The primary outcome was the survival to hospital discharge after post-arrest care. Statistical analysis involved multivariable logistic regression to modify potential confounders, reported as adjusted odds ratio (aOR) and 95% confidence interval (CI), and evaluate the association between echocardiographic findings and survival to hospital discharge. MAIN RESULTS: This study analyzed 950 patients, with 33.6% surviving to discharge. A higher pre-arrest LVEF was independently associated with increased survival. Compared to patients with LVEF < 40%, those with LVEF between 40% and 60% had significantly higher odds of survival (aOR = 3.68, 95% CI = 2.14-6.35, P < 0.001), and those with LVEF > 60% had even greater odds of survival (aOR = 5.46, 95% CI = 3.09-9.66, P < 0.001). There was also an association between lower tricuspid regurgitation pressure gradient and survival (aOR = 0.98, 95% CI = 0.97-1.00, P = 0.015). Younger age, male gender, dyslipidemia, stroke, cancer, witnessed arrest, initial shockable rhythm, and shorter low-flow time are other significant predictors of survival. CONCLUSION: In adult, nontraumatic, EMS-treated OHCA patients, a higher LVEF 6 months prior to OHCA was associated with improved survival at hospital discharge.

Spontaneous cervical epidural hematoma in a patient with end-stage renal disease.

Spontaneous spinal epidural hematoma (SEH) is extremely rare in patients with end-stage renal disease (ESRD). We report a case of a 71-year-old man with ESRD presented with progressive left limb weakness. Magnetic resonance imaging (MRI) revealed spinal cervical SEH involving C3-5 level. The patient received emergent decompression laminectomy with the evacuation of the epidural hematoma.

Intravenous antibiotics at the index emergency department visit as an independent risk factor for hospital admission at the return visit within 72 hours.

INTRODUCTION: Although infection was the most common symptom in patients returning to the ED, whether intravenous antibiotic administration at the index visit could serve as an indicator of patients with infectious diseases at high risk for hospital admission after returning to the ED within a short period of time remains unclear. The study aimed to investigate the potential risk factors for hospital admission in patients returning to the ED within 72 hours with a final diagnosis of infectious diseases. MATERIAL AND METHODS: This retrospective cohort study analyzed return visits to the ED from January to December 2019. Adult patients aged >20 years who had a return visit to the ED within 72 hours with an infectious disease were included herein. In total, 715 eligible patients were classified into the intravenous antibiotics and non-intravenous antibiotics group (reference group). The outcome studied was hospital admission to general ward and intensive care unit (ICU) at the return visits. RESULTS: Patients receiving intravenous antibiotics at index visits had significantly higher risk-approximately two times-for hospital admission at the return visits than those did not (adjusted odds ratio = 2.47, 95% CI = 1.34-4.57, p = 0.004). For every 10 years increase in age, the likelihood for hospital admission increased by 38%. Other factors included abnormal respiratory rate and high C-reactive protein levels. CONCLUSIONS: Intravenous antibiotic administration at the index visit was an independent risk factor for hospital admission at return visits in patients with an infection disease. Physicians should consider carefully before discharging patients receiving intravenous antibiotics.

Layer-specific distribution of myocardial deformation from anthracycline-induced cardiotoxicity in patients with breast cancer-From bedside to bench.

BACKGROUND: Anthracycline anticancer drugs such as epirubicin and doxorubicin may induce myocardial dysfunction, leading to poor prognosis. Early detection of minor left ventricular (LV) myocardial dysfunction is important for the prevention of anthracylcine-induced cardiotoxicity. Using layer-specific speckle tracking echocardiography (STE), we investigated the progressive distribution of myocardial dysfunction in both breast cancer patients and an animal toxicity model. METHODS: Patients with preserved LV ejection fraction (LVEF) preparing for epirubicin chemotherapy (N = 125) were prospectively enrolled. Layer-specific STE, including LV longitudinal and circumferential strains on subepicardium and subendocardium, were evaluated at baseline and after the first cycle, third cycle and six months of epirubicin therapy. A decline of LVEF above 10% to <55% at six months was defined as cardiotoxicity. These same strain measures were obtained in doxorubicin-treated rats and the distribution of myocardial fibrosis evaluated. RESULTS: In patients developing cardiotoxicity, LV longitudinal strain on subendocardium (LVLSendo) was significantly reduced after three cycles of therapy despite no significant changes in conventional LV systolic, diastolic parameters as well as LV circumferential strains at that moment. Compared to conventional echocardiographic parameters, LVLSendo was significantly predictive of cardiotoxicity. Declines in LVLSendo were also observed in doxorubicin-treated rats at an early stage. These reductions also predicted significant fibrosis in the subendocardial layer. CONCLUSION: LVLSendo is useful for the early detection of minor cardiac dysfunction during chemotherapy, thereby implicating endocardial involvement in the development of cardiotoxicity.

Public Awareness of Automated External Defibrillator Locations.

This cross-sectional study examines survey data from a 4-day nationwide telephone survey in Taiwan about awareness of and willingness to use automated external defibrillators.

p53 and p27 as predictors of clinical outcome for rectal-cancer patients receiving neoadjuvant therapy.

Our aim was to examine whether certain molecular markers, specifically p53, p21, p27, and Bcl-2, could be used to predict the tumor response of rectal cancer to neoadjuvant therapy and determine the overall and disease-free survival rates of patients following neoadjuvant therapy. Seventy-seven patients with rectal cancers were used in this study. All of them received neoadjuvant therapy and 53 of them were given radical surgery. Immunohistochemical tests were performed for the four markers mentioned above using biopsy specimens obtained from 70 of the patients prior to radiation. The identical tests were performed for the same markers using excised specimens from the patients after radical surgery. For the pre-radiation specimens, the positive rate for having p27 and Bcl-2 markers was 32.7% and 16.6%, respectively. This rate increased to 73.5% and 41.6% (p=0.001 and 0.012, respectively) in the specimens obtained after the surgery. With respect to "fair response (FR)" of patients, the pre-radiation biopsy specimens showed significant difference for the p53 (-) and p27 (+) markers (p=0.006). Patients with a 3-year overall survival rate were found to have, from their surgical specimens, 92% of the p27 (+) and 75% of p27 (-) markers (p=0.0058). Our study showed: first, the rate of positive identification of molecular markers, p27 and Bcl-2, increased following neoadjuvant therapy. Second, either the p53 (-) or p27 (+) status was a good predictor for FR in the pre-radiation biopsy specimens. Third, patients with p27 (+) markers in the surgical specimens lived longer at 3 years.

Angioimmunoblastic T-cell lymphoma with cutaneous involvement: a case report with subtle histologic changes and clonal T-cell proliferation.

Angioimmunoblastic T-cell lymphoma is a nodal peripheral T-cell lymphoma that rarely involves the skin. We describe a 62-year-old Taiwanese man who developed a second relapse of angioimmunoblastic T-cell lymphoma with generalized erythroderma and numerous plaquelike and nodular lesions. Biopsy of the erythematous skin lesion demonstrated mild infiltrate of atypical small lymphocytes, some with clear cytoplasm. The lymphoid infiltrate was located mainly around skin appendages and in the upper dermis without epidermotropism. Immunohistochemically, these atypical lymphocytes expressed CD3. Polymerase chain reaction analysis for T-cell receptor gamma-chain gene rearrangement using paraffin section showed the same-sized monoclonal bands in the skin and 2 previous nodal biopsies. We conclude that the histologic features of angioimmunoblastic T-cell lymphoma involving skin may be very subtle, showing only mild lymphoid infiltrate. Awareness of the history of angioimmunoblastic T-cell lymphoma with ancillary studies, including clonality testing for T-cell receptor gene rearrangement, is crucial for reaching an accurate diagnosis.

Acute leukemia with myeloid, B-, and natural killer cell differentiation.

Biphenotypic acute leukemias account for 4% to 8% of all acute leukemias. Most of these leukemias are of myeloid-B-cell or myeloid-T-cell lineage. Acute myeloid-natural killer cell leukemia has been recognized recently. We report the first case, to our knowledge, of CD56(+) acute leukemia showing unequivocal myeloid and B-cell differentiation in a 20-year-old woman, whose blast cells were positive for myeloperoxidase, CD13, CD33, CD117, terminal deoxynucleotidyl transferase, CD19, CD20, CD22, CD34, HLA-DR, and CD56 but negative for CD3, CD5, CD7, and CD10. Rare Auer rods were identified in the blast cells. Polymerase chain reaction assays showed rearrangement of immunoglobulin heavy-chain gene and absence of Epstein-Barr virus DNA. We propose that this novel form of multilineage leukemia may represent the neoplastic counterpart of a progenitor that can give rise to myeloid, B, and natural killer cells.

A prospective study of pain treatment for patients with advanced cancer who receive hospice home care.

BACKGROUND: Pain is often inadequately treated in patients with cancer. Previous studies have demonstrated the effectiveness of the World Health Organization (WHO) analgesic ladder in cancer pain management. METHODS: A total of 131 consecutive patients with advanced cancer referred to a hospice home care program were enrolled over one year period from Jan. 1 to Dec. 31, 2000. We assessed the adequacy of prescribed analgesic drugs using guidelines developed by the WHO. Age, gender, Eastern Cooperative Oncology Group performance status, pain mechanism at referral, pain and symptom intensity, and doses and days of drug administration during the course of treatment were recorded at regular intervals. RESULTS: Eighty-two percent of the patients (107 of 131) had pain symtoms at referral. Forty-seven patients were excluded from this study due to inadequate follow-up times or inability to express the pain intensity. Sixty patients who had measurable pain intensity requiring analgesic therapy were followed up until death for a mean duration of 65 days. At referral, 46% of the patients (28 of 60) received inadequate treatment. In the last week of life, 2%, 26% and 70% of patients were taking non-opioid drugs, moderate opioids and strong opioids, respectively. A significant improvement in pain and symptom intensity was achieved after referral. A minority of the patients (10%) had inadequate pain control in the last week of life. CONCLUSIONS: This study demonstrates that a managed hospice home care system enables patients to receive adequate pain treatment, according to WHO guidelines.

Primary brain lymphoma: a report of eight cases from a medical center in southern Taiwan.

BACKGROUND: Primary brain lymphoma (PBL) in Taiwan has been reported only in three series with very limited immunophenotypic characterization. METHODS: We retrospectively studied PBL cases with history review, immunohistochemistry, and in situ hybridization (ISH) for Epstein-Barr virus-encoded mRNA (EBER) from a single institution in southern Taiwan during 1989-2000. RESULTS: We found eight cases of PBL including four males and four females with mean age of 64.1 years and median of 63.0. The major presenting symptoms were headache, poor memory, slurred speech, and hemiplegia in three patients each. All patients had stage I solitary tumor. Half of the patients received tumor excision, the other half, stereotactic biopsy. Seven cases were of diffuse large B-cell type (DLBL), with expression of bcl-2 in six cases. They were all negative for CD5, CD10, bcl-6, and EBER. The eighth patient had anaplastic large cell lymphoma (ALCL) of T-cell phenotype with expression of cytotoxic markers and was positive for EBER. Two were lost to follow up. The median follow-up time for the remaining six was 11.2 months (range, 5.5 - 25.0). They all received radiotherapy with initial complete remission. Two died of the disease, another of cardiopulmonary failure, and the other of stroke or recurrence. The remaining two were free of disease for 9.6 and 25.0 months after radiotherapy alone. The 1-year survival rate was 60%. CONCLUSIONS: We have fully characterized eight cases of PBL, including seven DLBLs and one ALCL, in southern Taiwan that occurred in an older age group. Old age, immunophenotype (bcl-2-positivity and bcl-6-negativity), and lack of systemic chemotherapy were probably responsible for the shorter survival as compared to other studies. Radiotherapy seems to be effective for inducing complete remission and even long-term survival in some patients, however, systemic chemotherapy should be administered to prevent recurrence and to achieve long-term survival.