Integrating the clinical frailty scale with emergency department triage systems for elder patients: A prospective study.

BACKGROUND: This prospective study investigated whether integrating the Clinical Frailty Scale (CFS) with a triage system would improve triage for older adult emergency department (ED) patients. METHODS: We enrolled ED patients aged 65 years or older at 5 study sites in Taiwan between December 2020 and April 2021. All eligible patients were assigned a triage level by using the Taiwan Triage and Acuity Scale (TTAS) in accordance with usual practice. A CFS score was collected from them. The primary outcome was critical events, defined as ICU admission or in-hospital mortality. The secondary outcomes were ED medical expenditures, number of orders in the ED, and length of hospital stay (LOS). We applied a reclassification concept and integrated the CFS and TTAS to create the Triage Frailty Acuity Scale (TFAS). We compared the outcomes achieved between the TTAS and TFAS. RESULTS: Of 1023 screened ED patients, 890 were enrolled. The majority were assigned to TTAS level 3 (73.26%) and had CFS scores of 4 to 9 (55.96%). The primary outcomes were better predicted by the TFAS than the TTAS (area under the curve [AUC] 0.82 vs. 064). Using multivariable approach, TTAS level 1 (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.7-13.4) and CFS score (OR, 5.8; 95% CI, 1.9-17.2) were significantly associated with the primary outcomes. For older adults at the highest triage level, the TFAS was not associated with an increase in the primary outcomes compared with the TTAS; however, the TFAS was associated with a significant decrease in the number of older ED patients assigned to triage levels 3 to 5. In addition, TFAS had a longer average LOS but did not have a higher average number of orders or ED medical expenditures compared to TTAS. CONCLUSIONS: The TFAS identified more older ED patients who had been triaged as less emergent but proceeded to need ICU admission or in-hospital death. Incorporating the CFS into triage may reduce the under-triage of older adults in the ED.

Associations of Three-Dimensional Anthropometric Body Surface Scanning Measurements and Coronary Artery Disease.

Background and Objectives: The relationship between three-dimensional (3D) scanning-derived body surface measurements and biomarkers in patients with coronary artery disease (CAD) were assessed. Methods and Methods: The recruitment of 98 patients with CAD confirmed by cardiac catheterization and 98 non-CAD patients were performed between March 2016 and December 2017. A health questionnaire on basic information, life style variables, and past medical and family history was completed. 3D body surface measurements and biomarkers were obtained. Differences between the two groups were assessed and multivariable analysis performed. Results: It was found that chest width (odds ratio [OR] 0.761, 95% confidence interval [CI] = 0.586-0.987, p = 0.0399), right arm length (OR 0.743, 95% CI = 0.632-0.875, p = 0.0004), waist circumference (OR 1.119, 95% CI = 1.035-1.21, p = 0.0048), leptin (OR 1.443, 95% CI = 1.184-1.76, p = 0.0003), adiponectin (OR 0.978, 95% CI = 0.963-0.994, p = 0.006), and interleukin 6 (OR 1.181, 95% CI = 1.021-1.366, p = 0.0254) were significantly associated with CAD. The combination of biomarker scores and body measurement scores had the greatest area under the curve and best association with CAD (area under the curve of 0.8049 and 95% CI = 0.7440-0.8657). Conclusions: Our study suggests that 3D derived body surface measurements in combination with leptin, adiponectin, and interleukin 6 levels may direct us to those at risk of CAD, allowing a non-invasive approach to identifying high-risk patients.

Combination of Thigh Circumference and Indices of Central Obesity Helps Predict Incident Chronic Kidney Disease: A 14-Year Prospective Cohort Study Using a Three-Dimensional Body Laser Scanner.

OBJECTIVE: Obesity, high body mass index, and visceral fat accumulation are associated with renal diseases. However, the association between body measurements and chronic kidney disease (CKD) is still unclear. METHODS: A cohort of 7,825 participants scheduled for follow-up of CKD was recruited from 2000 to 2008 in Taiwan. A questionnaire was developed to collect the basic demographics, lifestyle variables, personal disease history, and family disease history of the participants. A 3-dimensional body surface scanning system was used to take their body measurements. The participants underwent an average follow-up of 14.3 years for evaluation of the incidence of CKD. A multiple Cox regression model was built. RESULTS: Three body measurements, namely chest width (hazard ratio [HR] 1.059, 95% confidence interval [CI] 1.011-1.110), waist circumference (HR 1.017, 95% CI 1.006-1.029), and thigh circumference (HR 0.941, 95% CI 0.922-0.961), were significantly associated with CKD. Two combinations of body measurements, namely the waist-to-thigh ratio and chest-to-thigh ratio, were derived to predict the occurrence of CKD. Participants with the highest quartile of waist-to-thigh ratio and chest-to-thigh ratio had a 2.175-fold and 2.182-fold risk of developing CKD, respectively. CONCLUSIONS: This study suggests that along with central obesity, body limb measurements can be used as an indicator to predict the occurrence of CKD. The effects of limb measurements on CKD could help provide an innovative perspective regarding the intervention to be developed for the treatment of CKD and a preventive medicine for high-risk individuals. The association of thigh circumference with CKD warrants further investigation.

Using mobility status as a frailty indicator to improve the accuracy of a computerised five-level triage system among older patients in the emergency department.

BACKGROUND: Owing to societal ageing, the number of older individuals visiting emergency departments (EDs) has increased in recent years. For this patient population, accurate triage systems are required. This retrospective cohort study assessed the accuracy of a computerised five-level triage system, the Taiwan Triage and Acuity System (TTAS), by determining its ability to predict in-hospital mortality in older adult patients and compare it with the corresponding rate in younger adult patients presenting to EDs. The association between frailty, which the current triage system does not consider, was also investigated. METHODS: The medical records of adult patients admitted to a single ED between 2016 and 2017 were reviewed. Data collected included information on demographics, triage level, frailty status, in-hospital mortality, and medical resource utilisation. The patients were divided into four age groups: two older adult groups (older: 65-84 years and very old: ≥85 years) and two younger adult groups (young: 18-39 and middle-aged: 40-64 years). RESULTS: Our study included 265,219 ED adult patients, of whom 64,104 and 16,009 were in the older and very old groups, respectively. The in-hospital mortality rate at each triage level increased with age. The ability of the TTAS to predict in-hospital mortality decreased with age (area under the receiver operating characteristic curve [AUROC]: young: 0.86; middle-aged, 0.84; and older and very old: 0.79). Frailty was associated with in-hospital mortality (odds ratio, 2.20; 95% confidence interval, 2.03-2.38). Adding mobility status as a frailty indicator to TTAS only slightly improved its ability to predict in-hospital mortality (AUROC: 0.74-0.77) in patients ≥65 years of age. CONCLUSIONS: The ability of the current triage system to predict in-hospital mortality decreases with age. Although frailty as mobility was associated with in-hospital mortality, its addition to the TTAS only slightly improved the accuracy with which in-hospital mortality in older patients presenting to EDs was predicted.

Two-stage prediction model for in-hospital mortality of patients with influenza infection.

BACKGROUND: Infleunza is a challenging issue in public health. The mortality and morbidity associated with epidemic and pandemic influenza puts a heavy burden on health care system. Most patients with influenza can be treated on an outpatient basis but some required critical care. It is crucial for frontline physicians to stratify influenza patients by level of risk. Therefore, this study aimed to create a prediction model for critical care and in-hospital mortality. METHODS: This retrospective cohort study extracted data from the Chang Gung Research Database. This study included the patients who were diagnosed with influenza between 2010 and 2016. The primary outcome of this study was critical illness. The secondary analysis was to predict in-hospital mortality. A two-stage-modeling method was developed to predict hospital mortality. We constructed a multiple logistic regression model to predict the outcome of critical illness in the first stage, then S1 score were calculated. In the second stage, we used the S1 score and other data to construct a backward multiple logistic regression model. The area under the receiver operating curve was used to assess the predictive value of the model. RESULTS: In the present study, 1680 patients met the inclusion criteria. The overall ICU admission and in-hospital mortality was 10.36% (174 patients) and 4.29% (72 patients), respectively. In stage I analysis, hypothermia (OR = 1.92), tachypnea (OR = 4.94), lower systolic blood pressure (OR = 2.35), diabetes mellitus (OR = 1.87), leukocytosis (OR = 2.22), leukopenia (OR = 2.70), and a high percentage of segmented neutrophils (OR = 2.10) were associated with ICU admission. Bandemia had the highest odds ratio in the Stage I model (OR = 5.43). In stage II analysis, C-reactive protein (OR = 1.01), blood urea nitrogen (OR = 1.02) and stage I model's S1 score were assocaited with in-hospital mortality. The area under the curve for the stage I and II model was 0.889 and 0.766, respectively. CONCLUSIONS: The two-stage model is a efficient risk-stratification tool for predicting critical illness and mortailty. The model may be an optional tool other than qSOFA and SIRS criteria.

Sarcopenia is a useful risk stratification tool to prognosticate splenic abscess patients in the emergency department.

BACKGROUND/PURPOSE: Splenic abscess is a life-threatening surgical emergency which requires early diagnosis and intervention to maximize patient outcomes. This can be achieved through accurate risk stratification in the emergency department (ED). Sarcopenia refers to an age-related loss of skeletal muscle mass and strength that is accompanied by major physiologic and clinical ramifications, and often signifies decreased physiologic reserves. It is associated with poor clinical outcomes in sepsis, acute respiratory failure, oncological surgery, and liver transplantation. This study evaluates the utility of sarcopenia as a radiological stratification tool to predict in-hospital mortality of splenic abscess patients in the ED. This will assist emergency physicians, internists and surgeons in rapid risk stratification, assessing treatment options, and communicating with family members. METHODS: 99 adult patients at four training and research hospitals who had undergone an abdominal contrast computed tomography scan in the ED with the final diagnosis of splenic abscess from January 2004 to November 2017 were recruited. Evaluation for sarcopenia was performed via calculating the psoas cross-sectional area at the level of the third lumbar vertebra and normalising for height, before checking it against pre-defined values. Univariate analyses were used to evaluate the differences between survivors and non-survivors. Sensitivity, specificity, and predictive values of the presence of sarcopenia in predicting in-hospital mortality were calculated. Kaplan-Meier methods, log-rank test, and Cox proportional hazards model were also performed to examine survival between groups with sarcopenia versus non-sarcopenia. RESULTS: Splenic abscess patients with sarcopenia were 7.56 times more at risk of in-hospital mortality than those without sarcopenia (multivariate-adjusted HR: 7.56; 95% CI: 1.55-36.93). Presence of sarcopenia was found to have 84.62% sensitivity and 96.49% negative predictive value in predicting mortality. CONCLUSION: Sarcopenia is associated with poor prognoses of in-hospital mortality in patients with splenic abscess presenting to the ED. We recommend its use in the ED to rapidly risk stratify and predict outcome to guide treatment strategies.

TEN-YEAR EPIDEMIOLOGY OF RETINOPATHY OF PREMATURITY TREATMENT IN TAIWAN.

PURPOSE: To understand the epidemiology of retinopathy of prematurity (ROP) requiring treatment in Taiwan from 2002 to 2011. METHODS: This retrospective cross-sectional study enrolled 11,180 premature patients with a length of stay >28 days who survived during hospitalization. The incidence of the first ROP treatment was analyzed. RESULTS: Among ROP patients (n = 4,096), 6.5% (n = 265) received treatment. The most frequently performed treatment was laser administration (n = 199), followed by intravitreal anti-vascular endothelial growth factor (VEGF) injection (n = 38), scleral buckle or pars plana vitrectomy (n = 14), and cryotherapy (n = 14). The incidence of ROP requiring treatment increased during the study period, as did the use of intravitreal anti-VEGF injection. Shifts in the treatment modality from cryotherapy and scleral buckle/pars plana vitrectomy to laser treatment after 2003 and from laser treatment to intravitreal anti-VEGF injection after 2010 were observed. CONCLUSION: In Taiwan, the incidence of the use of intravitreal anti-VEGF injection for treating ROP increased between 2002 and 2011. Laser treatment was less frequently used than intravitreal anti-VEGF injection in 2011.

The association between chronic musculoskeletal pain and clinical outcome in chronic kidney disease patients: a prospective cohort study.

BACKGROUND AND OBJECTIVES: Chronic musculoskeletal (MS) pain is common in chronic kidney disease (CKD) patients. The association of chronic MS pain and CKD progression has not yet been established. METHOD: We conducted a prospective cohort study to evaluate the association of chronic MS pain and CKD progression of pre-dialysis CKD patients. RESULT: A total of 53.2% of pre-dialysis CKD patients had chronic MS pain. Patients classified as progression and non-progression had a similar prevalence of chronic MS pain at baseline, and similar baseline use of NSAIDs and Chinese herbal medicines. Univariate Cox analysis indicated that chronic MS pain and baseline NSAID or Chinese herbal medicine use were not significantly associated with progression of CKD. But multivariate Cox regression found chronic MS pain was independently significantly associated with all-cause mortality (HR, 2.912, 95% CI, 1.004-8.444; p = .049). However, serum levels of hs-CRP were similar between those chronic MS pain patients and without chronic MS pain patients (4.96 ± 9.4 vs. 4.25 ± 13.3 mg/L, p = .535). CONCLUSION: The CKD patients with chronic MS pain was independently and significantly associated with all-cause mortality, but not independently and significantly associated with CKD progression and composite endpoints. The inflammatory marker-hs-CRP was similar between CKD patients with and without chronic MS pain.

Validation of the five-tier Taiwan Triage and Acuity Scale for prehospital use by Emergency Medical Technicians.

OBJECTIVES: This study aimed to determine the inter-rater reliability of the five-level Taiwan Triage and Acuity Scale (TTAS) when used by emergency medical technicians (EMTs) and triage registered nurses (TRNs). Furthermore, it sought to validate the prehospital TTAS scores according to ED hospitalisation rates and medical resource consumption. METHODS: This was a prospective observational study. After training in five-level triage, EMTs triaged patients arriving to the ED and agreement with the nurse triage (TRN) was assessed. Subsequently, these trained research EMTs rode along on ambulance calls and assigned TTAS scores for each patient at the scene, while the on-duty EMTs applied their standard two-tier prehospital triage scale and followed standard practice, blinded to the TTAS scores. The accuracy of the TTAS scores in the field for prediction of hospitalisation and medical resource consumption were analysed using logistic regression and a linear model, respectively, and compared with the accuracy of the current two-tier prehospital triage scale. RESULTS: After EMT's underwent initial training in five-level TTAS, inter-rater agreement between EMTs and TRNs for triage of ED patients was very good (κw=0.825, CI 0.750 to 0.900). For the outcome of hospitalisation, TTAS five-level system (Akaike's Information Criteria (AIC)=486, area under the curve (AUC)=0.75) showed better discrimination compared with TPTS two-level system (AIC=508, AUC=0.66). Triage assignments by the EMTs using the the five-level TTAS was linearly associated with hospitalisation and medical resource consumption. CONCLUSIONS: A five-level prehospital triage scale shows good inter-rater reliability and superior discrimination compared with the two-level system for prediction of hospitalisation and medical resource requirements.

Chest width, waist circumference, and thigh circumference are predictors of dementia.

OBJECTIVE: Few studies have investigated the relationship between specific body measures and dementia. METHODS: Three-dimensional anthropometric body surface scanning data containing 38 body measures were collected from 6831 participants from the health examination department of a medical center in Taiwan during 2000 to 2008, and 236 dementia cases were identified during the 10-year follow-up. A multiple Cox regression analysis was performed. RESULTS: Specific body measures, namely chest width (hazard ratio [HR] = 0.90; 95% confidence interval [CI] = 0.83-0.98), and right thigh circumference (HR = 0.93; 95% CI = 0.90-0.96), were protective predictors to dementia occurrence. Waist circumference (HR = 1.03; 95% CI = 1.02-1.05) was a risk factor in dementia occurrence. Among the combinations, dementia risk was higher in participants with a larger waist circumference and a smaller right thigh circumference, with the highest HR of 2.49 (95% CI = 1.54-4.03). CONCLUSION: The body measures provide clues for future applications and scientific merits in both clinical and preventive medicine.

Areca nut chewing is associated with common mental disorders: a population-based study.

INTRODUCTION: Forms of habitual substance use including cigarette smoking and alcohol consumption have been documented as risk factors of common mental disorders (CMDs). The effects of areca nut chewing on biophysiological tests, metabolic syndromes, and liver function have been reported previously; however, the relationship between areca nut chewing and CMDs remains unclear. This study examined the association between areca nut chewing and CMDs and explored the relationships between areca nut chewing and biophysiological indicators. METHODS: A total of 4477 community dwellers who had enrolled in a cohort study and participated in health examinations in 2 consecutive years were selected for analysis in the present study. The community cohort was established in northern Taiwan during 2006-2012. The Chinese health questionnaire (CHQ-12) was used as a self-reported screening instrument to assess the potential for developing psychotic mental disorders (CHQ-12 score ≥ 3) among the community residents. Biophysiological tests performed 1 year before CMD assessment were analyzed to examine the causal pathways between areca nut chewing and CMDs. Multiple logistic regression and stratified analyses were performed. RESULTS: A total of 18.23% of the participants were diagnosed as having CMDs. Factors including areca nut chewing [odds ratio (OR) 1.828; 95% confidence interval (CI) 1.165-2.869], sex (women; OR 1.828; 95% CI 1.165-2.869), age (30-49; OR 1.302; 95% CI 1.073-1.579), and socioeconomic status (lower status; OR 1.373; 95% CI 1.084-1.738) were associated with CMDs in a multiple logistic regression model. Areca nut chewers exhibited significantly more triglycerides (220.04 vs. 124.16 mg/dL) and white blood cells (65.17 102/µL vs. 60.36 102/µL) and significantly higher diastolic blood pressure (78.83 vs. 75.84 mmHg) and glutamic oxaloacetic transaminase (30.30 vs. 25.45 U/L) than did the controls. CONCLUSIONS: This study demonstrated the association between areca nut chewing and CMDs and its effects on biophysiological tests in a community-based population in Taiwan. The findings suggest the existence of mechanistic effects of areca nut chewing on CMDs exerted through multiple pathways that may interact with pre-existing biophysiological abnormalities. Lifestyle variables should be considered for the prevention and management of mental disorders in the future.

Arsenic Exposure From Drinking Water and the Incidence of CKD in Low to Moderate Exposed Areas of Taiwan: A 14-Year Prospective Study.

BACKGROUND: Arsenic exposure is associated with decreased kidney function. The association between low to moderate arsenic exposure and kidney disease has not been fully clarified. STUDY DESIGN: The association between arsenic exposure from drinking water and chronic kidney disease (CKD) was examined in a long-term prospective observational study. SETTING & PARTICIPANTS: 6,093 participants 40 years and older were recruited from arseniasis-endemic areas in northeastern Taiwan. Arsenic levels were 28.0, 92.8, and 295.7µg/L at the 50th, 75th, and 90th percentiles, respectively. PREDICTOR: Well-water arsenic and urinary total arsenic (inorganic plus methylated arsenic species) concentrations, adjusted for urinary creatinine concentration. OUTCOMES: Kidney diseases (ICD-9 codes: 250.4, 274.1, 283.11, 403.*1, 404.*2, 404.*3, 440.1, 442.1, 447.3, or 580-589) and CKD (ICD-9 code: 585) ascertained using Taiwan's National Health Insurance database 1998 to 2011. MEASUREMENTS: HRs contrasting CKD risk across arsenic exposure levels were estimated using Cox regression. Prevalence ORs for proteinuria (protein excretion ≥ 200mg/g) comparing quartiles of total urinary arsenic concentrations were estimated using logistic regression. RESULTS: We identified 1,104 incident kidney disease cases, including 447 CKD cases (incidence rates, 166.5 and 67.4 per 104 person-years, respectively). A dose-dependent association between well-water arsenic concentrations and kidney diseases was observed after adjusting for age, sex, education, body mass index, cigarette smoking, alcohol consumption, and analgesic use. Using arsenic concentration ≤ 10.0µg/L as reference, multivariable-adjusted HRs for incident CKD were 1.12 (95% CI, 0.88-1.42), 1.33 (95% CI, 1.03-1.72), and 1.33 (95% CI, 1.00-1.77) for arsenic concentrations of 10.1 to 49.9, 50.0 to 149.9, and ≥150.0µg/L, respectively (P for trend=0.02). The association between arsenic concentration and kidney diseases was stronger for women (P for interaction=0.06). Arsenic values in the range of 50th to 75th and 75th to 100th percentiles of total urinary arsenic concentrations were associated with 50% and 67% higher prevalences, respectively, of proteinuria. LIMITATIONS: Kidney diseases and CKD outcomes were based on diagnostic codes. Glomerular filtration rates were not available. Other heavy metals were not measured. CONCLUSIONS: This study describes the temporal relationship between arsenic concentrations ≥ 10µg/L in drinking water and CKD. A dose-dependent association between well-water arsenic concentration and kidney diseases was observed. Higher creatinine-adjusted urinary total arsenic concentrations were associated with a higher prevalence of proteinuria.

Effects of Arsenic in Drinking Water on Risk of Hepatitis or Cirrhosis in Persons With and Without Chronic Viral Hepatitis.

BACKGROUND & AIMS: Arsenic in drinking water is associated with hepatomegaly and death from liver cancer. However, confounding factors related to liver diseases have not been carefully studied. We examined associations between exposure of arsenic in drinking water and risk of hepatitis and cirrhosis, and the interaction with chronic viral hepatitis, in people living in the Lanyang Basin of northeastern Taiwan, where well water has an arsenic content that ranges from undetectable to 3590 µg/L. METHODS: We tested blood samples from 4387 people who lived in arseniasis-endemic areas in northeastern Taiwan from 1991 through 1994 for hepatitis B virus DNA, hepatitis B surface antigen (HBsAg), and antibodies against hepatitis C virus (anti-HCV). We measured arsenic concentrations in well water and collected information on residents' histories of major chronic diseases. Reports of chronic hepatitis or cirrhosis were ascertained using the Taiwan National Health Insurance database. Reports of liver cancer were ascertained using the Taiwan National Cancer Registry. RESULTS: Prevalence odds ratios in the overall study population for chronic hepatitis or cirrhosis for well water arsenic concentrations of ≤10 µg/L were 1.00 (reference), 0.93 for 10.1-49.9 µg/L (95% confidence interval [CI], 0.57-1.52), 1.24 for 50.0-99.9 µg/L (95% CI, 0.68-2.23), 0.98 for 100.0-299.9 (95% CI, 0.52-1.85), and 1.86 for ≥300.0 µg/L (95% CI, 1.08-3.20). Increasing levels of arsenic in drinking water were associated with increasing prevalence of chronic hepatitis or cirrhosis in residents who were seronegative for HBsAg and seronegative for anti-HCV, but not for seropositive for either HBsAg or anti-HCV. In individuals who were seropositive for HBsAg or anti-HCV, we observed an inverse association between hepatitis or cirrhosis and consumption of water with levels of arsenic ≥100.0 µg/L. Among participants who were seropositive for HBsAg or anti-HCV, consumption of water with levels of arsenic ≥100.0 µg/L was associated with a reduced risk of liver cancer (multivariate-adjusted hazard ratio, 0.29; 95% CI, 0.09-0.95; P < .05). A higher proportion of individuals exposed to cumulative arsenic level >14,000 µg/L ×year were carriers of inactive hepatitis B virus (DNA <10,000 copies/mL) and were positive for HBsAg (60%) than individuals exposed to water below this arsenic level (35%). CONCLUSIONS: Concentrations of arsenic concentration in drinking water ≥300.0 µg/L significantly increase risk of hepatitis or cirrhosis in people without chronic viral hepatitis. However, in people with chronic viral hepatitis, levels of arsenic ≥100.0 µg/L in drinking water significantly reduce the risk of chronic hepatitis or cirrhosis.

Increased p-cresyl sulfate level is independently associated with poor outcomes in patients with heart failure.

Amino acid-derived metabolites, including protein-bound uremic toxins, may have prognostic value for patients with heart failure (HF). The aim of this study was to investigate whether p-cresyl sulfate (PCS), indoxyl sulfate (IS), and arginine metabolites provided prognostic values in addition to the traditional biomarker, B-type natriuretic peptide (BNP), in patients with HF. Chromatography mass spectrometry was performed to measure tyrosine, tryptophan, arginine, PCS, IS, and asymmetric (ADMA) and symmetric dimethylarginine (SDMA) in the plasma from 51 normal controls and 136 HF patients. Compared to the normal controls, PCS levels significantly increased in HF patients (p = 0.003). During the follow-up (2.3 ± 1.1 years), 35 (25.7 %) patients experienced a composite event of death or HF-related re-hospitalization. In univariable analysis, PCS, estimated glomerular filtration rate (eGFR), BNP, DMA/arginine ratio, and ADMA/arginine ratio were associated with a higher rate of composite events. In the multivariable analysis, PCS was the only independent predictor of composite events [hazard ratio (HR) 1.06 (per 10 µM), 95 % confidence interval (CI) 1.01-1.11, p = 0.02]. Kaplan-Meier curves showed that a PCS level of ≥50 µM was significantly associated with a higher composite event rate than those with a PCS level of <50 µM (Log rank = 5.11, p = 0.024; HR 2.13, 95 % CI 1.09-4.16, p = 0.02). In conclusion, among protein-bound uremic toxins, eGFR, and DMA metabolites, increased PCS is the only independent predictor of HF-related events in patients with HF. A combination of PCS and BNP should better risk-stratify patients with HF.

Pediatric overtriage as a consequence of the tachycardia responses of children upon ED admission.

BACKGROUND: Overtriage has been observed among pediatric patients in emergency departments (EDs) under 5-level acuity pediatric triage systems. This study aimed to investigate the causes of overtriage and to provide suggestions for future amendments to such systems. METHODS: This study has a retrospective follow-up design in which 42000 pediatric patients who were admitted to the ED of the largest medical center in Taiwan between January and December of 2010 were recruited. The study variables included patient demographics, chief concerns, individual vital signs (ie, blood pressure, heart rate, body temperature, respiratory rate, and O2 saturation), triage level, ED final disposition, ED expenses, and total medical expenses. A logistic regression model was applied to explore the causes of overtriage and the effectiveness of a modified acuity system. RESULTS: Approximately 13.6% of the pediatric ED visits were upgraded to acuity level 1 based on vital signs that included heart rate (97.3%). The strength of the trend association (odds ratio) between decreasing acuity urgency (from levels 1 to 5) and hospitalization increased from 0.73 (95% confidence interval, 0.72-0.75) with the Pediatric Triage and Acuity System (Ped-TTAS) to 0.57 (95% confidence interval, 0.55-0.59) with the modified Ped-TTAS, which downgraded acuity levels by excluding the weighting of vital signs. Further validation was accomplished by comparing the trend association between decreasing acuity urgency and total medical expenses (Ped-TTAS: ß = -0.13; modified Ped-TTAS: ß = -0.18). CONCLUSIONS: Heart rate is prone to be affected by emotional responses among pediatric patients in certain specific age groups. Appropriate revisions of the pediatric triage system are suggested.

Prophylactic administration of fucoidan represses cancer metastasis by inhibiting vascular endothelial growth factor (VEGF) and matrix metalloproteinases (MMPs) in Lewis tumor-bearing mice.

Fucoidan, a heparin-like sulfated polysaccharide, is rich in brown algae. It has a wide assortment of protective activities against cancer, for example, induction of hepatocellular carcinoma senescence, induction of human breast and colon carcinoma apoptosis, and impediment of lung cancer cells migration and invasion. However, the anti-metastatic mechanism that fucoidan exploits remains elusive. In this report, we explored the effects of fucoidan on cachectic symptoms, tumor development, lung carcinoma cell spreading and proliferation, as well as expression of metastasis-associated proteins in the Lewis lung carcinoma (LLC) cells-inoculated mice model. We discovered that administration of fucoidan has prophylactic effects on mitigation of cachectic body weight loss and improvement of lung masses in tumor-inoculated mice. These desired effects are attributed to inhibition of LLC spreading and proliferation in lung tissues. Fucoidan also down-regulates expression of matrix metalloproteinases (MMPs), nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and vascular endothelial growth factor (VEGF). Moreover, the tumor-bearing mice supplemented with fucoidan indeed benefit from an ensemble of the chemo-phylacticity. The fact is that fucoidan significantly decreases viability, migration, invasion, and MMPs activities of LLC cells. In summary, fucoidan is suitable to act as a chemo-preventative agent for minimizing cachectic symptoms as well as inhibiting lung carcinoma metastasis through down-regulating metastatic factors VEGF and MMPs.

Oral adsorbent AST-120 potentiates the effect of erythropoietin-stimulating agents on Stage 5 chronic kidney disease patients: a randomized crossover study.

BACKGROUND: Indoxyl sulfate (IS) suppresses erythropoietin (EPO) activity and exerts renal damage. The oral adsorbent AST-120 reduces IS load and has antioxidant and renoprotective properties; however, its roles in the treatment of anemia remain unclear in chronic kidney disease (CKD) patients. METHODS: Fifty-one Stage 5 predialysis CKD patients with hemoglobin <10 g/dL were randomly assigned to receive two period treatments with AST-120 plus once-monthly administration of continuous EPO receptor activator (CERA, A) and CERA alone (B), with a 4-week washout period in between. Mean changes of serum creatinine, estimated glomerular filtration rate (eGFR) and hemoglobin levels from the baseline were compared between two treatments. RESULTS: The baseline and postintervention mean creatinine levels were 5.48 and 5.36 mg/dL in the Treatment A, and 5.14 mg/dL and 5.61 g/dL in the Treatment B group, respectively (treatment effect P = 0.025, period effect P = 0.467, carryover effect P = 0.384). The baseline and postintervention mean hemoglobin levels were 9.27 and 10.47 g/dL in the Treatment A, and 9.63 g/dL and 9.54 g/dL in the Treatment B group, respectively (treatment effect P = 0.039, period effect P = 0.001, carryover effect P = 0.060). Use of AST-120 significantly reduced IS and p-cresyl sulfate (PCS) levels. Hierarchical regression showed that eGFR was an independent predictor for hemoglobin after adjustment of serum free IS and PCS levels (B = 0.049, P = 0.005). CONCLUSIONS: Use of adjuvant AST-120 may improve renal function and hemoglobin levels than use of CERA alone in late-stage CKD patients. The change of eGFR might play an intermediate role between serum IS/PCS and improve hemoglobin levels. The finding offered insight into novel therapeutic strategies of anemia for late-stage CKD patients.

Performance assessment of the Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation II score, and the Sequential Organ Failure Assessment score in predicting the outcomes of adult patients with hepatic portal venous gas in the ED.

OBJECTIVE: This study aims to evaluate the performance of Simplified Acute Physiology Score II (SAPS II), the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and the Sequential Organ Failure Assessment (SOFA) score for predicting illness severity and the mortality of adult hepatic portal venous gas (HPVG) patients presenting to the emergency department (ED). This will assist emergency physicians in risk stratification. METHODS: Data for 48 adult HPVG patients who visited our ED between December 2009 and December 2013 were analyzed. The SAPS II, APACHE II score, and SOFA score were calculated based on the worst laboratory values in the ED. The probability of death was calculated for each patient based on these scores. The ability of the SAPS II, APACHE II score, and SOFA score to predict group mortality was assessed by using receiver operating characteristic curve analysis and calibration analysis. RESULTS: The sensitivity, specificity, and accuracy were 92.6%,71.4%, and 83.3%, respectively, for the SAPS II method; 77.8%, 81%, and 79.2%, respectively, for the APACHE II scoring system, and 77.8%, 76.2%, and 79.2%, respectively, for the SOFA score. In the receiver operating characteristic curve analysis, the areas under the curve for the SAPS II, APACHE II scoring system, and SOFA score were 0.910, 0.878, and 0.809, respectively. CONCLUSION: This is one of the largest series performed in a population of adult HPVG patients in the ED. The results from the present study showed that SAPS II is easier and more quickly calculated than the APACHE II and more superior in predicting the mortality of ED adult HPVG patients than the SOFA. We recommend that the SAPS II be used for outcome prediction and risk stratification in adult HPVG patients in the ED.

The prognostic factors of adult patients with hepatic portal venous gas in the ED.

OBJECTIVES: This study aimed to investigate the prognostic factors of adult patients with hepatic portal venous gas (HPVG) in the emergency department (ED) to facilitate clinical decision making by emergency physicians. METHODS: Data from adult patients with HPVG who visited our ED between December 2009 and December 2013 were analyzed. The computed tomographic scan images were reviewed, and the presence of HPVG with or without pneumatosis intestinalis (PI) was confirmed by a certified radiologist. The study end point was mortality or survival upon discharge. The factors associated with mortality were specifically analyzed with multiple logistic regression models. RESULTS: Among the total of 50 HPVG patients, the overall mortality rate was 56%. No deaths were observed among the patients with neither shock nor PI in the ED. Shock (odds ratio, 17.02; 95% confidence interval, 3.36-86.22) and PI (odds ratio, 5.14; 95% confidence interval, 1.03-25.67) were determined to be significant predictors of patient mortality after adjusting for age and sex. The mortality of the patients with both shock and PI was very high (84%). CONCLUSIONS: Early resuscitation should be initiated for the prevention of shock in adult patients with HPVG in the ED. To enhance the chance for survival, the prompt consultation of surgeons for emergency operations should be considered for adult ED patients exhibiting both shock and PI, which may indicate true ischemic bowel disease.

Factors associated with chronic musculoskeletal pain in patients with chronic kidney disease.

BACKGROUND: Chronic musculoskeletal (MS) pain is common in patients with chronic kidney disease (CKD) undergoing haemodialysis. However, epidemiological data for chronic MS pain and factors associated with chronic MS pain in patients with early- or late-stage CKD who are not undergoing dialysis are limited. METHOD: A cross-sectional study to evaluate the prevalence of chronic MS pain and factors associated with chronic MS pain in patients with early- and late-stage CKD who were not undergoing dialysis, was conducted. In addition, the distribution of pain severity among patients with different stages of CKD was evaluated. RESULTS: Of the 456 CKD patients studied, 53.3% (n = 243/456) had chronic MS pain. Chronic MS pain was independently and significantly associated with hyperuricemia as co-morbidity, as well as with the calcium × phosphate product levels. In CKD patients with hyperuricemia, chronic MS pain showed a negative, independent significant association with diabetes mellitus as a co-morbidity (odds ratio: 0.413, p = 0.020). However, in the CKD patients without hyperuricemia as a co-morbidity, chronic MS pain showed an independent significant association with the calcium × phosphate product levels (odds ratio: 1.093, p = 0.027). Furthermore, stage-5 CKD patients seemed to experience more severe chronic MS pain than patients with other stages of CKD. CONCLUSION: Chronic MS pain is common in CKD patients. Chronic MS pain was independently and significantly associated with hyperuricemia as co-morbidity, and with the calcium × phosphate product levels in early- and late-stage CKD patients who were not on dialysis.