NT-proBNP point-of-care testing for predicting mortality in end-stage renal disease: A survival analysis.

This study examines the predictive value of elevated N-terminal-pro brain natriuretic peptide (NT-pro BNP) levels for mortality among patients with end-stage renal disease (ESRD). Data from 768 ESRD patients, excluding those with cancer or lost follow-up, were analyzed using Kaplan-Meier curves and Cox proportional hazards models over three years. Results indicated that patients with very high NT-pro BNP levels had shorter average survival times and a significantly higher risk of mortality (hazard ratio 1.43). Advanced age, ICU admission, and comorbidities like cerebrovascular diseases and chronic obstructive pulmonary disease also contributed to increased mortality risks. Thus, elevated NT-pro BNP is an independent risk factor for mortality in ESRD patients.

Diagnosis, Treatment, and Prevention of Noninfectious Acute Anterior Uveitis with or without Human Leukocyte Antigen B27 in Adults - Expert Consensus in Taiwan.

BACKGROUND: Anterior uveitis is the most common anatomical type of uveitis. Patients with noninfectious anterior uveitis may develop various ocular complications and eventually visual impairment. Appropriately differentiating the etiologies can help clinicians to predict the outcome, arrange clinical follow-up, and decide the treatment or prevention strategy. Adequate treatment and effective prevention strategies can reduce the frequency of recurrence and the risk of developing complications. Human leukocyte antigen (HLA)-B27 is the most common positive finding in patients with noninfectious AAU in many countries including Taiwan. PURPOSE: To report a consensus from experienced uveitis specialists and rheumatologists was made in Taiwan. METHODS: A panel of nine ophthalmologists from nine different referral centers with expertise in the management of uveitis and an experienced rheumatologist was held on January 16, 2022. A comprehensive literature review was performed. Differential diagnoses for etiologies, general treatments, and prevention strategies were discussed. Each statement in the consensus was made only if more than 70% of the experts agreed. RESULTS: A flow chart and seven statements regarding the differential diagnoses for etiologies, treatments and preventions, and co-management with rheumatologists were included in the consensus. CONCLUSIONS: This article discusses the general diagnosis, treatment, and prevention of noninfectious acute anterior uveitis, with or without HLA-B27, in adults for general ophthalmologists to improve overall outcomes of these patients.

Differences of chronological seasonality in drug overdose.

OBJECTIVE: To investigate the association between seasonality and intentional drug overdose (IDO), a commonly seen method of self-harm in daily emergency medicine practice. METHODS: Cases of IDO were retrospectively selected using the International Classification of Diseases (ICD)-10 coding system (codes T36-T50), in patients who attended the Emergency Department of MacKay Memorial Hospital between January 2018 and August 2019. Data regarding age, sex, arrival time, marital status, vital signs, comorbidities, psychiatric history, social conflicts, substance of overdose, and length of hospital stay by season, were analysed using Student's t-test and χ2-test. RESULTS: Of all included cases (n = 196), IDO occurred most frequently in spring (32.1%), particularly in male patients (28/49 male cases). First-time IDO occurred most frequently in spring (51/133 first-time cases) and most spring cases were first-time IDO (51/63 spring cases). Repeat IDO occurred most frequently in autumn (20/63 repeat cases). Female conflict with father and/or boyfriend, and personality disorder in patients who overdosed, showed seasonality with a spring peak. Hospital admission rate was highest in winter (10/45 winter cases [22.2%]). CONCLUSION: Episodes of IDO exhibited seasonality, with a spring peak, particularly for male patients, female patients in conflict with father and/or boyfriend, and those with personality disorder. Clinicians should pay close attention to the abovementioned patient groups.

Clinical characteristics in new psychoactive substance users: A single center study.

New psychoactive substances (NPS) are emerging illegal substances or synthetic drugs that pose public health threats worldwide. This study was aimed at reporting the clinical characteristics of NPS and classical illicit substances used by patients who presented to the emergency room. We conducted a retrospective cohort study on patients with suspected illicit substance use who visited the emergency department (ED) with the suspicion of illicit substance use. We divided the patients into 4 groups based on the NPS testing results: NPS positive, NPS negative, NPS combined with classical illicit drugs (INPS), and subjects with negative testing results. The majority of patients in all groups were male. The NPS users were significantly younger than those with negative results on toxic testing (26.4 vs 37.5, P = .005 < 0.05). The heart rate of NPS users was significantly faster than that of the group with negative results of toxic testing (111.1 vs 93.5 beats per minute, P = .046). The heartbeats of INPS group were also significantly faster than those with a negative result in toxicology screen (119.6 vs 93.5 beats per minute, P = .024). Those who used classical illicit drugs combined with NPS had significantly higher palpitation than those with negative results of toxic testing (27.3% vs 3.1%, P = .017). Patients who were highly suspicious of NPS use were younger, had tachycardia, felt palpitations, and had fair oxygen saturation compared to patients who were negative for urine toxicity screening.

Clinical characteristics of new psychoactive substances: A multicenter study.

BACKGROUND: New psychoactive substances (NPS) are synthetic alternatives to illicit drug abuse that are not under international control but may pose a public health threat. Moreover, the symptoms and signs of NPS users may be quite variable. This study aimed to figure out the clinical characteristics of NPS users presented to the emergency department (ED). METHODS: A total of 1385 cases were tested via urine toxicity screening from March 25, 2019, to January 28, 2020, in six medical centers, and ten hospitals, in Taiwan. A total of 123 non-NPS cases and 77 NPS-use cases were enrolled in this study. We compared the patient data-vital signs, presentation, co-morbidities, behaviors, symptoms, electrocardiograms, laboratory data, length of stays-and outcomes of NPS users and non-NPS drug users. RESULTS: NPS users were 5.7 years younger than the non-NPS drug users (37 vs. 42.7 years, p = 0.022). Presently, NPS users had a 2.6-fold (27.2%) higher rate of suicide and a 2.9-fold (11.7%) greater possibility of violence than non-NPS drug users. Moreover, in NPS users, eye-opening was affected at a scale of 3.1 versus 3.4 (p = 0.048) in non-NPS drug users in the evaluation of consciousness and they experienced a 4.3-fold greater feeling of palpitation (p = 0.024) and had 8.1-fold higher chance of presenting facial flush (p = 0.032) than non-NPS drug users. CONCLUSION: NPS users are relatively younger, are more likely to experience facial flush and palpitation and engage in more self-harm, violence, and suicide than non-NPS drug users. Physicians need to pay attention to people who have altered, bizarre mental statuses with the clinical characteristics described above.

Bilateral Optic Disc Edema as an Initial Presentation of Acute Retinal Necrosis.

PURPOSE: We reported a case of acute retinal necrosis (ARN) that presented as isolated bilateral optic disc edema. METHODS: A case report. CASE: A 68-year-old male with a 3-day history of progressive blurred vision presented with isolated bilateral optic disc edema. Through history taking, we found that he was diagnosed with herpes zoster affecting the lumbar and sacral dermatomes in the past month. Five days later, the patient experienced acute deterioration in visual acuity, with the left eye deteriorating to perception of light only. Bilateral retinal necrosis was noticed. We tested the aqueous samples with polymerase chain reaction and identified positive varicella-zoster virus (VZV) results. A diagnosis of bilateral acute retinal necrosis caused by VZV infection was established and we administered intravitreal and intravenous antiviral medications, steroids, and performed prophylactic scleral buckling. SUMMARY: This report demonstrates a rare ARN case initially presented with isolated bilateral optic disc edema.

Sympathetic ophthalmia following radiation-induced scleral necrosis in choroidal melanoma.

Sympathetic ophthalmia (SO) is a bilateral granulomatous panuveitis. We report a rare case of SO presenting after scleral necrosis as a late complication of Gamma Knife radiotherapy for choroidal melanoma. A 55-year-old woman presented with primary choroidal melanoma in the right eye and has been treated with Gamma Knife radiotherapy with stable tumor size. Five years after radiotherapy, a pigmented protrusive uveal mass was visibly noted over the superior sclera of the same eye, corresponding to periocular soft tissue enhancement on computed tomography. Biopsies of the pigmented mass showed the absence of malignancy. One month later, acute blurred vision with signs of sympathetic ophthalmia developed in the left eye. The patient received high-dose systemic corticosteroids and immunomodulatory therapy. The intraocular inflammation in the left eye subsided with improving vision, and the uveal mass in the right eye flattened after the anti-inflammatory therapy. Scleral necrosis is a rare complication following radiotherapy for choroidal melanoma and may incite sympathetic ophthalmia, for which prompt and aggressive treatment is important to save vision, especially for the fellow eye.

Surgical intervention for acute pancreatitis in the COVID-19 era.

Approximately 15%-19% of patients with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infections develop gastrointestinal symptoms. Acute pancreatitis (AP) has been reported in 0.1% of patients with coronavirus disease 2019 (COVID-19). Biliary AP was most common (78.4%) before the COVID-19 pandemic; idiopathic AP is most common in patients with COVID-19 (up to 57.1%). The number of emergency department presentations decreased by 23.3% during the pandemic and many governments made national recommendations to delay nonurgent endoscopic procedures, leading to decrements of 22% in combined esophagogastroduodenoscopy (EGD) and colonoscopy and 20% in EGD after the COVID-19 pandemic. The symptoms and signs of COVID-19-related AP are fever (63%), abdominal pain (58%), respiratory symptoms (40%), nausea and vomiting (39%), and headache (4%). Approximately 5-10% of patients develop necrotizing or hemorrhagic AP, and patients who required surgical intervention had a higher mortality risk. Compared to 2019, the rates of elective surgery decreased by 41.8% in 2020; including cholecystectomy (40.1% decrease) and pancreas (111.1% decrease). Surgical volumes also decreased by 18.7% in 2020; device-assisted laparoscopic and robot-assisted procedures reduced by 45.4% and 61.9% during the COVID-19 Lockdown in 2020.

A fatal case of chlorfenapyr poisoning and a review of the literature.

BACKGROUND: Chlorfenapyr is a widely used pesticide and is classified as moderately hazardous to human health. Ingestion usually leads to mortality in humans. However, chlorfenapyr toxicity has a variable course and mechanism of action.Case presentation: We report the case of a 79-year-old female who ingested chlorfenapyr with the intent to commit suicide. The liquid was ingested 2 hours before she was brought to our emergency department. Gastric lavage was immediately performed. On admission, laboratory examinations revealed mildly elevated liver enzyme and creatinine kinase levels. Acute fever occurred on day 7; on day 8, the patient died of progressive respiratory distress and conscious disturbance. Chlorfenapyr toxicity leads to high rates of mortality (75%) and causes damage to the liver and the nervous system. CONCLUSIONS: It is necessary to observe patients with chlorfenapyr toxicity for 3 weeks because no significant abnormalities occur in the early phase. The onset of fever and deterioration of consciousness is a warning sign of a sudden fatal outcome. We review the literature and discuss neurologic and cardiopulmonary impairment in the clinical course of chlorfenapyr poisoning.

Clinical Presentations and Predictors of In-Hospital Mortality in Illicit Drug Users in the New Psychoactive Substances (NPS) Endemic Era in Taiwan.

Predictors of mortality in illicit drug users involving Novel Psychoactive Substances (NPS) and multiple substances have not been elucidated. We aimed to define predictors of mortality in the NPS endemic era's illicit drug users to strengthen patient care in emergency treatment. This was a retrospective study. LC-MS/MS-confirmed positive illicit drug users who visited the emergency departments (ED) of six medical systems were enrolled. Demographic information, physical examinations, and laboratory data were abstracted for mortality analysis. There were 16 fatalities in 355 enrolled patients. The most frequently used illicit drugs were amphetamines, followed by opioids, cathinones, and ketamine. The most frequently detected cathinones among the 16 synthetic cathinones were eutylone, followed by mephedrone. The combined use of cathinones and ketamine was most commonly observed in our results. Univariate analysis revealed that the mortality patients were older, with deep coma, faster heart rate and respiratory rate, lower blood pressures and O2 room air saturation, more seizures, abnormal breath sounds, and had urine incontinence compared to the survivor patients. The mortality patients also had acute kidney injury, higher potassium, blood sugar, liver function test, and lactate level. The results of multiple logistic regression demonstrated that SBP < 90 mmHg, dyspnea, blood sugar > 140 mg/dl, and HCO3 < 20.6 mmHg were independent predictors of in-hospital mortality. Regardless of the pattern of the use of illicit drugs, the predictors allow for risk stratification and determining the optimal treatment.

Report of a Patient With Anti-Jo-1 Syndrome With Loss of Consciousness.

A 51-year-old febrile woman presented to the emergency department because of loss of consciousness while worshipping at a temple. She experienced muscle weakness and blurred vision before fainting. She also felt pain in her left shoulder and suffered from dry cough and shortness of breath during the previous week. The chest radiograph (CXR) showed bilateral reticular infiltration, indicating interstitial lung disease (ILD), and chest computed tomography revealed reticular, nodular, and reticulonodular patterns of infiltration that were compatible with ILD. Blood tests showed a creatinine kinase level of 3,307 IU/L and an Anti-Jo-1 autoantibody level of 586 AU/mL. It was found via right thigh biopsy results 8 days later that she had polymyositis with perivascular inflammation and degenerative muscle fiber change. Pulse therapy with methylprednisolone (1 gm/day for 3 days) was administered. After 4 days, she felt better and was discharged. Around 25.0%-34.1% of myositis patients have anti-Jo-1 autoantibodies, and ILD was noted in 65%-68% of anti-Jo-1-positive patients. A ground glass pattern may be observed in the CXRs of anti-Jo-1 ILD patients, and some articles described multiple pulmonary nodules mimicking lung metastasis or concomitant with pleural effusion. The conditions of approximately 42%-66% of ILD patients are controlled or are not worsened after treatment with corticosteroid and immunosuppressive drug treatment. However, some rapidly progressive cases are not sensitive to corticosteroid therapy alone.

Sex-based differences in the predisposing factors of overdose: A retrospective study.

Drug overdose is one of the common events encountered in the emergency department (ED). The aim of the present study was to investigate the sex difference and predisposing factors of overdose in the ED. Data of 299 patients with self-poisoning reported at our poison center from January 2018 to August 2019 were retrospectively analyzed. Study cases categorized using the International Classification of Diseases, Tenth Revision coding system, which include codes T36 to T50, were selected. Data were collected including Glasgow Coma Scale scores and vital signs upon arrival (including body temperature, heart rate, systolic blood pressure, and diastolic blood pressure, sex, age, marital status, arrival time, season on admission, previous suicide attempts, psychiatric history, related comorbidities, recent arguments, categories of overdose with or without concurrent ethanol use, length of hospital stay, and survival to discharge) were analyzed. The top three types of substances that were frequently involved in drug overdose were benzodiazepine (42.9%), mixed medications (32.1%), and acetaminophen (6.1%). The 196 enrolled patients were aged 14 to 92 years (mean ± standard deviation, 39.2±18.3), and of these patients, male intentional overdose patients were 8.1 years older than their female counterparts (45.3±19.5 vs. 37.2±17.5, respectively; P<0.05). Most intentional overdose cases occurred during the spring season (n=63, 32.1%), especially in male patients (n=28, 57.1%; P<0.001). Approximately 11.2% (22/196) and 2% (4/196) of the total patients were admitted to the Toxicology ward and intensive care units, respectively. The length of hospital stay was 2±4.1 days. In summary, it is suggested that physicians notify the suicide prevention centers to be on alert for middle-aged men who are facing conflicts, especially during the spring season.

Learning Curve of ROSA ONE Spine System for Transpedicular Screw Placement.

OBJECTIVE: The study investigated our institutional learning curve for the ROSA ONE spine system (ROSA) based on ROSA usage time. METHODS: ROSA was designed to provide high accuracy for spinal pedicle screw placement through a built-in tracking technique. This study was conducted from November 2018 to January 2021. The time taken to complete each step of the robotic workflow was recorded. Patient demographics, comorbidities, surgical indications, and number of screw placements were examined in subgroup analysis. The Curve Fitting-General package (a part of NCSS 2021 software) was used to fit a mathematical model to the learning curve. Patient demographics, imaging data, and surgical time were reviewed retrospectively. RESULTS: A total of 167 patients who had undergone surgery were included. The mean total ROSA usage time was 107.1 ± 27.3 minutes. The estimated learning rate was 90.4%, and the largest slope change occurred close to the time of the 20th surgery. The observed overall learning trend in the 4-screw group could be attributed to screw planning. The presence of scoliosis (p = 0.73) or spondylolisthesis (p = 0.70) did not significantly influence the mean total time (TT) for all patients; however, the mean TT differed significantly (p < 0.01) among subgroups stratified by body mass index, screw number placement, and thoracic spine involvement. CONCLUSION: To the best of our knowledge, this is the first study to examine the learning curve for the various crucial steps of ROSA-guided pedicle screw placement. The indicative learning curve involved 20 patients who had undergone surgery.