Cost-Effectiveness of Diabetic Retinopathy Screening for Newly Diagnosed Type 2 Diabetic Patients: A Nationwide Population-based Propensity Score-Matched Cohort Study.

AIMS: This study investigated the association between the frequency of screening for diabetic retinopathy (DR) versus the development of DR and corresponding medical expenses among patients newly diagnosed with type 2 diabetes mellitus (T2DM). METHODS: This longitudinal, population-based study used the Taiwan National Health Insurance Research Database (2004 to 2020) as a data source. Propensity score matching (PSM) (sex, age, comorbidities and concurrent medication use) was employed in the grouping of T2DM patients according to different frequency of DR screening. Outcome measures included the proportion of patients who developed DR, who received DR treatment, and the associated medical expenses and hospitalizations. RESULTS: The 17-year cohort included 337,046 patients. After PSM, three groups each containing 35,739 patients were assembled and analyzed. Compared to low-frequency screening, high-frequency screening was more effective in detecting patients requiring treatment; however, the net cost for treatment was significantly lower. Standard-frequency screening appears to provide the best balance in terms of DR detection, diagnosis interval, the risk of DR-related hospitalization, and DR treatment costs. CONCLUSIONS: In this real-world cohort study covering all levels of the healthcare system, infrequent screening was associated with delayed diagnosis and elevated treatment costs, while a fundus screening interval of 1-2 years proved optimal in terms of detection and medical expenditures.

Incidence of deep vein thrombosis and symptomatic pulmonary embolism in Taiwanese patients with pelvic and/or acetabular fractures: a retrospective study.

Venous thromboembolism (VTE) is common in patients with trauma, and thromboprophylaxis has been advocated. However, conflicting results regarding VTE rates in the Asian population following orthopaedic procedures have been presented. We aimed to investigate the VTE incidence in Taiwanese patients with pelvic and/or acetabular fractures and identify the associated risk factors. We included 402 patients who underwent surgery for pelvic and/or acetabular fractures. All patients received mechanical thromboprophylaxis with graduated compression stockings. Duplex scanning was performed postoperatively or during follow-up when signs or symptoms of deep vein thrombosis (DVT) developed. Variables with a significance level of ≤ 0.1 in the univariate analyses were introduced into the multivariate logistic regression analysis to identify DVT risk factors. The overall DVT and symptomatic pulmonary embolism (PE) rate was 3.48% (14/402 patients). Among patients with DVT, 46.1% were asymptomatic. Patients with VTE were significantly older than those without. Multivariate logistic regression analysis revealed that age was a VTE risk factor. The incidence of DVT and symptomatic PE in our cohort was low. Advanced age was a risk factor for VTE. These findings could help clinicians develop appropriate prevention and treatment strategies for VTE in Taiwanese patients with pelvic and/or acetabular fractures.

Positive Predictive Values of Anaphylaxis Diagnosis in Claims Data: A Multi-Institutional Study in Taiwan.

Real-world data sources can facilitate essential understanding of the epidemiological features of anaphylaxis. However, the accuracy of case-identifying definitions based on diagnosis codes for anaphylaxis in healthcare databases remains understudied. We conducted a cross-sectional study analyzing claims data from the largest multi-institutional healthcare system in Taiwan during 2017-2021. We included patients with incident anaphylaxis identified by either ICD-10-CM codes for anaphylaxis (Group 1) or ICD-10-CM codes for severe allergic or drug adverse events and additional modifier codes for acute allergy events (Group 2). We randomly selected 20% of the cases to determine the positive predictive value (PPV) of anaphylaxis case-identifying definitions in Groups 1 and 2 after review of electronic medical records by two physicians. From the original cohort (n = 2,176), we randomly selected 433 patients with either a diagnosis of anaphylaxis (Group 1), or a diagnosis of severe allergic and drug adverse events with additional modifier codes for acute allergy events (Group 2). In Group 1, we judged 135 / 170 patients as true anaphylaxis cases, giving a PPV of 79.4% (95% CI: 73.3-85.5). In Group 2, we judged 47 / 263 patients as true anaphylaxis cases, giving a PPV of 17.9% (95% CI: 13.3-22.5). In conclusion, acceptable PPVs were observed when anaphylaxis cases were identified by ICD-10-CM codes for anaphylaxis, but not by ICD-10-CM codes for severe allergic or drug adverse event with additional modifier codes for acute allergy events. Our multi-institutional findings could serve as a fundamental reference for further studies of anaphylaxis based on real-world healthcare databases.

Effectiveness and Safety of Dabigatran Reversal with Idarucizumab in the Taiwanese Population: A Comparison Based on Eligibility for Inclusion in Clinical Trials.

Background and Objectives: The effectiveness and safety of idarucizumab for the reversal of the effects of dabigatran have been proven. However, there remains a paucity of literature comprehensively investigating outcomes in real-world patients. This is especially true when comparing patients who were eligible for inclusion in the RE-VERSE AD trial with patients who were ineligible. As the prescription of dabigatran has become increasingly popular, the generalizability of the results to real-world populations has come into question due to the broad variability of real-world patients receiving dabigatran. Our study aimed to identify all patients who were prescribed idarucizumab and examined how effectiveness and safety varied among those patients who were eligible and ineligible for the trial. Materials and Methods: This retrospective cohort study analyzed the largest medical database in Taiwan. We enrolled all patients who were prescribed and received idarucizumab from when it became available in Taiwan up until May 2021. A Total of 32 patients were included and analyzed, and they were further divided into subgroups based on their eligibility for inclusion in the RE-VERSE AD trial. Multiple outcomes were evaluated, including successful hemostasis rate, complete reversal efficacy of idarucizumab, 90-day thromboembolic events, intra-hospital mortality, and adverse event rate. Results: In our study, we found that 34.4% of real-world cases of idarucizumab use were ineligible for the RE-VERSE AD trials. The eligible group had higher successful hemostasis rates (95.2% vs. 80%) and anticoagulant effect reversal rates compared to the ineligible group (73.3% vs. 0%). The mortality rates were 9.5%, compared to 27.3% in the ineligible group. Few adverse effects (n = 3) and 90-day thromboembolic events (n = 1) were observed in either group. Among the ineligible cases, all acute ischemic stroke patients (n = 5) received definite, timely treatments without complications. Conclusions: Our study demonstrated the real-world effectiveness and safety of idarucizumab infusion for trial-eligible patients and all acute ischemic stroke patients. However, although it seems to be effective and safe, idarucizumab appears to be less effective in other trial-ineligible patients. Despite this result, our study provides further evidence for extending the applicability of idarucizumab in real-world scenarios. Our study suggests that idarucizumab can be a safe and effective option for reversing the anticoagulant effect of dabigatran, particularly for eligible patients.

Positive Predictive Value of ICD-10-CM Codes for Myocarditis in Claims Data: A Multi-Institutional Study in Taiwan.

Purpose: The validity of the diagnosis codes to identify myocarditis cases in healthcare databases research remains unclear, and this study aimed to determine the coding accuracy of myocarditis in Taiwan. Methods: We conducted a cross-sectional study based on Taiwan's largest multi-institutional healthcare system to identify inpatients newly diagnosed with ICD-10-CM myocarditis codes at discharge between January 1st, 2017 and March 31st, 2022. We ascertained the myocarditis diagnosis by a gold standard biopsy or by review of electronic medical records, and the positive predictive values (PPV) with 95% confidence intervals (CI) of the ICD-10-CM codes for myocarditis were determined. Results: We included a total of 498 inpatients (mean age: 33.8 years old; female: 38.8%) with new myocarditis diagnosis at discharge. Codes I409 (30.1%) and I514 (45.4%) constituted the majority of myocarditis diagnostic codes in any coding position, and the overall PPV of the myocarditis codes was 73.5% (95% CI: 69.6-77.4%). However, the highest PPV (96.6%) for myocarditis diagnosis was noted with code I409 as the primary diagnosis. We found 132 inpatients (26.5%) who were false-positive myocarditis cases, identified by the ICD-10-CM codes, and potential reasons for misclassification included other inflammation diseases (n=35, 26.5%), pre-existing heart failure (n= 25, 18.9%) and acute myocardial infarction (n=16, 12.1%). Conclusion: The PPV of ICD-10-CM codes for myocarditis in Taiwan was acceptable, but some other inflammation diseases and pre-existing heart diseases may be falsely coded as myocarditis. Our results may serve future secondary database studies as a fundamental reference on the validity of myocarditis diagnosis codes.

Validation of Diagnostic Codes to Identify Carbon Monoxide Poisoning in Taiwan's Claims Data.

Purpose: Previous studies identified the study cohort or outcome of carbon monoxide poisoning (COP) by using the relevant disease diagnosis codes in secondary databases, but the validity of diagnosis codes of COP is unclear in such secondary databases. This study aimed to evaluate the accuracy of case definitions for COP using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes in Taiwan's health insurance claims data. Methods: We selected a 10% simple random sample from an original cohort of patients newly undergoing carboxyhemoglobin (COHb) testing under any clinical diagnosis at four Chang Gung Memorial Hospitals in Taiwan during 2011-2020. Two clinical doctors independently ascertained the COP diagnosis by reviewing the medical records as the reference standard. We estimated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of various case definitions (e.g., ICD-9-CM code, ICD-10-CM code and the uses of hyperbaric oxygen therapy) in the claims data. Results: We randomly selected 557 cases from the original cohort of 5,571 cases newly receiving COHb test in the study hospitals. We found 90, 35, and 9 cases were true-positive, false-positive, and false-negative episodes of COP, respectively, among 278 cases with an ICD-9-CM code of 986. A further 111, 34, and 6 cases were true-positive, false-positive, and false-negative episodes of COP, respectively, among 279 cases with an ICD-10-CM code of T58. Using ICD-9-CM codes, the sensitivity, specificity, PPV and NPV for COP were 90.9, 80.4, 72, and 94.1%, respectively. Using ICD-10-CM codes they were 94.9, 79, 76.6, and 95.5%, respectively. PPV typically increased when COP was the primary diagnosis and could reach 100% if patients with ICD-CM code 986 or T58 also received hyperbaric oxygen therapy during hospitalization. Conclusion: The COP-related ICD-CM codes alone did not accurately identify COP patients, but accuracy improved after including oxygen therapy data with the ICD-CM codes in Taiwan's claims data.

Positive Predictive Value of ICD-10 Codes for Cerebral Venous Sinus Thrombosis in Taiwan's National Health Insurance Claims Database.

OBJECTIVE: This study aims to determine the positive predictive value (PPV) of case definitions for cerebral venous sinus thrombosis (CVST) in Taiwan's National Health Insurance claims database based on the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnostic codes. STUDY DESIGN AND SETTING: Inpatient records with ICD-10-CM codes of G08, I629, I636, or I676 were retrieved from the claims data of all hospital branches of Chang Gung Medical Foundation. Manual review of the medical records and images was performed in order to ascertain the diagnosis. The PPV of various case definitions for CVST was estimated. RESULTS: Of the 380 hospitalizations, 166 and 214 were determined to be true-positive and false-positive episodes of acute CVST, respectively. The PPV of the ICD-10-CM codes of G08, I629, I636, and I676 was 88.2%, 2.0%, 100.0%, and 91.3%, respectively. The PPV generally increased when acute CVST was defined as a primary diagnosis or as ICD-10-CM codes plus anticoagulant use. Miscoding in other conditions, tentative diagnosis, and remote episode of CVST were determined as the main reasons for false-positive diagnosis of acute CVST. CONCLUSION: This study determined the PPV of ICD-10-CM codes for identifying CVST, which may offer a reference for future claims-based research.

Quantifying the Effects of Climate Factors on Carbon Monoxide Poisoning: A Retrospective Study in Taiwan.

Background: Carbon monoxide (CO) poisoning is the leading cause of poisoning death worldwide, but associations between CO poisoning and weather remain unclear. Objective: To quantify the influence of climate parameters (e.g., temperature, relative humidity, and wind speed) on the incidence risk of acute CO poisoning in Taiwan. Methods: We used negative binomial mixed models (NBMMs) to evaluate the influence of weather parameters on the incidence risk of acute CO poisoning. Subgroup analyses were conducted, based on the seasonality and the intentionality of acute CO poisoning cases. Results: We identified a total of 622 patients (mean age: 32.9 years old; female: 51%) with acute CO poisoning in the study hospital. Carbon monoxide poisoning was associated with temperature (beta: -0.0973, rate ratio (RR): 0.9073, p < 0.0001) but not with relative humidity (beta: 0.1290, RR: 1.1377, p = 0.0513) or wind speed (beta: -0.4195, RR: 0.6574, p = 0.0806). In the subgroup analyses, temperature was associated with the incidence of intentional CO poisoning (beta: 0.1076, RR: 1.1136, p = 0.0333) in spring and unintentional CO poisoning (beta: -0.1865, RR: 0.8299, p = 0.0184) in winter. Conclusion: Changes in temperature affect the incidence risk for acute CO poisoning, but the impact varies with different seasons and intentionality in Taiwan. Our findings quantify the effects of climate factors and provide fundamental evidence for healthcare providers to develop preventative strategies to reduce acute CO poisoning events.

Guillain-​Barré Syndrome Associated with COVID-19 Vaccination.

We conducted a multi-institutional study in Taiwan and a systematic review of the literature for reports of Guillain-​Barré syndrome after coronavirus disease vaccination. This condition, mostly the classic form and the acute inflammatory demyelinating polyneuropathy subtype, has been reported in 39 cases and has occurred within 2 weeks of vaccine administration.

Does seniority always correlate with simulated intubation performance? Comparing endotracheal intubation performance across medical students, residents, and physicians using a high-fidelity simulator.

BACKGROUND: Endotracheal intubation is crucial in emergency medical care and anaesthesia. Our study employed a high-fidelity simulator to explore differences in intubation success rate and other skills between junior and senior physicians. METHODS: We examined the performance of 50 subjects, including undergraduate students (UGY), postgraduate trainees (PGY), residents (R), and attending physicians (VS). Each participant performed 12 intubations (i.e. 3 devices x 4 scenarios) on a high-fidelity simulator. Main outcome measures included success rate, time for intubation, force applied on incisor and tongue, and Cormack Lehane grades. RESULTS: There was no primary effect of seniority on any outcome measure except success rate and Cormack Lehane grades. However, VS demonstrated shorter duration than medical students using Glidescope and direct laryngoscopy, whereas VS and R applied significantly more force on the incisor in the normal airway and rigid neck scenario respectively. DISCUSSION: Seniority does not always correlate with skill perfection in detailed processes. Our study suggests that the use of video laryngoscopy enhances the intubation success rate and speed, but the benefit only accrues to senior learners, whereby they applied more force on the incisor at a single peak under difficult scenarios. These findings are discussed in terms of psychological and cognitive perspectives. CONCLUSION: Speed and safety are essential for high quality critical medical procedures. A tool should be designed and implemented to educate junior physicians with an emphasis on practice and efficiency, which should also contribute to updating senior physicians' knowledge and competence by providing instant feedback on their performance. This type of fine-grained feedback could serve as a complement to traditional training and provide a sustainable learning model for medical education.

Real-world effectiveness of hyperbaric oxygen therapy for delayed neuropsychiatric sequelae after carbon monoxide poisoning.

To assess real-world effectiveness of hyperbaric oxygen therapy (HBOT) on delayed neuropsychiatric sequelae (DNS) after carbon monoxide (CO) poisoning we conducted a retrospective review of patients with CO poisoning admitted to Linkou Chang-Gung Memorial Hospital, Taiwan's largest medical center, during 2009-2015. We included patients developing DNS after CO poisoning and compared improvements in neuropsychiatric function, with and without HBOT, after 12 months post-DNS to understand differences in recovery rates. DNS improvement-associated factors were also evaluated. We used receiver operating characteristic (ROC) curve analysis to assess the role of time elapsed between DNS diagnosis and HBOT initiation in predicting DNS improvement. A total of 62 patients developed DNS, of whom 11 recovered while the rest did not. Possible factors predicting DNS improvement included receiving HBOT post-DNS (72.7% vs 25.5%; P = 0.006), and treatment with more than three HBOT sessions during acute stage CO poisoning (81.8% vs 27.5%; P = 0.003). The relevant area under the ROC curve was 0.789 (95% CI 0.603-0.974), and the best cut-off point was 3 days post-DNS diagnosis, with 87.5% sensitivity and 61.5% specificity. Early HBOT in patients who developed DNS after CO poisoning significantly improved their DNS symptoms, with treatment effects sustained for 1 year after DNS diagnosis.

Prevalence, incidence and mortality of delirium in patients with COVID-19: a systematic review and meta-analysis.

BACKGROUND: Attention should be paid to delirium in coronavirus disease 2019 (COVID-19) patients, especially older people, since advanced age poses increased risk of both delirium and COVID-19-related death. OBJECTIVE: This study aims to summarise the evidence on prevalence, incidence and mortality of delirium in COVID-19 patients. METHODS: We conducted a comprehensive literature search on Pubmed and Embase from inception to 1 December 2020. Three independent reviewers evaluated study eligibility and data extraction, and assessed study quality. Outcomes were analysed as proportions with 95% confidence interval (CI). We also compared mortality differences in COVID-19 patients using odds ratio. RESULTS: In total, we identified 48 studies with 11,553 COVID-19 patients from 13 countries. Pooled prevalence, incidence and mortality rates for delirium in COVID-19 patients were 24.3% (95% CI: 19.4-29.6%), 32.4% (95% CI: 20.8-45.2%) and 44.5% (95% CI: 36.1-53.0%), respectively. For patients aged over 65 years, prevalence, incidence and mortality rates for delirium in COVID-19 patients were 28.2% (95% CI: 23.5-33.1%), 25.2% (95% CI: 16.0-35.6%) and 48.4% (95% CI: 40.6-56.1%), respectively. For patients under 65 years, prevalence, incidence and mortality rates for delirium in COVID-19 patients were 15.7% (95% CI: 9.2-23.6%), 71.4% (95% CI: 58.5-82.7%) and 21.2% (95% CI: 15.4-27.6%), respectively. Overall, COVID-19 patients with delirium suffered higher risk of mortality, compared with those without delirium (OR: 3.2, 95% CI: 2.1-4.8). CONCLUSION: Delirium developed in almost 1 out of 3 COVID-19 patients, and was associated with 3-fold overall mortality. Our findings suggest that first-line healthcare providers should systematically assess delirium and monitor related symptoms among COVID-19 patients.

Implementing the Richmond Agitation-Sedation Scale in a respiratory critical care unit: a best practice implementation project.

INTRODUCTION: Adequate sedation can lead to patient-ventilator synchrony, facilitation of treatment, and decreased physical and psychological discomfort for patients with respiratory failure in the intensive care unit (ICU). The Richmond Agitation-Sedation Scale (RASS) is considered to be the most appropriate tool in sedation assessment. OBJECTIVES: This aim of this project was to implement evidence-based recommendations for sedation assessment using the RASS in mechanically ventilated patients in the ICU. METHODS: This implementation project was conducted in an ICU at a tertiary medical center in Taiwan. Using the JBI Practical Application of Clinical Evidence System software, a baseline audit was conducted in the ICU, followed by an identification of barriers of RASS assessment and an implementation of management of strategies to improve the consistency of sedation assessment. RESULTS: Results of the baseline audit showed that four of the six selected criteria had 0% compliance. Following the implementation of the strategies, which included education, visual management and development of a "RASS Reminder Card", there was an improvement in all the criteria audited, with each criterion achieving 83-100% of compliance. CONCLUSION: The project successfully improved the implementation of RASS assessment in the respiratory ICU. Following the development and implementation of evidence-based resources, a high level of compliance was achieved for nurses using the RASS in the ICU to assess sedation in patients with a ventilator.

Syrian rue seeds interacted with acacia tree bark in an herbal stew resulted in N,N-dimethyltryptamine poisoning.

Introduction: Illicit substance use is an increasing problem all over the world, especially in adolescents and young adults. It is a challenge to make a definitive diagnosis of a specific substance in a poisoning case without toxicology laboratory confirmation. We confirmed the presence of N,N-dimethyltryptamine (DMT) by liquid chromatograph tandem mass spectrometer (LC/MS/MS) in biologic samples from two patients who presented with signs and symptoms consistent with sympathomimetic toxicity following the consumption of an herbal stew. Case: Two patients consumed an herbal stew together developed DMT poisoning from the interaction between Syrian rue seeds containing alkaloids with monoamine oxidase inhibitor (MAOI) activity and Acacia tree bark containing DMT. Patients' blood and spot urine was analyzed by LC/MS/MS which revealed the presence of DMT (case 1 urine: 1206 ng/mL, serum: 25 ng/mL; case 2 urine: 478 ng/mL, serum: undetectable) and harmaline (case 1 urine: 1564 ng/mL, serum: 3.3 ng/mL; case 2 urine: 1230 ng/mL, serum: undetectable). Discussion: The diagnosis of DMT poisoning is confirmed by the presence of DMT and harmaline in patients' serum and urine. Case 1 exhibited more severe signs and symptoms (e.g., altered consciousness, rhabdomyolysis, and elevated liver enzyme) than case 2. This may be explained by the presence of psychoactive DMT levels in the blood of case 1 whereas DMT was undetected in the blood of case 2. Conclusions: Consumption of an herbal stew composed of Syrian rue seeds and Acacia tree bark may be equivalent to taking a combination of DMT and MAOI, which may precipitate a sympathomimetic syndrome. Physicians should be aware that unusual clinical presentations may be the result of drug-drug interactions from a mixed herbal preparation.

Targeting optimal time for hyperbaric oxygen therapy following carbon monoxide poisoning for prevention of delayed neuropsychiatric sequelae: A retrospective study.

OBJECTIVES: Delayed neuropsychiatric sequelae (DNS) are serious complications of carbon monoxide poisoning; neuropsychiatric disorders can occur within a few days of recovery from acute poisoning. Hyperbaric oxygen therapy (HBOT) has been the main treatment of carbon monoxide (CO) poisoning and was recommended as the treatment choice for CO poisoning by the American Undersea and Hyperbaric Medical Society and the Tenth European Consensus Conference on Hyperbaric Medicine of the European Underwater and Baromedical Society. However, the optimal timing for commencing HBOT in patients with CO poisoning remains unknown. We therefore conducted a retrospective study in an attempt to target the optimal time of HBOT for DNS prevention. METHODS: A retrospective review of patient files/medical records was conducted on all patients with CO poisoning admitted to the Emergency Department of Linkou Chang-Gung Memorial Hospital, Taiwan between January 1, 2009 and December 31, 2015. A total of 279 patients who received HBOT were eligible for further DNS detection. DNS was defined as the presence of one of the following neurological, cognitive, or psychological sequelae that were documented in the medical record during hospital stay or outpatient clinic follow-up for at least 6 months. A multivariable logistic regression analysis was employed to identify potential determinants of DNS after receiving HBOT for CO poisoning. A receiver operating characteristic (ROC) curve was used to analyse the influence of duration from CO exposure to HBOT on DNS development. RESULTS: A Glasgow coma score of <9 (odds ratio [OR], 3.20; 95% confidence interval [CI], 1.19-8.60) and a longer duration from CO exposure to HBOT (OR, 1.06; 95% CI, 1.03-1.09) were associated with a higher risk of DNS. By contrast, the presence of multiple victims from the same incident was associated with a lower risk of DNS. The ROC curve for the duration between CO exposure and HBOT in predicting DNS development demonstrated an area under the curve of 0.638 (95% CI, 0.575-0.698). The optimal cut-off point according to the Youden index was 22.5 h, with a sensitivity of 41.7% and a specificity of 85.9%. We also stratified the duration from CO exposure to HBOT into 5 intervals (< 6 h, 6-11 h, 12-23 h, 24-47 h and ≥ 48 h) and revealed a trend of increasing DNS risk with time. CONCLUSIONS: We identified several potential predictors of DNS in patients with CO poisoning who received HBOT. Multivariable logistic regressions further revealed that longer duration from CO exposure to HBOT, loss of consciousness, and the presence of multiple victims were independent predictors of DNS development. HBOT should be performed as early as possible and preferably within 22.5 h after CO poisoning.

Predictive Role of QTc Prolongation in Carbon Monoxide Poisoning-Related Delayed Neuropsychiatric Sequelae.

OBJECTIVE: Delayed neuropsychiatric sequelae (DNS) are serious complications of carbon monoxide (CO) poisoning that adversely affect poisoned patients' quality of life as well as socioeconomic status. This study aimed to determine clinical predictors of DNS in patients with CO poisoning. METHODS: This retrospective study included all CO-poisoned patients admitted to the emergency department (ED) of Linkou Chang Gung Memorial Hospital in Taiwan from 1 January 2009 to 31 December 2015. The medical records of all patients with CO poisoning were carefully reviewed, and relevant data were abstracted into a standardised form. Univariate and multivariate logistic regression models were used to identify predictors of DNS after CO poisoning. Receiver operating characteristic (ROC) curve analysis was used to determine the ideal cut-off value for continuous variables that predict the development of DNS. RESULTS: A total of 760 patients with CO poisoning were identified during the study period. Among them, 466 were eligible for the analysis of predictors of DNS. In multivariate analysis, Glasgow Coma Scale <9 (odds ratio [OR], 2.74; 95% confidence interval [CI], 1.21-6.21), transient loss of consciousness (OR, 3.59; 95% CI, 1.31-9.79), longer duration from CO exposure to ED presentation (OR, 1.05; 95% CI, 1.03-1.08), and corrected QT (QTc) prolongation (OR, 2.61; 95% CI, 1.21-5.61) were found to be associated with a higher risk of DNS. The area under the ROC curve (AUC) for QTc interval measured within 6 h after exposure best predicted the development of DNS, with a result of 0.729 (95% CI 0.660-0.791). Moreover, the best cut-off value of the QTc interval was 471 ms, with a sensitivity of 53.3% and a specificity of 85.1%. CONCLUSIONS: We identified several potential predictors of DNS following CO poisoning. Among them, QTc prolongation found within 6 h after exposure is a novel predictor of DNS, which may be helpful in the future care of patients with CO poisoning.