Pre-hospital Prognostic Factors of Out-of-Hospital Cardiac Arrest: The Difference Between Pediatric and Adult.

The prognosis of out-of-hospital cardiac arrest (OHCA) is very poor. Although several pre-hospital factors are associated with survival, the different association of pre-hospital factors with OHCA outcomes in pediatric and adult groups remain unclear. To assess the association of pre-hospital factors with OHCA outcomes among pediatric and adult groups, a retrospective observational study was conducted using the emergency medical service (EMS) database in Kaohsiung from January 2015 to December 2019. Pre-hospital factors, underlying diseases, and OHCA outcomes were collected for the pediatric (Age ≤ 20) and adult groups. Kaplan-Meier type plots and multivariable logistic regression were used to analyze the association between pre-hospital factors and outcomes. In total, 7,461 OHCAs were analyzed. After adjusting for EMS response time, bystander CPR, attended by EMT-P, witness, and pre-hospital defibrillation, we found that age [odds ratio (OR) = 0.877, 95% confidence interval (CI): 0.764-0.990, p = 0.033], public location (OR = 7.681, 95% CI: 1.975-33.428, p = 0.003), and advanced airway management (AAM) (OR = 8.952; 95% CI, 1.414-66.081; p = 0.02) were significantly associated with survival till hospital discharge in pediatric OHCAs. The results of Kaplan-Meier type plots with log-rank test showed a significant difference between the pediatric and adult groups in survival for 2 h (p < 0.001), 24 h (p < 0.001), hospital discharge (p < 0.001), and favorable neurologic outcome (p < 0.001). AAM was associated with improved survival for 2 h (p = 0.015), 24 h (p = 0.023), and neurologic outcome (p = 0.018) only in the pediatric group. There were variations in prognostic factors between pediatric and adult patients with OHCA. The prognosis of the pediatric group was better than that of the adult group. Furthermore, AAM was independently associated with outcomes in pediatric patients, but not in adult patients. Age and public location of OHCA were independently associated with survival till hospital discharge in both pediatric and adult patients.

Effects of Fine Particulate Matter and Its Components on Emergency Room Visits for Pediatric Pneumonia: A Time-Stratified Case-Crossover Study.

Pneumonia, one of the important causes of death in children, may be induced or aggravated by particulate matter (PM). Limited research has examined the association between PM and its constituents and pediatric pneumonia-related emergency department (ED) visits. Measurements of PM2.5, PM10, and four PM2.5 constituents, including elemental carbon (EC), organic carbon (OC), nitrate, and sulfate, were extracted from 2007 to 2010 from one core station and two satellite stations in Kaohsiung City, Taiwan. Furthermore, the medical records of patients under 17 years old who had visited the ED in a medical center and had a diagnosis of pneumonia were collected. We used a time-stratified, case-crossover study design to estimate the effect of PM. The single-pollutant model demonstrated interquartile range increase in PM2.5, PM10, nitrate, OC, and EC on lag 3, which increased the risk of pediatric pneumonia by 18.2% (95% confidence interval (Cl), 8.8-28.4%), 13.1% (95% CI, 5.1-21.7%), 29.7% (95% CI, 16.4-44.5%), 16.8% (95% CI, 4.6-30.4%), and 14.4% (95% Cl, 6.5-22.9%), respectively. After PM2.5, PM10, and OC were adjusted for, nitrate and EC remained significant in two-pollutant models. Subgroup analyses revealed that nitrate had a greater effect on children during the warm season (April to September, interaction p = 0.035). In conclusion, pediatric pneumonia ED visit was related to PM2.5 and its constituents. Moreover, PM2.5 constituents, nitrate and EC, were more closely associated with ED visits for pediatric pneumonia, and children seemed to be more susceptible to nitrate during the warm season.

Fine particulate matter constituents associated with emergency room visits for pediatric asthma: a time-stratified case-crossover study in an urban area.

BACKGROUND: Global asthma-related mortality tallies at around 2.5 million annually. Although asthma may be triggered or exacerbated by particulate matter (PM) exposure, studies investigating the relationship of PM and its components with emergency department (ED) visits for pediatric asthma are limited. This study aimed to estimate the impact of short-term exposure to PM constituents on ED visits for pediatric asthma. METHODS: We retrospectively evaluated non-trauma patients aged younger than 17 years who visited the ED with a primary diagnosis of asthma. Further, measurements of PM with aerodynamic diameter of < 10 µm (PM10), PM with aerodynamic diameter of < 10 µm (PM2.5), and four PM2.5 components (i.e., nitrate (NO3-), sulfate (SO42-), organic carbon (OC), and elemental carbon (EC)) were collected between 2007 and 2010 from southern particulate matter supersites. These included one core station and two satellite stations in Kaohsiung City, Taiwan. A time-stratified case-crossover study was conducted to analyze the hazard effect of PM. RESULTS: Overall, 1597 patients were enrolled in our study. In the single-pollutant model, the estimated risk increase for pediatric asthma incidence on lag 3 were 14.7% [95% confidence interval (CI), 3.2-27.4%], 13.5% (95% CI, 3.3-24.6%), 14.8% (95% CI, 2.5-28.6%), and 19.8% (95% CI, 7.6-33.3%) per interquartile range increments in PM2.5, PM10, nitrate, and OC, respectively. In the two-pollutant models, OC remained significant after adjusting for PM2.5, PM10, and nitrate. During subgroup analysis, children were more vulnerable to PM2.5 and OC during cold days (< 26 °C, interaction p = 0.008 and 0.012, respectively). CONCLUSIONS: Both PM2.5 concentrations and its chemical constituents OC and nitrate are associated with ED visits for pediatric asthma. Among PM2.5 constituents, OC was most closely related to ED visits for pediatric asthma, and children are more vulnerable to PM2.5 and OC during cold days.

Impact of coronary risk scores on disposition decision in emergency patients with chest pain.

BACKGROUND: Coronary risk scores (CRS) including History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) score and Emergency Department Assessment of Chest pain Score (EDACS) can help identify patients at low risk of major adverse cardiac events. In the emergency department (ED), there are wide variations in hospital admission rates among patients with chest pain. OBJECTIVE: This study aimed to evaluate the impact of CRS on the disposition of patients with symptoms suggestive of acute coronary syndrome in the ED. METHODS: This retrospective cohort study included 3660 adult patients who presented to the ED with chest pain between January and July in 2019. Study inclusion criteria were age > 18 years and a primary position International Statistical Classification of Diseases and Related Health Problems-10th revision coded diagnosis of angina pectoris (I20.0-I20.9) or chronic ischemic heart disease (I25.0-I25.9) by the treating ED physician. If the treating ED physician completed the electronic structured variables for CRS calculation to assist disposition planning, then the patient would be classified as the CRS group; otherwise, the patient was included in the control group. RESULTS: Among the 2676 patients, 746 were classified into the CRS group, whereas the other 1930 were classified into the control group. There was no significant difference in sex, age, initial vital signs, and ED length of stay between the two groups. The coronary risk factors were similar between the two groups, except for a higher incidence of smokers in the CRS group (19.6% vs. 16.1%, p = 0.031). Compared with the control group, significantly more patients were discharged (70.1% vs. 64.6%) directly from the ED, while fewer patients who were hospitalized (25.9% vs. 29.7%) or against-advise discharge (AAD) (2.6% vs. 4.0%) in the CRS group. Major adverse cardiac events and mortality at 60 days between the two groups were not significantly different. CONCLUSIONS: A higher ED discharge rate of the group using CRS may indicate that ED physicians have more confidence in discharging low-risk patients based on CRS.

Delta Shock Index During Emergency Department Stay Is Associated With in Hospital Mortality in Critically Ill Patients.

Background: Delta shock index (SI; i.e., change in SI over time) has been shown to predict mortality and need for surgical intervention among trauma patients at the emergency department (ED). However, the usefulness of delta SI for prognosis assessment in non-traumatic critically ill patients at the ED remains unknown. The aim of this study was to analyze the association between delta SI during ED management and in-hospital outcomes in patients admitted to the intensive care unit (ICU). Method: This was a retrospective study conducted in two tertiary medical centers in Taiwan from January 1, 2016, to December 31, 2017. All adult non-traumatic patients who visited the ED and who were subsequently admitted to the ICU were included. We calculated delta SI by subtracting SI at ICU admission from SI at ED triage, and we analyzed its association with in-hospital outcomes. SI was defined as the ratio of heart rate to systolic blood pressure (SBP). The primary outcome was in-hospital mortality, and the secondary outcomes were hospital length of stay (HLOS) and early mortality. Early mortality was defined as mortality within 48 h of ICU admission. Result: During the study period, 11,268 patients met the criteria and were included. Their mean age was 64.5 ± 15.9 years old. Overall, 5,830 (51.6%) patients had positive delta SI. Factors associated with a positive delta SI were multiple comorbidities (51.2% vs. 46.3%, p < 0.001) and high Simplified Acute Physiology Score [39 (29-51) vs. 37 (28-47), p < 0.001). Patients with positive delta SI were more likely to have tachycardia, hypotension, and higher SI at ICU admission. In the regression analysis, high delta SI was associated with in-hospital mortality [aOR (95% CI): 1.21 (1.03-1.42)] and early mortality [aOR (95% CI): 1.26 (1.07-1.48)], but not for HLOS [difference (95% CI): 0.34 (-0.48 to 1.17)]. In the subgroup analysis, high delta SI had higher odds ratios for both mortality and early mortality in elderly [aOR (95% CI): 1.59 (1.11-2.29)] and septic patients [aOR (95% CI): 1.54 (1.13-2.11)]. It also showed a higher odds ratio for early mortality in patients with triage SBP <100 mmHg [aOR (95% CI): 2.14 (1.21-3.77)] and patients with triage SI ≥ 0.9 [aOR (95% CI): 1.62 (1.01-2.60)]. Conclusion: High delta SI during ED stay is correlated with in-hospital mortality and early mortality in patients admitted to the ICU via ED. Prompt resuscitation should be performed, especially for those with old age, sepsis, triage SBP <100 mmHg, or triage SI ≥ 0.9.

Short-Term Effects of Particulate Matter and Its Constituents on Emergency Room Visits for Chronic Obstructive Pulmonary Disease: A Time-Stratified Case-Crossover Study in an Urban Area.

BACKGROUND: PM2.5 exposure is associated with pulmonary and airway inflammation, and the health impact might vary by PM2.5 constitutes. This study evaluated the effects of increased short-term exposure to PM2.5 constituents on chronic obstructive pulmonary disease (COPD)-related emergency department (ED) visits and determined the susceptible groups. METHODS: This retrospective observational study performed in a medical center from 2007 to 2010, and enrolled non-trauma patients aged >20 years who visited the emergency department (ED) and were diagnosed as COPD. Concentrations of PM2.5, PM10, and the four PM2.5 components, including organic carbon (OC), elemental carbon (EC), nitrate (NO3-), and sulfate (SO42-), were collected by three PM supersites in Kaohsiung City. We used an alternative design of the Poisson time series regression models called a time-stratified and case-crossover design to analyze the data. RESULTS: Per interquartile range (IQR) increment in PM2.5 level on lag 2 were associated with increments of 6.6% (95% confidence interval (CI), 0.5-13.0%) in risk of COPD exacerbation. An IQR increase in elemental carbon (EC) was significantly associated with an increment of 3.0% (95% CI, 0.1-5.9%) in risk of COPD exacerbation on lag 0. Meanwhile, an IQR increase in sulfate, nitrate, and OC levels was not significantly associated with COPD. Patients were more sensitive to the harmful effects of EC on COPD during the warm season (interaction p = 0.019). The risk of COPD exacerbation after exposure to PM2.5 was higher in individuals who are currently smoking, with malignancy, or during cold season, but the differences did not achieve statistical significance. CONCLUSION: PM2.5 and EC may play an important role in COPD events in Kaohsiung, Taiwan. Patients were more susceptible to the adverse effects of EC on COPD on warm days.

In-Hospital Outcomes in Patients Admitted to the Intensive Care Unit after a Return Visit to the Emergency Department.

BACKGROUND: Intensive care unit (ICU) admission following a short-term emergency department (ED) revisit has been considered a particularly undesirable outcome among return-visit patients, although their in-hospital prognosis has not been discussed. We aimed to compare clinical outcomes between adult patients admitted to the ICU after unscheduled ED revisits and those admitted during index ED visits. METHOD: This retrospective study was conducted at two tertiary medical centers in Taiwan from 1 January 2016 to 31 December 2017. All adult non-trauma patients admitted to the ICU directly via the ED during the study period were included and divided into two comparison groups: patients admitted to the ICU during index ED visits and those admitted to the ICU during return ED visits. The outcomes of interest included in-hospital mortality, mechanical ventilation (MV) support, profound shock, hospital length of stay (HLOS), and total medical cost. RESULTS: Altogether, 12,075 patients with a mean (standard deviation) age of 64.6 (15.7) years were included. Among these, 5.3% were admitted to the ICU following a return ED visit within 14 days and 3.1% were admitted following a return ED visit within 7 days. After adjusting for confounding factors for multivariate regression analysis, ICU admission following an ED revisit within 14 days was not associated with an increased mortality rate (adjusted odds ratio (aOR): 1.08, 95% confidence interval (CI): 0.89 to 1.32), MV support (aOR: 1.06, 95% CI: 0.89 to 1.26), profound shock (aOR: 0.99, 95% CI: 0.84 to 1.18), prolonged HLOS (difference: 0.04 days, 95% CI: -1.02 to 1.09), and increased total medical cost (difference: USD 361, 95% CI: -303 to 1025). Similar results were observed after the regression analysis in patients that had a 7-day return visit. CONCLUSION: ICU admission following a return ED visit was not associated with major in-hospital outcomes including mortality, MV support, shock, increased HLOS, or medical cost. Although ICU admissions following ED revisits are considered serious adverse events, they may not indicate poor prognosis in ED practice.

Response Time Threshold for Predicting Outcomes of Patients with Out-of-Hospital Cardiac Arrest.

Ambulance response time is a prognostic factor for out-of-hospital cardiac arrest (OHCA), but the impact of ambulance response time under different situations remains unclear. We evaluated the threshold of ambulance response time for predicting survival to hospital discharge for patients with OHCA. A retrospective observational analysis was conducted using the emergency medical service (EMS) database (January 2015 to December 2019). Prehospital factors, underlying diseases, and OHCA outcomes were assessed. Receiver operating characteristic (ROC) curve analysis with Youden Index was performed to calculate optimal cut-off values for ambulance response time that predicted survival to hospital discharge. In all, 6742 cases of adult OHCA were analyzed. After adjustment for confounding factors, age (odds ratio [OR] = 0.983, 95% confidence interval [CI]: 0.975-0.992, p < 0.001), witness (OR = 3.022, 95% CI: 2.014-4.534, p < 0.001), public location (OR = 2.797, 95% CI: 2.062-3.793, p < 0.001), bystander cardiopulmonary resuscitation (CPR, OR = 1.363, 95% CI: 1.009-1.841, p=0.044), EMT-paramedic response (EMT-P, OR = 1.713, 95% CI: 1.282-2.290, p < 0.001), and prehospital defibrillation using an automated external defibrillator ([AED] OR = 3.984, 95% CI: 2.920-5.435, p < 0.001) were statistically and significantly associated with survival to hospital discharge. The cut-off value was 6.2 min. If the location of OHCA was a public place or bystander CPR was provided, the threshold was prolonged to 7.2 min and 6.3 min, respectively. In the absence of a witness, EMT-P, or AED, the threshold was reduced to 4.2, 5, and 5 min, respectively. The adjusted OR of EMS response time for survival to hospital discharge was 1.217 (per minute shorter, CI: 1.140-1299, p < 0.001) and 1.992 (<6.2 min, 95% CI: 1.496-2.653, p < 0.001). The optimal response time threshold for survival to hospital discharge was 6.2 min. In the case of OHCA in public areas or with bystander CPR, the threshold was prolonged, and without witness, the optimal response time threshold was shortened.

Association between prehospital prognostic factors on out-of-hospital cardiac arrest in different age groups.

BACKGROUND: The prognosis of out-of-hospital cardiac arrest (OHCA) is very poor. While several prehospital factors are known to be associated with improved survival, the impact of prehospital factors on different age groups is unclear. The objective of the study was to access the impact of prehospital factors and pre-existing comorbidities on OHCA outcomes in different age groups. METHODS: A retrospective observational analysis was conducted using the emergency medical service (EMS) database from January 2015 to December 2019. We collected information on prehospital factors, underlying diseases, and outcome of OHCAs in different age groups. Kaplan-Meier type survival curves and multivariable logistic regression were used to analyze the association between modifiable pre-hospital factors and outcomes. RESULTS: A total of 4188 witnessed adult OHCAs were analyzed. For the age group 1 (age ≦75 years old), after adjustment for confounding factors, EMS response time (odds ratio [OR] = 0.860, 95% confidence interval [CI]: 0.811-0.909, p < 0.001), public location (OR = 1.843, 95% CI: 1.179-1.761, p < 0.001), bystander CPR (OR = 1.329, 95% CI: 1.007-1.750, p = 0.045), attendance by an EMT-Paramedic (OR = 1.666, 95% CI: 1.277-2.168, p < 0.001), and prehospital defibrillation by automated external defibrillator (AED)(OR = 1.666, 95% CI: 1.277-2.168, p < 0.001) were prognostic factors for survival to hospital discharge in OHCA patients. For the age group 2 (age > 75 years old), age (OR = 0.924, CI:0.880-0.966, p = 0.001), EMS response time (OR = 0.833, 95% CI: 0.742-0.928, p = 0.001), public location (OR = 4.290, 95% CI: 2.450-7.343, p < 0.001), and attendance by an EMT-Paramedic (OR = 2.702, 95% CI: 1.704-4.279, p < 0.001) were independent prognostic factors for survival to hospital discharge in OHCA patients. CONCLUSIONS: There were variations between younger and older OHCA patients. We found that bystander CPR and prehospital defibrillation by AED were independent prognostic factors for younger OHCA patients but not for the older group.

Influence of physicians' seniority on head computed tomography use for patients with isolated vertigo/dizziness.

OBJECTIVE: Vertigo/dizziness is a common reason for emergency department (ED) visits. Emergency physicians (EPs) must distinguish patients with dizziness/vertigo owing to serious central nervous system (CNS) disorders. We aimed to evaluate the association between physician seniority and use of head computed tomography (CT) and ED length of stay (LOS) in patients presenting to the ED with isolated dizziness/vertigo. METHODS: This retrospective cohort study included adult patients with non-traumatic dizziness/vertigo in the ED. EPs were categorized according to seniority: junior (less than 6 years' clinical experience), intermediate (7-12 years), and senior (≥12 years). RESULTS: Among 2589 patients with isolated dizziness/vertigo, 460 (17.8%) received brain CT; 46 (1.78%) had CNS disorder as a final diagnosis. Junior and intermediate EPs ordered more CT examinations than senior EPs: (odds ratio [OR] = 1.329, 95% confidence interval [CI]: 1.002-1.769 and OR = 1.531, 95% CI: 1.178-2.001, respectively). Patients treated by junior and intermediate EPs had lower patient ED LOS (OR = -0.432, 95% CI: -0.887 to 0.024 and OR = -0.436, 95% CI: -0.862 to -0.011). CONCLUSIONS: We revealed different judgment strategies among senior, intermediate, and junior EPs. Senior EPs ordered fewer CT examinations for patients with isolated vertigo/dizziness but had longer patient LOS.

Risk factors associated with snake antivenom reaction and the role of skin test.

Antivenom reactions are a common complication of snake antivenom. This study aimed to identify predicators of antivenom reaction and the involvement of antivenom skin test in antivenom reaction development. This retrospective cohort study was conducted in six medical institutions in Taiwan. Data were extracted from the Chang Gung Research Database (CGRD) from January 2006 to December 2016. The association between antivenom reaction and patient demographics, type and dose of antivenom, and skin test results was analyzed. The study enrolled 799 patients, including 219 who developed antivenom reactions. Compared to patients receiving both freeze-dried hemorrhagic (FH) and freeze-dried neurotoxic (FN) antivenom, those administered a single type had a lower antivenom reaction risk (adjusted odds ratios [aORs]: 0.5 and 0.4, 95% confidence interval [CI]: 0.35-0.74 and 0.24-0.69, FH and FN respectively). Patients administered a higher antivenom dose (≥ 5 vials) had higher antivenom reaction risk (aOR: 1.8, 95% CI: 1.23-2.76). A positive skin test result was also associated with antivenom reaction (aOR: 16.7, 95% CI: 5.42-51.22). The skin test showed high specificity (98.5%, 95% CI: 97.49%-99.83%) but low sensitivity (17.5%, 95% CI: 10.74%-24.18%). The antivenom skin test should be abolished because of the extremely low sensitivity and possible misinterpretation of results because of the limitation of this examination.

Massive Pulmonary Embolism Concomitant With Cardiac Tamponade as Initial Presentation of Lung Adenocarcinoma: A Diagnostic and Therapeutic Dilemma.

Pulmonary embolism and cardiac tamponade are potentially fatal acute conditions that rarely present concomitantly in the emergency department (ED). Both require early diagnosis and urgent intervention, and are usually observed as separate easily identifiable diseases. However, in a patient exhibiting a concomitant presentation of pulmonary embolism with cardiac tamponade, diagnosis and therapeutic intervention are extremely challenging. A 48-year-old woman presented with cardiac tamponade as an initial symptom of an underlying lung adenocarcinoma and masked massive pulmonary embolism (MPE), which led to the development of sudden cardiac arrest after successful pericardiocentesis. She presented with a high index of suspicion for a diagnosis of MPE using echocardiography after successful pericardiocentesis, and this diagnosis was confirmed using computed tomography. Extracorporeal membrane oxygenation and adjusted-dose unfractionated intravenous heparin administration were performed; unfortunately, they were unsuccessful. This report would help ED physicians because this case demonstrates that lung cancer can initially present as pulmonary embolism with cardiac tamponade and pulmonary embolism can be misdiagnosed in the presence of concomitant cardiac tamponade. Bedside echocardiography may fail to diagnose life-threatening MPE with coexisting cardiac tamponade. MPE can also lead to the development of sudden cardiac arrest after successful pericardiocentesis. Thrombolytic and anticoagulant use in MPE with coexisting hemorrhagic cardiac tamponade is a controversial issue. The risk-benefit ratio of both therapies needs to be considered on a case-by-case basis for improved clinical outcomes.

Lead Poisoning Can Be Easily Misdiagnosed as Acute Porphyria and Nonspecific Abdominal Pain.

Lead poisoning (LP) is less commonly encountered in emergency departments (ED). However, lead exposure still occurs, and new sources of poisoning have emerged. LP often goes unrecognized due to a low index of suspicion and nonspecific symptoms. We present a case of a 48-year-old man who had recurring abdominal pain with anemia that was misdiagnosed. His condition was initially diagnosed as nonspecific abdominal pain and acute porphyria. Acute porphyria-like symptoms with a positive urine porphyrin test result led to the misdiagnosis; testing for heme precursors in urine is the key to the differential diagnosis between LP and acute porphyria. The final definitive diagnosis of lead toxicity was confirmed based on high blood lead levels after detailed medical history taking. The lead poisoning was caused by traditional Chinese herbal pills. The abdominal pain disappeared after a course of chelating treatment. The triad for the diagnosis of lead poisoning should be a history of medicine intake, anemia with basophilic stippling, and recurrent abdominal pain.

Methadone enhances human influenza A virus replication.

Growing evidence has indicated that opioids enhance replication of human immunodeficiency virus and hepatitis C virus in target cells. However, it is unknown whether opioids can enhance replication of other clinically important viral pathogens. In this study, the interaction of opioid agonists and human influenza A/WSN/33 (H1N1) virus was examined in human lung epithelial A549 cells. Cells were exposed to morphine, methadone or buprenorphine followed by human H1N1 viral infection. Exposure to methadone differentially enhanced viral propagation, consistent with an increase in virus adsorption, susceptibility to virus infection and viral protein synthesis. In contrast, morphine or buprenorphine did not alter H1N1 replication. Because A549 cells do not express opioid receptors, methadone-enhanced H1N1 replication in human lung cells may not be mediated through these receptors. The interaction of methadone and H1N1 virus was also examined in adult mice. Treatment with methadone significantly increased H1N1 viral replication in lungs. Our data suggest that use of methadone facilitates influenza A viral infection in lungs and might raise concerns regarding the possible consequence of an increased risk of serious influenza A virus infection in people who receive treatment in methadone maintenance programs.

Adverse event and error of unexpected life-threatening events within 24hours of ED admission.

OBJECTIVES: Errors and adverse events associated with unexpected life-threatening events including unplanned transfer to the intensive care unit (ICU) and unexpected death after emergency department (ED) hospitalization are not well characterized. We performed this study to investigate the role of unexpected life-threatening events as a trigger to capture errors and adverse events for ED patient safety. METHODS: This prospective observational study enrolled adult non-trauma patients with unexpected life-threatening events within 24h of general ward admission from the ED of a medical center in Taiwan. The period of study was one year (in 2013); the medical records of enrolled patients were reviewed to identify adverse events and errors. We measured the incidence rate of adverse events or errors. Preventability, type, and physical injury severity of adverse events were investigated. RESULTS: Of 33,224 adult non-trauma ward admissions from the ED, 100 admissions (0.3%) met the study criteria. Incidence rate was 2% and 15% for errors and adverse events, respectively. In admissions involving error, all were preventable and the error type was overlooked of severity. In admissions that involved adverse events, 93.3% were preventable. There were 20% of admissions that resulted in death and 60% developed with severe physical injury. The adverse event types were diagnosis issues (53.3%), management issues (40%), and medication adverse events (6.7%). CONCLUSIONS: Unexpected life-threatening events within 24h of admission from the ED could be a useful trigger tool to identify preventable adverse events with serious physical injury in ED.

An analysis of causative factors in closed criminal medical malpractice cases of the Taiwan Supreme Court: 2000-2014.

Most medical malpractice in Taiwan leads to criminal prosecution. This study examined the epidemiologic factors and clinical errors that led to medical malpractice convictions in Taiwanese criminal prosecutions. A retrospective, 15-year population-based review of criminal Supreme Court judgments pertaining to medical malpractice against physicians and nurses was conducted. Eighty-four cases were reviewed, yielding data that included the number and specialty involved, accused hospitals, the diagnosis, the time interval between incidents to closure, result of adjudication, the origin of cases (private vs. public prosecution), the result of medical appraisal, and the primary error. Overall, the cases averaged 7.6years to achieve final adjudication. Seventy-five percent were settled in favor of the clinician; twenty-three physicians and three nurses were found guilty, but all of these avoided imprisonment via probation or replacement with forfeit. The single most risky specialty was emergency medicine (22.6% of the cases), with 36.8% of those resulting in guilty verdicts. The most common diagnosis groups were infectious diseases (23.8%), intracranial hemorrhages (10.7%), and acute coronary syndrome (9.5%). Public prosecutions had a 41.2% conviction rate; no guilty verdicts resulted from private prosecution. Nineteen (22.6%) cases were commuted, and 73.7% of those had a controversial appraisal result. The characteristics of criminal malpractice prosecution in Taiwan that could be improved to relieve the stress of frivolous lawsuits on the judicial process include lengthy jurisdiction process; low public-prosecution conviction rate; frequent commuted jurisdiction related to a controversial appraisal; and zero imprisonment rate for clinicians.

The influence of emergency department crowding on the efficiency of care for acute stroke patients.

OBJECTIVE: To investigate the impact of emergency department (ED) crowding (number of ED patients) and number of ED staff on the efficiency of the ED care process for acute stroke patients. DESIGN: Retrospective cohort study conducted from 1 May 2008 to 31 December 2013. SETTING: Largest primary stroke center (3000-bed tertiary academic hospital) in southern Taiwan. PARTICIPANTS: Patients aged 18-80 years presenting to the ED with acute stroke symptoms ≤3 h from symptom onset (n = 1142). MAIN OUTCOME MEASURES: Door-to-assessment time (DTA), door-to-computed tomography completion time (DTCT) and door-to-needle time (DTN). RESULTS: Of the 785 patients with ischemic stroke, 90 (11.46%) received thrombolysis. In the multivariate regression analysis, the number of ED patients and the number of attending physicians were significantly associated with delayed DTA and DTCT but not DTN. Initial assessment by a resident was also associated with delayed DTA and DTCT. The number of nurses was associated with delayed DTCT and DTN. CONCLUSIONS: Although ED crowding was not associated with delayed DTN, it predicted delayed DTA and DTCT in thrombolysis-eligible stroke patients. The number of attending physicians affected initial assessment and DTCTs, whereas the number of nurses impacted thrombolytic administration times.

The effect of free-standing GaN substrate on carrier localization in ultraviolet InGaN light-emitting diodes.

In this study, we have grown 380-nm ultraviolet light-emitting diodes (UV-LEDs) based on InGaN/AlInGaN multiple quantum well (MQW) structures on free-standing GaN (FS-GaN) substrate by atmospheric pressure metal-organic chemical vapor deposition (AP-MOCVD), and investigated the relationship between carrier localization degree and FS-GaN. The micro-Raman shift peak mapping image shows low standard deviation (STD), indicating that the UV-LED epi-wafer of low curvature and MQWs of weak quantum-confined Stark effect (QCSE) were grown. High-resolution X-ray diffraction (HRXRD) analyses demonstrated high-order satellite peaks and clear fringes between them for the UV-LEDs grown on the FS-GaN substrate, from which the interface roughness (IRN) was estimated. The temperature-dependent photoluminescence (PL) measurement confirmed that the UV-LEDs grown on the FS-GaN substrate exhibited better carrier confinement. Besides, the high-resolution transmission electron microscopy (HRTEM) and energy-dispersive spectrometer (EDS) mapping images verified that the UV-LEDs on FS-GaN have fairly uniform distribution of indium and more ordered InGaN/AlInGaN MQW structure. Clearly, the FS-GaN can not only improve the light output power but also reduce the efficiency droop phenomenon at high injection current. Based on the results mentioned above, the FS-GaN can offer UV-LEDs based on InGaN/AlInGaN MQW structures with benefits, such as high crystal quality and small carrier localization degree, compared with the UV-LEDs on sapphire.

Characterization of the thermal-tolerant mutants of Chlorella sp. with high growth rate and application in outdoor photobioreactor cultivation.

In this study, two thermal-tolerant mutants of Chlorella sp. MT-7 and MT-15, were isolated. In indoor cultivation, specific growth rate (micro, d(-1)) of the mutants were 1.4 to 1.8-fold at 25 degrees Celsius and 3.3 to 6.7-fold at 40 degrees Celsius higher than those of wild type. The carbon dioxide fixation rate of both microalgal mutants was also significantly higher than that of wild type. In outdoor closed cultivation, where the temperature of culture broth was 41 + or - 1 degrees Celsius, the micro of mutant strain MT-15 was 0.238 d(-1) during an 8-day cultivation. Whereas, the growth of wild type was inhibited in the outdoor cultivation. Our results show that the isolated microalgal strains are adaptable to be applied in outdoor cultivation in subtropical zones.