Assessing the Impact of the COVID-19 Pandemic on Pediatric Emergency Department Visits in Taiwan.

Background and Objectives: The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted healthcare systems worldwide. To assess the effects of the pandemic on pediatric emergency department (ED) visits in Taiwan, we conducted a study to evaluate changes in pediatric ED visits during the COVID-19 pandemic. Materials and Methods: This retrospective study included pediatric patients (age ≤ 18) who visited the ED between 21 January 2019 and 30 April 2019, at three hospitals of the Cathay Health System, and compared them with a corresponding period in 2020. Basic information, including mode of arrival, triage level, disposition, chief complaints, and incidence rates, were analyzed before and during the pandemic. Results: A total of 10,116 patients, with 6009 in the pre-pandemic group and 4107 in the pandemic group, were included in this study. The mean number of daily pediatric ED visits decreased from 60.09 before the pandemic to 40.66 during the pandemic, while ambulance use increased significantly by 2.56%. The percentage of patients with high acuity triage levels (levels 1 and 2) was significantly lower during the pandemic period (0.63% and 10.18%, respectively) than the pre-pandemic period (0.7% and 10.9%, respectively). Additionally, a significantly higher proportion of patients were discharged during the pandemic period (89.36%) than during the pre-pandemic period (88.33%). The proportion of COVID-19-related complaints, such as fever and respiratory tract infections, as well as other complaints including gastrointestinal issues, trauma, and psychological problems, significantly increased during the pandemic. Conclusions: In preparation for future pandemics, we recommend increasing emergency medical service capacity, establishing a non-contagious route for obtaining chronic medication prescriptions, optimizing staff allocation in pediatric emergency departments, and increasing the number of hospital social workers for enhanced support.

Impact of the COVID-19 pandemic on medical-seeking behavior in older adults by comparing the presenting complaints of the emergency department visits.

BACKGROUND: The outbreak of the coronavirus disease 2019 (COVID-19) has caused a catastrophic event worldwide. Since then, people's way of living has changed in terms of personal behavior, social interaction, and medical-seeking behavior, including change of the emergency department (ED) visiting patterns. The objective of this study was to analyze the impact of the COVID-19 pandemic on the ED visiting patterns of the older people to explore its variable expression with the intention of ameliorating an effective and suitable response to public health emergencies. METHODS: This was a retrospective study conducted in three hospitals of the Cathay Health System in Taiwan. Patients aged ≥ 65 years who presented to the ED between January 21, 2020, and April 30, 2020 (pandemic stage), and between January 21, 2019, and April 30, 2019 (pre-pandemic stage) were enrolled in the study. Basic demographics, including visit characteristics, disposition, and chief complaints of the patients visiting the ED between these two periods of time, were compared and analyzed. RESULTS: A total of 16,655 older people were included in this study. A 20.91% reduction in ED older adult patient visits was noted during the pandemic period. During the pandemic, there was a decrease in ambulance use among elderly patients visiting the ED, with the proportion decreasing from 16.90 to 16.58%. Chief complaints of fever, upper respiratory infections, psychological and social problems increased, with incidence risk ratios (IRRs) of 1.12, 1.23, 1.25, and 5.2, respectively. Meanwhile, the incidence of both non-life-threatening and life-threatening complaints decreased, with IRRs of 0.72 and 0.83, respectively. CONCLUSION: Health education regarding life-threatening symptom signs among older adult patients and avocation of the proper timing to seek medical attention via ambulance were crucial issues during the pandemic.

Klebsiella pneumoniae invasive syndrome with liver abscess and purulent meningitis presenting as acute hemiplegia: a case report.

BACKGROUND: Klebsiella pneumoniae can infect a variety of sites, with the risk of infection being higher in the immunocompromised state such as diabetes mellitus. A distinct invasive syndrome has been detected mostly in Southeast Asia in the past two decades. A common destructive complication is pyogenic liver abscess that can be complicated by metastatic endophthalmitis as well as the involvement of the central nervous system, causing purulent meningitis or brain abscess. CASE PRESENTATION: We report a rare case of an invasive liver abscess caused by K. pneumoniae, with metastatic infections of meninges. A 68-year-old man with type 2 diabetes mellitus presented to our emergency department as sepsis. Sudden disturbed consciousness was noticed with presentation of acute hemiplegia and gaze preference mimicking a cerebrovascular accident. CONCLUSIONS: The above case adds to the scarce literature on K. pneumoniae invasive syndrome with liver abscess and purulent meningitis. K. pneumoniae is a rare cause of meningitis and should raise suspicions about the disease in febrile individuals. In particular, Asian patients with diabetes presenting with sepsis and hemiplegia prompt a more thorough evaluation with aggressive treatment.

Accessing Apoptosis Induction and Metastasis Inhibition Effect of Magnolol on Triple Negative Breast Cancer In Vitro.

BACKGROUND/AIM: Triple-negative breast cancer (TNBC) is an aggressive type of breast cancer that still requires improvement in treatment. Magnolol extract, derived from the bark of Magnolia officinalis, has traditionally been used in Asia to treat sleeping disorders and anxiety, and as an anti-inflammatory agent. Several reports have indicated that magnolol may have the potential to inhibit the progression of hepatocellular carcinoma and glioblastoma. However, the anti-tumor effect of magnolol on TNBC remains unknown. MATERIALS AND METHODS: In this study, we used two TNBC cell lines, MDA-MB-231 and 4T1, to examine the cytotoxicity, apoptosis, and metastasis effects of magnolol. These were evaluated using MTT assay, flow cytometry, western blotting, and invasion/migration transwell assay, respectively. RESULTS: Magnolol significantly induced cytotoxicity and extrinsic/intrinsic apoptosis in both TNBC cell lines. It also decreased metastasis and associated protein expression in a dose-dependent manner. Furthermore, the anti-tumor effect was associated with the inactivation of the epidermal growth factor receptor (EGFR)/Janus kinase (JAK)/signal transducer and activator of transcription (STAT3) signaling pathway. CONCLUSION: Magnolol may not only induce cell death in TNBC through apoptosis signaling activation but also by down-regulating EGFR/JAK/STAT3 signaling, which mediates TNBC progression.

Magnolol Induces Apoptosis Through Extrinsic/intrinsic Pathways and Attenuates NF-κB/STAT3 Signaling in Non-small-cell Lung Cancer Cells.

BACKGROUND/AIM: Non-small-cell lung cancer (NSCLC) is the most common type of lung cancer worldwide, and treatment outcomes are still poor. Magnolol, a hydroxylated biphenyl isolated from Magnolia officinalis, was found to be effective against hepatocellular carcinoma via inactivating nuclear-factor-kappa B (NF-B) signaling. However, whether magnolol targets not only NF-B but also other factors in NSCLC and may contribute to the suppression of tumor progression is unclear. MATERIALS AND METHODS: Cell viability, flow cytometry, and western blotting assays were used to identify the mechanism of magnolol action in human lung adenocarcinoma cell lines A549 and CL1-5-F4. RESULTS: Our results indicated that magnolol induced cytotoxicity through extrinsic/intrinsic apoptosis signaling and suppressed phosphorylation of signal transducer and activator of transcription 3 (STAT3)/NF-B and expression of their downstream proteins. CONCLUSION: Magnolol not only induced extrinsic and intrinsic apoptosis signaling but also inactivated STAT3/NF-B and attenuated their signaling of epithelial-mesenchymal transition and metastasis-related protein expression in NSCLC.

Analysis of COVID-19 pandemic impact on the presenting complaints of the emergency department visits.

ABSTRACT: The impact of coronavirus disease 2019 (COVID-19) on economic and medical systems is significant, especially in the emergency department (ED). The patterns of ED visits have also changed significantly and may play a crucial role in rearranging medical resources to the most needed departments during the pandemic.This was a retrospective study conducted in hospitals of the Cathay Health System. All patients presented to the EDs between January 21, 2020 to April 30, 2020 (pandemic stage) and January 21, 2019 to April 30, 2019 (before the pandemic stage). Basic demographics, including visit characteristics, disposition, and chief complaints, of the patients visiting the ED between these 2 periods of time will be compared and analyzed.A total of 71,739 patients were included in the study. A reduction in ED visits was noted in 15.1% (32,950 ED visits) during the pandemic stage. ED visiting patients with the chief complaints of upper respiratory infection and social problems increased by 14.23% and 1.86%, respectively, during the pandemic period. Critical chief complaints such as cardiac arrest, chest pain and altered mental status decreased to less than the ED visits difference (-15.1%) between the pandemic and prepandemic stages, for 0%, -7.67%, and -13.8% respectively.Rearrangement of the ED pediatric staff to the COVID-19 special units and recruiting more social workers to the ED should be performed to respond to the COVID-19 pandemic.

Induction of Apoptosis, Inhibition of MCL-1, and VEGF-A Expression Are Associated with the Anti-Cancer Efficacy of Magnolol Combined with Regorafenib in Hepatocellular Carcinoma.

While regorafenib was approved for the treatment of advanced HCC in 2017, with a partial response and survival benefit; other combination agents to facilitate the efficacy of regorafenib still need to be explored. Magnolol is a potential natural anti-tumor compound for many types of cancers. Combination indexes calculated on the basis of both in vitro and in vivo models have indicated a synergistic effect of the combination of regorafenib and magnolol. The overexpression of the VEGF-A protein significantly diminished regorafenib's inhibition of cell viability, while the transient knockdown of VEGF-A by siRNA effectively sensitized HCC cells to regorafenib. In addition, the inhibition of MCL-1 by siRNA combined with regorafenib allowed for a significantly greater inhibition of cell growth, compared to regorafenib alone. A lower protein expression level for VEGF-A and MCL-1 was found for the combination treatment of HCC in vitro and in vivo. A superior metastasis inhibition was also found in the combination group, as compared to the single-treatment groups, using a transwell assay, wound healing assay, and Western blotting. The caspase-dependent and -independent and DNA damage effects, as determined by flow cytometry and a comet assay, were increased by the combination therapy. Taken together, magnolol sensitized HCC to regorafenib, which was correlated with the reduction of VEGF-A and MCL-1 and the induction of apoptosis.

Comprehensive residency-based point-of-care ultrasound training program increases ultrasound utilization in the emergency department.

ABSTRACT: Point-of-care ultrasonography (POCUS) is a prompt and simple tool for the urgent diagnosis and treatment of patients in the emergency department (ED). We developed a comprehensive residency-based POCUS training program for ED residents and determined its effect on ultrasound utilization in the ED.We conducted a retrospective cohort study in the ED of a university-affiliated medical center, to evaluate a centralized residency-based POCUS training course for ED residents, which included 12 core ultrasound applications, from July 2017 to June 2018. Each application comprised a combined lecture and hands-on practice session that lasted for 2 hours. Pre-tests and post-tests, including still image and video interpretation, were performed. The use of POCUS (number of ultrasound studies performed divided by the number of patients each resident saw in 1 year) among ED residents, before and after the POCUS training course (July 2016-June 2017 and July 2018-June 2019), was calculated and analyzed using the Wilcoxon signed-rank test.Sixteen residents participated and completed the entire training course. The post-test score was significantly better than the pre-test score, by a median of 12 points (P = .04). Utilization of POCUS among the ED residents increased significantly, from 0.15 ultrasound studies per patient per year to 0.41 ultrasound studies per patient per year (P < .01), after completion of the entire training course. Increased POCUS scanning percentages over the cardiac tissue, soft tissue, abdominal region, vascular system, procedural guidance, and ocular regions were also noted after providing the curriculum.Conducting a comprehensive POCUS education program may enhance POCUS utilization among residents in the ED.

Clinical physiological parameters for the prediction of gram-negative bacterial infection in the emergency department.

BACKGROUND: Early detection and treatment of Gram-negative bacteria (GNB), major causative pathogens of sepsis (a potentially fatal condition caused by the body's response to an infection), may benefit a patient's outcome, since the mortality rate increases by 5-10% for each hour of delayed therapy. Unfortunately, GNB diagnosis is based on bacterial culture, which is time consuming. Therefore, an economic and effective GNB (defined as a positive blood, sputum, or urine culture) infection detection tool in the emergency department (ED) is warranted. METHODS: We conducted a retrospective cohort study in the ED of a university-affiliated medical center between January 01, 2014 and December 31, 2017. The inclusion criteria were as follows: (1) age ≥ 18; (2) clinical suspicion of bacterial infection; (3) bacterial culture from blood, sputum, or urine ordered and obtained in the ED. Descriptive statistics was performed on patient demographic characteristics, vital signs, laboratory data, infection sites, cultured microorganisms, and clinical outcomes. The accuracy of vital signs to predict GNB infection was identified via univariate logistic regression and receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 797 patients were included in this study; the mean age was 71.8 years and 51.3% were male. The odds ratios of patients with body temperature ≥ 38.5 °C, heart rate ≥ 110 beats per minute, respiratory rate ≥ 20 breaths per minute, and Glasgow coma scale (GCS) < 14, in predicting GNB infection were found to be 2.3, 1.4, 1.9, and 1.6, respectively. The area under the curve values for ROC analysis of these measures were 0.70, 0.68, 0.69, and 0.67, respectively. CONCLUSION: The four physiological parameters were rapid and reliable independent predictors for detection of GNB infection.

Aortic Saddle Embolism: A Common Complaint With Multifaceted Catastrophe Disease.

Non-traumatic lower back pain is a common complaint seen in all emergency department (ED) visits. For many individuals, episodes of back pain are self-limited, but rarely, back pain is a signal of serious medical illness. A 58-year-old male was admitted to our ED suffering from lower back pain with radiation to the lower legs. Examination found bilateral lower limbs weakness with numbness and weak dorsalis pedis pulse. This is the point which peripheral arterial disease was considered and contrast computed tomography scan of abdomen and pelvis was arranged. Enormous aortic bifurcation clots were seen. This patient was soon to recover from the illness after receiving transfemoral catheterization thrombolysis and stenting. Aortic saddle embolism is a rare case of spontaneous acute aortic occlusion which the embolus terminated and straddled at the aortic bifurcation, producing bilateral lower extremity arterial obstruction and led to serious hemodynamic and metabolic consequences. The objective in this report is to raise awareness about this potentially fatal condition. In addition, to emphasize the importance of a thorough assessment and expeditious treatment in order to prevent serious complications including limb loss and potential mortality.

Thyroid Cancer With Cardiac Metastasis Presented With New Onset of Atrial Fibrillation.

Atrial fibrillation (Af) is frequently seen in the emergency department (ED), and the main concern of which is the potential to lead to blockage of blood flow. Cardiac tumors can also present with Af, which are often overlooked due to the rarity but clinically significant. A 70-year-old woman presented at our ED with intermittent palpitation and dizziness for several weeks. She has an underlying disease of right thyroid follicular carcinoma status-post surgery many years ago, but no history of heart disease. Her electrocardiogram (ECG) showed Af, and the transthoracic echocardiography showed a huge mass occupying the left atrium. The patient underwent an open-heart surgery with tumor excision. The pathology revealed metastatic thyroid follicular carcinoma. The patient recovered smoothly, and her ECG showed normal sinus rhythm after the operation. Most cardiac secondary tumors remain clinically silent and are often diagnosed postmortem. These conditions are rare but clinically significant; therefore, the physician should always raise suspicion of metastatic cardiac tumor as the differential diagnosis when patient presents with an unexplained Af.

A Rare Case of Spontaneous Pseudo-Aneurysm Rupture of an Extra-Anatomical Axillo-Femoral Bypass Graft: A Case Report.

BACKGROUND: Sudden onset of chest wall bulging is a rare chief symptom in the emergency department (ED). However, it may represent life-threatening diseases, such as tumor bleeding, aneurysm rupture, or subcutaneous emphysema. CASE REPORT: We present an 89-year-old woman who visited our ED with a chief symptom of abrupt bulging of the right chest wall accompanied with severe pain. The patient had a history of peripheral artery disease and 10-year post-extra-anatomical axillo-femoral bypass (AxFB) status. After several examinations, the patient was diagnosed as having spontaneous pseudo-aneurysm rupture of an extra-anatomical AxFB graft. Emergency endovascular intervention with stent insertion was performed immediately, and the patient was eventually discharged successfully. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Although spontaneous pseudo-aneurysm rupture of an extra-anatomical AxFB graft is rare, the disease may consequently lead to a fatal outcome once misdiagnosed, and prompt intervention is warranted. Therefore, we should always consider the differential diagnosis of this disease in patients with a bulging chest wall and history of AxFB graft placement.

The In Vivo Radiosensitizing Effect of Magnolol on Tumor Growth of Hepatocellular Carcinoma.

BACKGROUND/AIM: Radiation (RT) induced ERK/NF-κB in hepatocellular carcinoma (HCC) has been reported in our previous works; it weakens the toxicity of RT or triggers a radioresistance effect. Thus, combining RT with a suitable NF-κB inhibitor may sensitize HCC to RT. Magnolol, a bioactive compound, was known to have anti-inflammatory and anti-tumor functions. Here, we aimed to investigate whether magnolol may enhance anti-HCC efficacy of RT in vivo. MATERIALS AND METHODS: We established a Hep3B bearing mouse to evaluate the efficacy of the combination treatment of magnolol and RT. RESULTS: Most significantly, tumor volume and tumor weight inhibition was found in the combination group. Tumor immunohistochemistry staining also illustrated the suppression of RT-induced ERK/NF-κB-related proteins expression by magnolol. In addition, intrinsic apoptosis-related proteins, such as caspase-3 and -9, were markedly increased in the combination group. CONCLUSION: Magnolol may effectively enhance anti-HCC ability of RT by downregulating the expression of ERK/NF-κB-related proteins and increasing the expression of apoptosis-related proteins.

Depressed sympathovagal modulation indicates sepsis in patients with suspected infection.

This study explored whether sympathovagal modulation assessed through frequency domains of heart rate variability (HRV) can indicate sepsis in patients with suspected infection.In total, 370 consecutive adult patients with suspected infection admitted to the emergency department were enrolled in this single-center cohort study. A continuous 10-minute electrocardiography for HRV analysis was recorded immediately for these patients after inclusion. Patients were stratified into non-sepsis and sepsis groups based on a sepsis-related organ failure assessment score of ≥2 that met the Third International Consensus Definitions for Sepsis. Seven frequency domains of HRV were compared between these 2 groups.Compared with the non-sepsis group (n = 98), the sepsis group (n = 272) had a significantly lower incidence of respiratory tract infection, higher total power, higher very-low-frequency component, higher high-frequency (HF) component, higher normalized HF component, lower normalized low-frequency (LF) component, and lower LF component/HF component ratio (LF/HF). Multiple logistic regression model identified HF component (odds ratio [OR] = 0.994; 95% confidence interval [CI], 0.990-0.999) and LF/HF (OR = 0.494; 95% CI, 0.423-0.578) as significant variables associated with sepsis. The area under receiver operating characteristic curves of HF component and LF/HF was 0.741 (95% CI, 0.685-0.797) and 0.930 (95% CI, 0.900-0.960), respectively, in identifying sepsis in patients with suspected infection.Tilted sympathovagal balance toward increased vagal activity and depressed sympathetic modulation, assessed by the HF component and LF/HF, may indicate sepsis in patients with suspected infection.

Quick-SOFA score ≥ 2 predicts prolonged hospital stay in geriatric patients with influenza infection.

PURPOSE: The quick Sepsis-Related Organ Failure Assessment (qSOFA) score was designed to predict mortality among sepsis patients. However, it has never been used to identify prolonged length of hospital stay (pLOS) in geriatric patients with influenza infection. We conducted this study to clarify this issue. METHODS: We conducted a retrospective case-control study, including geriatric patients (aged ≥ 65 years) with influenza infection visiting the emergency department (ED) of a medical center between January 01, 2010 and December 31, 2015. The included patients were divided into two groups on the basis of their qSOFA score: qSOFA < 2, and qSOFA ≥ 2. Data regarding demographics, vital signs, qSOFA score, underlying diseases, subtypes of influenza, and outcomes were included in the analysis. We investigated the association between qSOFA score ≥ 2 and pLOS (>9 days) via logistic regression. RESULTS: Four hundred and nine geriatric patients were included in this study with a mean age of 79.5 (standard deviation [SD], 8.3) years. The median length of stay (LOS) was 7.0 (interquartile range [IQR], 4-12) days, while the rate of pLOS (> 9 days) was 32%. The median LOS in the qSOFA ≥ 2 group, 11.0 (7-15) days, was longer than the qSOFA < 2 group, 6.0 (4-10) days (p-value <0.01). Logistic regression showed that qSOFA ≥ 2 predicts pLOS with an odds ratio of 3.78 (95% confidence interval, 2.04-6.97). CONCLUSION: qSOFA score ≥ 2 is a prompt and simple tool to predict pLOS in geriatric patients with influenza infection.

Utilization of systemic inflammatory response syndrome criteria in predicting mortality among geriatric patients with influenza in the emergency department.

BACKGROUND: Systemic Inflammatory Response Syndrome (SIRS) criteria are often used to evaluate the risk of sepsis and to identify in-hospital mortality among patients with suspected infection. However, utilization of the SIRS criteria in mortality prediction among geriatric patients with influenza in the emergency department (ED) remains unclear. Therefore, we conducted a research to delineate this issue. METHODS: This is a retrospective case-control study including geriatric patients (age ≥ 65 years) with influenza, who presented to the ED of a medical center between January 1, 2010 and December 31, 2015. Vital signs, past history, subtype of influenza, demographic data, and outcomes were collected from all patients and analyzed. We calculated the accuracy for predicting 30-days mortality using the SIRS criteria. We also performed covariate adjustment of the area under the receiver operating characteristic curve (AUROC) via regression modeling. RESULTS: We recruited a total of 409 geriatric patients in the ED, with mean age 79.5 years and an equal sex ratio. The mean SIRS criteria score was 1.9 ± 1.1. The result of a Hosmer-Lemeshow goodness-of-fit test was 0.34 for SIRS criteria. SIRS criteria score ≥ 3 showed better mortality prediction, with odds ratio (OR) 3.37 (95% confidence interval (CI), 1.05-10.73); SIRS score ≥ 2 showed no statistical significance, with p = 0.85 (OR, 1.15; 95% CI, 0.28-4.69). SIRS score ≥ 3 had acceptable 30-days mortality discrimination, with AUROC 0.77 (95% CI, 0.68-0.87) after adjustment. SIRS score ≥ 3 also had a notable negative predictive value of 0.97 (95% CI, 0.94-0.99). CONCLUSION: The presence of a higher number of SIRS criteria (≥ 3) showed greater accuracy for predicting mortality among geriatric patients with influenza.

Quick-SOFA score to predict mortality among geriatric patients with influenza in the emergency department.

The quick sequential organ failure assessment (qSOFA) score is widely used to assess the risk of sepsis and predict in-hospital mortality in patients with suspected infection. However, its ability to predict mortality among geriatric patients with influenza in the emergency department (ED) remains unclear. Therefore, this study was conducted to delineate this issue.A retrospective case-control study was conducted on geriatric patients (age ≥65 years) with influenza who visited the ED of a medical center between January 01, 2010, and December 31, 2015. Demographic data, vital signs, past histories, influenza subtypes, and treatment outcomes were included in the analysis. We assessed the accuracy of the qSOFA score in predicting 30-day mortality via logistic regression. Covariate adjustment of the area under the receiver operating characteristic curve (AUROC) via regression modeling was performed too.In total, 409 geriatric ED patients with mean age of 79.5 years and nearly equal sex ratio were recruited. The mean qSOFA score was 0.55 ±â€Š0.7. The Hosmer-Lemeshow goodness-of-fit test was 0.79 for qSOFA score. Patients with qSOFA score of ≥2 (odds ratio, 4.21; 95% confidence interval [CI], 1.56-11.40) had increased in-hospital mortality. qSOFA score of ≥2 also had excellent in-hospital mortality discrimination with an adjusted AUROC of 0.81 (95% CI, 0.71-0.90). A qSOFA of ≥2 had prominent specificity of 0.89 (95% CI, 0.86-0.92).An increase in qSOFA score of 2 greatly predicts mortality in geriatric patients with influenza.

Shock index predicted mortality in geriatric patients with influenza in the emergency department.

BACKGROUND: The shock index is a rapid and simple tool used to predict mortality in patients with acute illnesses including sepsis, multiple trauma, and postpartum hemorrhage. However, its ability to predict mortality in geriatric patients with influenza in the emergency department (ED) remains unclear. This study was conducted to clarify this issue. METHODS: We conducted a retrospective case-control study, recruiting geriatric patients (≥ 65 years) with influenza visiting the ED of a medical center between January 01, 2010 and December 31, 2015. Demographic data, vital signs, shock index, past histories, subtypes of influenza, and outcomes were included for the analysis. We investigated the association between shock index ≥1 and 30-day mortality. RESULTS: In total, 409 geriatric ED patients with mean age of 79.5 years and nearly equal sex ratio were recruited. The mean shock index ±â€¯standard deviation was 0.7 ±â€¯0.22 and shock index ≥1 was accounted for in 7.1% of the total patients. Logistic regression showed that shock index ≥1 predicted mortality (odds ratio: 6.80; 95% confidence interval: 2.39-19.39). The area under the receiver operating characteristic was 0.62 and the result of the Hosmer-Lemeshow goodness-of-fit test was 0.23. The sensitivity, specificity, positive predictive value, and negative predictive value of a shock index ≥1 were 30.0%, 94.1%, 20.0%, and 96.4%. CONCLUSIONS: A shock index ≥1 has a high specificity, negative predictive value, and good reliability to predict 30-day mortality in geriatric ED patients with influenza.

Magnolol Induces Apoptosis and Inhibits ERK-modulated Metastatic Potential in Hepatocellular Carcinoma Cells.

BACKGROUND/AIM: The aim of the present study was to evaluate the anti-cancer effect of magnolol in hepatocellular carcinoma (HCC) cells in vitro. MATERIALS AND METHODS: HCC SK-Hep1 cells were treated with different concentrations of magnolol or PD98059 [extracellular-signal-regulated kinase (ERK) inhibitor] for 48 h, and then cell viability, apoptosis, signal transduction, expression of anti-apoptotic and metastasis-related proteins, and cell invasion were investigated by [3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] (MTT) assay, flow cytometry, nuclear factor kappa B (NF-ĸB) reporter gene, western blotting, and cell invasion assays. RESULTS: Magnolol significantly induced accumulation of sub-G1 phase and caspase-3 activation and inhibited NF-ĸB activation, cell invasion, expression of phosphorylated ERK (pERK), anti-apoptotic and metastatic-related proteins. ERK inactivation was required for magnolol-induced inhibition of metastatic potential of SK-Hep1 cells. CONCLUSION: Taken together, these results indicated that magnolol not only induced apoptosis, but also inhibited ERK-modulated metastatic potential of HCC SK-Hep1 cells.