Developing a Simple Score for Diagnosis of Acute Cholecystitis at the Emergency Department.

We aim to develop a diagnostic score for acute cholecystitis that integrates symptoms, physical examinations, and laboratory data to help clinicians for timely detection and early treatment of this disease. We retrospectively collected data from our database from 2010 to 2020. Patients with acute abdominal pain who underwent an ultrasound or computed tomography (CT) scan at the emergency department (ED) were included. Cases were identified by pathological, CT, or ultrasound reports. Non-cases were those who did not fulfill any of these criteria. Multivariable regression analysis was conducted to identify predictors of acute cholecystitis. The model included 244 patients suspected of acute cholecystitis. Eighty-six patients (35.2%) were acute cholecystitis confirmed cases. Five final predictors remained within the reduced logistic model: age < 60, nausea and/or vomiting, right upper quadrant pain, positive Murphy's sign, and AST ≥ two times upper limit of normal. A practical score diagnostic performance was AuROC 0.74 (95% CI, 0.67−0.81). Patients were categorized with a high probability of acute cholecystitis at score points of 9−12 with a positive likelihood ratio of 3.79 (95% CI, 1.68−8.94). ED Chole Score from these five predictors may aid in diagnosing acute cholecystitis at ED. Patients with an ED Chole Score >8 should be further investigated.

Optimal Landmark for Chest Compressions during Cardiopulmonary Resuscitation Derived from a Chest Computed Tomography in Arms-Down Position.

Compressions at the left ventricle increase rate of return of spontaneous circulation. This study aimed to identify the landmark of the point of maximal left ventricular diameter on the sternum (LVmax) by using chest computed tomography (CCT) in the arms-down position, which was similar to an actual cardiac arrest patient. A retrospective study was conducted between September 2014 and November 2020. We included adult patients who underwent CCT in an arms-down position and measured the rescuer's hand. We measured the distance from the sternal notch to LVmax (DLVmax), to the lower half of sternum (DLH), and to the point of maximal force of hand, which placed the lowest palmar margin of the rescuer's reference hand at the xiphisternal junction. Thirty-nine patients were included. The LVmax was located below the lower half of the sternum; DLVmax and DLH were 12.6 and 10.0 cm, respectively (p < 0.001). Distance from the sternal notch to the point of maximal force of the left hand, with the ulnar border located at the xiphisternal junction, was close to DLVmax; 11.3 and 12.6 cm, respectively (p = 0.076). In conclusion, LVmax was located below the lower half of the sternum, which is recommended by current guidelines.

Comparing methods of adenosine administration in paroxysmal supraventricular tachycardia: a pilot randomized controlled trial.

BACKGROUND: Intravenous adenosine is the recommended treatment for paroxysmal supraventricular tachycardia (PSVT). There is no official recommended method of giving adenosine. We compared the success rates between a standard and alternative method of first dose intravenous adenosine in PSVT. METHODS: A pilot parallel randomized controlled study was conducted in the emergency department of a tertiary care hospital. Eligible patients were stable PSVT adult patients. We used block randomization and divided them into two groups, the standard method (double syringe technique of 6 mg of adenosine), and the alternative method (similar to the standard method, then immediately followed by elevating the arm to 90° perpendicular to a horizontal plane for 10 s). The primary outcome was the success rate of electrocardiogram (ECG) response which demonstrated termination of PSVT (at least two-fold of the RR-interval widening or sinus rhythm conversion). Secondary outcomes were complications within one minute after the injection. RESULTS: We allocated 15 patients in each group and analyzed them as intention-to-treat. The success rate was 86.7% in the alternative group and 80% in the standard group (risk difference 6.7%, 95% confidence interval - 19.9 to 33.2%, P 1.00). Complications within one minute after adenosine injection were also similar in both groups, 14 of 15 patients (93%) in each group had no complications, without significant difference. CONCLUSIONS: No evidence of the difference between alternative and standard methods occurred, in terms of the success rate of ECG response and complications within one minute after adenosine injection. The standard method of adenosine injection is a safe, easy-to-administer, and widely available treatment for PSVT. TRIAL REGISTRATION: TCTR20200609001.

The Treatment of Unidentified Hematotoxic Snake Envenomation and the Clinical Manifestations of a Protobothrops kelomohy Bite.

Hematotoxic snake envenomation is clinically important and has serious complications. This case report describes the clinical manifestations of a bite from a newly described species of hematotoxic snake and the outcomes of treatment using locally available antivenom and supportive management. A 39-y-old male was bitten on his right ankle by an unidentified snake. The patient developed coagulopathy, rhabdomyolysis, and clinical signs of compartment syndrome of his right leg within the first day. Eight doses (30 mL, or 3 vials per dose), or a total of 240 mL, of hemato-polyvalent antivenin (Thai Red Cross, Thailand) were given. Aggressive intravenous hydration and alkalinization of urine were performed, and a fasciotomy was performed for the treatment of suspected compartment syndrome. The patient's clinical symptoms and laboratory results indicated progressive improvement during the 5 d of hospitalization. The snake was later identified as Protobothrops kelomohy, a novel snake species with no clinical data available regarding its envenomation of humans. This case shows that P kelomohy envenomation can produce severe effects that occur both locally and systemically. The benefits of the use of polyvalent antivenom in this situation were unclear. However, with supportive treatment in conjunction with serial clinical and laboratory monitoring, the patient recovered, albeit after 7 d of hospitalization.

A comparison of scoring systems for predicting mortality and sepsis in the emergency department patients with a suspected infection.

OBJECTIVE: We aimed to compare the modified National Early Warning Score (mNEWS), quick Sequential Organ Failure Assessment (qSOFA) score, modified Systemic Inflammatory Response Syndrome (mSIRS) score, and modified Search Out Severity (mSOS) score in predicting mortality and sepsis among patients suspected of first observed infections in the emergency department. The modified scores were created by removing variables for simplicity. METHODS: This was a prospective cohort study that enrolled adult patients presenting at the emergency department with signs and symptoms suggesting infection. The mNEWS, qSOFA score, mSIRS score, and mSOS score were calculated using triage data. The SOFA score was a reference standard for sepsis diagnosis. All patients were monitored for up to 30 days after the initial visit to measure each scoring system's ability to predict 30-day mortality and sepsis. RESULTS: There were 260 patients included in the study. The 30-day mortality prediction with mNEWS ≥5 had the highest sensitivity (91.18%). The highest area under the receiver operating characteristic curve (AUC) for the 30-day mortality prediction was mNEWS (0.607), followed by qSOFA (0.605), mSOS (0.550), and mSIRS (0.423). The sepsis prediction with mNEWS ≥5 had the highest sensitivity (96.48%). The highest AUC for the sepsis prediction was also mNEWS (0.685), followed by qSOFA (0.605), mSOS (0.480), and mSIRS (0.477). CONCLUSION: mNEWS was an acceptable scoring system screening tool for predicting mortality and sepsis in patients with a suspected infection.

High central venous oxygen saturation is associated with mitochondrial dysfunction in septic shock: A prospective observational study.

To test the hypothesis that an impaired mitochondrial function is associated with altered central venous oxygen saturation (ScvO2 ), venous-to-arterial carbon dioxide tension difference (delta PCO2 ) or serum lactate in sepsis patients. This prospective cohort study was conducted in a single tertiary emergency department between April 2017 and March 2019. Patients with suspected sepsis were included in the study. Serum lactate was obtained in sepsis, ScvO2 and delta PCO2 were evaluated in septic shock patients. Mitochondrial function was determined from the peripheral blood mononuclear cells. Forty-six patients with suspected sepsis were included. Of these, twenty patients were septic shock. Mitochondrial oxidative stress levels were increased in the high ScvO2 group (ScvO2  > 80%, n = 6), compared with the normal (70%-80%, n = 9) and low ScvO2 (<70%, n = 5) groups. A strong linear relationship was observed between the mitochondrial oxidative stress and ScvO2 (r = .75; P = .01). However, mitochondrial respiration was increased in the low ScvO2 group. In addition, mitochondrial complex II protein levels were significantly decreased in the high ScvO2 group (P < .05). Additionally, there was no correlation between serum lactate, delta PCO2 , and mitochondria oxidative stress or mitochondria function. ScvO2 can be potentially useful for developing new therapeutics to reduce mitochondrial dysfunction in septic shock patient.

Management of patients with severe hypertension in emergency department, Maharaj Nakorn Chiang Mai hospital.

BACKGROUND: Management of patients with severe hypertension without progressive target organ damage remains controversial. Some guidelines mentioned oral anti-hypertensive medication as a treatment to reduce blood pressure in the emergency department, while others recommended against such treatment. OBJECTIVE: To review the management ofpatients with severe hypertension without progressive target organ damage in the emergency department, Maharaj Nakorn Chiang Mai hospital. MATERIAL AND METHOD: In a retrospective descriptive analysis study, medical records ofadult patients diagnosed with severe hypertension without progressive target organ damage between January 2011 and December 2012 were reviewed. Patient demographics, data on management including investigation sent and treatment given were collected. Statistical analysis was done by using descriptive statistics and Kruskal-Wallis one-way analysis of variance test. RESULTS: One hundred fifty one medical records were reviewed. Four oral anti-hypertensive medication were used to reduce blood pressure, Amlodipine, Captopril, Hydralazine, and Nifedipine. There were no significant diference between each medication in terms of their effect on bloodpressure reduction (p = 0.513). No side effect or other complications from the use of oral anti-hypertensive medication were recorded CONCLUSION: The choice of medication used for the treatment of hypertensive urgency ranged from Amlodipine, Captopril, Hydralazine, and Nifedipine, which varied in dosage. However their efficacies were the same when compared with each other and none produced any notable side effects.

Urban environments and obesity in southeast Asia: a systematic review, meta-analysis and meta-regression.

Many environmental factors contribute to the rise in prevalence of obesity in populations but one key driver is urbanization. Countries in Southeast (SE) Asia have undergone rapid changes in urbanization in recent decades. The aim of this study is to provide a systematic review of studies exploring the relationship between living in an urban or rural environment (urbanicity) and obesity in Southeast Asia. In particular, the review will investigate whether the associations are uniform across countries and ages, and by sex. The literature search was conducted up to June 2014 using five databases: EMBASE, PubMed, GlobalHealth, DigitalJournal and Open Grey. Forty-five articles representing eight of the eleven countries in SE Asia were included in the review. The review found a consistent positive association between urbanicity and obesity in countries of Southeast Asia, in all age groups and both genders. Regional differences between the associations are partly explained by gross national income (GNI). In countries with lower GNI per capita, the association between urbanicity and obesity was greater. Such findings have implications for policy makers. They imply that population level interventions need to be country or region specific, tailored to suit the current stage of economic development. In addition, less developed countries might be more vulnerable to the negative health impact of urbanization than more developed countries.

Usefulness of syncope guidelines in risk stratification of syncope in emergency department.

BACKGROUND: Management of patients with syncope in the Emergency Department now focuses on identifying patients who will be at future risk of serious morbidity. Among the risk stratification scoring systems being used were the San Francisco Syncope Rule (SFSR) and Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score. OBJECTIVE: To assess the accuracy of SFSR and OESIL score at predicting short-term serious outcome in Maharaj Nakorn Chiang Mai Hospital. MATERIAL AND METHOD: In a prospective descriptive analysis study, adult patients presenting with syncope or near syncope between October 1, 2009 and April 24, 2010 were enrolled. All patients were followed-up at 7-day and 1-month. Statistical analysis included accuracy, sensitivity, specificity, predictive values, and likelihood ratios. RESULTS: One hundred seventy eight patients were enrolled in the present study. Fifty-three patients had a short-term serious outcome on follow-up. SFSR had 74.7% accuracy, 90.6% sensitivity, 68% specificity, 54.5% PPV 94.4% NPV likelihood ratio positive (LR+) of 2.8, and likelihood ratio negative (LR-) of 0.1, whereas OESIL score had 80.9% accuracy, 79.4% sensitivity, 81.6% specificity, 64.6% PPV 90.3% NPV, LR+ of 4.3, and LR- of 0.2. CONCLUSION: Both scores have good accuracy and sensitivity, but they should not be used as the only device in patient disposition. However, both scores showed a low false negative rate. Therefore, they may help in helping physician discharge low-risk patients.

ECG leads I and II to evaluate diuresis of patients with congestive heart failure admitted to the hospital via the emergency department.

BACKGROUND: Attenuation of electrocardiogram (ECG) QRS complexes is observed in patients with a variety of illnesses and peripheral edema (PERED), and augmentation with alleviation of PERED. Serial ECGs in stable individuals display variation in the amplitude of QRS complexes in leads V1-V6, stemming from careless placement of recording electrodes on the chestwall. Electrocardiographs record only leads I and II, and mathematically derive the other four limb leads in real time. This study evaluated the sum of the amplitudes of ECG leads I and II, along with other sets of ECG leads in the monitoring of diuresis in patients with congestive heart failure (CHF). METHODS: Twenty patients with CHF had ECGs and weights recorded on admission and at discharge. The amplitude of the QRS complexes in all ECG leads were measured and sums of I and II, all limb leads, V1-V6, and all 12 leads were calculated. RESULTS: There was a good correlation between the weight loss and the increase in the sums of the amplitudes of the QRS complexes from leads I and II (r = 0.55, P = 0.012), and the six limb leads (r = 0.68, P = 0.001), but a poor correlation with the V1-V6 leads (r = 0.04, P = 0.85) and all 12 leads (r = 0.1, P = 0.40). CONCLUSIONS: Sums of the amplitudes of the ECG QRS complexes from leads I and II constitute a reliable, easily obtainable, ubiquitously available, bedside clinical index, which can be employed in the diagnosis, monitoring of management, and follow-up of patients with CHF.