Prehospital Shock Index Multiplied by the Alert/Verbal/Painful/Unresponsive Score as a Predictor of Clinical Outcomes in Traumatic Injury.

OBJECTIVE: Various prediction scores have been developed to predict mortality in trauma patients, such as the shock index (SI), modified SI (mSI), age-adjusted SI (aSI), and the shock index (SI) multiplied by the alert/verbal/painful/unresponsive (AVPU) score (SIAVPU). The SIAVPU is a novel scoring system but its prediction accuracy for trauma outcomes remains in need of further validation. Therefore, we investigated the accuracy of four scoring systems, including SI, mSI, aSI, and SIAVPU, in predicting mortality, admission to the intensive care unit (ICU), and prolonged hospital length of stay ≥ 30 days (LOS). METHODS: This retrospective multicenter study used data from the Tzu Chi Hospital trauma database. The area under the receiver operating characteristic curve (AUROC) was determined for each outcome to assess their discrimination capabilities and comparing by Delong's test. Subgroup analyses were conducted to investigate the prediction accuracy of the SIAVPU in different patient populations. RESULTS: In total, 5355 patients were included in the analysis. The median of SIAVPU were significantly higher among patients at those with major injury (1.47 vs 0.63), those admitted to the ICU (0.73 vs 0.62), those with prolonged hospital LOS≥ 30 days (0.83 vs 0.64), and those with mortality (1.08 vs 0.64). The AUROC of the SIAVPU was significantly higher than that of the SI, mSI, and aSI for 24-h mortality (AUROC: 0.845 vs 0.533, 0.540, and 0.678), 3-day mortality (AUROC: 0.803 vs 0.513, 0.524, and 0.688), 7-day mortality (AUROC: 0.755 vs 0.494, 0.505, and 0.648), in-hospital mortality (AUROC: 0.722 vs 0.510, 0.524, and 0.667), ICU admission (AUROC: 0.635 vs 0.547, 0.551, and 0.563). At the optimal cutoff value of 0.9, the SIAVPU had an accuracy of 82.2% for predicting 24-h mortality, 82.8% for predicting 3-day mortality, of 82.8% for predicting 7-day mortality, of 82.5% for predicting in-hospital mortality, of 73.9% for predicting Intensive Care Unit (ICU) admission, and of 81.7% for predicting prolonged hospital LOS ≥30 days. CONCLUSIONS: Our results reveal that SIAVPU has better accuracy than the SI, mSI, and aSI for predicting 24-h, 3-day, 7-day, and in-hospital mortality; ICU admission; and prolonged hospital LOS ≥30 days among patients with traumatic injury.

Reverse shock index multiplied by simplified motor score as a predictor of clinical outcomes for patients with COVID-19.

BACKGROUND: The reverse shock index (rSI) combined with the Simplified Motor Score (sMS), that is, the rSI-sMS, is a novel and efficient prehospital triage scoring system for patients with COVID-19. In this study, we evaluated the predictive accuracy of the rSI-sMS for general ward and intensive care unit (ICU) admission among patients with COVID-19 and compared it with that of other measures, including the shock index (SI), modified SI (mSI), rSI combined with the Glasgow Coma Scale (rSI-GCS), and rSI combined with the GCS motor subscale (rSI-GCSM). METHODS: All patients who visited the emergency department of Taipei Tzu Chi Hospital between January 2021 and June 2022 were included in this retrospective cohort. A diagnosis of COVID-19 was confirmed through a SARS-CoV-2 reverse-transcription polymerase chain reaction test or SARS-CoV-2 rapid test with oropharyngeal or nasopharyngeal swabs and was double confirmed by checking International Classification of Diseases, Tenth Revision, Clinical Modification codes in electronic medical records. In-hospital mortality was regarded as the primary outcome, and sepsis, general ward or ICU admission, endotracheal intubation, and total hospital length of stay (LOS) were regarded as secondary outcomes. Multivariate logistic regression was used to determine the relationship between the scoring systems and the three major outcomes of patients with COVID-19, including. The discriminant ability of the predictive scoring systems was investigated using the area under the receiver operating characteristic curve, and the most favorable cutoff value of the rSI-sMS for each major outcome was determined using Youden's index. RESULTS: After 74,183 patients younger than 20 years (n = 11,572) and without COVID-19 (n = 62,611) were excluded, 9,282 patients with COVID-19 (median age: 45 years, interquartile range: 33-60 years, 46.1% men) were identified as eligible for inclusion in the study. The rate of in-hospital mortality was determined to be 0.75%. The rSI-sMS scores were significantly lower in the patient groups with sepsis, hyperlactatemia, admission to a general ward, admission to the ICU, total length of stay ≥ 14 days, and mortality. Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS exhibited a significantly higher accuracy for predicting general ward admission, ICU admission, and mortality but a similar accuracy to that of the rSI-GCS. The optimal cutoff values of the rSI-sMS for predicting general ward admission, ICU admission, and mortality were calculated to be 3.17, 3.45, and 3.15, respectively, with a predictive accuracy of 86.83%, 81.94%%, and 90.96%, respectively. CONCLUSIONS: Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS has a higher predictive accuracy for general ward admission, ICU admission, and mortality among patients with COVID-19.

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.

Use of Reverse Shock Index Multiplied by Simplified Motor Score in a Five-Level Triage System: Identifying Trauma in Adult Patients at a High Risk of Mortality.

Background and Objectives: The Taiwan Triage and Acuity Scale (TTAS) is reliable for triaging patients in emergency departments in Taiwan; however, most triage decisions are still based on chief complaints. The reverse-shock index (SI) multiplied by the simplified motor score (rSI-sMS) is a more comprehensive approach to triage that combines the SI and a modified consciousness assessment. We investigated the combination of the TTAS and rSI-sMS for triage compared with either parameter alone as well as the SI and modified SI. Materials and Methods: We analyzed 13,144 patients with trauma from the Taipei Tzu Chi Trauma Database. We investigated the prioritization performance of the TTAS, rSI-sMS, and their combination. A subgroup analysis was performed to evaluate the trends in all clinical outcomes for different rSI-sMS values. The sensitivity and specificity of rSI-sMS were investigated at a cutoff value of 4 (based on previous study and the highest score of the Youden Index) in predicting injury severity clinical outcomes under the TTAS system were also investigated. Results: Compared with patients in triage level III, those in triage levels I and II had higher odds ratios for major injury (as indicated by revised trauma score < 7 and injury severity score [ISS] ≥ 16), intensive care unit (ICU) admission, prolonged ICU stay (≥14 days), prolonged hospital stay (≥30 days), and mortality. In all three triage levels, the rSI-sMS < 4 group had severe injury and worse outcomes than the rSI-sMS ≥ 4 group. The TTAS and rSI-sMS had higher area under the receiver operating characteristic curves (AUROCs) for mortality, ICU admission, prolonged ICU stay, and prolonged hospital stay than the SI and modified SI. The combination of the TTAS and rSI-sMS had the highest AUROC for all clinical outcomes. The prediction performance of rSI-sMS < 4 for major injury (ISS ≥ 16) exhibited 81.49% specificity in triage levels I and II and 87.6% specificity in triage level III. The specificity for mortality was 79.2% in triage levels I and II and 87.4% in triage level III. Conclusions: The combination of rSI-sMS and the TTAS yielded superior prioritization performance to TTAS alone. The integration of rSI-sMS and TTAS effectively enhances the efficiency and accuracy of identifying trauma patients at a high risk of mortality.

Association between Time to Emergent Surgery and Outcomes in Trauma Patients: A 10-Year Multicenter Study.

Background: Research on the impact of reduced time to emergent surgery in trauma patients has yielded inconsistent results. Therefore, this study investigated the relationship between waiting emergent surgery time (WEST) and outcomes in trauma patients. Methods: This retrospective, multicenter study used data from the Tzu Chi Hospital trauma database. The primary clinical outcomes were in-hospital mortality, intensive care unit (ICU) admission, and prolonged hospital length of stay (LOS) of ≥30 days. Results: A total of 15,164 patients were analyzed. The median WEST was 444 min, with an interquartile range (IQR) of 248-848 min for all patients. Patients who died in the hospital had a shorter median WEST than did those who survived (240 vs. 446 min, p < 0.001). Among the trauma patients with a WEST of <2 h, the median time was 79 min (IQR = 50-100 min). No significant difference in WEST was observed between the survival and mortality groups for patients with a WEST of <120 min (median WEST: 85 vs. 78 min, p < 0.001). Multivariable logistic regression analysis revealed that WEST was not associated with an increased risk of in-hospital mortality (adjusted odds ratio [aOR] = 1.05, 95% confidence interval [CI] = 0.17-6.35 for 30 min ≤ WEST < 60 min; aOR = 1.12, 95% CI = 0.22-5.70 for 60 min ≤ WEST < 90 min; and aOR = 0.60, 95% CI = 0.13-2.74 for WEST ≥ 90 min). Conclusions: Our findings do not support the "golden hour" concept because no association was identified between the time to definitive care and in-hospital mortality, ICU admission, and prolonged hospital stay of ≥30 days.

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.

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.

Performance of Six Clinical Physiological Scoring Systems in Predicting In-Hospital Mortality in Elderly and Very Elderly Patients with Acute Upper Gastrointestinal Bleeding in Emergency Department.

Background and Objectives: The aim of this study is to compare the performance of six clinical physiological-based scores, including the pre-endoscopy Rockall score, shock index (SI), age shock index (age SI), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS), in predicting in-hospital mortality in elderly and very elderly patients in the emergency department (ED) with acute upper gastrointestinal bleeding (AUGIB). Materials and Methods: Patients older than 65 years who visited the ED with a clinical diagnosis of AUGIB were enrolled prospectively from July 2016 to July 2021. The six scores were calculated and compared with in-hospital mortality. Results: A total of 336 patients were recruited, of whom 40 died. There is a significant difference between the patients in the mortality group and survival group in terms of the six scoring systems. MEWS had the highest area under the curve (AUC) value (0.82). A subgroup analysis was performed for a total of 180 very elderly patients (i.e., older than 75 years), of whom 27 died. MEWS also had the best predictive performance in this subgroup (AUC, 0.82). Conclusions: This simple, rapid, and obtainable-by-the-bed parameter could assist emergency physicians in risk stratification and decision making for this vulnerable group.

Temporal Trends in the Microbiological Characteristics of Sepsis in the United States: A Population Based Study.

BACKGROUND: Epidemiologic studies are needed for monitoring population-level trends in sepsis. This study examines sepsis-causing microorganisms from 2006 to 2014 in the United States using data from the Nationwide Inpatient Sample database. METHODS: 7 860 686 adults hospitalized with sepsis were identified using a validated ICD-9 coding approach. Associated microorganisms were identified by ICD-9 code and classified by major groups (Gram-positive, Gram-negative, fungi, anaerobes) and specific species for analysis of their incidence and mortality. RESULTS: The rate of sepsis incidence has increased for all four major categories of pathogens, while the mortality rate decreased. In 2014, Gram-negative pathogens had a higher incidence than Gram-positives. Anaerobes increased the fastest with an average annual increase of 20.17% (p < 0.001). Fungi had the highest mortality (19.28%) and the slowest annual decrease of mortality (-2.31%, p = 0.006) in 2013, while anaerobic sepsis had the highest hazard of mortality (adjusted HR 1.60, 95% CI 1.53-1.66). CONCLUSIONS: Gram-negative pathogens have replaced Gram-positives as the leading cause of sepsis in the United States in 2014 during the study period (2006-2014). The incidence of anaerobic sepsis has an annual increase of 20%, while the mortality of fungal sepsis has not decreased at the same rate as other microorganisms. These findings should inform the diagnosis and management of septic patients, as well as the implementation of public health programs.

A Case of Psoas Muscle Abscess With Hematuria, Detected Initially by Point-of-Care Ultrasound in the Emergency Department.

BACKGROUND: Psoas muscle abscess (PMA) is a collection of pus in the psoas muscle. It is considered a rare clinical entity and is often misdiagnosed due to highly vague symptoms. We report that point-of-care ultrasound (POCUS) serves as a useful and noninvasive tool for early detection of PMA. CASE REPORT: Our patient was a 35-year-old man without any past medical illness who visited the emergency department due to right lower back pain and hematuria for 8 months. He denied fever, trauma, or recreational drug use. On arrival, the patient's vital signs were stable and had no fever. Laboratory tests showed white blood cell count 12,800/µL with neutrophil segment 83.2%, C-reactive protein 0.2 mg/dL, and normal renal function. Urine routine showed red blood cells > 100/high-power field. Kidney-ureter-bladder radiograph revealed a positive psoas sign on the right. POCUS showed a mixed echogenic mass adjacent to the right kidney. Subsequently, contrast abdominal computed tomography revealed T10-T11 collapsed vertebral bodies with disc erosion and right psoas muscle abscess at the right kidney level. The patient received open drainage of psoas muscle abscess and T11-T12 laminectomy. He was discharged 13 days post admission. Why ShouldanEmergency PhysicianBe Aware of This? Early and accurate diagnosis of PMA is important because, if left untreated, mortality rate can reach 100%. A potential pitfall in our case is the presence of hematuria with flank pain that could lead to incorrect diagnosis of renal calculi, a much more common condition. This case illustrates the importance of using POCUS in any patient with back or flank pain, with or without hematuria.

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.

Validation of shock index for predicting mortality in older patients with dengue fever.

BACKGROUND: Older adults have a higher mortality for dengue fever (DF). However, the best method for predicting mortality is still unclear. AIMS: We conducted this study to evaluate the shock index (SI) for this issue. METHODS: A retrospective case-control study was conducted by recruiting older patients (≥ 65 years old) with DF who visited the study hospital in southern Taiwan during the 2015 DF outbreak. Demographic data, vital signs, past histories, decision groups, complications, and mortality were included in the analyses. We evaluated the accuracy of SI ≥ 1 for predicting 30-day mortality in this population. RESULTS: A total of 626 patients with a mean age of 74.1 years and nearly equal sex distribution were recruited. The mean of SI (± standard deviation [SD]) was 0.6 (± 0.2) and patients with a SI ≥ 1 accounted for 3.5% of the total patients. Logistic regression showed that patients with SI ≥ 1 had a higher mortality than those with SI < 1 (odds ratio: 8.49; 95% confidence interval: 1.76-17.92). The area under the receiver-operating characteristic was 0.76, and the Hosmer-Lemeshow goodness of fit test was 0.48. The SI ≥ 1 had a sensitivity, specificity, positive predictive value, and negative predictive value of 14.8%, 97.0%, 18.2%, and 96.2% for predicting mortality. CONCLUSIONS: The SI ≥ 1 is an easy tool that can be potentially used to predict 30-day mortality in older DF patients, especially in DF outbreak. It has a high specificity and negative predictive value for excluding patients with high-risk mortality.

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.

A Case of Right Renal Arteriovenous Malformation Mimicking the Symptoms of Urinary Tract Infection in the Emergency Department.

BACKGROUND: Renal arteriovenous malformation (AVM) is a rare cause of massive hematuria, and patients with renal AVM may present with symptoms like urinary tract infections in the emergency department. CASE REPORT: A 37-year-old woman presented to the emergency department with symptoms of hematuria, urinary hesitancy, and severe suprapubic pain that had been present for a few hours. A urine examination revealed no pyuria, but urine occult blood for 3+ and a red blood cell count of >100 per high-power field. Bedside echocardiography revealed right kidney hydronephrosis and a distended bladder with a blood clot. A 3-way Foley catheter was inserted and drained 800 mL of bloody urine. A contrast-enhanced computed tomography scan was ordered that showed a 1.1-cm hypervascular tumor in the lower pole of right kidney, with active bleeding and rupture into the adjacent collecting system. Active renal tumor bleeding or renal AVM was suspected. The patient was transferred to a tertiary medical center where right renal artery angiography was arranged and disclosed an AVM with aneurysm formation at the right renal lower pole. Transarterial embolization was performed immediately to embolize the 3 feeders of the AVM. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Renal AVM is a rare but potentially life-threatening cause of massive hematuria. Delayed or missed diagnosis is possible because renal AVM may present with symptoms like urinary tract infection, especially in young females. Renal artery angiography is the diagnosis of choice, and emergent transarterial embolization is now the standard of treatment.

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.

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.

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.

Risk of diabetes mellitus in physicians: a nationwide study in Taiwan.

BACKGROUND: The heavy workload of physicians in Taiwan may contribute to poor lifestyles and increased risk for diabetes mellitus (DM). We conducted this study to determine the risk for DM among physicians in Taiwan. METHODS: We used the Taiwan National Health Insurance Research Database to identify 28,440 physicians and 56,880 comparisons (general population) matched at a ratio of 1:2 by age and sex. Participants who had been diagnosed with DM before 2007 were excluded. We compared the risk for DM between physicians and comparisons by following up since 2007 to 2013. Comparisons among physician subgroups were also performed. RESULTS: After adjustment for hypertension, hyperlipidemia, hyperuricemia, coronary artery disease, congestive heart failure, hyperthyroidism, hypothyroidism, and polycystic ovary syndrome, physicians had a lower risk for DM than the comparisons (adjusted odds ratio [AOR]: 0.75; 95% confidence interval [CI]: 0.68-0.82). In comparisons among physicians, emergency physicians (AOR: 2.21; 95% CI: 1.44-3.40) and surgeons (AOR: 1.26; 95% CI: 1.05-1.52) had a higher risk for DM than other specialists. CONCLUSIONS: This study found that physicians have a lower risk for DM than the general population and emergency physicians and surgeons have a higher risk for DM than other specialists. Thus, more attention should be paid to the occupational health of these doctors.

Association between acute methanol poisoning and subsequent mortality: a nationwide study in Taiwan.

BACKGROUND: Methanol poisoning (MP) often causes acute mortality and morbidities; however, the association between MP and subsequent mortality has not been well studied. METHODS: We conducted a nationwide population-based cohort study by identifying 621 participants with MP from the Nationwide Poisoning Database and 6210 participants without MP from the Longitudinal Health Insurance Database 2000 by matching the index date at a 1:10 ratio between 1999 and 2012. Comparison of the mortality rate between the two cohorts was performed by following up until 2013. RESULTS: A total of 249 (40%) participants with MP and 154 (2.5%) participants without MP died during the follow-up (p < 0.001). Statistic analysis showed that participants with MP had a higher risk for mortality than did the participants without MP (adjusted hazard ratio [AHR]: 13.48; 95% confidence interval [CI]: 10.76-16.88). The risk of mortality was highest in the first 6 months after MP (AHR: 480.34; 95% CI: 117.55-1962.75). Hypertension, chronic obstructive pulmonary disease, liver disease, malignancy, drug abuse, and lower monthly income also predicted mortality. CONCLUSIONS: MP was associated with increased subsequent mortality. Close follow-up for comorbidity control and socioeconomic assistance are suggested for patients with MP.