Can different physicians providing urgent and non-urgent treatment improve patient flow in emergency department?

BACKGROUND: Emergency Department (ED) overcrowding is a worldwide problem, and it might be caused by prolonged patient stay in the ED. This study tried to analyze if different practice models influence patient flow in the ED. MATERIALS AND METHODS: A retrospective, 1-year cohort study was conducted across two EDs in the largest healthcare system in Taiwan. A total of 37,580 adult non-trauma patients were involved in the study. The clinical practice between two ED practice models was compared. In one model, urgent and non-urgent patients were treated by different emergency physicians (EPs) separately (separated model). In the other, EPs treated all patients assigned randomly (merged model). The ED length of stay (LOS), diagnostic tool use (including laboratory examinations and computed tomography scans), and patient dispositions (including discharge, general ward admission, intensive care unit (ICU) admissions, and ED mortality) were selected as outcome indicators. RESULT: Patients discharged from ED had 0.4h shorter ED LOS in the separated model than in merged model. After adjusting for the potential confounding factors through regression model, there was no difference of patient disposition of the two practice models. However, the separated model showed a slight decrease in laboratory examination use (adjusted odds ratio, 0.9; 95% confidence interval, 0.83-0.96) compared with the merged model. CONCLUSION: The separated model had better patient flow than the merged model did. It decreased the ED LOS in ED discharge patients and laboratory examination use.

Early exposure to agricultural soil accelerates the maturation of the early-life pig gut microbiota.

Reduced microbial exposure in early childhood is postulated to be associated with subsequent immune deficiencies and associated health conditions. This corollary to the "hygiene hypothesis" has grown of popularity in the medical field, but can only be really tested with animal models. Based on previous observation that access to outdoor environment improves piglets' growth performance, we simulated early microbial exposure by providing pigs with topsoil during the lactation phase. Specifically, pigs from 20 litters were assigned to either control treatments (C) or soil treatments (S): pigs exposed to topsoil from day 4 postpartum to the end of lactation. At weaning, five unisex littermates of 10 sows from each treatment were penned together and grew up in the same conditions. Fecal samples were collected at on d 13 (Lactation: L), 21 (Weaning: WT), 35 (Mid-nursery, MNT), 56 (End of Nursery: EONT) and 96 (End of Growth: EGT) for 16s rRNA amplicon high-throughput sequencing. Overall, common trends of gut microbiota maturation, associated with diet switch from maternal milk to plant-based diet, were observed. Bacteroides, Clostridium XIVa and Enterobacteriaceae were most abundant during lactation, while Prevotella, Megasphaera and Blautia became abundant after weaning. Remarkably, exposure to soil resulted in a faster maturation of the piglets gut microbiota at weaning, while a completely distinct phase was observed at day 35 for control piglets. Soil-exposed piglets tened to harbor a more diverse gut microbiota at weaning and day35, however the more significant changes were at those time points in terms of composition. Prevotella, and a wide range of Firmicutes members were significantly enriched in soil-exposed piglets from the lactation to the end of nursery phase. It can be hypothesized that those taxa were either directly transmitted from the soil or stimulated by the presence of plant material in the soil. Those changes were accompanied by depletion in several potentially harmful taxa, as well as improved growth performance between weaning and the end of nursery phase. Our findings suggest that early exposure to soil strongly influences the maturation of the early-life piglets, probably allows for a better adaptation to the plant-based diet, and possibly improves overall health.

The characteristics and prognostic predictors of unplanned hospital admission within 72 hours after ED discharge.

OBJECTIVES: The aims of this study were (1) to identify the characteristics of patients who return to the emergency department (ED) within 72 hours and are admitted to the hospital and (2) to identify the characteristics and predictors of in-hospital mortality subgroup. METHODS: This study was conducted in a tertiary teaching hospital to identify characteristics of adult nontraumatic revisit-admission patients from January 1 to December 31, 2011. Demographic data, cause of revisit, and the underlying diseases as well as the in-hospital complications were reviewed. RESULTS: Of the 72188 ED discharged patients, 690 revisit-admission patients were enrolled. The top 3 disease classifications were infection (38.7%), neurology (11.3%), and gastroenterology (11.2%). The etiology of the revisit included recurrent symptoms (72%), disease complications (15.8%), and inadequate diagnosis (12.1%). A total of 150 patients (21.7%) had complications, including receiving operation (17.2%), intensive care unit admission (4.2%), and cardiovascular conditions (2.5%). Forty-nine patients (7.1%) died during hospitalization owing to sepsis (57.1%), malignancy (34.7%), cardiogenic diseases (4.1%), and cerebrovascular conditions (4.1%). The nonsurvival group was older (64.1 ± 15.3 vs 55.7 ± 17.8; P < .001), had more patients with a diagnosis of moderate to severe liver disease (18.4% vs 4.8%; P < .001), malignancy (69.3% vs 20.1%; P < .001), and metastatic solid tumor (38.8% vs 6.2%; P < .001). CONCLUSIONS: Age and diagnosis with malignancy, metastatic tumors, or moderate-to-severe liver disease were predictors of in-hospital mortality among 72-hour revisit-admission patients.

Plasma nuclear and mitochondrial DNA levels as predictors of outcome in severe sepsis patients in the emergency room.

BACKGROUND AND AIM: The sensitivity and specificity of biomarkers and scoring systems used for predicting fatality of severe sepsis patients remain unsatisfactory. This study aimed to determine the prognostic value of circulating plasma DNA levels in severe septic patients presenting at the Emergency Department (ED). METHODS: Sixty-seven consecutive patients with severe sepsis and 33 controls were evaluated. Plasma DNA levels were estimated by real-time quantitative polymerase chain reaction assay using primers for the human ß-hemoglobin and ND2 gene. The patients' clinical and laboratory data on admission were analyzed. RESULTS: The median plasma nuclear and mitochondria DNA levels for severe septic patients on admission were significantly higher than those of the controls. The mean plasma nuclear DNA level on admission correlated with lactate concentration (γ = 0.36, p = 0.003) and plasma mitochondrial DNA on admission (γ = 0.708, p < 0.001). Significant prognostic factors for fatality included mechanical ventilation within the first 24 hours (p = 0.013), mean sequential organ failure assessment (SOFA) score on admission (p = 0.04), serum lactate (p < 0.001), and both plasma nuclear and mitochondrial DNA on admission (p < 0.001). Plasma mitochondrial DNA was an independent predictor of fatality by stepwise logistic regression such that an increase by one ng/mL in level would increase fatality rate by 0.7%. CONCLUSION: Plasma DNA has potential use for predicting outcome in septic patients arriving at the emergency room. Plasma mitochondrial DNA level on admission is a more powerful predictor than lactate concentration or SOFA scores on admission.

The Impact of Do-Not-Resuscitate Order in the Emergency Department on Respiratory Failure after ICU Admission.

(1) Background: It has been hypothesized that a discrepancy exists in the understanding of a do-not-resuscitate (DNR) order among physicians. We hypothesized that a DNR order signed in the emergency department (ED) could influence the patients' prognosis after intensive care unit (ICU) admission. (2) Methods: We included patients older than 17 years, who visited the emergency department for non-traumatic disease, who had respiratory failure, required ventilator support, and were admitted to the ICU between January 2010 and December 2016. The associations between DNR and mortality, hospital length of stay (LOS), and medical fees were analyzed. Prolonged hospital LOS was defined as hospital stay ≥75th percentile (≥26 days for the study). Patients were classified as those who did and did not sign a DNR order. A 1:4 propensity score matching was conducted for demographics, comorbidities, and etiology. (3) Results: The study enrolled a total of 1510 patients who signed a DNR and 6040 patients who did not sign a DNR. The 30-day mortality rates were 47.4% and 28.0% among patients who did and did not sign a DNR, respectively. A DNR order was associated with mortality after adjusting for confounding factors (hazard ratio, 1.9; confidence interval, 1.70−2.03). It was also a risk factor for prolonged hospital LOS in survivors (odds ratio, 1.2; confidence interval, 1.02−1.44). Survivors who signed a DNR order were charged higher medical fees than those who did not sign a DNR (217,159 vs. 245,795 New Taiwan Dollars, p < 0.001). (4) Conclusions: Signing a DNR order in the ED increased the ICU mortality rate among patients who had respiratory failure and needed ventilator support. It increased the risk of prolonged hospital LOS among survivors. Finally, signing a DNR order was associated with high medical fees among survivors.

Effect of phytase on phosphorous balance in 20-kg barrows fed low or adequate phosphorous diets.

The effects of phytase on phosphorus (P) digestibility are well established. However, there are few studies that report P balance, particularly when phytase is used in diets that have adequate or deficient P. The main objective of the study was to determine the effect of dietary P levels and exogenous phytase on P balance in growing pigs. The first part of the experiment was a 14-d metabolism study conducted with 80 barrows (initial body weight 18.5 ± 0.5 kg) with a 2 × 5 factorial arrangement of treatments and main effects of available P (0.13% available P, low P [Low-P] diet; 0.35% available P, adequate P [Adeq-P] diet) and phytase (0, 250, 500, 2,500, and 12,500 U/kg). A portion of the pigs (n = 24) fed the Low-P diet, with 0, 500, 2,500, 12,500 U/kg phytase, and those fed the Adeq-P diet, with 0 and 12,500 U/kg phytase, remained on test diets for another 4 d, and tissues were collected for determination of bone characteristics and tissue P concentration. There was a P × phytase interaction for P retention that was accounted for by a lack of response to phytase in pigs fed the Adeq-P diet. Retention of P was greater with incremental levels of phytase in pigs fed Low-P diets as compared to those fed Adeq-P diets (P level × phytase, P < 0.01), but calcium (Ca) retention was greater in pigs fed Adeq-P diets (P level × phytase P < 0.01). Apparent total tract digestibility (ATTD) of P was improved by phytase (P < 0.001) and was greater in pigs fed Adeq-P diets as compared to those fed Low-P diets (P = 0.006). Metatarsal bone ash (quadratic, P = 0.01) and strength (linear, P = 0.03) was increased by phytase addition to the Low-P diets. There were no phytase or dietary P effects on P concentrations of the heart, kidney, liver, muscle, and spleen. These results suggest that as compared to the effects in an Adeq-P diet, adding phytase to a Low-P diet was more effective at reducing the P and Ca excretion and restoring average daily gain (ADG). The P released by phytase is absorbed and contributes to improved bone growth, greater rates of tissue accretion, and increased body weight, but does not change tissue P concentrations. There is, however, a threshold for P retention, beyond which it is excreted in the urine.

Liver Cirrhosis Predisposes One to Complicated Deep Neck Infection: Retrospective Analysis of 161 Cases.

INTRODUCTION: Without appropriate and prompt diagnosis and treatment, life-threatening complications may occur in patients with deep neck infection. Liver cirrhosis occurs more common in Asians and few studies mention if it predisposes to complicated deep neck infection. We aimed to identify predisposing factors of complications to reduce morbidity and mortality. MATERIALS AND METHODS: A retrospective analysis of 161 patients with deep neck infection at emergency department of Kaohsiung Chang Gung Memorial Hospital between 2010 and 2012 was performed. We also analyzed the differences between patients with complicated and non-complicated deep neck infection. RESULTS: One hundred and twenty-two patients were men (75.8%). The most common past medical history was diabetes mellitus, followed by liver cirrhosis, which occurs more commonly in Asians. The most common site of involvement was the peritonsillar space (42.9%). The most common pathogen was Streptococcus viridans (23.1%). Fourteen patients (8.7%) had complications and six (3.7%) died during hospitalization. Complicated cases had significantly lower heart rate and mean arterial pressure but higher blood sugar level. They also had higher opportunity to have liver cirrhosis, multiple sites and mediastinum involvement, resulting in longer duration of hospitalization and higher mortality rate. Logistic regression analysis determined that liver cirrhosis was the only predisposing factor for life-threatening complications. CONCLUSION: People with liver cirrhosis have higher occurrence of complication if they suffered from deep neck infection. Adequate treatment including airway maintenance, appropriate antibiotics, intravenous fluid support and surgical intervention should be provided as soon as possible to decrease complications and mortality.

Influence of a whole yeast product (Pichia guilliermondii) fed throughout gestation and lactation on performance and immune parameters of the sow and litter.

A study was conducted using 3 groups of gestating gilts and sows (n = 98) to determine the effects of Pichia guilliermondii (Pg), a whole cell-inactivated yeast product (CitriStim; ADM Alliance Nutrition), on performance and immune parameters of dams and litters. Within 24 h of breeding, gilts and sows were allotted to 1 of 3 treatments consisting of a control (SC) diet or SC diet supplemented with 0.1 (S1) or 0.2% (S2) Pg. Dietary treatments were maintained through lactation. Colostrum and milk (day 14) samples were collected for IgA, IgG, and IgM analysis. Blood samples were collected from sows on day 110 of gestation (group 3 only), while at weaning for all 3 groups, and from piglets at 14 d of age for peripheral white blood cell counts and serum IgA, IgG, and IgM analysis. Inclusion of Pg resulted in an increase in number born alive as the level of Pg increased (12.49, 13.33, and 13.43 born alive per litter for SC, S1, and S2, respectively; linear effect [LS], P = 0.003). Additionally, the percentage of piglets weighing less than 0.9 kg at birth was reduced in sows provided Pg at 0.1% or 0.2% compared with control (LS, P = 0.006). Sows receiving Pg during gestation and lactation also weaned a greater number of piglets (10.31, 10.55, and 10.60 weaned per litter in control, 0.1% and 0.2% Pg, respectively; LS, P = 0.02). However, percent preweaning mortality was 17.58%, 19.38%, and 19.61% for control, 0.1%, and 0.2% Pg, respectively (LS, P = 0.02). There were no differences in gestation BW gain, farrowing (days 110 to 48 h postfarrowing) or lactation (day 110 to weaning) BW loss, number of mummies or stillborn, or piglets' individual birth or weaning weight. On day 110 of gestation, the neutrophil concentration (quadratic effect [QS], P = 0.03) and neutrophil:lymphocyte ratio (QS, P = 0.04) in peripheral blood were greater in S1 than SC, with S2 being intermediate. At weaning there was a linear increase in neutrophil concentration (P = 0.03), neutrophil:lymphocyte ratio (P = 0.01), and percentage of neutrophils in the leukocyte population (P = 0.01) as level of Pg increased in sow diets. In conclusion, Pg inclusion in sow diets linearly increased total number born alive and weaned, with no change in average birth or weaning weight, and decreased the number of lightweight pigs at birth. However, inclusion of Pg had no effect on immune parameters measured in milk, colostrum, or day 14 piglet serum, but increased the peripheral blood neutrophil concentration of gilts and sows.

Metformin Affects Serum Lactate Levels in Predicting Mortality of Patients with Sepsis and Bacteremia.

This study determined if the use of metformin affected the prognostic value of hyperlactatemia in predicting 28-day mortality among patients with sepsis and bacteremia. We enrolled adult diabetic patients with sepsis and bacteremia. Of 590 patients, 162 and 162 metformin users and nonusers, respectively, were selected in propensity matching. The mean serum lactate levels in metformin users were higher than those in nonusers (4.7 vs. 3.9 mmol/L, p = 0.044). We divided the patients into four groups based on quick Sepsis-related Organ Failure Assessment (qSOFA) scores. No significant difference was found among nonusers with qSOFA score <2, nonusers with qSOFA score ≥2, and metformin users with qSOFA score <2. The lactate levels in metformin users with qSOFA score ≥2 were higher than those in other groups, and significant differences were found in both nonsurvivors (8.9 vs. 4.6 mmol/L, p = 0.027) and survivors (6.4 vs. 3.8 mmol/L, p = 0.049) compared with metformin users with qSOFA score <2. The best cut-off point to predict 28-day mortality in metformin users (5.9 mmol/L; area under the receiver operating characteristic curve (AUROC), 0.66; 95% confidence interval (CI), 0.55⁻0.77) was higher than that in nonusers (3.6 mmol/L; AUROC 0.63; 95% CI, 0.56⁻0.70). Metformin users had higher lactate levels than nonusers in increasing sepsis severity. Serum lactate levels could be useful in predicting mortality in patients using metformin, but higher levels are required to obtain more precise results.

Quick Sepsis-related Organ Failure Assessment predicts 72-h mortality in patients with suspected infection.

OBJECTIVE: The aim of this study was to compare quick Sepsis-related Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) scores for predicting mortality. PATIENTS AND METHODS: A single-center, retrospective study of adult patients with suspected infection was conducted. Area under the curve (AUC) and multivariate analyses were used to explore associations between the qSOFA and SIRS scores and mortality. RESULTS: Of the 69 115 patients enrolled, 1798 died within 72 h and 5640 within 28 days. The qSOFA scores were better than SIRS scores at predicting 72-h mortality (AUC: 0.77 vs. 0.64). However, the discriminatory power of both scores was low in terms of 28-day mortality (AUC: 0.69 vs. 0.60). Patients with qSOFA score of at least 2 had a higher hazard ratio for 72-h mortality than for 28-day mortality (2.64 vs. 1.91). CONCLUSION: The qSOFA scores are more accurate than SIRS scores for predicting 72-h mortality and are better at predicting 72-h mortality than 28-day mortality.

An electron-transporting host material compatible with diverse triplet emitters used for highly efficient red- and green-electrophosphorescent devices.

A bifluorene analogue, T2N, containing a pyridyl moiety serves as both a host and an efficient electron-transporting material that is compatible with various heavy metal-containing red (Ir, Ru, Os, and Pt) and green (Ir) phosphors for highly efficient phosphorescent OLEDs possessing simple device architectures.

Delayed diagnosis of active pulmonary tuberculosis in emergency department.

BACKGROUND AND PURPOSE: Tuberculosis (TB) is a worldwide health challenge. Emergency department (ED) is the major public access to the health care system. Delayed diagnosis of active pulmonary TB was believed to precipitate mortality and morbidity. The study was designed to investigate clinical characteristics and factors in patients with delayed diagnosis of active TB in ED. METHODS: We used a retrospective chart review. PATIENTS: A total of 103 patients were enrolled between December 2003 and March 2006. RESULTS: Typical chest radiographic findings were noted in 79.8% of nondelayed TB group and 31.6% of delayed TB group (P < .001). Diagnosis of pneumonia was made at ED in 22.6% of nondelayed TB group and 68.4% of delayed TB group (P < .001). Length of initiation of TB treatment intervention was 0 days (0-1 days) and 9 days (6-16 days), respectively (P < .001). In-hospital mortality rate was 15.5% and 47.4%, respectively (P < .01). Age (odds ratio, 1.07; 95% confidence interval, 1.01-1.1) and intensive care unit admission (odds ratio, 5.01; 95% confidence interval, 1.18-21.3) were associated with lower in-hospital survival. Delayed ED diagnosis of TB was associated with mortality in results of univariate analysis (P = .002), but no statistical significance was noted in the final result of stepwise logistic regression analysis. CONCLUSION: Intensive care unit admission and age are associated with mortality. Awareness of varying features of pulmonary TB by physicians is important.

Difference between elderly and non-elderly patients in using serum lactate level to predict mortality caused by sepsis in the emergency department.

Elderly people are more susceptible to sepsis and experience more comorbidities and complications than young adults. Serum lactate is a useful biomarker to predict mortality in patients with sepsis. Lactate production is affected by the severity of sepsis, organ dysfunction, and adrenergic stimulation. Whether the predictive ability of serum lactate will be different between non-elderly and elderly patients is unknown.A retrospective cohort study was conducted to compare the prognostic value of hyperlactatemia in predicting the mortality between elderly (≥65 years) and non-elderly (<65 years) patients with sepsis.This is a single-center retrospective observational cohort study conducted from January 2007 to December 2013 in southern Taiwan. All patients with sepsis, who used antibiotics, with blood culture collected, and with available serum lactate levels in the emergency department, were included in the analysis. We evaluated the difference in serum lactate level between the elderly and non-elderly septic patients by using multiple regression models.A total of 7087 patients were enrolled in the study. Elderly and non-elderly patients accounted for 62.3% (4414) and 40.2% (2673) of all patients, respectively. Statistically significant difference of serum lactate levels was not observed between elderly and non-elderly survivors (2.9 vs 3.0 mmol/L; P = .57); however, elderly patients had lower lactate levels than those within the 28-day in-hospital mortality (5.5 vs 6.6 mmol/L, P < .01). Multiple logistic regression revealed higher adjusted mortality risk in elderly and non-elderly patients with lactate levels of ≥4.0 mmol/L (odds ratio [OR], 4.98 and 5.82; P < .01, respectively), and lactate level between 2 and 4 mmol/L (OR, 1.57 and 1.99; P < .01, respectively) compared to that in the reference group with lactate levels of <2.0 mmol/L in each group. In receiver operating characteristic curve analysis, sensitivity rates for predicting mortality were 0.80 and 0.77 for non-elderly and elderly patients, respectively, by using serum lactate levels higher than 2.0 mmol/L.Septic elderly non-survivors had 1 mmol/L lower serum lactate level than those of the non-elderly non-survivors. Lactate >2 mmol/L still could provide enough sensitivity in predicting sepsis mortality in elder patients.

How Does the Severity of Injury Vary between Motorcycle and Automobile Accident Victims Who Sustain High-Grade Blunt Hepatic and/or Splenic Injuries? Results of a Retrospective Analysis.

BACKGROUND: High-grade blunt hepatic and/or splenic injuries (BHSI) remain a great challenge for trauma surgeons. The main aim of this study was to investigate the characteristics, mortality rates, and outcomes of high-grade BHSI in motorcyclists and car occupants hospitalized for treatment of traumatic injuries in a Level I trauma center in southern Taiwan. METHODS: High-grade BHSI are defined as grade III-VI blunt hepatic injuries and grade III-V blunt splenic injuries. This retrospective study reviewed the data of 101 motorcyclists and 32 car occupants who experienced a high-grade BHSI from 1 January 2011 to 31 December 2013. Two-sided Fisher's exact or Pearson's chi-square tests were used to compare categorical data, unpaired Student's t-test was used to analyze normally distributed continuous data, and Mann-Whitney's U test was used to compare non-normally distributed data. RESULTS: In this study, the majority (76%, 101/133) of high-grade BHSI were due to motorcycle crashes. Car occupants had a significantly higher injury severity score (ISS; 26.8 ± 10.9 vs. 20.7 ± 10.4, respectively, p = 0.005) and organ injured score (OIS; 3.8 ± 1.0 vs. 3.4 ± 0.6, respectively, p = 0.033), as well as a significantly longer hospital length of stay (LOS; 21.2 days vs. 14.6 days, respectively, p = 0.038) than did motorcyclists. Car occupants with high-grade BHSI also had worse clinical presentations than their motorcyclist counterparts, including a significantly higher incidence of hypotension, hyperpnea, tube thoracostomy, blood transfusion >4 units, LOS in intensive care unit >5 days, and complications. However, there were no differences in the percentage of angiography or laparotomy performed or mortality rate between these two groups of patients. CONCLUSIONS: This study demonstrated that car occupants with high-grade BHSI were injured more severely, had a higher incidence of worse clinical presentation, had a longer hospital LOS, and had a higher incidence of complications than motorcyclists. The results also implied that specific attention should be paid to those car occupants with high-grade BHSI, whose critical condition should not be underestimated because of the concept that the patients within in a car are much safer.

Influence of CT utilisation on patient flow in the emergency department: a retrospective 1-year cohort study.

OBJECTIVE: CT, an important diagnostic tool in the emergency department (ED), might increase the ED length of stay (LOS). Considering the issue of ED overcrowding, it is important to evaluate whether CT use delays or facilitates patient disposition in the ED. DESIGN: A retrospective 1-year cohort study. SETTING: 5 EDs within the same healthcare system dispersed nationwide in Taiwan. PARTICIPANTS: All adult non-trauma patients who visited the 5 EDs from 1 July 2011 to 30 June 2012. INTERVENTIONS: Patients were grouped by whether or not they underwent a CT scan (CT and non-CT groups, respectively). PRIMARY AND SECONDARY OUTCOME MEASURES: The ED LOS and hospital LOS between patients who had and had not undergone CT scans were compared by stratifying different dispositions and diagnoses. RESULTS: CT use prolonged patient ED LOS among those who were directly discharged from the ED. Among patients admitted to the observation unit and then discharged, patients diagnosed with nervous system disease had shorter ED LOS if they underwent a CT scan. CT use facilitated patient admission to the general ward. CT use also accelerated patients' admission to the intensive care unit (ICU) for patients with nervous system disease, neoplasm and digestive disease. Finally, patients admitted to the general wards had shorter hospital LOS if they underwent CT scans in the ED. CONCLUSIONS: CT use did not seem to have delayed patient disposition in ED. While CT use facilitated patient disposition if they were finally hospitalised, it mildly prolonged ED LOS in cases of patients discharged from the ED.

STROBE-compliant article: Blood Transfusions within the First 24 Hours of Hospitalization Did Not Impact Mortality Among Patients with Severe Sepsis.

Transfusion of packed red blood cells is common during resuscitation of critically ill patients. However, the association between in-hospital mortality and blood transfusion among patients with severe sepsis during the first 24  hours of hospitalization has not yet been determined. A cohort study was conducted of adult nontrauma patients who visited the emergency department of a tertiary hospital and were diagnosed with severe sepsis. Propensity score (PS) matching was conducted, based on patient demographics, underlying illnesses, laboratory results, and vital signs presented at the emergency department, and multivariate logistic regression was performed to adjust for potential residual confounding between the 2 transfused and nontransfused groups to assess the risk of in-hospital mortality. Of 3448 patients included in this study, 265 underwent blood transfusion during the first 24  hours of hospitalization. Despite comparable severity of sepsis, patients who received transfusions tended to have lower mean arterial pressures (86 vs 98  mmHg) and hemoglobin levels (7.6 vs 11.2  g/dL), and were more likely to have chronic kidney disease (12% vs 6%) and hematologic organ dysfunction (57% vs 35%, all P < 0.001). Transfused patients tended to have higher mortality rates (26% vs 9%, respectively, P < 0.001). After PS matching, 177 pairs of transfused and nontransfused patients were analyzed. After adjusting for residual confounding factors by multivariate logistic regression in the matched patient pairs, no significant differences in in-hospital mortality were observed (odds ratio [OR] = 1.52, 95% confidence interval: 0.92-2.51). In this PS-matched cohort study of adult nontrauma patients with severe sepsis, the in-hospital mortality rate was not significantly different in patients who received blood transfusions during the first 24  hours of hospitalization.

The Impact of Emergency Physician Seniority on Clinical Efficiency, Emergency Department Resource Use, Patient Outcomes, and Disposition Accuracy.

The ability of emergency physicians (EPs) to continue within the specialty has been called into question due to high stress in emergency departments (EDs).The purpose of this study was to investigate the impact of EP seniority on clinical performance.A retrospective, 1-year cohort study was conducted across 3 EDs in the largest health-care system in Taiwan. Participants included 44,383 adult nontrauma patients who presented to the EDs. Physicians were categorized as junior, intermediate, and senior EPs according to ≤5, 6 to 10, and >10 years of ED work experience. The door-to-order and door-to-disposition time were used to evaluate EP efficiency. Emergency department resource use indicators included diagnostic investigations of electrocardiography, plain film radiography, laboratory tests, and computed tomography scans. Discharge and mortality rates were used as patient outcomes. Disposition accuracy was evaluated by ED revisit rate.Senior EPs were found to have longer door-to-order (11.3, 12.4 minutes) and door-to-disposition (2, 1.7 hours) time than nonsenior EPs in urgent and nonurgent patients (junior: 9.4, 10.2 minutes and 1.7, 1.5 hours; intermediate: 9.5, 10.7 minutes and 1.7, 1.5 hours). Senior EPs tended to order fewer electrocardiograms, radiographs, and computed tomography scans in nonurgent patients. Adjusting for age, sex, disease acuity, and medical setting, patients treated by junior and intermediate EPs had higher mortality in the ED (adjusted odd ratios, 1.5 and 1.6, respectively).Compared with EPs with ≤10 years of work experience, senior EPs take more time for order prescription and patient disposition, use fewer diagnostic investigations, particularly for nonurgent patients, and are associated with a lower ED mortality rate.

Factors associated with delayed recognition of pulmonary tuberculosis in emergency departments in Taiwan.

OBJECTIVE: To identify and evaluate factors associated with delayed recognition of pulmonary tuberculosis (TB) in the emergency department (ED). BACKGROUND: Delayed recognition of pulmonary TB in ED may precipitate mortality and morbidity. METHODS: Medical records of newly diagnosed TB patients admitted to four hospitals in Taiwan were retrospectively reviewed. Patients were divided into two groups based on ED physicians' recognition or not of TB and statistically compared to identify differences in their characteristics. RESULTS: 310 newly diagnosed TB patients were identified; 150 were unrecognized in the ED. Cough, chest tightness, general malaise, and body weight loss were more common for those with recognized TB. Older age (≥65 yrs, P = 0.035) and chronic renal insufficiency (P = 0.005) were associated with delayed TB recognition. CONCLUSION: Older age and chronic renal insufficiency are risk factors for delayed TB while in the ED. Typical symptoms should heighten alertness for recognizing TB.

Body mass index-mortality relationship in severe hypoglycemic patients with type 2 diabetes.

BACKGROUND: Hypoglycemia is associated with a higher risk of death. This study analyzed various body mass index (BMI) categories and mortalities of severe hypoglycemic patients with type 2 diabetes mellitus (DM) in a hospital emergency department. METHODS: The study included 566 adults with type 2 diabetes who were admitted to 1 medical center in Taiwan between 2008 and 2009 with a diagnosis of severe hypoglycemia. Mortality data, demographics, clinical characteristics and the Charlson's Comorbidity Index were obtained from the electronic medical records. Patients were stratified into 4 study groups as determined by the National Institute of Health (NIH) and World Health Organization classification for BMI, and the demographics were compared using the analysis of variance and χ² test. Kaplan-Meier's analysis and the Cox proportional-hazards regression model were used for mortality, and adjusted hazard ratios were adjusted for each BMI category among participants. RESULTS: After controlling for other possible confounding variables, BMI <18.5 kg/m² was independently associated with low survival rates in the Cox regression analysis of the entire cohort of type 2 DM patients who encountered a hypoglycemic event. Compared to patients with normal BMI, the mortality risk was higher (adjusted hazard ratios = 4.9; 95% confidence interval [CI] = 2.4-9.9) in underweight patients. Infection-related causes of death were observed in 101 cases (69.2%) and were the leading cause of death. CONCLUSIONS: An independent association was observed between BMI less than 18.5 kg/m² and mortality among type 2 DM patient with severe hypoglycemic episode. Deaths were predominantly infection related.

The prognostic value of leukocyte apoptosis in patients with severe sepsis at the emergency department.

BACKGROUND AND AIM: Cell apoptosis in critically ill patients plays a pivotal role in the pathogenesis of sepsis. This study aimed to determine the prognostic value of leukocyte apoptosis in patients with severe sepsis. METHODS: Leukocyte apoptosis was determined by flow cytometry. The values of annexin V, APO2.7, and 7-amino-actinomycin D (7AAD) for each subtype of leukocyte were analyzed in 87 patients with severe sepsis and 27 controls. RESULTS: The percentages of apoptosis (APO2.7 [%]) in the leukocyte subsets were significantly higher in the patients with severe sepsis than in the controls. The percentages of APO2.7 in leukocyte apoptosis, APO2.7 in lymphocytes apoptosis, and annexin V+7AAD in monocytes apoptosis were significantly higher in non-survivors than in survivors. Levels of APO2.7 in lymphocytes apoptosis, annexin V+7AAD in monocytes apoptosis, and serum lactate were all independently predictive of mortality. CONCLUSION: Leukocyte apoptosis is significantly higher in patients with severe sepsis. The percentages of late lymphocyte and monocyte apoptosis may be predictive of outcome in such patients. Aside from serum lactate, APO2.7 level in lymphocyte apoptosis is also a useful predictor of outcome on admission to the emergency department.