Chia-Te Kung

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

Background and aimThe 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).MethodsSixty-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 β-hemoglobin and ND2 gene. The patients’ clinical and laboratory data on admission were analyzed.ResultsThe 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%.ConclusionPlasma 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 Roles of Biomarkers of Oxidative Stress and Antioxidant in Alzheimer’s Disease: A Systematic Review

Purpose. Oxidative stress plays an important role in the pathogenesis of Alzheimers disease (AD). This paper aims to examine whether biomarkers of oxidative stress and antioxidants could be useful biomarkers in AD, which might form the bases of future clinical studies. Methods. PubMed, SCOPUS, and Web of Science were systematically queried to obtain studies with available data regarding markers of oxidative stress and antioxidants from subjects with AD. Results and Conclusion. Although most studies show elevated serum markers of lipid peroxidation in AD, there is no sufficient evidence to justify the routine use of biomarkers as predictors of severity or outcome in AD.

Transcatheter Arterial Embolization in the Emergency Department for Hemodynamic Instability Due to Ruptured Hepatocellular Carcinoma: Analysis of 167 Cases

OBJECTIVE The purpose of this study was to analyze the prognostic factors associated with emergency transcatheter arterial embolization in the treatment of patients in hemodynamically unstable condition caused by rupture of hepatocellular carcinoma. MATERIALS AND METHODS An 8-year retrospective cohort study was conducted to evaluate emergency transcatheter arterial embolization in the treatment of 167 patients in unstable hemodynamic condition (systolic blood pressure < 90 mm Hg at presentation) due to rupture of hepatocellular carcinoma. The clinical, laboratory, and imaging findings of a group who died (survival period, < or = 30 days) were compared with those of a group who survived more than 30 days. RESULTS On arrival in the emergency department, the group who died (n = 52) were in significantly worse condition than the group who survived (n = 115). The group who died had a poorer Child-Pugh class, lower hemoglobin and serum albumin levels, higher demand for blood transfusion, higher incidence of acute respiratory failure, worse neurologic status (Glasgow Coma Scale score, < or = 12), greater prevalence of portal vein thrombosis, and higher serum total bilirubin and creatinine levels (p < 0.05, two-sample Students t test and Fishers exact or chi-square test). Multivariate logistic regression analysis showed that patients who did not have portal venous thrombosis (odds ratio, 0.241; p = 0.012) or a lower creatinine level (odds ratio, 0.458; p = 0.003) had better probability of survival. Successful hemostasis with transcatheter arterial embolization was achieved in 99% of patients (30-day mortality rate, 31%). Patients with coexistent acute respiratory failure or impaired neurologic status and marked hyperbilirubinemia (> 2.7 mg/dL) had exceptionally high mortality rate (> 70%). CONCLUSION Emergency transcatheter arterial embolization is effective for hemostasis of ruptured hepatocellular carcinoma in patients in hemodynamically unstable condition being treated in the emergency department. However, patients with portal venous thrombosis, a high serum creatinine level, acute respiratory failure, impaired neurologic status, and a high serum total bilirubin level continue to be at high risk of death.

Testicular dislocation: An uncommon and easily overlooked complication of blunt abdominal trauma☆

STUDY OBJECTIVE We report testicular dislocation as an unusual complication of blunt abdominal trauma. METHODS The computer data bank of Chang Gung Memorial Hospital was searched for the period from 1987 to 2002, and 1,967 male patients with blunt abdominal trauma were admitted to the emergency department. Among these patients, records of 9 patients associated with testicular dislocation were collected. A retrospective review of the clinical records, abdominal computed tomography (CT) results, and subsequent scrotal sonograms was jointly performed by 2 radiologists, an emergency physician, and a trauma surgeon. RESULTS Of these 9 patients (age range 6 to 53 years; mean 23 years), 7 patients were in motorcycle crashes, 1 patient had explosive injury, and 1 patient had seat belt injury. Associated testicular dislocation was initially missed in all patients. CT for evaluating blunt abdominal trauma revealed liver lacerations in 2 patients and pancreatic fracture, pancreatitis, bowel perforation, pubic bone fracture, and contralateral inguinal hernia in 1 each. Typical CT findings of testicular dislocation (empty scrotum and displaced testis) were retrospectively seen in 7 patients, but prompt CT diagnosis of testicular dislocation was achieved only in 3 patients, who were subsequently treated with closed manual reduction, obviating surgery. In the remaining 2 patients, CT examination did not include the scrotum and testicular dislocation, which was diagnosed by subsequent sonography. Delayed diagnosis occurred in 6 patients (duration 3 to 60 days; mean 19 days). Five of the patients underwent orchiopexy, and 1 underwent orchiectomy. CONCLUSION In blunt abdominal trauma patients, associated testicular dislocation is easily overlooked. A complete physical examination in the trauma patient, including palpation of both testes, is strongly recommended.

Predictors and outcomes of shunt-dependent hydrocephalus in patients with aneurysmal sub-arachnoid hemorrhage

BackgroundHydrocephalus following spontaneous aneurysmal sub-arachnoid hemorrhage (SAH) is often associated with unfavorable outcome. This study aimed to determine the potential risk factors and outcomes of shunt-dependent hydrocephalus in aneurysmal SAH patients but without hydrocephalus upon arrival at the hospital.MethodsOne hundred and sixty-eight aneurysmal SAH patients were evaluated. Using functional scores, those without hydrocephalus upon arrival at the hospital were compared to those already with hydrocephalus on admission, those who developed it during hospitalization, and those who did not develop it throughout their hospital stay. The Glasgow Coma Score, modified Fisher SAH grade, and World Federation of Neurosurgical Societies grade were determined at the emergency room. Therapeutic outcomes immediately after discharge and 18 months after were assessed using the Glasgow Outcome Score.ResultsHydrocephalus accounted for 61.9% (104/168) of all episodes, including 82 with initial hydrocephalus on admission and 22 with subsequent hydrocephalus. Both the presence of intra-ventricular hemorrhage on admission and post-operative intra-cerebral hemorrhage were independently associated with shunt-dependent hydrocephalus in patients without hydrocephalus on admission. After a minimum 1.5 years of follow-up, the mean Glasgow outcome score was 3.33 ± 1.40 for patients with shunt-dependent hydrocephalus and 4.21 ± 1.19 for those without.ConclusionsThe presence of intra-ventricular hemorrhage, lower mean Glasgow Coma Scale score, and higher mean scores of the modified Fisher SAH and World Federation of Neurosurgical grading on admission imply risk of shunt-dependent hydrocephalus in patients without initial hydrocephalus. These patients have worse short- and long-term outcomes and longer hospitalization.

Factors associated with fall-related fractures in Parkinson's disease

PURPOSE Fall-related fracture is one of the most disabling features of idiopathic Parkinsons disease (PD). A better understanding of the associated factors is needed to predict PD patients who will require treatment. METHODS This prospective study enrolled 100 adult idiopathic PD patients. Stepwise logistic regressions were used to evaluate the relationships between clinical factors and fall-related fracture. RESULTS Falls occurred in 56 PD patients, including 32 with fall-related fractures. The rate of falls in the study period was 2.2 ± 1.4 per 18 months. The percentage of osteoporosis was 34% (19/56) and 11% in PD patients with and without falls, respectively. Risk factors associated with fall-related fracture were sex, underlying knee osteoarthritis, mean Unified Parkinsons Disease Rating Scale score, mean Morse fall scale, mean Hoehn and Yahr stage, and exercise habit. By stepwise logistic regression, sex and mean Morse fall scale were independently associated with fall-related fracture. Females had an odds ratio of 3.8 compared to males and the cut-off value of the Morse fall scale for predicting fall-related fracture was 72.5 (sensitivity 72% and specificity 70%). DISCUSSION Higher mean Morse fall scales (>72.5) and female sex are associated with higher risk of fall-related fractures. Preventing falls in the high-risk PD group is an important safety issue and highly relevant for their quality of life.

Risk factors for the outcome of cirrhotic patients with soft tissue infections.

Goal The aims of this study were to identify risk factors that influence outcomes of cirrhotic patients with soft tissue infections and to describe specific management for such patients. Background Soft tissue infections account for 11% of infections overall in cirrhotic patients and the severe form of necrotizing infection carries a high mortality rate. It is essential that clinicians make an early diagnosis and start appropriate treatment to improve outcomes of cirrhotic patients with soft tissue infections. Methods Cirrhotic patients who had been admitted to our hospital with the diagnosis of soft tissue infection from June 1, 2003 to June 1, 2005 were included in this retrospective study. Clinical manifestations, laboratory data, and microbiologic results were recorded and compared between survivor and nonsurvivor groups. Results There was a total of 118 episodes of admission for soft tissue infection with 26 episodes resulting in mortality and 92 in survival. The following clinical parameters showed significant differences between the 2 groups: Child-Pugh grade C, pain, altered consciousness, emergence of hemorrhagic bullae, and local injury. The following laboratory data showed significant differences between the 2 groups: appearance of band form, serum creatinine, serum albumin below 2.5 g/dL, serum bilirubin above 3 mg/dL, and prothrombin time prolongation greater than 5 seconds. Gram-negative bacterial infection was predominant in the nonsurvivor group and was statistically significant. Multivariate analysis showed that the emergence of hemorrhagic bullae and Child-Pugh grade C were independent predictive factors for outcome. Conclusions When treating soft tissue infection in cirrhotic patients, especially in those with Child-Pugh C liver function or emergence of hemorrhagic bullae, it is essential to start surgical evaluation and specific broad-spectrum antibiotics early to reduce the high mortality associated with this disease.

Determining delayed admission to the intensive care unit for mechanically ventilated patients in the emergency department

IntroductionThe adverse effects of delayed admission to the intensive care unit (ICU) have been recognized in previous studies. However, the definitions of delayed admission vary across studies. This study proposed a model to define `delayed admission’, and explored the effect of ICU waiting time on patients’ outcome.MethodsThis retrospective cohort study included nontraumatic adult patients on mechanical ventilation in the emergency department (ED), from July 2009 to June 2010. The primary outcomes measures were 21-ventilator-day mortality and prolonged hospital stays (over 30 days). Models of Cox regression and logistic regression were used for multivariate analysis. The non-delayed ICU waiting was defined as a period in which the time effect on mortality was not statistically significant in a Cox regression model. To identify a suitable cutoff point between `delayed’ and `non-delayed’ subsets from the overall data were made based on ICU waiting time and the hazard ratio of ICU waiting hour in each subset was iteratively calculated. The cutoff time was then used to evaluate the impact of delayed ICU admission on mortality and prolonged length of hospital stay.ResultsThe final analysis included 1,242 patients. The time effect on mortality emerged after 4 hours, thus we deduced ICU waiting time in the ED of >4 hours as delayed. By logistic regression analysis, delayed ICU admission affected the outcomes of 21-ventilator-day mortality and prolonged hospital stay, with an odds ratio of 1.41 (95% confidence interval, 1.05 to 1.89) and 1.56 (95% confidence interval, 1.07 to 2.27) respectively.ConclusionsFor patients on mechanical ventilation in the ED, delayed ICU admission is associated with higher probability of mortality and additional resource expenditure. A benchmark waiting time of no more than 4 hours for ICU admission is recommended.

Gallbladder carcinoma manifesting as acute cholecystitis: Clinical and computed tomographic features

BACKGROUND Gallbladder carcinoma is uncommon and may manifest as acute cholecystitis. An accurate diagnosis is helpful for operative planning and this study attempted to explore the distinctive clinical and computed tomographic (CT) features for differentiating acute cholecystitis alone from that with contemporaneous gallbladder carcinoma. METHODS This 20-year, retrospective study evaluated the CT features of 26 patients with surgically proven gallbladder carcinoma with clinical presentations of acute cholecystitis (carcinoma group). Thirty elderly patients with surgically proven simple acute cholecystitis were enrolled as age-matched controls (cholecystitis group). The clinical, laboratory, and CT findings were compared between the 2 groups. RESULTS The carcinoma and cholecystitis groups showed no significant differences with respect to clinical symptoms (abdominal pain, fever, and jaundice), serum total bilirubin level, leukocyte count, percentage of segmented leukocytes, presence of gallstones, and CT features of pericholecystic stranding/fluid and focally increased enhancement of adjacent liver. Fifteen of the 26 (57.6%) patients in the carcinoma group exhibited diffuse gallbladder wall thickening on CT and the other 11 exhibited focal thickening or intraluminal masses. Beside female predominance, the patients in the carcinoma group had significantly higher serum aspartate/alanine aminotransferase and alkaline phosphatase levels, a thicker gallbladder wall, smaller volume, lower frequency of triple-layer gallbladder wall enhancement pattern, and a higher frequency of enlarged regional lymph nodes than those in the cholecystitis group. CONCLUSION For elderly patients, especially women, presenting with acute cholecystitis and abnormal liver function, CT demonstration of focal gallbladder wall thickening, intraluminal masses, small gallbladder with diffuse wall thickening, and enlarged regional lymph nodes are suggestive of concurrent gallbladder carcinoma. Triple-layer gallbladder wall enhancement is suggestive of simple acute cholecystitis.

Statin therapy reduces oxidized low density lipoprotein level, a risk factor for stroke outcome

IntroductionStatins are reported to have anti-inflammatory and anti-oxidative effects aside from cholesterol-lowering effects. This study aimed to evaluate the effects of statin therapy on oxidized LDL (Ox-LDL) and the clinical outcome of patients with acute ischemic stroke (AIS).MethodsThis prospective study enrolled 120 patients with AIS divided in the statin (n = 55) and non-statin (n = 65) groups. Eighty sex- and age- matched participants were recruited as risk controls. Ox-LDL was measured using a monoclonal antibody-based enzyme-linked immune-sorbent assay at different time points after AIS. The clinical outcomes were analyzed between the statin and non-statin groups.ResultsPlasma Ox-LDL was significantly higher in stroke patients than in the controls (P < 0.001). Plasma Ox-LDL level was significantly reduced in the statin group on day 7 and day 30 compared to the non-statin group (P < 0.01). The plasma Ox-LDL positively correlated with serum total cholesterol, LDL-cholesterol, and hemoglobin A1c (HbA1c). Among the potential risk factors, only National Institutes of Health stroke scale (NIHSS) score and Ox-LDL level on admission were independently associated with 3-month outcome.ConclusionsOur study demonstrates that statin therapy reduces plasma Ox-LDL level after AIS. Plasma Ox-LDL may be a more powerful predictor than serum LDL, high-sensitivity C-reactive protein or white blood cell counts for stroke outcome. Therefore, assay of plasma Ox-LDL should be added as a predictor among the panel of conventional biomarkers in stroke outcome.