Chien-Ying Wang

Prognostic factors for mortality following falls from height

AIM To identify the potential prognostic factors for mortality after falls from height. METHOD A retrospective clinical observational study included victims of fall of >6m from October 2000 to December 2007. Variables studied comprised each casualtys age, gender, height of fall, Glasgow Coma Scale (GCS) score, Abbreviated Injury Scale scores, Injury Severity Score, heart rate, Mean Arterial Pressure (MAP), White Blood Cell (WBC) count, haemoglobin, serum glucose, Creatine Kinase and duration of hospital stay. The relationships between these variables and outcomes were evaluated. RESULTS Among the 66 patients studied the mortality rate was 22.7%, i.e. 7 out-of-hospital and 8 in-hospital deaths. In univariate analysis, Glasgow Coma Score < or =14, Injury Severity Score > or =16, head/neck Abbreviated Injury Scale score > or =4, chest Abbreviated Injury Scale score > or =4, heart rate > or =100 or < or =50 beats/min, Mean Arterial Pressure < or =60 and serum glucose > or =140 mg/dl were significantly related to mortality. In multivariate analysis, head/neck Abbreviated Injury Scale score > or =4 was independently correlated with mortality. CONCLUSIONS Severe head injury (head/neck Abbreviated Injury Scale score > or =4) is a significant factor for mortality following falls from >6 m.

Induced pluripotent stem cells mediate the release of interferon gamma-induced protein 10 and alleviate bleomycin-induced lung inflammation and fibrosis.

ABSTRACT Chronic lung diseases cause serious morbidity and mortality, and effective treatments are limited. Induced pluripotent stem cells (iPSCs) lacking the reprogramming factor c-Myc (3-gene iPSCs) can be used as ideal tools for cell-based therapy because of their low level of tumorigenicity. In this study, we investigated whether 3-gene iPSC transplantation could rescue bleomycin-induced pulmonary fibrosis. After the induction of pulmonary inflammation and fibrosis via intratracheal delivery of bleomycin sulfate, mice were i.v. injected with 3-gene iPSCs or conditioned medium (iPSC-CM) at 24 h after bleomycin treatment. Administration of either 3-gene iPSCs or iPSC-CM significantly attenuated collagen content and myeloperoxidase activity, diminished neutrophil accumulation, and rescued pulmonary function and recipient survival after bleomycin treatment. Notably, both treatments reduced the levels of inflammatory cytokines and chemokines, including interleukin 1 (IL-1), IL-2, IL-10, tumor necrosis factor-&agr;, and monocyte chemotactic protein 1 yet increased the production of the antifibrotic chemokine interferon-&ggr;–induced protein 10 (IP-10) in bleomycin-injured lungs. Furthermore, IP-10 neutralization via treatment with IP-10–neutralizing antibodies ameliorated the reparative effect of either 3-gene iPSCs or iPSC-CM on collagen content, neutrophil and monocyte accumulation, pulmonary fibrosis, and recipient survival. Intravenous delivery of 3-gene iPSCs/iPSC-CM alleviated the severity of histopathologic and physiologic impairment in bleomycin-induced lung fibrosis. The protective mechanism was partially mediated by the early moderation of inflammation, reduced levels of cytokines and chemokines that mediate inflammation and fibrosis, and an increased production of antifibrotic IP-10 in the injured lungs.

Persistently high serum carcinoembryonic antigen levels after surgery indicate poor prognosis in patients with stage I non-small-cell lung cancer.

BACKGROUND The aim of this study is to evaluate the prognostic significance of preoperative and postoperative serum carcinoembryonic antigen (CEA) levels in patients with stage I non-small-cell lung cancer. MATERIAL AND METHODS A retrospective review of the medical records of 257 patients with stage I lung cancer undergoing surgical resection was performed. The clinical data of each patient was collected for analysis including age, smoking habits, gender, preoperative and postoperative serum CEA levels, tumor diameter, histologic type, visceral pleural invasion, pathologic stage, and type of operation. RESULTS Adenocarcinoma was more often associated with elevated preoperative CEA level compared with non-adenocarcinoma. Tumor histology, however, did not influence postoperative CEA levels. In the univariate analysis, age, serum CEA level, and pathologic stage were prognostic factors. Patients with normal preoperative serum CEA levels had better 5-y survival than patients with high preoperative serum CEA levels (71.1% versus 54.6%, P = 0.016). The patients with a persistently high serum CEA level after surgery had worst prognosis. Multivariate analysis demonstrated that older age (≥65) and persistently high serum CEA levels were independent significant prognostic factors in patients with stage I lung cancer. CONCLUSIONS Age (≥65 years) and preoperative and postoperative serum CEA levels are independent prognostic factors in patients with stage I lung cancer. Patients with a persistently high serum CEA level after surgery had worst survival, and may be good candidates for adjuvant chemotherapy.

Intramural Lipoma of the Esophagus

Lipomas of the gastrointestinal tract are rare, and those of the esophagus are extremely rare. Indeed, fewer than 20 resected cases of esophageal lipoma have been reported in the literature. In the current case, a 71-year-old man presented with a 4-month history of a slight swallowing disturbance in the upper chest. Upper gastrointestinal endoscopy revealed a submucosal space-occupying mass, with normal mucosa, in the upper third of the thoracic esophagus; the mass was yellowish in color, soft in consistency, and about 3.5 x 3.0 cm in diameter. The patient underwent video-assisted thoracoscopic enucleation of the submucosal esophageal tumor, which pathologically, was proved to be a lipoma.

Spleen artery embolization aggravates endotoxin hyporesponse of peripheral blood mononuclear cells in patients with spleen injury.

BACKGROUND : Spleen artery embolization (SAE) increases the success of nonoperative management of spleen injury; however, the immune alternation after SAE is unclear. This study searched the endotoxin responses of peripheral blood mononuclear cells (PBMCs) in injured patients who received SAE. METHODS : Patients were subsequently enrolled when their spleen injuries were confirmed by computed tomographic scan. Peripheral blood samples were obtained within first, at third, fifth, and seventh postinjury days. PBMCs were isolated; nuclear factor (NF)-kB translocations, phosphorylated I-kB expressions, and in vitro tumor necrosis factor (TNF)-alpha levels were assayed after endotoxin stimulation (ES). RESULTS : Sixteen patients who received nonoperative managements were enrolled. Five patients received SAE (embolized patients) and 11 patients did not (nonembolized patients). Compared with those in controls, NF-kB translocations, phosphorylated I-kB expressions, and TNF-alpha levels after ES decreased significantly early in injured patients. NF-kB translocation and TNF-alpha levels after ES were indifferent at seventh day between nonembolized patients and controls, whereas significantly lower NF-kB p65 translocation and TNF-alpha levels after ES were found at seventh postinjury day in embolized patients than in controls. Compared with nonembolized patients, embolized patients had significantly lower levels of NF-kBp50 translocations after ES from first to third postinjury days and lower levels of NF-kB p65 translocations, TNF-alpha, and phosphorylated I-kB expressions after ES from first to fifth postinjury days. CONCLUSIONS : SAE dysregulates the NF-kB system and aggravates the cytokine hyporesponse upon ES of PBMCs in patients with spleen injury. These results implicate that SAE alters immune response and may increase susceptibility to infections in injured patients.

Spleen artery embolization increases the success of nonoperative management following blunt splenic injury

Background: Spleen artery embolization (SAE) may increase the success rate of nonoperative management (NOM). The present study investigated the clinical outcome after the installation of SAE in the management of blunt splenic injury. Methods: A retrospective review of hospital records was performed to enroll patients with blunt injury of the spleen. Demographic data and information about the injury severity score, organ injury scale, hospitalization days, management and final outcomes were evaluated. Patients were separated into early and late groups according to the year that SAE was selectively used (2003–2004 and 2005–2008). Results: Six of eleven (55%) patients in the early group were successfully managed without surgery for blunt splenic injury, whereas all of the 38 patients (100%) in the late group were successfully managed without surgery. Eleven patients (11 of 38; 28.9%) received SAE in the late group. The rate of NOM increased from 55% in the early group to 100% in the late group (p < 0.001). Both early and late groups had similar injury severity score, length of hospitalization, blood transfusion, and complications, and there was no mortality. Conclusion: Performance of SAE for the patients with blunt splenic injury could increase the successful rate of NOM significantly and safely. An algorithm including the angioembolization might be beneficial in the management of patients with blunt spleen trauma.

Predictive indications of operation and mortality following renal trauma

Background: This study is a review of our experiences related to managing patients with renal injuries and identifying the predictive indicators of surgery and mortality. Methods: A retrospective review study was performed in our university hospital. Patients with renal injuries were enrolled. Data comparisons were performed between four patient groups (operation vs. nonoperation groups and mortality vs. survival groups, respectively). Results: Seventy‐three patients were enrolled in this study, 55 of whom (75.34%) were male. Nine patients (12.33%) were severely injured (Injury severity score (ISS) ≥ 16), and nine (12.33%) had high renal injury scores (Renal injury scale (RIS) ≥ 4). Seven patients (9.59%) had received operations, and four (5.48%) died of hemorrhagic shock and multiple organ failure. After performing multivariate analysis, patients who received operations had significantly higher ISS (≥16) and RIS (≥4) scores compared with patients who did not undergo operations. ISS ≥ 16 and Glasgow coma scale (GCS) < 8 were significantly correlated with mortality. Conclusion: In conclusion, ISS ≥ 16 and RIS ≥ 4 are predictive factors for necessitating an operation, and higher injury severity (ISS ≥ 16) and lower consciousness level (GCS < 8) scores are significantly associated with mortality after renal trauma.

Comparing characteristics of adverse drug events between older and younger adults presenting to a Taiwan emergency department

AbstractTo compare the proportion, seriousness, preventability of adverse drug events (ADEs) between the older adults (≥65 years old) and younger adults (<65 years old) presenting to the emergency department (ED), we conducted a prospective observational cohort study of patients 18 years and older presenting to the ED. For all ED visits between March 1, 2009, and Feb 28, 2010, investigators identified ADEs and assessed cases using the Naranjo adverse drug reaction probability scale. Outcomes (proportion, seriousness, and preventability of ADE, length of ED stay, and hospitalization) and associated variables were measured and compared between younger and older adults. The results showed that of 58,569 ED visits, 295 older adults, and 157 younger adults were diagnosed as having an ADE and included in our analysis. The proportion of ADEs leading to ED visits in the older group, 14.3 per 1000 (295/20,628), was significantly higher than the younger group of 4.1 per 1000 (157/37,941).The older group with ADE had a longer ED stay (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.9–6.4 for stay ≥ 24 hours) and larger proportion of preventable ADEs (OR 2.2, 95% CI 1.4–3.6) than the younger group, but there was no significant difference in terms of serious ADEs (OR 0.6, 95% CI 0.3–1.3 for fatal and life threatening) and hospitalization (OR 1.5, 95% CI 0.9–2.6) between the 2 groups. In addition, patients in the older group were more likely to be male, to have symptoms of fatigue or altered mental status, to involve cardiovascular, renal, and respiratory systems, and to have higher Charlson comorbidity index scores, higher number of prescription medications, and higher proportion of unintentional overdose. In conclusion, the proportion of ADE-related ED visits in older adults was higher than younger adults, and many of these were preventable. The most common drug categories associated with preventable ADEs in the older adults were antithrombotic agents, antidiabetic agents, and cardiovascular agents.

Analysis of the causes of surgery-related medical disputes in Taiwan: Need for acute care surgeons to improve quality of care.

Background This study investigated surgery‐related medical disputes and analyzed disease etiologies and the main causes of disputes in order to identify key points for the purpose of improving the quality of surgical patient care in Taiwan. Methods Reports on all surgery‐related cases appraised by the Taiwan Witness Examiner Committee of the Department of Health between 2004 and 2008 were reviewed retrospectively by three senior physicians from the emergency department who specialize in both trauma and emergency general surgery. The causes of the various medical disputes were categorized under the following descriptions: operation‐ or procedure‐related complication, anesthesia complication, inappropriate management or decision, delayed diagnosis or misdiagnosis, and unsatisfactory result. Results A total of 154 cases were reviewed, of which 39 were trauma‐related and 115 were disease‐related. The two leading causes of disputes in this review were found to be operation‐ or procedure‐related complications (35.7%) and unsatisfactory results (31.8%), followed by delayed diagnoses or misdiagnoses, inappropriate management, and anesthesia complications. Among these, 74 cases (48.1%) required the care of an acute care surgeon and 40 cases (26.0%) required emergency general surgery intervention. Conclusion Surgery‐ or procedure‐related complications and unsatisfactory treatment results constituted the major causes of medical disputes in Taiwan. The majority of these cases involved acute care surgery; thus, the establishment of an acute care surgery system should be considered to improve patient care. The management of hemorrhagic shock and incarcerated hernia should be reinforced in future medical training.

Hepatic hydrothorax after blunt chest trauma.

We report a successful treatment result in a rare case of hepatitis C virus-related cirrhosis, who had sustained hydrothorax after blunt thoracoabdominal trauma. This was a female patient with liver cirrhosis, Child-Turcotte-Pugh class A, without ascites before injury. She sustained blunt thoracoabdominal trauma with a left clavicle fracture dislocation and right rib fractures. There was no hemopneumothorax at initial presentation. However, dyspnea and right pleural effusion developed gradually. We inserted a chest tube to relieve the patients symptoms, and the daily drainage amount remained consistent. Hepatic hydrothorax was confirmed by the intraperitoneal injection of radioisotope 99mTc-sulfur colloid that demonstrated one-way transdiaphragmatic flow of fluid from the peritoneal cavity to pleural cavities. Finally, the hydrothorax was treated successfully by minocycline-induced pleural symphysis. To the best of our knowledge, this is the first case of hepatic hydrothorax developed after thoracoabdominal trauma.