h Hsien Chi

Serum total antioxidant capacity reflects severity of illness in patients with severe sepsis.

IntroductionWe conducted the present study to evaluate the changes in serum total antioxidant capacity (TAC) in patients with severe sepsis and to investigate the association between serum TAC and clinical severity.MethodThis was a prospective observational study involving a sample of patients who met established criteria for severe sepsis and were admitted to the emergency department of a university teaching hospital. Serum TAC was determined using the total radical-trapping antioxidant parameter method. The levels of TAC, uric acid, albumin, and bilirubin in sera were obtained in the emergency department and evaluated to determine whether there were any correlations between the major antioxidant biomarkers and clinical severity of sepsis. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was used for clinical evaluation of the severity of sepsis.ResultsA total of 73 patients with sepsis, with a mean (± standard deviation) APACHE II score of 23.2 ± 8.2 and a mortality rate of 26.0%, were included. Seventy-six healthy individuals served as control individuals. Among the patients, serum TAC levels correlated significantly with APACHE II scores. Patients who died also had higher TAC than did those who survived. Serum uric acid levels correlated significantly with serum TAC and APACHE II scores in patients with severe sepsis.ConclusionElevated serum TAC level may reflect clinical severity of sepsis. In addition, serum uric acid levels appear to contribute importantly to the higher TAC levels observed in patients with severe sepsis.

Quadruple therapy containing amoxicillin and tetracycline is an effective regimen to rescue failed triple therapy by overcoming the antimicrobial resistance of Helicobacter pylori

Aim : To identify optimal antibiotics for second‐line quadruple therapy of Helicobacter pylori after failed 1‐week triple therapy.

Necrotizing fasciitis in patients with liver cirrhosis: predominance of monomicrobial Gram-negative bacillary infections

Necrotizing fasciitis (NF), a rare but severe infection, usually occurs in individuals with underlying chronic illness, but its clinical presentation among cirrhotic patients is infrequently discussed. Forty-two cirrhotic patients with 47 episodes of NF between 1995 and 2006 were analyzed. Their mean age was 55.6 years, with male preponderance (34 patients, 81%). Lower extremities were mainly involved (70%). Of 42 episodes with identified pathogens, 41 (97%) were monomicrobial infections and were caused mainly by Gram-negative rods (GNBs) (32, 76%), including Vibrio (15, 36%), Klebsiella (9, 21%), and Aeromonas spp. (6, 14%). As compared with NF caused by Gram-positive cocci (GPCs), NF caused by GNBs tended to have concurrent bacteremia (81% versus 50%, P=0.09) and initially presented with septic shock (75% versus 30%, P=0.02). However, the in-hospital mortality rate was similar for NF caused by GNBs and GPCs (34% versus 30%, P=1.00). In multivariate analyses, higher sepsis-related organ failure assessment scores (>8) and Child-Pugh class C at initial presentation were independently associated with poor prognoses.

Presentations of patients of poisoning and predictors of poisoning-related fatality: Findings from a hospital-based prospective study

BackgroundPoisoning is a significant public health problem worldwide and is one of the most common reasons for visiting emergency departments (EDs), but factors that help to predict overall poisoning-related fatality have rarely been elucidated. Using 1512 subjects from a hospital-based study, we sought to describe the demographic and clinical characteristics of poisoning patients and to identify predictors for poisoning-related fatality.MethodsBetween January 2001 and December 2002 we prospectively recruited poisoning patients through the EDs of two medical centers in southwest Taiwan. Interviews were conducted with patients within 24 hours after admission to collect relevant information. We made comparisons between survival and fatality cases, and used logistic regressions to identify predictors of fatality.ResultsA total of 1512 poisoning cases were recorded at the EDs during the study period, corresponding to an average of 4.2 poisonings per 1000 ED visits. These cases involved 828 women and 684 men with a mean age of 38.8 years, although most patients were between 19 and 50 years old (66.8%), and 29.4% were 19 to 30 years. Drugs were the dominant poisoning agents involved (49.9%), followed by pesticides (14.5%). Of the 1512 patients, 63 fatalities (4.2%) occurred. Paraquat exposure was associated with an extremely high fatality rate (72.1%). The significant predictors for fatality included age over 61 years, insufficient respiration, shock status, abnormal heart rate, abnormal body temperature, suicidal intent and paraquat exposure.ConclusionIn addition to well-recognized risk factors for fatality in clinical settings, such as old age and abnormal vital signs, we found that suicidal intent and ingestion of paraquat were significant predictors of poisoning-related fatality. Identification of these predictors may help risk stratification and the development of preventive interventions.

Bacteremia Due to Extended-Spectrum-β-Lactamase-Producing Enterobacter cloacae: Role of Carbapenem Therapy

ABSTRACT Enterobacter cloacae is an important nosocomial pathogen. However, few studies specifically dealing with the clinical characteristics and outcome of extended-spectrum β-lactamase (ESBL)-producing E. cloacae infections have been published. During an 8-year period in a medical center, of 610 E. cloacae bacteremic isolates, 138 (22.6%) with ESBL genes were designated the ESBL group, and 120 (19.6%) cefotaxime-nonsusceptible isolates without the ESBL phenotype and genes were designated the control group. Of the former group of isolates, 133 (96.3%) carried the blaSHV-12 gene, 3 (2.1%) had blaCTX-M3, and 2 (1.4%) had both the blaSHV-12 and blaCTX-M3 genes. After patients under the age of 18 years were excluded, there were 206 adults with E. cloacae bacteremia, and these consisted of 121 patients in the ESBL group and 85 in the control group. More episodes of hospital-onset and polymicrobial bacteremia, increased severity of illness, more cases of bacteremia onset in intensive care units (ICUs), and longer stays in the hospital and ICU after bacteremia onset were noted in the ESBL group. However, the crude and sepsis-related mortality rates in two groups were similar. Of the ESBL group, the in-hospital sepsis-related mortality rate of patients definitively treated by a carbapenem was lower than that of those treated by noncarbapenem β-lactams (5/53, or 9.4%, versus 13/44, or 29.5%; P = 0.01) though the difference was not significant in the hierarchical multivariate analysis (P = 0.46). Among 62 patients with follow-up blood cultures within 14 days of bacteremia onset, breakthrough bacteremia was more common in those treated by a noncarbapenem β-lactam agent than in those treated by a carbapenem (18/31, or 58.0%, versus 3/31, or 9.6%; P < 0.001). Thus, carbapenem therapy for ESBL-producing E. cloacae that cause bacteremia may provide therapeutic benefits.

Impact of intravenous omeprazole on Helicobacter pylori eradication by triple therapy in patients with peptic ulcer bleeding

To test the impact of intravenous omeprazole on Helicobacter pylori eradication for bleeding peptic ulcers.

Comparison of the Emergency Severity Index (ESI) and the Taiwan Triage System in predicting resource utilization.

BACKGROUND/PURPOSE The importance of accurate triage in Taiwan is becoming more apparent with the increasing number of emergency department (ED) patients, and resources for the National Health Insurance becoming constrained. This study compared the ability of the Taiwan triage system (TTS) and the standardized 5-level Emergency Severity Index (ESI) triage system to predict ED resource utilization. METHODS Patients arriving at the ED were triaged by both TTS and by using a two-page checklist of ESI criteria during the 3-month study period. The ESI triage level was calculated independently to avoid bias. Disease category (trauma vs. nontrauma), length of stay (LOS) and hospitalization data were evaluated. RESULTS A total of 3172 patients with both ESI and TWN evaluation were included. The distributions of ESI ratings within TTS level 1 were: ESI 1, 21.1%; ESI 2, 68.1%; ESI 3, 7.4%; ESI 4, 3.4%; ESI 5, 0%. For TTS level 3, they were: ESI 1, 0.1%; ESI 2, 26.2%; ESI 3, 39.5%; ESI 4, 27.5%; ESI 5, 6.8%. Hospitalization rates were 74.5%, 40.9% and 22.2% in TTS levels 1, 2 and 3, respectively; and were 96.2%, 47.0%, 30.9%, 6.7%and 6.6% in ESI levels 1, 2, 3, 4 and 5, respectively. TTS triaged more trauma patients as life-threatening/emergent condition than nontrauma patients (68.8% vs. 48.4%, p < 0.001). Triage by ESI, however, showed no significant difference in the percentage of trauma and nontrauma patients with highly acute conditions (44.2% vs. 46.6%, p = 0.230). Patients with ESI level 4 or 5 have significantly shorter ED LOS than those with ESI level 3. CONCLUSION ESI produces more accurate discriminating patient acuity, ED LOS and hospitalization rate than TTS. Adopting a standardized 5-level triage tool might improve resource utilization planning of ED practice.

Etiology and outcome of patients presenting for poisoning to the emergency department in Taiwan: a prospective study

Poisoning is one of the most common reasons for visiting the emergency department in many countries, and the pattern varies from countries to countries and time to time. To compare the etiology and outcome of poisoning patients in different gender and age groups, we conducted a prospective study at the emergency departments of two medical centers in southern Taiwan between January 2001 and December 2002. All cases of poisoning, excluding patients diagnosed as cases of alcohol or food poisoning, were included, and relevant information was collected. There were 1512 cases of poisoning observed with a male to female ratio of 1:1.2 (684/828). Overall, drugs (49.9%) were the main agents involved, and a suicidal attempt (66.1%) was the predominant etiology. A total of 63 fatalities (4.2%) were observed and pesticides, especially paraquat, resulted in most fatalities. Patients aged 19–30 years constituted the most cases, and significant differences in exposure agents, causes, and fatality rates were found among different age and gender groups. The results are compatible with the trend reported by other Asian countries. This study also shows important differences existing in poisoning patients of different age and gender groups. Therefore, different poisoning-prevention strategies should be applied to different groups.

Impact of an outbreak of severe acute respiratory syndrome on a hospital in Taiwan, ROC

Study objective: To estimate the impact of the severe acute respiratory syndrome (SARS) outbreak in early 2003 on a tertiary care hospital in Taiwan, ROC. Methods: The study estimated the utilisation of resources related to infection control, SARS related medical services, and routine medical services, and SARS related medical outcomes at National Cheng Kung University Hospital (NCKUH) from 25 March to 16 June 2003 through a cross sectional survey of hospital records. Results: A mean of 5100 persons per day (95%CI 4580 to 5610) underwent fever screening at the outpatient and emergency department (ED) entrances to the hospital, of which 35 per day (95% CI 30 to 40) were referred for further evaluation for suspected or probable SARS. ED isolation surge capacity was created via 12 new beds outside the ED: eight for SARS assessment, three for patients awaiting inhospital bed assignment, and one for resuscitation. A total of 382 patients were fully evaluated for suspected or probable SARS outside the ED, of which 27 were admitted. The mean numbers of outpatient clinic patient visits, ED visits, ED trauma patient visits, ED admissions, hospital admissions, and operative procedures decreased during the outbreak. Thirty eight patients were hospitalised with suspected SARS, of which three received the final diagnosis of probable SARS. Two patients with probable SARS died. No cases of nosocomial SARS transmission occurred. Conclusions: This SARS outbreak was associated with substantial use of hospital and ED resources aimed at infection control, comparatively less use of resources related to the medical care of patients with suspected or probable SARS, and decreased use of routine medical services.

Implementation of the Hospital Emergency Incident Command System during an outbreak of severe acute respiratory syndrome (SARS) at a hospital in Taiwan, ROC.

Abstract We sought to describe the implementation of the Hospital Emergency Incident Command System (HEICS) at National Cheng Kung University Hospital (NCKUH) in Taiwan, ROC during the outbreak of severe acute respiratory syndrome (SARS) in early 2003. We administered a 14-question survey via structured interviews to individuals occupying activated HEICS leadership positions at NCKUH to identify the organization, structure, and function of the HEICS units and subunits they led and the job actions they performed from 25 March to 16 June 2003 Thirty-three of 38 persons (87%) occupying 39 of 44 (89%) activated HEICS leadership positions directly participated in the survey. The participants collectively reported: 1) the creation of four new HEICS unit leader positions and corresponding units during the outbreak, including the infection control officer (administrative section) and SARS assessment, isolation, and critical care unit leaders (operations section); 2) the creation of six new HEICS subunits, including functional areas for fever screening, SARS assessment, and resuscitation outside the hospital, and SARS patient care, SARS critical care, and employee isolation inside the hospital; and 3) the performance of new job actions related to infection control by all HEICS unit leaders. HEICS provides a flexible framework that seems to have assisted NCKUH in the organization of its emergency response to the SARS outbreak in Taiwan, ROC.