Chun-I Huang

Heart rate variability measures as predictors of in-hospital mortality in ED patients with sepsis

OBJECTIVE To determine the predictive capability of heart rate variability (HRV) measures of patients with sepsis in the ED for in-hospital death. METHODS This was a prospective, observational study. A consecutive cohort of patients visiting the ED of a university teaching hospital who met the criteria of sepsis over a 6-month period were enrolled in this study. General demographics, vital signs, laboratory data, and Mortality in Emergency Department Sepsis score were obtained in the ED; the in-patient medical record was reviewed; and a series of continuous 10-minute electrocardiographic signals were recorded for off-line HRV analysis to assess the in-hospital mortality of the patients. RESULTS One hundred thirty-two patients aged 27 to 86 years who met the inclusion criteria were enrolled. According to the in-hospital outcome, the patients were categorized into 2 groups: nonsurvivors (n = 10) and survivors (n = 122). The baseline HRV measures, including SDNN, TP, VLFP, LFP, and LFP/HFP ratio, of nonsurvivors were significantly lower, whereas the nHFP was significantly higher, than those of survivors. Multiple logistic regression model identified SDNN and nHFP as the significant independent variables in the prediction of in-hospital mortality for ED patients with sepsis. The receiver operating characteristic area for SDNN and nHFP in predicting the risk of death was 0.700 and 0.739, respectively. CONCLUSIONS Heart rate variability measures, especially the SDNN and nHFP, may be used as valuable predictors of in-hospital mortality in patients with sepsis attending the ED.

D-dimer in patients with suspected acute mesenteric ischemia.

OBJECTIVES The aims of this study were to assess the diagnostic value of D-dimer in patients with suspected acute mesenteric ischemia (AMI) and to evaluate the correlation between D-dimer levels and the severity of bowel necrosis. METHODS A prospective, noninterventional study of 67 patients with clinical suspicion of AMI was performed. Measurement of D-dimer levels was performed using a latex turbidimetric method. RESULTS Acute mesenteric ischemia was diagnosed in 23 patients (34.3%) and non-AMI in 44 patients (65.7%). Median D-dimer levels on admission were 6.24 microg fibrinogen equivalent units (FEU)/mL (range, 0.96-53.48 microg FEU/mL) in patients with AMI and 3.45 microg FEU/mL (range, 0.50-44.69 microg FEU/mL) in non-AMI patients (P = .064). D-dimer had poor discriminative value to differentiate the presence from the absence of AMI with an area under the receiver operating characteristic curve of 0.64 (95% confidence interval, 0.50-0.78). A serum D-dimer cutoff value of 1.0 microg FEU/mL had a sensitivity of 96%, a specificity of 18%, a positive likelihood ratio of 1.17, and a negative likelihood ratio of 0.24. Among patients with AMI verified at operation, 8 had resectable bowl necrosis and 9 had unresectable bowel necrosis. There was no difference in serum D-dimer levels between resectable and unresectable bowel necrosis (P = .665). CONCLUSIONS Detection of serum D-dimer could not help to differentiate patient with AMI from those with non-AMI. We did not find a correlation between serum D-dimer levels and the severity of AMI. However, measurement of D-dimer levels can be of value for a small decrease in the likelihood of AMI, when the result is low.

Risk factors associated with adverse drug events among older adults in emergency department

BACKGROUND Little is known about the emergency department (ED) visits from drug-related injury among older adults in Taiwan. This study seeks to identify risk factors associated with adverse drug events (ADEs) leading to ED visits. METHODS We prospectively conducted a case-control study of patients 65years and older presenting to the ED. ED visits between March 1, 2009 and Feb 28, 2010 identified by investigators for suspected ADEs were further assessed by using the Naranjo Adverse Drug Reaction probability scale. For each patient with an ADE, a control was selected and time-matched from the ED population of the study hospital. The association between the risk of adverse drug events and triage, age, gender, serum alanine transaminase (ALT), serum creatinine, number of medications, and Charlson Comorbidity Index scores were analyzed using logistic regression. RESULTS Of 20,628 visits, 295 ADEs were physician-documented in older adults. Independent risk factors for ADEs included number of medications (adjusted odds ratio [OR]=4.1; 95% confidence interval [CI] 2.4-6.9 for 3-7 drugs; adjusted OR=6.4; 95% CI 3.7-11.0 for 8 or more drugs) and increased concentration of serum creatinine (adjusted OR=1.5; 95% CI 1.1-2.2). Diuretics, analgesics, cardiovascular agents, anti-diabetic agents and anticoagulants were the medications most commonly associated with an ADE leading to ED visits. CONCLUSIONS This study suggests that prevention efforts should be focused on older patients with renal insufficiency and polypharmacy who are using high risk medications such as anticoagulants, diuretics, cardiovascular agents, analgesics, and anti-diabetic agents.

Urgent laparotomy versus emergency craniotomy for multiple trauma with head injury patients.

In blunt multiple trauma (MT) with head injury (HI) patients, it is difficult to decide whether to proceed with immediate laparotomy or craniotomy. In August 1989, abdominal ultrasonography (US) using a simple US scoring system was introduced for MT and HI patients as an initial rapid screening procedure. In MT and HI patients with a US score > or = 3 (n = 14), urgent laparotomy was the procedure of first choice. However, immediate head CT scan, then emergency craniotomy, may be justified in hemodynamically stable MT and HI patients with a US score < 3 (n = 98). Appropriate decision making can be applied to decide which procedure is most exigent.

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.

Reappraisal of radiographic signs of pneumoperitoneum at emergency department

PURPOSE This study aimed to evaluate the sensitivities of the reported free air signs on supine chest and abdominal radiographs of hollow organ perforation. We also verified the value of supine radiographic images as compared with erect chest and decubitus abdominal radiographs in detection of pneumoperitoneum. METHODS Two hundred fifty cases with surgically proven hollow organ perforation were included. Five hundred twenty-seven radiographs were retrospectively reviewed on the picture archiving and communication system. Medical charts were reviewed for operative findings of upper gastrointestinal tract, small bowel, or colon perforations. The variable free air signs on both supine abdominal radiographs (KUB) and supine chest radiographs (CXR) were evaluated and determined by consensus without knowledge of initial radiographic reports or final diagnosis. Erect CXR and left decubitus abdominal radiographs were evaluated for subphrenic free air or air over nondependent part of the right abdomen. RESULT Upper gastrointestinal tract perforation was proven in 91.2%; small bowel perforation, in 6.8%; and colon perforation, in 2.0%. The positive rate of free air was 80.4% on supine KUB, 78.7% on supine CXR, 85.1% on erect CXR, and 98.0% on left decubitus abdominal radiograph. Anterior superior oval sign was the most common radiographic sign on supine KUB (44.0%) and supine CXR (34.0%). Other free air signs ranged from 0% to 30.4%. CONCLUSIONS Most free air signs on supine radiographs are located over the right upper abdomen. Familiarity with free air signs on supine radiographs is very important to emergency physicians and radiologists for detection of hollow organ perforation.

Emergency department (ED) utilization of oldest old men in a veterans care home in Taiwan

ED is a common channel for older people to seek for medical services. However, unlike most care homes in the world, veterans care home in Taiwan has a constantly operating outpatient and inpatient services. Therefore, utilization of ED services among veterans care home may be different from most care home residents. Records of residents in Banciao Veterans Home residents visiting the ED of Taipei Veterans General Hospital from January to December of 2006 were retrospectively collected and analyzed. Demographic variables including age, sex, modes of arrival, category of triage, time of visit, main presenting symptoms, principal diagnosis, medical expenditure and the disposition after the ED visit or after admission to wards were carefully recorded. In total, 368 residents (mean age=81.9+/-5.9 years, all men) with 635 visits were identified. Nearly a half of Banciao Veterans Home residents had visited ED for at least once in 2006 and the medical expenditure was four times higher than other ED visitors. In average, 52.3% of ED visitors would be hospitalized and the most common diagnosis was infectious conditions. Onsite primary care geriatricians may play an important role in such settings.

Assessment of Bilateral Inferior Petrosal Sinus Sampling (BIPSS) in the Diagnosis of Cushing's Disease

Background: The differential diagnosis of adrenocorticotropin (ACTH)‐dependent Cushings syndrome (CS) remains a challenging issue for clinical endocrinologists. In this respect, bilateral inferior petrosal sinus sampling (BIPSS) appears to be the most sensitive and specific test. Here, we report our 15‐year experience of analyzing the performance of BIPSS, both in the correct diagnosis and in the precise lateralization of tumors in patients with Cushings disease (CD). Methods: Between 1992 and 2006, 18 patients with CD (16 females, 2 males; age range, 14‐56 years) were admitted to Taipei Veterans General Hospital and subjected to BIPSS plus ovine corticotropin‐releasing hormone (oCRH) stimulation. Four of them had previously undergone transsphenoidal hypophysectomy (TSH) and had a recurrence thereafter. BIPSS was performed by inserting a catheter in the right and left inferior petrosal sinus for ACTH assay via a femoral vein puncture. An inferior petrosal sinus/peripheral ACTH ratio (C/P ratio) = 2 at baseline or = 3 after oCRH injection indicated a pituitary origin of ACTH secretion, and an interpetrosal ACTH gradient (IPS ratio) = 1.4 at baseline or after oCRH indicated evidence of lateralization. Results: Positive BIPSS results were found in 16 patients at baseline and in 17 patients after oCRH injection. In 17 out of 18 patients, TSH was subsequently carried out and a pituitary source was confirmed on histopathologic examination. The only 1 false‐negative test result was noted in a patient who had undergone previous TSH. Thus, the sensitivities of BIPSS for the diagnosis of CD before and after oCRH stimulation were 89% and 94%, respectively. Moreover, using an IPS ratio = 1.4 as a criterion, BIPSS correctly lateralized the tumor in 9 of 17 and 10 of 17 patients at baseline and after oCRH stimulation, respectively, including in 2 patients who had a centrally located tumor and who had an IPS ratio < 1.4. Thus, the sensitivities of lateralization of BIPSS were 53% and 59%, respectively. None of the 4 patients who had previous TSH were precisely localized by BIPSS. If these 4 patients were excluded, the sensitivities of BIPSS for localizing in the patients who had not undergone previous operation increased to 70% (9/13) at baseline and 77% (10/13) after oCRH stimulation, respectively. Conclusion: BIPSS combined with oCRH stimulation is a safe and reliable examination both in the differential diagnosis of CD and in the correct lateralization of pituitary microadenoma in patients without previous pituitary surgery. Nevertheless, this procedure may provide misleading results in patients who have received previous pituitary surgery.

Is ward experience in resuscitation effort related to the prognosis of unexpected cardiac arrest

Background: The aim of this study was to investigate the outcome of patients of unexpected cardiac arrest initially resuscitated by first responders with dissimilar experiences under the support of cardiac arrest team (CAT). Methods: All unexpected cardiac arrest patients receiving in‐hospital resuscitation with the activation of CAT in a tertiary‐care teaching hospital over a 12‐month period were recorded according to the Utstein criteria. We prospectively recorded various factors at resuscitation and retrospectively evaluated the outcome. Outcome measures included return of spontaneous circulation (ROSC), survival longer than 24 hours, and survival to discharge. Results: Altogether, 76 emergency calls were registered, and among these, 44 calls (58%) were cardiac arrests, including 8 ventricular tachycardia/fibrillation, 15 pulseless electrical activity, and 21 asystole. The rate of ROSC was 61%, the rate of survival longer than 24 hours was 37%, and the rate of survival to discharge was 18%. The response time of our CAT was 271 seconds (4 minutes and 31 seconds) on average. The patients who collapsed in the wards experienced in resuscitation effort received higher rates of appropriate basic and advanced cardiac life support interventions before CAT arrival (79% vs. 44%; p = 0.019), had an increased chance of ROSC (75% vs. 38%; p = 0.014), survival longer than 24 hours (54% vs. 13%; p = 0.007), and survival to discharge (29% vs. 0%; p = 0.036). Conclusion: Hospital wards with more than 5 cardiac arrests per year have a better patient survival rate than those with fewer arrests. This is despite all ward staff receiving the same level of training.

Expression of the triggering receptor expressed on myeloid cells‐1 mRNA in a heterogeneous infected population

This study is to investigate the clinical utility of detection of peripheral blood triggering receptor expressed on myeloid cells (TREM)‐1 mRNA as an early indicator of sepsis among critically ill patients and to compare the results of TREM‐1 with those of C‐reactive protein (CRP). A prospective, non‐interventional study of 127 patients with at least two criteria of the systemic inflammatory response (SIRS) was performed. TREM‐1 was assessed by real‐time quantitative reverse transcription‐polymerase chain reaction.