Hsiang Chin Hsu

An Increased Risk of Reversible Dementia May Occur After Zolpidem Derivative Use in the Elderly Population: A Population-Based Case-Control Study

AbstractWe evaluate the effects of zolpidem use to develop dementia or Alzheimer disease from the Taiwan National Health Insurance Research Database (NHIRD).A retrospective population-based nested case–control study. Newly diagnosed dementia patients 65 years and older and controls were sampled. A total of 8406 dementia and 16,812 control subjects were enrolled from Taiwan NHIRD during 2006 to 2010. The relationships between zolpidem use and dementia were measured using odds and adjusted odds ratios. The relationship between the average cumulative doses for zolpidem and dementia was also analyzed.Zolpidem alone or with other underlying diseases, such as hypertension, diabetes, and stroke, was significantly associated with dementia after controlling for potential confounders, such as age, sex, coronary artery disease, diabetes, anti-hypertension drugs, stroke, anticholesterol statin drugs, depression, anxiety, benzodiazepine, anti-psychotic, and anti-depressant agents’ use (Adjusted OR = 1.33, 95% CI 1.24–1.41). Zolpidem use also has significant dose–response effects for most of the types of dementia. In patient with Alzheimer diseases, the effects of zolpidem among patients with Alzheimers disease remained obscure. The adjusted OR for patients whose cumulative exposure doses were between 170 and 819 mg/year (adjusted OR: 1.65, 95% CI 1.08–2.51, P = 0.0199) was significant; however, the effects for lower and higher cumulative dose were not significant.Zolpidem used might be associated with increased risk for dementia in elderly population. Increased accumulative dose might have higher risk to develop dementia, especially in patients with underlying diseases such as hypertension, diabetes, and stroke.

Atypical presentations of dengue disease in the elderly visiting the ED

OBJECTIVE The objective was to compare the clinical characteristics of elderly and young adult patients with dengue in the emergency department (ED). METHODS Demographic characteristics, clinical presentation, disease severity, laboratory characteristics, and outcomes were analyzed prospectively as a case-control study. RESULTS Of the 193 adults with serologically confirmed dengue disease in 2007, 31 (16.1%) were elderly patients (aged ≥65) and 162 were young adults (aged <65). More dengue hemorrhagic fever (12.9% vs 2.5%, P = .02), a longer ED stay (13.3 vs 8.6 hours, P = .004), a longer hospital stay (7.4 vs 3.4 days, P < .001), a higher Simplified Acute Physiology Score II in the ED (29.7 vs 17.4, P < .001), and a higher rate of at least 1 comorbidity (61.8 vs 22.8%, P < .001) were found in the elderly. However, the length of the intensive care unit stay (elderly 0.7 vs young adults 0.3 day, P = .47) and the 14-day mortality rate (0% vs 0.6%, P = 1.00) were similar. Of note, in terms of clinical presentations of dengue in the ED, there were more elderly patients with isolated fever (41.9% vs 17.9%, P = .003) and fewer with typical presentation (41.9% vs 75.9%, P = <.001) than there were young adults. CONCLUSIONS The present study found a higher number of atypical presentations, a longer hospitalization, and a higher degree of clinical illness in elderly patients with dengue.

Prognostic values of blood ammonia and partial pressure of ammonia on hospital arrival in out-of-hospital cardiac arrests

PURPOSES Outcome prediction for out-of-hospital cardiac arrest (OHCA) is of medical, ethical, and socioeconomic importance. We hypothesized that blood ammonia may reflect tissue hypoxia in OHCA patients and conducted this study to evaluate the prognostic value of ammonia for the return of spontaneous circulation (ROSC). METHODS This prospective, observational study was conducted in a tertiary university hospital between January 2008 and December 2008. The subjects consisted of OHCA patients who were sent to the emergency department (ED). The primary outcome was ROSC. The prognostic values were calculated for ammonia levels and the partial pressure of ammonia (pNH(3)), and the results were depicted as a receiver operating characteristics curve with an area under the curve. RESULTS Among 119 patients enrolled in this study, 28 patients (23.5%) achieved ROSC. Ammonia levels and pNH(3) in the non-ROSC group were significantly higher than those in the ROSC group (167.0 μmol/L vs 80.0 μmol/L, P < .05; 2.61 × 10(-5) vs 1.67 × 10(-5) mm Hg, P < .05, respectively). The predictive capacity of area under the curve for ammonia and pNH(3) for non-ROSC was 0.85 (95% confidence interval, 0.75-0.95) and 0.73 (95% confidence interval, 0.61-0.84), respectively. The multivariate analysis confirmed that ammonia and pNH(3) are independent predictors of non-ROSC. The prognostic value of ammonia was better than that of pNH(3). The cutoff level for ammonia of 84 μmol/L was 94.5% sensitive and 75.0% specific for predicting non-ROSC with a diagnostic accuracy of 89.9%. CONCLUSIONS Hyperammonemia on ED arrival is independently predictive of non-ROSC for OHCA patients. The findings may offer useful information for clinical management.

Applications of a rapid and sensitive dengue DUO rapid immunochromatographic test kit as a diagnostic strategy during a dengue type 2 Epidemic in an Urban City

Dengue infection is a major health problem in tropical and subtropical countries. A prospective observational study in a university-affiliated hospital was conducted between August 2015 and September 2015. Patients who visited the emergency department (ED) with a presentation of any symptoms of dengue were eligible for the dengue non-structural protein 1 (NS1), IgM/IgG rapid immunochromatographic tests and real-time polymerase chain reaction (RT-PCR) to evaluate the performance of the rapid tests. Considering the RT-PCR as the gold standard for the dengue diagnosis, the ideal primary results of sensitivity (80–100%), specificity (60–84%), positive predicted value(75%-95%), and negative predicted value (70–100%) suggested that the NS1-based test with or without a combination of IgM and IgG tests have good diagnostic performances in detecting dengue infections, even in the afebrile or elderly populations.

Factors Associated with Blood Culture Contamination in the Emergency Department: Critical Illness, End-Stage Renal Disease, and Old Age

Background Blood culture contamination in emergency departments (ED) that experience a high volume of patients has negative impacts on optimal patient care. It is therefore important to identify risk factors associated with blood culture contamination in EDs. Methodology/Principal Findings A prospectively observational study in a university-affiliated hospital were conducted between August 2011 and December 2012. Positive monomicrobial and negative blood cultures drawn from adult patients in the ED were analyzed to evaluate the possible risk factors for contamination. A total of 1,148 positive monomicrobial cases, 391 contamination cases, and 13,689 cases of negative blood culture were identified. Compared to patients with negative blood cultures, patients in triage levels 1 and 2 (Incidence Rate Ratio, IRR = 2.24), patients with end-stage renal disease (ESRD) (IRR = 2.05), and older patients (IRR: 1.02 per year) were more likely to be associated with ED blood culture contamination. Conclusions/Significance Critical patients (triage levels 1 and 2), ESRD patients, and older patients were more commonly associated with blood culture contamination in the ED. Further studies to evaluate whether the characteristics of skin commensals contribute to blood culture contamination is warranted, especially in hospitals populated with high-risk patients.

Viral Respiratory Tract Infections in Adult Patients Attending Outpatient and Emergency Departments, Taiwan, 2012-2013: A PCR/Electrospray Ionization Mass Spectrometry Study.

AbstractViral etiologies of respiratory tract infections (RTIs) have been less studied in adult than in pediatric populations. Furthermore, the ability of PCR/electrospray ionization mass spectrometry (PCR/ESI-MS) to detect enteroviruses and rhinoviruses in respiratory samples has not been well evaluated. We sought to use PCR/ESI-MS to comprehensively investigate the viral epidemiology of adult RTIs, including testing for rhinoviruses and enteroviruses.Nasopharyngeal or throat swabs from 267 adults with acute RTIs (212 upper RTIs and 55 lower RTIs) who visited a local clinic or the outpatient or emergency departments of a medical center in Taiwan between October 2012 and June 2013 were tested for respiratory viruses by both virus isolation and PCR/ESI-MS. Throat swabs from 15 patients with bacterial infections and 27 individuals without active infections were included as control samples.Respiratory viruses were found in 23.6%, 47.2%, and 47.9% of the 267 cases by virus isolation, PCR/ESI-MS, and both methods, respectively. When both methods were used, the influenza A virus (24.3%) and rhinoviruses (9.4%) were the most frequently identified viruses, whereas human coronaviruses, human metapneumovirus (hMPV), enteroviruses, adenoviruses, respiratory syncytial virus, and parainfluenza viruses were identified in small proportions of cases (<5% of cases for each type of virus). Coinfection was observed in 4.1% of cases. In the control group, only 1 (2.4%) sample tested positive for a respiratory virus by PCR/ESI-MS. Patients who were undergoing steroid treatment, had an active malignancy, or suffered from chronic obstructive pulmonary disease (COPD) were at risk for rhinovirus, hMPV, or parainfluenza infections, respectively. Overall, immunocompromised patients, patients with COPD, and patients receiving dialysis were at risk for noninfluenza respiratory virus infection. Rhinoviruses (12.7%), influenza A virus (10.9%), and parainfluenza viruses (7.3%) were the most common viruses involved in the 55 cases of lower RTIs. The factors of parainfluenza infection, old age, and immunosuppression were independently associated with lower RTIs.In conclusion, PCR/ESI-MS improved the diagnostic yield for viral RTIs. Non-influenza respiratory virus infections were associated with patients with comorbidities and with lower RTIs. Additional studies that delineate the clinical need for including non-influenza respiratory viruses in the diagnostic work-up in these populations are warranted.

Impact of delayed admission to intensive care units on patients with acute respiratory failure

Background/Purpose: To determine the impact of delayed admission to the intensive care unit (ICU) on the clinical outcomes of patients with acute respiratory failure (ARF) in the emergency department (ED). Methods: This retrospective cohort study included non‐traumatic adult patients with ARF and mechanical ventilation support in the ED of a tertiary university hospital in Taiwan from January 1, 2013, to August 31, 2013. Clinical data were extracted from chart records. The primary and secondary outcome measures were a prolonged hospital stay (>30 days) and the in‐hospital crude mortality within 90 days, respectively. Results: For 267 eligible patients (age range 21.0‐98.0 years, mean 70.5 ± 15.1 years; male 184, 68.9%), multivariate analysis was used to determine the significant adverse effects of an ED stay >1.0 hour on in‐hospital crude mortality (odds ratio 2.19, P < .05), which was thus defined as delayed ICU admission. In‐hospital mortality significantly differed between patients with delayed ICU admission and those without delayed admission, as revealed by the Kaplan‐Meier survival curves (P < .05). Moreover, a linear‐by‐linear correlation was observed between the length of ICU waiting time in the ED and the lengths of total hospital stay (r = 0.152, P < .05), ICU stay (r = 0.148, P < .05), and ventilator support (r = 0.222, P < .05). Conclusions: For patients with ARF who required mechanical ventilation support and intensive care, a delayed ICU admission more than 1.0 hour is a strong determinant of mortality and is associated with a longer ICU stay and a longer need for ventilation.

Macrolide combination antibiotic therapy should be prudently considered in complicated CAP cases and in regions with low macrolide susceptibility

Dear Editor, In response to the article by MartinLoeches et al. [1] regarding improved survival in intubated patients with community-acquired pneumonia treated with combination antibiotic therapy with macrolides, we would like to address several points regarding macrolide resistance and study population. In the recent decade, susceptibility of pneumococcus to macrolides in Asia has been very low. Erythromycin susceptibility is \20% in Taiwan and Korea, and about 25% in Hong Kong and China [2]. Macrolideresistant strains (ermB and mefA) are widely circulating in Asia. Low susceptibility of pneumococci to macrolides is difficult to deny. According to a study in Taiwan, macrolide susceptibility of pneumococci remains low, even though macrolide usage has been decreasing for many years. The rate of erythromycin resistance in streptococcal pneumonia showed an increasing trend, from 80.2% in 1999 to 92% in 2003 [3, 4]. The 2007 ATS/IDSA guidelines for community-acquired pneumonia (CAP) were based on epidemiology studies in the USA. In the USA and Europe, appropriate therapies, in which a macrolide would be combined with a beta-lactam, showed that macrolides may be effective in treating bacteremic pneumococcal pneumonia, CAP, severe sepsis, and septic shock due to CAP [1, 5]. However, synergic effects of macrolides and beta-lactams in treating invasive pneumococcal pneumonia in Asia may not be as good as in the USA and Europe. Macrolides may be used only to empirically cover atypical pathogens such as Legionella or Mycoplasma. Moreover, in this article, MartinLoeches et al. did not indicate such detailed characteristics as underlying diseases, pathogens, disease severity, or number of days of intensive care unit (ICU) stay for the empirical antimicrobial therapy group that was treated with a macrolide or for the empirical antimicrobial therapy group treated with fluoroquinolones. The authors only indicated ICU mortality and that overall mortality in the macrolide group was lower than in the fluoroquinolones group. Furthermore, according to the 2007 ATS/IDSA guidelines for CAP, subjects who were suggested to be treated by a fluoroquinolone and a beta-lactam combination were those with possible Pseudomonas infection. In this study, compared with the macrolide and betalactam combination group, cases receiving fluoroquinolone and betalactam combination had lower proportions receiving third-generation cephalosporins and higher proportions receiving fourth-generation cephalosporins, carbapenem, and piperacillin/ tazobactam. Therefore, cases receiving fluoroquinolone and beta-lactam combinations may have more complicated conditions than those receiving macrolide and beta-lactam combinations. Since cases receiving a fluoroquinolone tended to have more complicated predisposing factors, we could not expect that they would have better shortand long-term prognosis. Accordingly, prudent antibiotic use remains essential in complicated cases with severe CAP in regions with low macrolide susceptibility.

Rapid Human Immunodeficiency Virus Screening in an Emergency Department in a Region with Low HIV Seroprevalence.

Human immunodeficiency virus (HIV) tests are commonly performed in emergency departments (EDs) in the United States (US), but the experience and effectiveness of conducting rapid HIV tests in EDs in regions with low HIV seroprevalence outside the US have seldom been reported. An observational cross-sectional opt-in rapid HIV test and counseling program was conducted at an ED in a teaching hospital in Taiwan, a country with low seroprevalence, to determine the acceptance of rapid HIV tests as well as risky behaviors and illness presentations of people who agreed to undergo the tests. Among 7,645 ED patients between 20 and 55 years of age, 2,138 (28%) agreed to undergo rapid HIV tests, and only 2 (0.09%) tested positive. Patients diagnosed with urinary tract infections, respiratory tract infections, infectious diarrhea, and pelvic inflammatory disease were more likely to be willing to undergo rapid HIV tests in the ED. Stratified analysis revealed that sexually active patients were more likely to consent to HIV testing. Therefore, non-targeted opt-in HIV testing and counseling in the ED was feasible but was not effective in a region with low HIV seroprevalence.