Hsien-Hao Huang

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.

The association between on-scene blood pressure and early neurological deterioration in patients with spontaneous intracerebral haemorrhage

Objective To determine whether on-scene BP is associated with early neurological deterioration (END) in patients with spontaneous intracerebral haemorrhage (SICH). Methods This retrospective cohort study enrolled consecutive ambulance-transported adult SICH patients treated at our emergency department (ED) from January 2007 through December 2012. END was defined as a ≥2-point decrease in GCS within 24 h of ED arrival. The exact relationship between on-scene BP and END was assessed using multiple logistic regression analyses for adjusting age, gender, Charlson Index, aspirin use, smoking, elapsed time, consciousness level on ED arrival, haematoma size, intraventricular extension, midline shift and infratentorial ICH. We further calculated the −2 log-likelihood decrease for each regression model incorporated with the BP values measured at different times to compare model fitness. Results After adjusting for the covariates, on-scene systolic BP (by 10 mm Hg incremental: OR = 1.126, 95% CI 1.015 to 1.265), diastolic BP (by 10 mm Hg incremental: OR=1.146, 95% CI 1.019 to 1.303) and mean arterial pressure (MAP) (by 10 mm Hg incremental: OR=1.225, 95% CI 1.057 to 1.443) were significantly associated with END; adding on-scene MAP into the regression model yielded the highest model fitness increase. Adding on-scene BPs into the regression model yielded higher model fitness increase than adding ED and admission BPs. Conclusions Few on-scene BP indices were associated with neuroworsening within 24 h after ED arrival in non-comatose SICH patients. Compared with BP measured on ED arrival or admission, on-scene BP had a stronger correlation with END.

Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.

Objectives: To investigate clinical features and outcomes in patients with acute cholecystitis with gall bladder perforation receiving open cholecystectomy or percutaneous transhepatic gall bladder drainage in the emergency department. Methods: From 1996 through 2005, 33 patients with non-traumatic gall bladder perforation, among 585 patients with acute cholecystitis, were enrolled. Patients were divided into two groups: open cholecystectomy in 16 patients and percutaneous transhepatic gall bladder drainage in 17 patients. Medical records, including demographic data, past history of systemic diseases or gallbladder stones, initial clinical presentations, laboratory data, physical status, therapeutic interventions, and outcomes, were analysed. Results: Mean patient age was 72.6 years (range 54–92 years). 28 patients (84.8%) were male. Median time of symptom onset before emergency department diagnosis was 5 days (range 0.5–30 days). Estimated incidence of gall bladder perforation was 5.6% (33/585). 27 patients (81.8%) had gallstones operatively or in image studies. All patients had either right upper quadrant pain/tenderness or epigastric pain/tenderness. Only 9 (27.3%) patients had positive Murphy’s sign. Six patients in the percutaneous transhepatic gall bladder drainage group received further open cholecystectomy. Overall mortality was 24.2% (8/33). The direct cause of death was disease related sepsis in all patients. Patients receiving percutaneous transhepatic gall bladder drainage had a higher survival rate than those receiving open cholecystectomy (100% vs 50%, p<0.001). No differences in complications and length of hospital stay of survivors were observed between groups. Conclusions: In this study, we delineated clinical features of patients with gall bladder perforation. Better clinical outcome is observed for percutaneous transhepatic gall bladder drainage, and this is suggested as an initial therapeutic choice, especially in high risk patients who are likely to need surgery.

Impact of Severe Acute Respiratory Syndrome (SARS) Outbreaks on the Use of Emergency Department Medical Resources

Background: The impact of the severe acute respiratory syndrome (SARS) outbreak in 2003 on the emergency department (ED) medical needs of adult patients has not been elucidated. The purpose of this study was to investigate the demographic and clinical characteristics of ED adult patients before, during and after the SARS epidemic in a SARS‐dedicated hospital. Methods: A retrospective, ED chart review was conducted, and demographic data were obtained from a computer database, for a total of 17,586 patients. Patient information, including age, gender, mode of arrival, triage category, time of visit, main diagnosis, use of ED services, and status after the ED visit, were collected and compared for pre‐, early‐, peak‐, late‐, and post‐SARS epidemic stages. Results: Demographic data demonstrated a significant decrease in patient attendances per day, with a mean reduction of 92.5 ± 8.3 patients (43.7 ± 3.9% reduction in rate; p < 0.01) during peak‐versus pre‐epidemic stages, but revealed no differences in patient age and gender. The numbers of patients with ambulance transport, inter‐hospital referral, and critical illnesses, including DOA, categorized as triage 1, or admitted to a ward or intensive care unit after the ED visit, were not influenced by the SARS epidemic. The number of patients with upper airway infections and suicide attempts from drug overdoses increased, but not statistically significantly. The number of patients with other diagnoses decreased progressively from early‐ to peak‐epidemic stages, but returned to their earlier levels at the post‐epidemic stage. Statistically significant decreases (p < 0.05) were noted in mean attendance at peak‐versus pre‐ and early‐epidemic stages for patients with cardiovascular disease, inflammatory or functional bowel disease, endocrine disease, dizziness or vertigo, or trauma. Conclusion: The SARS outbreak did not eliminate the need of critically ill patients for advanced medical support. However, besides an overall decrease in patient numbers, the SARS epidemic markedly altered demographic information, clinical characteristics, and the use of medical services by adult patients in the ED of a SARS‐dedicated hospital.

Acute Erycibe Henryi Prain (“Ting Kung Teng”) Poisoning

Erycibe henryi Prain (“Ting Kung Teng”), a species of Convolvulaceae, has been used in Chinese medicine to relieve pain involving the musculoskeletal system, such as arthritis, sciatica, and traumatic tissue swelling. E. henryi can be mistaken for another herbal plant, Tripterygium wilfordii Hook F, used to treat gouty arthritis. We report here three cases of E. henryi poisoning. All three cases presented with vomiting, diarrhea, salivation, diaphoresis, lacrimation, and rhinorrhea; two patients also had miosis, hypothermia, bradycardia, hypotension, and ventricular tachyarrhythmias. Laboratory abnormalities included leucocytosis, hyperglycemia, hyperamylasemia, hypocalcemia, and transiently elevated liver enzymes, creatinine and creatinine phosphokinase. The active constituents of E. henryi include several tropane alkaloids, which exhibit cholinergic activities. Gastrointestinal disturbances and ventricular tachyarrhythmias may occur with ingestion of either E. henryi or T. wilfordii, but the cholinergic symptoms can help to differentiate them.

Anticoagulant-induced intramural intestinal hemorrhage

BACKGROUND Long-term use of warfarin can provide benefits in the treatment of many diseases, but adverse bleeding events are unpreventable because of a narrow therapeutic range. OBJECTIVE The aim of this retrospective chart review with data abstraction was to investigate the clinical presentations of intestinal intramural hemorrhage in emergency department (ED) patients. METHODS We reviewed the cases of 17 patients with acute abdominal pain in our ED. Medical records including demographic data and results of abdominal computed tomography were retrospectively reviewed and analyzed. RESULTS The mean ± SD age of the reviewed patients was 77.7 ± 8.5 years (range, 60-93 years). The mean ± SD duration from onset of symptoms to ED visit was 2.5 ± 1.3 days (range, 1-5 days). All patients had abdominal pain, and 64.7% had nausea/vomiting. A total of 64.7% of patients had peritoneal signs. The jejunum was most commonly involved (88.2% of all cases). The maximal mean ± SD wall thickening of the bowel was 14.1 ± 4.4 mm (range, 7.4-26.7 mm), and the estimated mean ± SD length was 35.6 ± 24.4 cm (range, 9-105 cm). The mean ± SD prothrombin time and activated partial thromboplastin time were prolonged to 86.5 ± 26.9 and 116.2 ± 43.1 seconds, respectively. All patients received medical treatment and survived. At the last follow-up (mean, 27.4 months), none of the patients had recurrence of intestinal intramural hemorrhage or intestinal obstruction. CONCLUSION Prolonged prothrombin time and drug history can indicate the possibility of intramural intestinal hemorrhage, and abdominal computed tomography may help to exclude surgical diseases and prevent unnecessary surgery.

A new strategy for emergency department crowding: High-turnover utility bed intervention

Background This study applied a new strategy, termed high‐turnover utility bed intervention, to offer early admission chances for emergency department (ED) patients and alleviate ED crowding. Methods This before‐and‐after observational cohort study was conducted at the ED of an urban tertiary hospital. On January 1, 2012, 14 utility beds were prepared exclusively for ED patient use. A strict 48‐hour course limit for each patient was formulated to govern these high‐turnover beds. The primary outcome measure for this study was ED length of stay. Secondary outcome measures were the number of ED admissions, patients who left without being seen, and revisits within 72 hours of discharge, as well as the outcomes of cardiac arrest management and ambulance diversion hours. Results There were 70,515 adult ED visits enrolled during the preintervention period (January–December 2011), and 69,706 during the postintervention period (July 2012–June 2013). In the postintervention period, this new strategy offered 1401 early admission opportunities. The ambulance diversion hours decreased prominently from 5.4 hours to 1.6 hours per day. A shortening in ED length of stay from 9.7 hours to 8.0 hours was achieved, mainly in cases of nontrauma. More patients (31.2% vs. 29.7%) were admitted to the wards with a lower discharge rate in the postintervention period. Additionally, there was no difference in ED revisit within 72 hours and cardiac arrest management. Conclusion The high‐turnover ED utility bed intervention offered improved admission chance and alleviated ED crowding output. ED efficiency improved, with shortened ED length of stay and fewer ambulance diversion hours.

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.

How to differentiate spontaneous intramural intestinal hemorrhage from acute mesenteric ischemia

OBJECTS The purpose of our study was to assess the diagnostic values of laboratory tests to differentiate spontaneous intramural intestinal hemorrhage (SIIH) from acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department (ED). METHOD We retrospectively included 76 patients diagnosed SIIH or AMI after abdominal CT. RESULTS The mean ages of 28 SIIH patients and 48 AMI patients were 75.9 ± 13.7 years and 75.8 ± 11.6 years, respectively. Patients with SIIH had significantly higher rate of Coumadin use (P < .001) and localized tenderness (P < .05). In laboratory findings, SIIH patients had prolonged prothrombin time (PT) (83.6 ± 30.0 vs. 13.4 ± 3.2, P < .001), lower blood urea nitrogen (P < .05), lower creatinine (P < .05), and lower creatine kinase (P < .05). Prolonged PT showed good discriminative value to differentiate acute abdomen patients with SIIH from AMI after abdominal CT, with an area under the receiver operating characteristic curve of 0.980 (95% confidence interval, 0.918-0.998; P < .0001). Prolonged PT cut-off value of ≧22.5 seconds had a sensitivity of 92.9% and a specificity of 100%. Logistic regression analysis identified prolonged PT as an independent predictor of SIIH (odds ratio, OR, 22.2; P = .007). CONCLUSION Abdominal pain patients with either SIIH or AMI are rare in the ED, but abdominal CT sometimes cannot help to differentiate them due to similar CT findings. Prolonged PT might help emergency physicians and surgeons differentiate SIIH from AMI in such cases.

Induced pluripotent stem cells alleviate lung injury from mesenteric ischemia-reperfusion.

BACKGROUND Mesenteric ischemia-reperfusion (I/R) injury is a serious pathophysiologic process that can trigger the development of multiorgan dysfunction. Acute lung injury is a major cause of death among mesenteric I/R patients, as current treatments remain inadequate. Stem cell–based therapies are considered novel strategies for treating several devastating and incurable diseases. This study examined whether induced pluripotent stem cells (iPSCs) lacking c-myc (i.e., induced using only the three genes oct4, sox2, and klf4) can protect against acute lung injury in a mesenteric I/R mouse model. METHODS C57BL/6 mice were randomly divided into the following groups: sham/no treatment, vehicle treatment with phosphate-buffered saline, treatment with iPSCs, and treatment with iPSC-conditioned medium. The mice were subjected to mesenteric ischemia for 45 minutes followed by reperfusion for 24 hours. After I/R, the lungs and the ileum of the mice were harvested. Lung injury was evaluated by histology, immunohistochemistry, and analyses of the levels of inflammatory cytokines, cleaved caspase 3, and 4-hydroxynonenal. RESULTS The intravenously delivered iPSCs engrafted to the lungs and the ileum in response to mesenteric I/R injury. Compared with the phosphate-buffered saline–treated group, the iPSC-treated group displayed a decreased intensity of acute lung injury 24 hours after mesenteric I/R. iPSC transplantation significantly reduced the expression of proinflammatory cytokines, oxidative stress markers, and apoptotic factors in injured lung tissue and remarkably enhanced endogenous alveolar cell proliferation. iPSC-conditioned medium treatment exerted a partial effect compared with iPSC treatment. CONCLUSION When considering the anti-inflammatory, antioxidant, and antiapoptotic properties of iPSCs, the transplantation of iPSCs may represent an effective treatment option for mesenteric I/R-induced acute lung injury.