Ju-Sing Fan

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.

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.

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.

Urine output and performance of runners in a 12-hour ultramarathon.

Objective:To understand the urination pattern and to determine the relationships between urine output and performance of ultramarathon runners. Design:Prospective observational study. Setting:The 2005 Soochow University international ultramarathon, in which each athlete ran for 12 hours. Participants:All entrants in the 12-hour race were invited to participate in the study. Interventions:None. Main Outcome Measures:Athletes were weighed immediately before and after the race. Urine samples were collected during the race and immediately after the race. Results:There was a trend toward better performance of the group with less urination (LU), although the difference was not statistically significant. Further analysis of hourly running distances between groups showed better performance in the group with LU during the first 11 hours of the competition. Comparison of athletes in 3 levels of running distance (tertiles) showed statistically significant differences between groups in total urine output. The fastest tertile had lower prerace body weight and greater body weight change than the slowest and intermediate tertiles, but the differences were not statistically significant. Linear regression analysis using the stepwise method showed that total urine output and prerace body weight were negatively associated with performance. Conclusions:Runners with LU had better performance during the first 11 hours of the competition. Linear regression analysis showed that total urine output and prerace body weight were negatively associated with performance.

Interhospital transfer neurological deterioration in patients with spontaneous intracerebral haemorrhage: incidence and risk factors

Objective To explore the incidence and risk factors for interhospital transfer neurological deterioration (IHTND) in patients with spontaneous intracerebral haemorrhage (SICH). Methods Consecutive adult patients with first-ever SICH referred to our emergency department (ED) and transported by ambulance from July 2011 through June 2015 were eligible for this prospective observational study. Enrolled patients had SICH with elapsed time <12 hours and a nearly normal Glasgow Coma Scale (GCS) score (≥13) at presentation. IHTND was defined as GCS score drop ≥2 points during the time from last GCS measure in first ED (shortly before transport) and first measure in second ED (shortly after arrival), which was confirmed by the accompanying nurse practitioner. The potential risk factors for IHTND were screened by χ2 test, unpaired t test (parametric data) or Mann–Whitney U test (non-parametric data) in univariate analysis. Multiple logistic regression analysis was used to adjust for other covariates. Results Among 217 enrolled patients, 36 (16.6%) had IHTND. After adjustment for other covariates in multiple logistic regression analysis, the significant predictors of IHTND were arrival systolic blood pressure ≥180 mm Hg (p=0.026, OR=2.741, 95% CI 1.126 to 6.674), infratentorial ICH (p=0.015, OR=3.182, 95% CI 1.248 to 8.113), presence of intraventricular haemorrhage (p=0.023, OR=2.533, 95% CI 1.137 to 5.645) and larger ICH (by 1 mL increment of haematoma, p=0.013, OR=1.027, 95% CI 1.006 to 1.048). Conclusions About one-sixth of referred not comatose patients with SICH developed IHTND. Some risk factors were identified for the first time. Modifying procedures for proper transfer of patients at high-risk for IHTND might help in safely transferring patients with SICH.

Emergency department DNR order in patients with spontaneous intracerebral hemorrhage

Objectives To explore the determinant factors and prognostic significance of emergency department do‐not‐resuscitate (ED‐DNR) orders for patients with spontaneous intracerebral hemorrhage (SICH). Methods Consecutive adult SICH patients treated in our ED from January 1, 2012 to December 31, 2016 were selected as the eligible cases from our hospitals stroke database. Patients’ information was comprehensively reviewed from the database and medical and nursing charts. ED‐DNR orders were defined as DNR orders written during ED stay. Multiple logistic regression analysis was used to identify significant determinants of ED‐DNR orders. Thirty‐ and 90‐day neurological outcomes were analyzed to test the prognosis impact of ED‐DNR orders. Results Among 835 enrolled patients, 112 (12.1%) had ED‐DNR orders. Significant determinant factors of ED‐DNR orders were age, ambulatory status before the event, brain computed tomography findings of midline shift, intraventricular extension, larger hematoma size, and ED arrival GCS ≤8. Patients with and without ED‐DNR orders had a similar 30‐day death rate if they had the same initial ICH score point. During 30 to 90 days, patients with ED‐DNR orders had a significantly increased mortality rate. However, the rate of improvement in neurological status between the two groups was not significantly different. Conclusions Older and sicker SICH patients had higher rate of ED‐DNR orders. The mortality rates between patients with and without ED‐DNR orders for each ICH score point were not significantly different. During the 30‐to‐90‐day follow‐up, the rates of neurological improvement in both groups were similar.

Protobothrops mucrosquamatus Bites to the Head: Clinical Spectrum from Case Series

Protobothrops mucrosquamatus (Trimeresurus mucrosquamatus) is a medically important species of pit viper with a wide geographic distribution in Southeast Asia. Bites by P. mucrosquamatus mostly involve the extremities. Little is known about the toxic effects of P. mucrosquamatus envenoming to the head because of the infrequency of such occurrence. To better delineate the clinical manifestations of envenoming to the head, we report three patients who suffered from P. mucrosquamatus bites to the head and were treated successfully. All three patients developed progressive soft tissue swelling extending from head to neck, with two patients expanding further onto the anterior chest wall. Mild thrombocytopenia was noted in two patients. One patient had transient acute renal impairment and airway obstruction, necessitating emergent intubation. All three patients received high doses of species-specific antivenom with recovery within 1 week. No adverse reactions to antivenom were observed.

Coordination between medical care providers and information technology resources in the management of patients with suicide attempts attending the emergency department.

Attempted suicide, often considered synonymous with selfharm, is a complex behavior or issue for health professionals to treat, particularly for staff in the emergency department (ED). However, it has been shown that an initial risk assessment at triage and treatment, detailed mental health assessment, an assessment of psychological and social needs and management, evaluation of risk of subsequent suicide, and enhanced care including inpatient or outpatient follow-up care were all important treatment components to best facilitate efficacious ED and specialist mental health services. Lin et al determined the characteristics, management, and aftercare of suicidal attempters visiting the ED and identified the factors relevant to optimize psychiatric outpatient aftercare. In Taiwan, patients with suicide attemptwere triaged to level 1 or 2, depending on the extent of their life-threatening problems and corresponding emergency management needs. An immediate risk assessment, including physical and psychological, was made by an emergency physician upon the patient’s arrival in the ED. Then the patient consulted with mental health professionals for further assessment of mental health and social service needs, which was also suggested by the National Institute for Clinical Excellence (NICE) guidelines. Of particular note was that the most common attempted suicide method was self-poisoning, comprising approximately 57.5% of all study patients; older patients would typically use more serious methods of suicide attempt than younger people. In our previous study focusing on elderly patients with acute poisoning in the ED, suicidal attempt patients experienced more complications including respiratory failure, aspiration pneumonia, hypotension, and mortality. Therefore, it is important to properly justify mandatory referral for aftercare and/or referral for specialist mental health or social services in cases where active medical supervision is necessary as a result of ongoing issues or in older people. In addition, the results of this study demonstrated that 91.7% of the suicide attempt patients received ED on-site psychosocial assessment, which were attended by social workers and psychiatrists (84% and 53.4% of the time, respectively). However, a low percentage of suicide attempt patients, only 45.1%, were referred to psychiatric outpatient aftercare, and only 26.1% of those referral patients contacted psychiatric outpatient clinics after discharge from the ED. However, the risk of non-fatal

Predictors of Suspected Pulmonary TB in an Isolation Room of an ED

Background: Early detection and isolation of pulmonary tuberculosis (PTB) patients are the key stones in controlling the disease. The objective of the study was to investigate the characteristics of PTB and non-PTB patients in emergent department (ED) isolation room and help us to early diagnosis and recognition of suspected PTB patients in ED. Design: Retrospective chart review. Methods: From January 1, 2005, through December 31, 2005, 127 adult patients admitted to the ED isolation room were enrolled under the suspicion of PTB infection. Medical records including demographic data, results of sputum stain and culture, and hospital days were retrospectively reviewed and analyzed. Results: PTB was disclosed in 82 (64.6%) of total 127 patients or 49 (52.1%) of 94 patients if excluded 33 transferred PTB patients who were confirmed in other hospital. The PTB group had lower white blood cell counts (WBCx103) (8.8±3.4 vs 12.4±5.3, p＜0.001) and C-reactive protein (CRP) (6.9±6.9 mg/dl vs 12.5±10.2 mg/dl, p=0.002) than the non-PTB group. The likelihood ratio of PTB was 7.96 when CXR showed a high suspicion of active PTB and elevated to 9.20 when both CXR and chest CT reports favored active PTB. Independent factors of the PTB group, based on multiple logistic regression analyses, were WBCx103 (odds ratio [OR], 0.795; P＜0.001), fibronodular change of upper lung field in CXR (OR, 8.499; P＜ 0.001), pleural thickening in CXR (OR, 4.880; P＜ 0.05). The area under the receiver-operating characteristic (ROC) curve for the model was 85.4% (P＜0.001), suggesting good model discrimination. Conclusions: Almost half of patients were finally diagnosed as PTB (52.1%, 49/94). Isolation rooms do provide suitable places for suspected PTB patients and play an important role in controlling the spreading of PTB in an ED. We identified normal WBC, fibronodular change of upper lung field and pleural thickening in CXR were significant independent predictors.