Kaung-Chau Tsai

Bacterial Infections in Patients with Liver Cirrhosis

Bacterial infections are common and severe complication of liver cirrhosis which is frequently encountered in the emergency department and hospitalized cirrhotic patients. The most frequent infections include spontaneous bacterial peritonitis, pneumonia, urinary tract infections, and bacteremia. Cirrhotic patients are particularly susceptible to bacterial infections because of increased bacterial translocation, possibly related to liver dysfunction and reduced reticuloendothelial function, and iatrogenic factors. In fact, the in-hospital mortality of cirrhotic patients with infections is approximately 15%, more than twice that of patients without infection. In this article, we provide a brief overview of the epidemiology, manifestations, management and prophylaxis of these complications in cirrhotic patients.

Hiatal Hernia with Gastric Volvulus and Small Bowel Strangulation

1. Sarti GM, Haddy RI, Schaffer D et al. Black hairy tongue. Am Fam Physician 1990;41:1751–1755. 2. Avcu N, Kanli A. The prevalence of tongue lesions in 5150 Turkish dental outpatients. Oral Dis 2003;9:188–195. 3. Harada Y, Gaafar H. Black hairy tongue. A scanning electron microscopic study. J Laryngol Otol 1977;91:91–96. 4. Akay BN, Sanli H, Topcuoglu P et al. Black hairy tongue after allogeneic stem cell transplantation: An unrecognized cutaneous presentation of graftversus-host disease. Transplant Proc 2010;42:4603–4607. 5. Luo Y, Zou P, Li QB et al. Black hairy tongue associated with allo peripheral blood hematopoietic stem cell transplantation. Chin Med J 2010;123:1807–1808. 6. Thompson DF, Kessler TL. Drug-induced black hairy tongue. Pharmacotherapy 2010;30:585–593. 7. Cheshire WP Jr. Unilateral black hairy tongue in trigeminal neuralgia. Headache 2004;44:908–910. 8. McGrath EE, Bardsley P, Basran G. Black hairy tongue: What is your call? CMAJ 2008;178:1137–1138. 9. Langtry JAA, Carr MM, Steele MC et al. Topical tretinoin: A new treatment for black hairy tongue (lingua villosa nigra). Clin Exp Dermatol 1992;17:163–164. 10. Tamam L, Annagur BB. Black hairy tongue associated with olanzapine treatment: A case report. Mt Sinai J Med 2006;73:891–894.

Delayed herniation of intra-abdominal contents after blunt right-sided diaphragm rupture

Right diaphragmatic hernia is a rare injury (0.25%-1%) after blunt abdominal trauma. The diagnosis may be delayed and achieved years after the trauma. We currently report a case of a 48-year-old man who presented to the emergency department at Far Eastern Memorial Hospital, New Taipei City, Taiwan, demonstrating signs of herniation of the right diaphragm. The herniation was confirmed using a chest radiograph. The patient reported falling 3 years before the current evaluation and was symptom-free before arrival in the emergency department. The diagnosis was further confirmed through thoracoabdominal computed tomography. The diaphragmatic hernia was subsequently repaired via abdominal approach. For patients with a history of prior thoracoabdominal trauma with complaints of new abdominal pain, a delayed diaphragmatic hernia should be considered.

Development of new core competencies for Taiwanese Emergency Medical Technicians

Objectives Core competencies are considered the foundation for establishing Emergency Medical Technician (EMT) and paramedic curricula, and for ensuring performance standards in the delivery of prehospital care. This study surveyed EMT instructors and medical directors to identify the most desirable core competencies for all levels of EMTs in Taiwan. Methods A principal components analysis with Varimax rotation was conducted. An online questionnaire was distributed to obtain perspectives of EMT instructors and medical directors on the most desirable core competencies for EMTs. The target population was EMT training-course instructors and medical directors of fire departments in Taiwan. The questionnaire comprised 61 competency items, and multiple-choice and open-ended questions were used to obtain respondents’ perspectives of the Taiwanese EMT training and education system. Results The results identified three factors at EMT-1 and EMT-2 levels and five factors at the EMT-Paramedic level. The factors for EMT-1 and EMT-2 were similar, and those for EMT-Paramedics identified further comprehensive competence perspectives. The key factors that appear to influence the development of the Taiwanese Emergency Medical Services (EMS) education system are the attitude of authorities, the licensure system, and legislation. Conclusion The findings present new core competencies for the Taiwanese EMT system and provide capacity to redesign curricula and reconsider roles for EMT-1 and EMT-2 technicians. At the EMT-Paramedic level, the findings demonstrate the importance of incorporating competency standards in the current skills-based curriculum. Moreover, the core-competencies gap that exists between Taiwanese EMT-1s, EMT-2s, and EMT-Paramedics and internationally recognized core competencies needs to be addressed. By identifying the key factors that potentially impact the development of the EMS education system, such as the attitude of authorities, the licensure system, and legislation, these findings will inform future curricula design in Taiwan.

What are the educational and curriculum needs for emergency medical technicians in Taiwan? A scoping review

Purpose The development of emergency medical services (EMS) training in Taiwan is in a transitional phase because of increasing demand for, and advancements in, clinical skill sets. The aim of this study is to review the current literature to compare the key factors of EMS training and education development in different countries in order to provide a new curricula blueprint for the Taiwanese EMS training system. Method The method follows Arksey and O’Malley’s six stages of scoping review. Results Five databases were searched for relevant articles: MEDLINE, EMBASE, Allied and Complementary Medicine Database; Education Resources Information Center, and Google Scholar. The initial search of five databases produced 1,230 articles, of which title and abstract screening excluded 1,156 articles. The 74 remaining articles underwent a full-text screening process, which further reduced the number of articles to 22. Researching references and citations produced an additional 23 articles, national curriculum standards produced a further six documents, and one article derived from emergency medical technician (EMT) regulation in Taiwan. In total, 52 articles were included in the study, categorized by competency and standards, EMT education and learning environment, curriculum design, and teaching and learning method. Conclusion This study reviewed international EMS training and education literature and documents to summarize the essential elements for developing an EMS education system: for example, core competencies and standards, education environment, curriculum design, and teaching and learning method. By connecting the essential elements for developing an EMS education system, a blueprint for the Taiwanese EMS education system can be identified. Analysis and study of the essential elements will provide educators with clear direction in developing the EMS education system in Taiwan.

Superior Mesenteric Artery Syndrome: A Case Report

A case of superior mesenteric artery syndrome is reported. A 16-year-old boy with bilious vomiting for six months and weight loss within the previous year is presented. In this symptomatic period, he was fed many dietary formulations. This conservative management failed. Physical examination revealed that he was malnourished. The diagnosis was made by means of an upper gastrointestinal barium study performed through a tube. Gastrojejunostomy was preferred over duodenal mobilization because he had a markedly dilated stomach and enlarged pylorus. The postoperative course was satisfactory.

Comment on “Emphysematous Infections of the Prostate and Scrotum in an Older Adult in a Nursing Home”

cological therapy) that inpatient psychiatric facilities can offer to individuals with dementia. Many people experience improvement or resolution of their symptoms. In Wisconsin, a fundamental misunderstanding about the care of individuals with dementia has resulted in the exclusion of individuals with dementia from the civil commitment process. That process is an unpleasant but necessary step on the path to stabilization for many people with psychiatric or behavioral symptoms of dementia. It is our hope that the misunderstanding in Wisconsin will be quickly corrected. Perhaps even more important, we hope that Wisconsin’s mistake does not spread to other states. California and Florida are the two states with the greatest number of people aged 65 and older. There is a real possibility that both could follow Wisconsin. California’s attorney general has concluded that individuals with Alzheimer’s disease may be held for 72 hours in the first step toward civil commitment, but further detention must be for treatment. A California court could, as in Wisconsin, conclude that treatment is not possible for dementia. Indeed, one California court upheld a conservator’s determination that an individual’s “inability to care for himself [was] not a product of a mental disorder for which treatment [was] available in a state mental hospital, but a result of dementia.” The definition of “mental illness” in Florida is broad enough to include dementia and even specifies that etiology is irrelevant. The Florida Supreme Court has held that a person who is involuntarily committed has a right to treatment. Florida statutes codify and broaden this right to include “such medical, vocational, social, educational, and rehabilitative services as his or her condition requires in order to live successfully in the community.” This broad definition of treatment may appear encouraging, but a court could conclude that civil commitment is inappropriate for individuals with advanced dementia who will never be able “to live successfully in the community.” Success in treating individuals with dementia, as with other mental illnesses, often means modest and sometimes temporary improvement in symptoms. To twist that unfortunate reality into a reason to deny supportive care in what may be the best setting is a legal blunder of colossal proportions. We must educate policy-makers to reverse the Wisconsin error and to prevent its spread.

Gastric ulcer bleeding caused by press-through package mis-swallowing.

To the Editor: After taking medicine 11 hours before arrival to the emergency department (ED), an 81-year-old man with a history of hypertension and dementia presented with epigastric pain, passing of tarry stool, and one episode of hematemesis. Vital signs were notable for resting tachycardia and oxygen saturation of 92% on room air. He was provided with supplemental oxygen and intravenous fluids. His initial hemoglobin of 11.9 g/dL dropped to 8.9 g/dL. He received intravenous normal saline and two units of packed red blood cells. Other blood tests including coagulation tests were in the normal range. An emergency upper gastrointestinal endoscopy was performed (Figure 1A, B) and discovered a medicine tablet with its package stuck in a deep gastric ulcer (distal antrum) with subsequent bleeding. The final diagnosis was gastric ulcer bleeding complicated by press-through packaging (PTP) due to mis-swallowing. A PTP (Figure 1C) was removed using an alligator clip and protective hood attached to a scope. The follow-up erect chest radiograph showed no perforation. Follow-up hemoglobin was 10.2 g/dL, and he had no more tarry stool or hematemesis. He was prescribed a proton-pump inhibitor and was doing well at outpatient follow-up. Press-through packaging, which consists of a polyvinylchloride and aluminium blister-wrapped pack, is commonly used to protect freeze-dried tablets from exposure to moisture. Foreign body ingestion is not infrequently seen in the ED, and the PTP is increasingly being seen in cases of foreign bodies in the digestive tract. PTP are usually used to dispense single-tablet allotments by cutting them from the blister packs. The pieces of PTP are small and square, often with sharp corners. When they are inadvertently swallowed, they can become lodged in the gastrointestinal tract, and they pose a risk of bowel perforation. Intestinal or esophageal perforation by blister-wrapped tablets has previously been reported. PTP ingestion is frequently seen in older adults and in individuals with mental or visual impairment. A case series from the Japanese literature reported 28 cases of perforation of the small intestine by a blister-wrapped tablet in PTP. Most individuals with perforation were elderly (mean age 77). The aging population, the rising number of individuals taking more than one drug, and the increasing number of drugs dispensed in blister packages may all contribute to an increase in the incidence of these accidents, although other factors may be involved. A statistical analysis of 32 cases reported an apparent increase in the number of incidents between 1986 and 1993. Moreover, in 1997, one study found that, in Japan, the number of PTPs involved in cases of foreign objects in the digestive tract was increasing. Because of its radiolucency, PTP material is often difficult to detect directly on a plain radiograph, but the air trapped in the PTP makes the drug tablet visible on a plain radiograph. Attempts should be made to remove PTP in the esophagus and stomach; if it passes through the pyloric ring, and the individual develops symptoms, computed tomography and early laparotomy should be considered. An effort to prevent the swallowing of PTP should be an essential part of everyday practice, especially in elderly adults. Prevention should be the most important part in PTP swallowing in face of the increasing number of cases and elderly adults taking multiple medications. Preparing medicines by cutting up sheets of blister-wrapped tablets is hazardous and should be avoided. In hospitals and nursing homes, procedures should be instituted to ensure that only fully unpacked medication is distributed to patients. Health authorities should take measures to assure that patients and caregivers are aware of the risk. More research should be performed to investigate fully the extent of the problem.

Gastric Emphysema Secondary to Gastric Outlet Obstruction

Received: March 25, 2011 Accepted for publication: May 26, 2011 From the Department of Emergency Medicine, Department of Medical Imaging Far Eastern Memorial Hospital, Taipei, Taiwan Address reprint requests and correspondence: Dr. Chun-Jen Wu Department of Emergency Medicine, Far Eastern Memorial Hospital 21 Section 2, Nanya South Road, Banchiao District, New Taipei City 22050, Taiwan (R.O.C.) Tel: (02)89667000 ext 1122 Fax: (02)89660454 E-mail: wuchunjen@yahoo.com.tw 急重症影像

Acute Postpartum Pulmonary Edema: A Case Report

Acute pulmonary edema after pregnancy is rare. Pulmonary emobolism, pneumonia, aspiration and pulmonary edema are some of the potentially devastating causes that should be considered. We report a case of a previously healthy 45 year-old woman had pulmonary edema 3 hours after a normal vaginal delivery at a local clinic. Two days before admission, the patient had received tocolytic therapy to suppress premature labor. After medical treatment, her symptoms subsided and a chest radiograph showed resolution of pulmonary edema 12 hours later. She was discharged the next day in stable condition.