Sai-Wai Ho

Risk of Stroke-Associated Pneumonia With Acid-Suppressive Drugs: A Population-Based Cohort Study.

Abstract Acid-suppressive drugs, including histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs), are common medications used for treating upper gastrointestinal tract disorders. However, acid-suppressive drugs have been reported to increase the risk of pneumonia in numerous disease populations. However, the relationship between acid-suppressive drugs and stroke-associated pneumonia (SAP) remains controversial. The purpose of this study was to investigate the association between acid-suppressive drug usage and pneumonia among patients with stroke by using a nationwide data set. A population-based cohort study was conducted using a data set from the Taiwanese National Health Insurance Research Database. Data on patients with new-onset stroke from 2010 to 2011 were collected. Patients with and without acid-suppressive drug usage were followed up to identify the occurrence of any type of pneumonia. We estimated the adjusted hazard ratios (HRs) by using the Cox proportional hazards model. The study cohort comprised 7965 patients with new-onset stroke. The incidence of pneumonia was 6.9% (552/7965) and more than 40% (225/552) of patients developed pneumonia within 3 months after an acute stroke. Acid-suppressive drug usage was an independent risk factor of pneumonia. The adjusted HR for the risk of pneumonia in patients with new-onset stroke using acid-suppressive drugs was 1.44 (95% confidence interval [CI] = 1.18–1.75, P < 0.01). Only PPI usage increased risk of chronic SAP (adjusted HR = 1.46, 95% CI = 1.04–2.05). Acid-suppressive drug usage was associated with a slightly increased risk of SAP. Physicians should exercise caution when prescribing acid-suppressive drugs to patients with stroke, particularly at the chronic stage.

Population-based cohort study on the risk of pneumonia in patients with non-traumatic intracranial haemorrhage who use proton pump inhibitors

Objectives This nationwide cohort study investigated the association between proton pump inhibitor (PPI) usage and the risk of pneumonia in patients with non-traumatic intracranial haemorrhage (ICH). Design Nationwide population-based cohort study. Setting Longitudinal Health Insurance Database 2010 (LHID2010) sampled from the Taiwan National Health Insurance Research Database. Participants 4644 patients with non-traumatic ICH from 2010 to 2011 were identified. Patients aged <18 years and newly diagnosed with non-traumatic ICH complicated with pneumonia during the same admission period were excluded. A total of 2170 participants were eligible for the final analysis. Main outcome measure Patients using PPIs or not during the study period were tracked to identify the occurrence of any type of pneumonia. Results The adjusted HR of the risk of pneumonia for ICH patients who used PPIs was 1.61 (95% CI 1.32 to 1.97, p<0.001). The risk of pneumonia was positively associated with the administration of PPIs. We observed a greater risk of pneumonia in patients who used PPIs than in those who did not. Moreover, we observed that the risk of pneumonia in patients who used PPIs was 2.60 and 2.04 (95% CI 2.01 to 3.38, p<0.001; 95% CI 1.34 to 3.10, p<0.001) greater than that in patients who did not use PPIs when the defined daily dose was <30 and 30−60, respectively. Conclusions The results of this study indicate that the use of PPIs in patients with non-traumatic ICH is associated with an increased risk of pneumonia, and the severity of this risk depends on the defined daily dose. Physicians should exercise caution when prescribing PPIs for patients with non-traumatic ICH.

Association of Proton Pump Inhibitors Usage with Risk of Pneumonia in Dementia Patients

To determine the association between usages of proton pump inhibitors (PPIs) and subsequent risk of pneumonia in dementia patients.

Risk of pneumonia in patients with isolated minor rib fractures: a nationwide cohort study

Objectives Isolated minor rib fractures (IMRFs) after blunt chest traumas are commonly observed in emergency departments. However, the relationship between IMRFs and subsequent pneumonia remains controversial. This nationwide cohort study investigated the association between IMRFs and the risk of pneumonia in patients with blunt chest traumas. Design Nationwide population-based cohort study. Setting Patients with IMRFs were identified between 2010 and 2011 from the Taiwan National Health Insurance Research Database. Participants Non-traumatic patients were matched through 1:8 propensity-score matching according to age, sex, and comorbidities (namely diabetes, hypertension, cardiovascular disease, asthma and chronic obstructive pulmonary disease (COPD)) with the comparison cohort. We estimated the adjusted HRs (aHRs) by using the Cox proportional hazard model. A total of 709 patients with IMRFs and 5672 non-traumatic patients were included. Main outcome measure The primary end point was the occurrence of pneumonia within 30 days. Results The incidence of pneumonia following IMRFs was 1.6% (11/709). The aHR for the risk of pneumonia after IMRFs was 8.94 (95% CI=3.79 to 21.09, p<0.001). Furthermore, old age (≥65 years; aHR=5.60, 95% CI 1.97 to 15.89, p<0.001) and COPD (aHR=5.41, 95% CI 1.02 to 3.59, p<0.001) were risk factors for pneumonia following IMRFs. In the IMRF group, presence of single or two isolated rib fractures was associated with an increased risk of pneumonia with aHRs of 3.97 (95% CI 1.09 to 14.44, p<0.001) and 17.13 (95% CI 6.66 to 44.04, p<0.001), respectively. Conclusions Although the incidence of pneumonia following IMRFs is low, patients with two isolated rib fractures were particularly susceptible to pneumonia. Physicians should focus on this complication, particularly in elderly patients and those with COPD.

Retrosternal Gastric Tube Ulcer Complicated by Pneumopericardium and Pneumomediastinum: A Case Report

Pneumopericardium and pneumomediastinum caused by retrosternal gastric tube ulcer after esophagoplasty is rare. A 73-year-old man who had received retrosternal esophageal reconstruction with gastric tube presented to the emergency department with chest pain and dyspnea. Chest radiography revealed pneumomediastinum, and chest computed tomography (CT) revealed conditions of pneumopericardium and pneumomediastinum. Emergency surgery including removal of retrosternal gastric tube, duodenostomy, partial pericardiectomy and tube thoracostomy was performed to repair the lesion and prevent life threatening complications. Perforation of a peptic ulcer from the retrosternal gastric tube into the pericardium was found during surgery and the diagnosis was proved by pathology. The patient recovered uneventfully.

Pneumonia is an independent risk factor for pyogenic liver abscess: A population-based, nested, case-control study

Background Bacteremic pneumonia is considered a potential cause of distal organ abscess formation. Therefore, we hypothesize that pneumonia is a risk factor for pyogenic liver abscess (PLA).The aim of this study is to explore the association between pneumonia and PLA. Methodology/Principal findings A nationwide, population-based, nested, case–control study was conducted using data from the Taiwan National Health Insurance Research Database. In total, 494 patients with PLA and 1,976 propensity score matched controls were enrolled. Conditional logistic regression was used to estimate adjusted odds ratios (aORs) in patients with exposure to pneumonia before PLA. After matched and adjusted for confounding factors including age, sex, urbanization, income, chronic liver disease, alcohol-related disease, biliary stone, chronic kidney disease, diabetes mellitus, chronic liver disease, and cancer, hospitalization for pneumonia remained an independent risk factor for PLA with an aORs of 2.104 [95% confidence interval (CI) = 1.309–3.379, p = 0.0021]. Moreover, the aORs were significantly higher among patients hospitalized for pneumonia within 30 days (aORs = 10.73, 95% CI = 3.381–34.054), 30–90 days (aORs = 4.698, 95% CI = 1.541–14.327) and 90–180 (aORs = 4.000, 95% CI = 1.158–13.817) days before PLA diagnosis. Conclusion Pneumonia is an independent risk factor for subsequent PLA. Moreover, hospitalization for pneumonia within 180 days before PLA diagnosis was associated with an increased risk of PLA.

Practice Variations between Emergency Physicians and Pediatricians in Treating Acute Bronchiolitis in the Emergency Department: A Nationwide Study.

BACKGROUND Although supportive care is the mainstay management for acute bronchiolitis, non-evidence-based diagnostic testing and medications remain common in emergency departments (EDs). OBJECTIVE Our aim was to compare emergency physicians (EPs) and pediatricians practice patterns in the management of acute bronchiolitis in the ED. METHODS A cross-sectional study was conducted by using registration and claims datasets from 2008 to 2011. Patients with acute bronchiolitis were divided into EP group and pediatrician group. RESULTS A total of 2174 patients were enrolled. The diagnostic tests used, including chest x-ray (63.7% vs. 46%; adjusted odds ratio [OR] = 2.27; 95% CI 1.77-2.91), complete blood count (33.2% vs. 21.8%; adjusted OR = 1.74; 95% CI 1.33-2.26), C-reactive protein (35.1% vs. 22.6%; adjusted OR = 1.79; 95% CI 1.38-2.33), blood culture (23.9% vs. 14.3%; adjusted OR = 1.79; 95% CI 1.33-2.39), and arterial blood gas (3.7% vs. 1.8%, adjusted OR = 2.38; 95% CI 1.21-4.67), were higher in the EP group than in the pediatrician group. Intravenous fluid administration was also higher in the EP group (20.8% vs. 3.5%; adjusted OR = 7.49; 95% CI 5.12-10.8). In addition, EPs more frequently arranged for hospital admissions (36% vs. 19.5%; adjusted OR = 2.51; 95% CI 1.15-3.26). CONCLUSIONS Both EPs and pediatricians had high rates of ordering diagnostic testing for acute bronchiolitis patients in ED. Compared with pediatricians, EPs used more diagnostic tests for the patients with acute bronchiolitis in ED.

Febrile Man with Pneumoperitoneum

A previously healthy 57-year-old man was managed as a patient with community-acquired pneumonia in the Outpatient Department due to fever and cough for 2 days. An initial chest x-ray study revealed increased infiltration of the lower lobe of the right lung and abnormal gas bubbles collection under the right hemidiaphragm (Figure 1). Due to sudden onset of epigastric pain and the appearance of subphrenic air on a subsequent chest x-ray study on day 3 (Figure 2), he was referred to the Emergency Department (ED) for exploratory laparotomy. In the ED, his vital signs revealed a heart rate of 120 beats/min, a blood pressure of 116/64 mm Hg, a respiratory rate of 20 breaths/min, and a body temperature of 37.4 C. Physical examination revealed marked tenderness in the epigastric area. Laboratory findings showed a white blood cell count of 33,960/mm, a hemoglobin level of 14.1 g/ dL, and a C-reactive protein level of 31.6 mg/dL. There was minor impaired liver function, as indicated by aspartate transaminase and alanine transaminase test results of 117 U/L and 90 U/L, respectively. His

Spontaneous Rupture of Hepatocellular Carcinoma Mimicking ST-Segment Elevation Myocardial Infarction

BACKGROUND Several medical conditions that mimic ST-elevation myocardial infarction (STEMI) have been reported previously, but acute abdominal disease mimicking STEMI is rare. CASE REPORT We report on a 72-year-old man who presented to the emergency department (ED) with epigastric pain. Meanwhile, STEMI with shock developed. Anticoagulation medication and emergent percutaneous coronary intervention (PCI) were arranged in a timely manner. However, hepatocellular carcinoma (HCC) rupture was the true cause of the ST-segment elevation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report highlights the fact that acute myocardial infarction is not the only cause of ST-segment elevation. HCC rupture should be one of the differential diagnoses.

Massive pulmonary embolism after overdose of oral benzodiazepine

Overdose of benzodiazepines rarely causes morbidity or mortality. A 58-year-old woman presented to the emergency department in coma after ingestion of 30 tablets of 0.5 mg alprazolam. She recovered after flumazenil was administered. However, massive pulmonary embolism developed during observation in the emergency department. Endotracheal intubation and recombinant tissue plasminogen activator infusion were initiated. This case report highlights that benzodiazepine overdose can contribute to pulmonary embolism which is a life-threatening condition.