Te-Fa Chiu

Diagnosis of acute flank pain caused by ureteral stones: value of combined direct and indirect signs on IVU and unenhanced helical CT

The aim of this study was to assess the usefulness of combined direct and indirect signs on intravenous urography (IVU) and unenhanced helical computed tomography (UHCT) for the diagnosis of ureteral stones in emergency patients with acute flank pain. During an 8-month period, 82 emergency patients with acute flank pain undergoing IVU and UHCT with sufficient clinical follow-up formed the study group. The presence or absence of direct sign (visualization of ureteral stones) and indirect signs on IVU and UHCT was recorded. The diagnostic accuracy of each direct/indirect sign and their combination for the diagnosis of ureteral stones on IVU and UHCT were analyzed and compared. Of the 82 patients, 66 had ureteral stones, four had passed urinary stones prior to imaging and 12 had other diseases. The diagnostic accuracies of direct signs on IVU and UHCT for the diagnosis of ureteral stones were 79.3 and 98.8%, respectively, which was more accurate than that of any single indirect sign on IVU and UHCT. However, the diagnostic accuracy of ureteral stones by IVU increased to 90.2% when using diagnostic criteria requiring the presence of a direct sign or at least three indirect signs, and by UHCT, it increased to 100% when using diagnostic criteria requiring the presence of a direct sign with at least one indirect sign. Therefore, for emergency patients with acute flank pain, the use of the above combinations of direct/indirect signs is useful as the diagnostic criterion for ureteral stones.

Comparison Between Canadian Triage and Acuity Scale and Taiwan Triage System in Emergency Departments

BACKGROUND/PURPOSE Since the implementation of National Health Insurance in Taiwan, Emergency Department (ED) volume has progressively increased, and the current triage system is insufficient and needs modification. This study compared the prioritization and resource utilization differences between the four-level Taiwan Triage System (TTS) and the standardized five-level Canadian Triage and Acuity Scale (CTAS) among ED patients. METHODS This was a prospective observational study. All adult ED patients who presented to three different medical centers during the study period were included. Patients were independently triaged by the duty triage nurse using TTS, and a single trained research nurse using CTAS with a computer support software system. Hospitalization, length of stay (LOS), and medical resource consumption were analyzed by comparing TTS and CTAS by acuity levels. RESULTS There was significant disparity in patient prioritization between TTS and CTAS among the 1851 enrolled patients. With TTS, 7.8%, 46.1%, 45.9% and 0.2% were assigned to levels 1, 2, 3, and 4, respectively. With CTAS, 3.5%, 24.4%, 44.3%, 22.4% and 5.5% were assigned to levels 1, 2, 3, 4, and 5, respectively. The hospitalization rate, LOS, and medical resource consumption differed significantly between the two triage systems and correlated better with CTAS. CONCLUSION CTAS provided better discrimination for ED patient triage, and also showed greater validity when predicting hospitalization, LOS, and medical resource consumption. An accurate five-level triage scale appeared superior in predicting patient acuity and resource utilization.

Altered neutrophil apoptosis activity is reversed by melatonin in liver ischemia-reperfusion.

Delayed neutrophil apoptosis has been implicated as the mechanism of the systemic inflammatory response. Herein, we examined the effect of melatonin on the neutrophil apoptosis in ischemia and reperfusion of the human liver. We studied seven patients receiving elective hepatectomy for liver tumor and ten patients receiving laparoscopic cholecystectomy for gallstones. Ten milli liters of blood was drawn isolation and incubation of the human neutrophils. Neutrophil apoptosis activity and CD18 expression and respiratory burst activity were assessed flow cytometrically. Another group of neutrophils included those from the patients receiving hepatectomy and isolated and incubated with melatonin. Neutrophil apoptosis is delayed from patients after hepatectomy or laparoscopic cholecystectomy when compared with that of the preoperative state. The decrease in the apoptosis activity is more severe in patients receiving hepatectomy as compared with those receiving laparoscopic cholecystectomy. Neutrophils from patients receiving hepatectomy or laparoscopic cholecystectomy are functionally activated. Melatonin can reverse the delayed process and enhance the apoptosis activity in neutrophils from patients receiving hepatectomy. This study demonstrates that melatonin enhances neutrophil apoptosis in patients receiving hepatectomy involving ischemia and reperfusion of the human liver.

Rapid Life-Threatening Hyperkalemia After Addition of Amiloride HC1/Hydrochlorothiazide to Angiotensin-Converting Enzyme Inhibitor Therapy

STUDY OBJECTIVE To highlight the dangers of a precipitous rise in serum potassium levels in patients at risk for renal insufficiency, already receiving an angiotensin-converting enzyme (ACE) inhibitor, who are given a potassium-sparing diuretic. METHODS We conducted a retrospective chart review of five patients who were taking the above combination of medications who were seen in our ED with hyperkalemia. RESULTS All five patients had diabetes and were older than 50 years of age. Except for one patient, they had some degree of renal impairment and all were receiving an ACE inhibitor. Each had amiloride HCl/hydrochlorothiazide added to their therapeutic regimen 8 to 18 days before presenting to our ED with hyperkalemia. Potassium levels were between 9.4 and 11 mEq/L in 4 of the patients; 2 did not respond to resuscitation measures. CONCLUSION The concomitant use of ACE inhibitor and potassium-sparing diuretic therapy should be avoided. If impossible, weekly monitoring of both renal function and serum potassium should be performed. In the ED patients who are receiving such a combination should receive immediate ECG monitoring.

Tuberculous peritonitis: Analysis of 211 cases in Taiwan

BACKGROUND Tuberculosis infection caused by Mycobacterium tuberculosis or other Mycobacterium species is a major communicable disease worldwide. AIM We evaluated the epidemiology of tuberculous peritonitis to determine diagnostic features and factors related to late diagnosis. METHODS We retrospectively reviewed 211 tuberculous peritonitis cases diagnosed between January 1999 and December 2009. Clinical features, laboratory data, and diagnostic methods were analysed. RESULTS Subjects included 115 males (54.5%) and 96 females (45.5%) with median age 61.0 years (range 43-72) and 29.2 days mean duration from symptoms to diagnosis. Disease histories included end-stage renal disease (20.9%), pulmonary tuberculosis (36.0%) and liver cirrhosis (23.7%). Most common symptoms were abdominal distension (80.1%), abdominal pain (68.7%) and weight loss (45.5%). Most common signs were ascites (62.6%) and fever (55.5%). One-year survival rate was 89.9%; 21 patients died during follow-up. Mortality risk was higher in patients with more concomitant diseases, including liver cirrhosis, AIDS, chronic steroid use, alcoholism, GI bleeding, haemoptysis, period from symptom presentation to treatment, secondary bacterial peritonitis requiring emergent operation. CONCLUSIONS Increased duration between symptoms and definitive diagnosis increases mortality risk. Early diagnosis and prompt initiation of anti-tuberculosis therapy improve prognosis. Neutrophil-predominant ascites influences poor prognosis when correlated with secondary bacterial peritonitis.

Is initial C-reactive protein level associated with corticosteroid use in lupus erythematosus patients during a bacterial infection episode?

OBJECTIVE C-reactive protein (CRP), a marker for inflammation, indicates bacterial infection in systemic lupus erythematosus (SLE) when markedly elevated. Our study investigated the association of regular corticosteroid or immunosuppressant use with initial CRP level in febrile SLE patients with bacterial infection. METHODS This retrospective cohort study included adult SLE patients (18 years of age or older) who presented with fever at the emergency department from January 2008 to December 2012. Data were retrieved from our institutional database. RESULTS CRP levels in the total 193 patient database were significantly increased in the bacterial infection group compared to the no infection and non-bacterial infection groups. Seventy-eight (86.7%) of the 90 patients in the bacterial infection group took regular corticosteroids (mean equivalent dose of prednisolone 0.33±0.26mg/kg/day) and 55 (61.1%) used immunosuppressants. Mean CRP level in the bacterial infection group was 97.8mg/L. CRP level was lower in patients using corticosteroids, but the difference between users and nonusers of corticosteroids was not statistically significant (p=0.367). The difference in CRP level between immunosuppressant and non-immunosuppressant users was also not significant (p=0.599). The Spearman test found no correlation between corticosteroid dosage and CRP level (p=0.911). CONCLUSION Initial CRP level was not significantly associated with regular corticosteroid or immunosuppressant use in SLEs patients during a bacterial infection episode, and CRP level was not dose-dependently related to daily corticosteroid use. An elevated CRP level might be an appropriate marker for bacterial infection at the emergency department for febrile SLE patients.

Validation of different score systems in predicting cardiac arrest occurrence of ST-elevation myocardial infarction

Introduction: Patients with ST-elevation myocardial infarction are at risk of developing cardiac arrest. A validated tool for predicting cardiac arrest would help physicians recognize these high-risk patients earlier. This study assessed the usefulness of various score systems in predicting cardiac arrest in patients hospitalized for ST-elevation myocardial infarction. Methods: Patients’ data were retrieved from the hospital’s ST-elevation myocardial infarction registry records. Patients aged 18 years or older seen at the emergency department with a diagnosis of ST-elevation myocardial infarction between 1 July 2013 and 30 June 2014 were enrolled. The Thrombolysis in Myocardial Infarction score, the 6-month Global Registry of Acute Coronary Event risk score, CHADS2 score, and HEART score were calculated and compared. Results: A total of 249 patients were recruited. The Thrombolysis in Myocardial Infarction score, 6-month Global Registry of Acute Coronary Event risk score, CHADS2 score, and HEART scores were calculated. In total, 41 (16.5%) patients had cardiac arrest at emergency department or during hospitalization and 12 (29.3%) of them survived. The 6-month Global Registry of Acute Coronary Event risk score had the biggest area under the receiver-operating characteristic curve (0.72). Conclusion: The 6-month Global Registry of Acute Coronary Event risk score is more useful in predicting cardiac arrest in patients hospitalized for ST-elevation myocardial infarction than the other three scores. It is recommended that the 6-month Global Registry of Acute Coronary Event risk score be calculated for identifying emergency department patients hospitalized for ST-elevation myocardial infarction who are at risk of cardiac arrest during their hospital stay.