Wen-Han Chang

Atypical chest pain in the elderly: prevalence, possible mechanisms and prognosis.

SUMMARY Acute chest pain is a major complaint quite commonly presented at emergency departments. A differential diagnosis of acute chest pain includes various disease entities, including some life-threatening disorders. Of these, acute coronary syndrome garners much clinical attention and forms a specific disease that includes a critical ST-segment elevation myocardial infarction and a less severe form of non-ST-segment elevation myocardial infarction and unstable angina. As an urgent and life-threatening disease leading to a high morbidity and mortality, accurate diagnosis of acute coronary syndrome remains a clinical challenge. Efficient management of this syndrome may rely on a quick yet accurate diagnosis. A high misdiagnosis rate and inappropriate discharge rate for acute coronary syndrome are still observed, especially in the elderly population, owing to a higher prevalence of atypical symptoms presented in this group. Moreover, the existence of high comorbidities in the elderly population makes effective clinical approach complicated. A delay in the identification and treatment may lead to worse outcomes in this patient population. The underlying pathophysiology and exact mechanisms are various. Patient evaluation strategies are currently being developed, as are new diagnostic facilities aimed at preparing physicians for urgent intervention in a more cost-effective

MASS GATHERING EMERGENCY MEDICINE: A REVIEW OF THE TAIWAN EXPERIENCE OF LONG-DISTANCE SWIMMING ACROSS SUN-MOON LAKE

Summary Once a year during the festival of Sun-Moon Lake in Nan-Tou County, Taiwan, a long-distance swimming mass gathering (LDSMG) event takes place. This event, in which participants swim an estimated 30 km, is very popular; the total number of spectators and participants at the 2002 festival was 15,189. This study, the first pertaining to the LDSMG, aimed to review the effect of the environmental factors at this particular mass gathering event, with mass being defined here as more than 1,000 people, upon the events patient presentation rate (PPR). This was done to provide improved medical services at this event in future years The study also aimed to collect patient data from the two medical stations (one upstream and one downstream) and analyze the differences between them. In 2002, the number of patients requiring first aid treatment was determined from data gathered on-site. A total of 63 presented at on-site medical stations (PPR, 4.15 per 1,000 attendees), where 14 patients presented to a downstream medical station and 49 to an upstream medical station. The mean age of the patients was 35.46 ± 15.14 years; ages ranged from 1 to 65 years. Forty-nine of the patients (78%) were male. Fifty-nine patients were treated with medication (3.88 per 1,000 attendees), and two were taken to hospital (0.13 per 1,000 attendees). Injuries sustained included trauma (71%), such as impact, fall, sprain, stabbed laceration and burn, hypothermia (5%), and foreign bodies (3%). The PPR at the LDSMG was related to factors including the presence or absence of seating, whether the event was outdoors or indoors, mobility of the crowd, whether the activity was contained within a boundary, attendance figures, and humidity level. The weather, particularly the relative humidity (81%), was also positively correlated with an increase in the number of presentations at the medical stations.

Attaining good end-of-life care in intensive care units in Taiwan - The dilemma and the strategy

SUMMARY One of the major challenges for intensivists is resolving the conflicting interests in end-of-life care. We reviewed patients characteristics in an intensive care unit to determine the major barriers of practicing good end-of-life care and the medical ethics involved for the care team to resolve these conflicts. (International Journal of Gerontology 2009; 3(1): 26-30)

The feasibility and diagnostic accuracy by multiple cardiac biomarkers in emergency chest pain patients: a clinical analysis to compare 290 suspected acute coronary syndrome cases stratified by age and gender in Taiwan.

BackgroundAccurate diagnosis of acute coronary syndrome (ACS) in a timely fashion is challenging in the elderly population, especially elderly women, who usually exhibit atypical clinical symptoms. A multiple cardiac biomarker (MCB) based approach has been shown to improve diagnostic efficacy of ACS. However, data in various age groups and sex differences remain largely unexplored.MethodsPoint-of-care testing (POCT) was performed on 290 patients (aged ≥18xa0years) who were admitted to the emergency department (ED) with symptoms of acute chest pain under suspicion of acute coronary syndrome (ACS). The MCB approach in current work assessed four cardiac biomarkers: myoglobin, troponin I, creatine kinase-myocardial band isoenzyme fraction (CK-MB), and brain natriuretic peptide (BNP).ResultsOverall, the MCB approach demonstrated considerably higher sensitivity for elderly patients than for younger patients in identifying ACS (80.0xa0% [64.1–90.0] vs. 52.6xa0% [37.3–67.5] for ≥65xa0years and <65xa0years groups), with younger population showed greater specificity (44.1xa0% [35.3–53.4] vs. 84.9xa0% [76.9–90.5] for ≥65xa0years and <65xa0years groups, respectively). The highest sensitivity achieved for elderly women who reported chest pain was 87.5xa0% [95xa0% CI: 64–96.5]). In general, the sensitivity of this approach was higher for female patients than for male patients (80xa0% [58.4–91.9] vs. 61xa0% [47.8–73.0]).ConclusionsThe MCB approach can provide a quick and accurate clinical diagnosis in elderly and female patients, both of whom have traditionally proven to be challenging to diagnose from suspected acute coronary syndrome.

SPONTANEOUS PNEUMOMEDIASTINUM: A CLINICAL RADIOLOGIC ANALYSIS

SUMMARY Background Spontaneous pneumomediastinum is clinically distinct from pneumomediastinum occurring secondary to thoracic hollow organ perforation. The latter may be a catastrophic event requiring invasive intervention, but it is questionable whether such interventions are necessary in spontaneous pneumomediastinum. Limited data are available regarding the characteristics of history and radiologic manifestations in spontaneous pneumomediastinum. The present study aimed to systematically evaluate the initial and subsequent clinical and radiologic manifestations of spontaneous pneumomediastinum as well as the need for additional diagnostic procedures and therapy. Methods A retrospective study of patients with a diagnosis of spontaneous pneumomediastinum in a tertiary medical center from January 1990 to November 2006 was performed. The patients clinical information and results of radiologic interventions were analyzed. Results A total of 42 patients were included. Spontaneous pneumomediastinum was diagnosed in all cases by chest films. A left pericardial airstrip was the most common initial manifestation. In this series, there was only one patient with a pneumothorax, and none of the patients developed pleural effusion or mediastinal fluid as shown by chest X-rays after the disease onset. Conclusion Spontaneous pneumomediastinum occurs mostly in non-elderly patients. Evaluation of typical clinical information and uncomplicated serial chest X-ray findings of spontaneous pneumomediastinum could avoid unnecessary invasive procedures and intensive care unit stays, which could put pressure on medical resources. A plain film X-ray is adequate for diagnosing spontaneous pneumomediastinum as long as the appropriate findings are sought and there is adequate application of lateral radiography.

Evaluation of the Accuracy of ECG Captured by CardioChip through Comparison of Lead I Recording to a Standard 12-Lead ECG Recording Device

BackgroundnRemote cardiac rhythm monitoring and recording, using hand-carried electrocardiogram (ECG) device had been widely used in telemedicine. The feasibility and accuracy analysis on the data recorded by a new miniature ECG system-on-chip (SoC) system has not been explored before.nnnMethodsnThis study evaluated the accuracy of the ECG recordings captured by CardioChip - a single-channeled, low-powered, miniature ECG SoC designed for mobile applications; comparing against Philips Pagewriter Trim III - a Food and Drug Administration certified, widely-used standard 12-lead ECG recording device, within Mackay Memorial Hospital in Taiwan.nnnResultsnTotal of 111 participants, age ranging from 39 to 87years old [mean age: 61.2 ± 13.4, 57 male (51.3%)] were enrolled. Two experienced cardiologists rated and scored the ECG morphology to be the same between the two devices, while CardioChip ECG was more sensitive to baseline noise. R-peak amplitudes measured both devices using single lead information (CardioChip ECG vs. Lead 1 in standard 12-lead ECG) showed statistical consistency. Offline analysis of signal correlation coefficients and coherence showed good correlation with both over 0.94 in average (0.94 ± 0.04 and 0.95 ± 0.04, respectively), high agreement between raters (94% agreement) for detecting abnormal cardiac rhythm with excellent R-peak amplitude (r = 0.98, p < 0.001) and PR interval (r = 0.91, p < 0.001) correlations, indicating excellent correlation between ECG recordings derived from two different modalities.nnnConclusionsnThe results suggested that CardioChip ECG is comparable to medical industry standard ECG. The future implementation of wearable ECG device embedded with miniature ECG system-on-chip (SoC) system is ready for clinical use, which will potentially enhance efficacy on identifying subjects with suspected cardiac arrhythmias.