Wen I. Liao

Pyogenic liver abscess treated by percutaneous catheter drainage: MDCT measurement for treatment outcome

OBJECTIVE To analyze multidetector computed tomographic (MDCT) parameters in patients with pyogenic liver abscess (PLA), and to identify which parameters can be predicted percutaneous catheter drainage (PCD) treatment outcome. MATERIALS AND METHODS Clinical, laboratory and MDCT findings of 175 patients with PLA who had undergone PCD were retrospectively reviewed. All abscesses shown on MDCT were evaluated for size, margin, attenuation values, location, number of large (>3cm) abscesses, presence of a cystic component, presence of gas, and the shortest length to the liver capsule. Univariate and multivariate analyses of the MDCT parameters that affect PCD treatment outcome was performed. For continuous data of MDCT parameters (abscess size and the shortest length), we used receiver-operating-characteristic (ROC) curve to determine the optimal cut-off values. RESULTS PCD was failed in 32 patients and the overall failure rate was 18.28%. Multivariate analysis revealed that PCD failure was predicted by the presence of gas (odds ratio [OR], 42.67), a large abscess (OR 1.21), low minimal attenuation values (OR 1.02), wide range of attenuation values (OR 1.01), a shorter length to the liver capsule (OR 0.09) and lack of a cystic component (OR 0.09) of the PLA. ROC curve showed that the shortest length less than 0.25cm and an abscess size greater than 7.3cm were the optimal cut-off values predicting PCD treatment failure. CONCLUSION Among these MDCT parameters, gas formation within PLA was the most important predictor for PCD failure. Surgical intervention might be considered early in high-risk patients of PCD failure.

An Elevated Gap between Admission and A1C-Derived Average Glucose Levels Is Associated with Adverse Outcomes in Diabetic Patients with Pyogenic Liver Abscess

Objectives To assess whether chronic glycemic control and stress-induced hyperglycemia, determined by the gap between admission glucose levels and A1C-derived average glucose (ADAG) levels adversely affects outcomes in diabetic patients with pyogenic liver abscess (PLA). Methods Clinical, laboratory, and multi-detector computed tomography (MDCT) findings of 329 PLA patients (2004–2010) were retrospectively reviewed. HbA1C levels were used to determine long-term glycemic control status, which were then converted to estimated average glucose values. For the gap between admission glucose levels and ADAG levels, we used receiver operating characteristic (ROC) curve to determine the optimal cut-off values predicting adverse outcomes. Univariate and multivariate logistic regressions were used to identify predictors of adverse outcomes. Results Diabetic PLA patients with poorer glycemic control had significantly higher Klebsiella pneumoniae (KP) infection rates, lower albumin levels, and longer hospital stays than those with suboptimal and good glycemic control. The ROC curve showed that a glycemic gap of 72 mg/dL was the optimal cut-off value for predicting adverse outcomes and showed a 22.3% relative increase in adverse outcomes compared with a glycemic gap<72 mg/dL. Multivariate analysis revealed that an elevated glycemic gap≥72 mg/dL was important predictor of adverse outcomes. Conclusions A glycemic gap≥72 mg/dL, rather than admission hyperglycemia or chronic glycemic control, was significantly correlated with adverse outcomes in diabetic PLA patients. Poorer chronic glycemic control in diabetic PLA patients is associated with high incidence of KP infection, hypoalbuminemia and longer hospital stay.

Usefulness of glycemic gap to predict ICU mortality in critically ill patients with diabetes

AbstractStress-induced hyperglycemia (SIH) has been independently associated with an increased risk of mortality in critically ill patients without diabetes. However, it is also necessary to consider preexisting hyperglycemia when investigating the relationship between SIH and mortality in patients with diabetes. We therefore assessed whether the gap between admission glucose and A1C-derived average glucose (ADAG) levels could be a predictor of mortality in critically ill patients with diabetes.We retrospectively reviewed the Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores and clinical outcomes of patients with diabetes admitted to our medical intensive care unit (ICU) between 2011 and 2014. The glycosylated hemoglobin (HbA1c) levels were converted to the ADAG by the equation, ADAG = [(28.7 × HbA1c) − 46.7]. We also used receiver operating characteristic (ROC) curves to determine the optimal cut-off value for the glycemic gap when predicting ICU mortality and used the net reclassification improvement (NRI) to measure the improvement in prediction performance gained by adding the glycemic gap to the APACHE-II score.We enrolled 518 patients, of which 87 (17.0%) died during their ICU stay. Nonsurvivors had significantly higher APACHE-II scores and glycemic gaps than survivors (P < 0.001). Critically ill patients with diabetes and a glycemic gap ≥80 mg/dL had significantly higher ICU mortality and adverse outcomes than those with a glycemic gap <80 mg/dL (P < 0.001). Incorporation of the glycemic gap into the APACHE-II score increased the discriminative performance for predicting ICU mortality by increasing the area under the ROC curve from 0.755 to 0.794 (NRI = 13.6%, P = 0.0013).The glycemic gap can be used to assess the severity and prognosis of critically ill patients with diabetes. The addition of the glycemic gap to the APACHE-II score significantly improved its ability to predict ICU mortality.

Acute ruptured appendicitis and peritonitis with pseudomyocardial infarction.

Acute abdominal conditions unexpectedly present with electrocardiographic changes. However, the presence of electrocardiographic changes and misleading clinical manifestations may obscure true etiology and delay surgical interventions. We present a patient who developed ruptured appendicitis with peritonitis manifested as acute inferior wall myocardial infarction-like electrocardiographic changes. A thorough physical examination and early echocardiographic evaluation helped to differentiate this pseudomyocardial infarction. A 64-multidetector-row computed tomography of the abdomen showed ruptured retrocecal appendicitis, and emergent appendectomy was done. Normalization of ST segments was observed after surgery.

Bradyarrhythmia caused by ginseng in a patient with chronic kidney disease.

One of the most popularly used Chinese herbal medicines (CHMs) is ginseng, which is a highly valued herb in the Far East and has gained popularity in the West during the last decades. Ginseng has been reported to have pharmacological effects, including modulation of immune response and anticancer, antiaging, anti-amnestic, cardiovascular protective, and wound-healing effects. It is known that ingestion of ginseng can cause false-positive reading in certain digoxin immunoassays; however, bradyarrhythmiacaused by ginseng-associated digitalis glycoside–like effect has not been reported before. We propose that Asian ginseng could exhibit cardiac glycoside-like cardiovascular effects in susceptible patients. Here, we present a patient who had chronic renal insufficiency who developed atrial fibrillation (AF) with slow ventricular rate after taking Asian ginseng for 1 week. An 83-year-old woman presented to the emergency department because of dizziness and general weakness for 1 day. She denied having any systemic illness before. She had been well until 1 month earlier, when she got a cold and started to take ginseng preparation. On arrival, her blood pressure was 101/52 mm Hg, pulse rate was 42 beats/min, and body temperature was 36.3°C. Physical examination disclosed irregular, slow heartbeat and grade II systolic murmur over the left lower sternum border. Results of focused neurological examinations were normal. The electrocardiogram demonstrated AF with slow ventricular rate and left ventricular hypertrophy. Her chest radiography disclosed only mild cardiomegaly. The results of laboratory examinations revealed the following: hemoglobin, 8.9 g/dL; blood urea nitrogen, 59 mg/dL; creatinine, 4.3 mg/dL; sodium, 133 mmol/L; potassium, 4.0 mmol/L; magnesium, 3.3 mg/dL; and free calcium, 4.09 mg/dL. The results of the remaining tests, including 0735-6757/

The physiological effects and quality of chest compressions during CPR at sea level and high altitude

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An Elevated Glycemic Gap is Associated with Adverse Outcomes in Diabetic Patients with Acute Myocardial Infarction

BACKGROUND Rescuers that undergo acute ascent without acclimatization can experience acute mountain sickness. Although performing cardiopulmonary resuscitation (CPR) for a short period requires intensive effort at sea level, performing CPR at high altitude is even more exhausting and can endanger the rescuer. Therefore, we conducted a pilot study to compare the quality of resuscitation in health professionals at high altitude (3100 m) and that at sea level. METHODS Thirty-eight participants were asked to performed continuous chest compression CPR (CCC-CPR) for 5 minutes at sea level and at high altitude. Cardiopulmonary resuscitation recording technology was used to objectively quantify the quality of the chest compressions (CCs), including the depth and rate thereof. RESULTS At high altitude, rescuers showed a statistically significant decrease in blood oxygen saturation and an increase in systolic blood pressure, diastolic blood pressure, heart rate, and fatigue, as measured with the Borg score, after CCC-CPR compared with resting levels. The analysis of the time-dependent deterioration in the quality of CCC-CPR showed that the depth of CCs declined from the mean depth of the first 30 seconds after CCC-CPR to that at more than 120 seconds after CCC-CPR at both sea level and high altitude. The average number of effective CCs declined after CCC-CPR was performed for 1 minute at sea level and high altitude. CONCLUSIONS The quality of CC rapidly declined at high altitude. At high altitude, the average number of effective CC decreases; and this decrease became significant after continuous CCs had been performed for 1 minute.

Usefulness of glycated hemoglobin A1c-based adjusted glycemic variables in diabetic patients presenting with acute ischemic stroke

Acute hyperglycemia is a frequent finding in patients presenting to the emergency department (ED) with acute myocardial infarction (AMI). The prognostic role of hyperglycemia in diabetic patients with AMI remains controversial. We retrospectively reviewed patients’ medical records to obtain demographic data, clinical presentation, major adverse cardiac events (MACEs), several clinical scores and laboratory data, including the plasma glucose level at initial presentation and HbA1c levels. The glycemic gap, which represents changes in serum glucose levels during the index event, was calculated from the glucose level upon ED admission minus the HbA1c-derived average glucose (ADAG). We enrolled 331 patients after the review of medical records. An elevated glycemic gap between admission serum glucose levels and ADAG were associated with an increased risk of mortality in patients. The glycemic gap showed superior discriminative power regarding the development of MACEs when compared with the admission glucose level. The calculation of the glycemic gap may increase the discriminative powers of established clinical scoring systems in diabetic patients presenting to the ED with AMI. In conclusion, the glycemic gap could be used as an adjunct parameter to assess the severity and prognosis of diabetic patients presenting with AMI. However, the usefulness of the glycemic gap should be further explored in prospective longitudinal studies.

An Elevated Glycemic Gap is Associated with Adverse Outcomes in Diabetic Patients with Community-Acquired Pneumonia

ABSTRACT Acute hyperglycemia is a common condition among patients with diabetes who are admitted to the emergency department (ED) for acute ischemic stroke (AIS). Previous findings regarding the association between hyperglycemia at admission and adverse outcomes among patients with diabetes and AIS have been inconsistent. When investigating this association, it is necessary to consider premorbid blood glucose control. The objective of the current study was to assess whether HbA1c‐based adjusted glycemic variables were associated with unfavorable outcomes among patients admitted to the hospital for AIS. We retrospectively analyzed data from 309 patients who were hospitalized for AIS at a single medical center in Taiwan between January 1, 2013, and October 31, 2015. We found that 1) HbA1c‐based adjusted glycemic variables, including the glycemic gap and stress hyperglycemia ratio, were associated with both AIS severity and neurological status at discharge; additionally, 2) HbA1c‐based adjusted glycemic variables showed superior discriminative power compared with acute hyperglycemia regarding the development of severe AIS. We conclude that both the glycemic gap and stress hyperglycemia ratio might be useful in assessing the disease severity and prognosis of patients presenting with AIS. Further prospective long‐term follow‐up studies should be performed to validate these findings.

Post-traumatic cerebral infarction following low-energy penetrating craniocerebral injury caused by a nail.

AbstractSeveral studies argue against the association between admission hyperglycemia and adverse outcomes in infected diabetic patients. When investigating the association, it is necessary to consider preexisting hyperglycemia. The objective of this study was to assess whether stress-induced hyperglycemia, determined by the glycemic gap between admission glucose levels and A1c-derived average glucose levels adversely affects outcomes in diabetic patients admitted to hospital with community-acquired pneumonia (CAP).We retrospectively analyzed the glycemic gap and adverse outcomes of diabetic patients hospitalized because of CAP from June 1, 2007 to August 31, 2012 in single medical center in Taiwan.A total of 203 patients admitted with principal diagnosis of CAP and available data of glycemic gap.Patients with glycemic gaps ≥40 mg/dL had greater AUROC values for the development of adverse outcomes compared with acute hyperglycemia and long-term glycemic controls. Patients with an elevated glycemic gap had an odds ratio of 3.84 for the incidence of combined adverse outcomes. Incorporation of the glycemic gap into pneumonia severity index, CURB-65 or SMART-COP scores, increased the discriminative performance of predicting the development of adverse outcomes.Glycemic gaps were associated with adverse outcomes of diabetic CAP patients. The discriminative performance of the calculated glycemic gaps was comparable with those of current clinical scoring systems and may further increase the AUROC of each system.