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The Geriatric Influenza Death (GID) score was developed to help decision making in older patients with influenza in the emergency department (ED), but external validation is unavailable. Thus, we conducted a study was to fill the data gap. We recruited all older patients (≥65 years) who visited the ED of three hospitals between 2009 and 2018. Demographic data and clinical characteristics were retrospectively collected. Discrimination, goodness of fit, and performance of the GID score were evaluated. Of the 5,508 patients (121 died) with influenza, the mean age was 76.6±7.4 (standard deviation) years, and 49.3% were males. The GID score was higher in the mortality group (1.7±1.1 vs. 0.8±0.8, p

Glioblastoma (GBM) has the highest fatality rate among primary malignant brain tumors and typically tends to recur locally just adjacent to the original tumor site following surgical resection and adjuvant radiotherapy. We conducted a study to evaluate the survival outcomes between a standard dose (≤ 60 Gy) and moderate radiation dose escalation (>60 Gy), and to identify prognostic factors for GBM. We retrospectively reviewed the medical records of primary GBM patients diagnosed between 2005 and 2016 in two referral hospitals in Taiwan. They were identified from the cancer registry database and followed up from the date of diagnosis to October 2018. The progression-free survival (PFS) and overall survival (OS) were compared between the two dose groups, and independent factors for survival were analyzed through Cox proportional hazard model. We also affirmed the results using Cox regression with least absolute shrinkage and selection operator (LASSO) approach. From our cancer registry database, 142 GBM patients were identified, and 84 of them fit the inclusion criteria. Of the 84 patients, 52 (62%) were males. The radiation dose ranged from 50.0 Gy to 66.6 Gy, but their treatment volumes were similar to the others. Fifteen (18%) patients received an escalated dose boost >60.0 Gy. The escalated group had a longer median PFS (15.4 vs. 7.9 months, p = 0.01 for log-rank test), and a longer median OS was also longer in the escalation group (33.8 vs. 12.5 months, p 70 (HR = 1.55), diagnosis after 2010 (HR = 1.42), and a larger radiation volume (≥ 250ml; HR = 0.81) were predictors of PFS. The escalated dose (HR = 0.47) and a larger radiation volume (HR = 0.76) were identified as predictors for better OS. Following detailed statistical analysis, a moderate radiation dose escalation (> 60 Gy) was found as an independent factor affecting OS in GBM patients. In conclusion, a moderate radiation dose escalation (> 60 Gy) was an independent predictor for longer OS in GBM patients. However, prospective studies including more patients with more information, such as molecular markers and completeness of resection, are needed to confirm our findings.

The flood after a typhoon may lead to increase in patients with cellulitis of lower limbs. However, the microbiological features of these cases are rarely reported. We conducted a study of patients with lower extremity cellulitis after a typhoon followed in southern Taiwan to study the risk factors of cellulitis and the bacteriological features of the patients.We reviewed all the medical records of cellulitis at emergency departments of two teaching hospitals in southern Taiwan 30 days before and after the landing of Typhoon Morakot and collected data on the demographic and bacteriological characteristics. In addition, we evaluated the relationship between the daily number of patients and the rainfall in the Tainan area.The number of cellulitis patients increased from 183 to 344 during the 30-day period after the typhoon. The number peaked in the third and fourth days and lasted for 3 weeks. The proportion of patients with water immersion of the affected limb was higher after the typhoon (6% vs. 37%, odds ratio [OR]: 9.0, 95% Confidence interval [CI]: 4.7-17.2). We found cultures from the infected limbs with immersion had more polymicrobial (73% vs. 26%, OR: 7.8, 95% CI: 3.2-19.2) and Gram-negative bacilli infection (86% vs. 34%, OR: 11.8, 95% CI: 4.1-34.5).Flood arose from Typhoon Morakot caused increases in cellulitis patients, which lasted for 3 weeks. Antibiotic treatment that were effective to both Gram-positive cocci and Gram-negative bacilli are recommended for patients with limbs emerged in the water.

Background Dioxin is an industrial pollutant related to various diseases, but epidemiological data on its effects on the kidney are limited. Therefore, we conducted a study to evaluate the association between dioxin exposure and chronic kidney disease (CKD) and identify the related factors. Methods We conducted a community-based cross-sectional study and recruited participants from an area where the residents were exposed to dioxin released from a factory. We defined a “high dioxin level” as polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) ≥ 20 pg WHO98-TEQDF/g lipid in the serum and defined CKD as having an estimated glomerular filtration rate (e-GFR) ≤ 60 mL/min/1.73m2 or a diagnosis of CKD by a physician. The renal function was assessed between 2005 and 2010, and we excluded those who had had kidney diseases before the study started. Comparisons between patients of CKD and those who did not have CKD were made to identify the risk factors for CKD. Results Of the 2898 participants, 1427 had high dioxin levels, and 156 had CKD. In the univariate analyses, CKD was associated with high dioxin levels, age, gender, metabolic syndrome, diabetes mellitus, hypertension, and high insulin and uric acid levels. After adjusting for other factors, we found high dioxin levels (adjusted odds ratio [AOR] = 1.76, 95% confidence interval [CI]: 1.04–2.99), female gender (AOR = 1.74, 95%CI: 1.20–2.53), hypertension (AOR = 1.68, 95%CI: 1.17–2.42), high insulin levels (AOR = 2.14, 95% CI: 1.26–3.61), high uric acid levels (AOR = 4.25, 95% CI: 2.92–6.20), and older age (AOR = 4.66, 95% CI: 1.87–11.62 for 40–64 year and AOR = 26.66, 95% CI: 10.51–67.62 for age ≥ 65 year) were independent predictors of CKD. Conclusion A high dioxin level was associated with an increased prevalence of CKD. Therefore, the kidney function of populations with exposure to dioxin should be monitored.

Background Predicting the neurological sequelae of carbon monoxide poisoning (COP) has not been well studied. We investigated the independent predictors of neurological sequelae in patients with COP and combined these predictors to predict the prognosis. Methods This study was conducted at four hospitals in Shandong Province, China. Data were retrospectively collected from 258 patients with COP between November 1990 and October 2011. Thirty-day neurological sequelae were the primary endpoints. Results A lack of pupil reflex and a loss of consciousness appear to be independent predictors for neurological sequelae in patients with COP. The presence of either one had a sensitivity of 77.0% (95% confidence interval [CI]: 69.3–83.2), a specificity of 47.1% (95% CI: 38.3–56.0), positive predictive value (PPV) of 62.9% (95% CI: 55.2–70.1), and a negative predictive value (NPV) of 63.6% (95% CI: 52.6–73.4). With both predictors present, the sensitivity was 11.5% (95% CI: 6.9 to 18.3), the specificity was 99.2 (95% CI: 94.7–100.0), the PPV was 94.1% (95% CI: 69.2–99.7), and the NPV was 49.0% (95% CI: 42.5–55.5). Conclusions The risk for neurological sequelae apparently increased with the number of independent predictors. In patients with both predictors, the risk for neurological sequelae was 94.1%. Almost all (99.2%) patients with neither predictor had no neurological sequelae. This finding may help physicians make decisions about and dispositions for patients with COP. For patients with a higher risk, earlier treatment and more appropriate utilization of health care services, including hyperbaric oxygen, should be considered.

BACKGROUND: Carbon monoxide poisoning (COP) often produces severe complications and can be fatal. Because this topic has not been well delineated, we investigated long-term prognoses of patients with COP (COP[+]). METHODS: In this retrospective nationwide cohort study, 441 COP[+] patients and 8820 COP[-] controls (120) from 1999 to 2010 were selected from Taiwan's National Health Insurance Research Database. RESULTS: Thirty-seven (8.39%) COP[+] patients and 142 (1.61%) controls died (P

Background The survival rate of patients with out-of-hospital cardiac arrest is low, and measures to improve the quality of cardiopulmonary resuscitation (CPR) during ambulance transportation are desirable. We designed a stabilization device, and in a randomized crossover trial we found performing CPR in a moving ambulance with the device (MD) could achieve better efficiency than that without the device (MND), but the efficiency was lower than that in a non-moving ambulance (NM). Purpose To evaluate whether a modified version of the stabilization device, can promote further the quality of CPR during ambulance transportation. Methods Participants of the previous study were recruited, and they performed CPR for 10 minutes in a moving ambulance with the modified version of the stabilization device (MVSD). The primary outcomes were effective chest compressions and no-flow fraction recorded by a skill-reporter manikin. The secondary outcomes included back pain, physiological parameters, and the participants' rating about the device after performing CPR. Results The overall effective compressions in 10 minutes were 86.4±17.5% for NM, 60.9±14.6% for MND, 69.7±22.4% for MD, and 86.6%±13.2% for MVSD (p

BACKGROUND: Falls are common in older people and may lead to functional decline, disability, and death. Many risk factors have been identified, but studies evaluating effects of nutritional status are limited. To determine whether nutritional status is a predictor of falls in older people living in the community, we analyzed data collected through the Survey of Health and Living Status of the Elderly in Taiwan (SHLSET). METHODS: SHLSET include a series of interview surveys conducted by the government on a random sample of people living in community dwellings in the nation. We included participants who received nutritional status assessment using the Mini Nutritional Assessment Taiwan Version 2 (MNA-T2) in the 1999 survey when they were 53 years or older and followed up on the cumulative incidence of falls in the one-year period before the interview in the 2003 survey. RESULTS: At the beginning of follow-up, the 4440 participants had a mean age of 69.5 (standard deviation = 9.1) years, and 467 participants were "not well-nourished," which was defined as having an MNA-T2 score of 23 or less. In the one-year study period, 659 participants reported having at least one fall. After adjusting for other risk factors, we found the associated odds ratio for falls was 1.73 (95% confidence interval, 1.23, 2.42) for "not well-nourished," 1.57 (1.30, 1.90) for female gender, 1.03 (1.02, 1.04) for one-year older, 1.55 (1.22, 1.98) for history of falls, 1.34 (1.05, 1.72) for hospital stay during the past 12 months, 1.66 (1.07, 2.58) for difficulties in activities of daily living, and 1.53 (1.23, 1.91) for difficulties in instrumental activities of daily living. CONCLUSION: Nutritional status is an independent predictor of falls in older people living in the community. Further studies are warranted to identify nutritional interventions that can help prevent falls in the elderly. Language: en

Prior studies of upper gastrointestinal bleeding (UGIB) and acute myocardial infarction (AMI) are small, and long-term effects of UGIB on AMI have not been delineated. We investigated whether UGIB in patients diagnosed with coronary artery disease (CAD) increased their risk of subsequent AMI. This was a population-based, nested case-control study using Taiwan’s National Health Insurance Research Database. After propensity-score matching for age, gender, comorbidities, CAD date, and follow-up duration, we identified 1,677 new-onset CAD patients with AMI (AMI[+]) between 2001 and 2006 as the case group and 10,062 new-onset CAD patients without (AMI[−]) as the control group. Conditional logistic regression was used to examine the association between UGIB and AMI. Compared with UGIB[−] patients, UGIB[+] patients had twice the risk for subsequent AMI (adjusted odds ratio [AOR] = 2.08; 95% confidence interval [CI], 1.72–2.50). In the subgroup analysis for gender and age, UGIB[+] women (AOR = 2.70; 95% CI, 2.03–3.57) and patients < 65 years old (AOR = 2.23; 95% CI, 1.56–3.18) had higher odds of an AMI. UGIB[+] AMI[+] patients used nonsignificantly less aspirin than did UGIB[−] AMI[+] patients (27.69% vs. 35.61%, respectively). UGIB increased the risk of subsequent AMI in CAD patients, especially in women and patients < 65. This suggests that physicians need to use earlier and more aggressive intervention to detect UGIB and prevent AMI in CAD patients.

Health care workers (HCWs) in Taiwan have heavy, stressful workloads, are on-call, and have rotating nightshifts, all of which might contribute to peptic ulcer disease (PUD). We wanted to evaluate the PUD risk in HCWs, which is not clear. Using Taiwan's National Health Insurance Research Database, we identified 50,226 physicians, 122,357 nurses, 20,677 pharmacists, and 25,059 other HCWs (dieticians, technicians, rehabilitation therapists, and social workers) as the study cohort, and randomly selected an identical number of non-HCW patients (i.e., general population) as the comparison cohort. Conditional logistical regression analysis was used to compare the PUD risk between them. Subgroup analysis for physician specialties was also done. Nurses and other HCWs had a significantly higher PUD risk than did the general population (odds ratio [OR]: 1.477; 95% confidence interval [CI]: 1.433-1.521 and OR: 1.328; 95% CI: 1.245-1.418, respectively); pharmacists had a lower risk (OR: 0.884; 95% CI: 0.828-0.945); physicians had a nonsignificantly different risk (OR: 1.029; 95% CI: 0.987-1.072). In the physician specialty subgroup analysis, internal medicine, surgery, Ob/Gyn, and family medicine specialists had a higher PUD risk than other physicians (OR: 1.579; 95% CI: 1.441-1.731, OR: 1.734; 95% CI: 1.565-1.922, OR: 1.336; 95% CI: 1.151-1.550, and OR: 1.615; 95% CI: 1.425-1.831, respectively). In contrast, emergency physicians had a lower risk (OR: 0.544; 95% CI: 0.359-0.822). Heavy workloads, long working hours, workplace stress, rotating nightshifts, and coping skills may explain our epidemiological findings of higher risks for PUD in some HCWs, which might help us improve our health policies for HCWs.

BackgroundEvaluating geriatric patients with fever is time-consuming and challenging. We investigated independent mortality predictors of geriatric patients with fever and developed a prediction rule for emergency care, critical care, and geriatric care physicians to classify patients into mortality risk and disposition groups.Materials and methodsConsecutive geriatric patients (≥65 years old) visiting the emergency department (ED) of a university-affiliated medical center between June 1 and July 21, 2010, were enrolled when they met the criteria of fever: a tympanic temperature ≥37.2°C or a baseline temperature elevated ≥1.3°C. Thirty-day mortality was the primary endpoint. Internal validation with bootstrap re-sampling was done.ResultsThree hundred thirty geriatric patients were enrolled. We found three independent mortality predictors: Leukocytosis (WBC >12,000 cells/mm3), Severe coma (GCS ≤ 8), and Thrombocytopenia (platelets ConclusionsWe found that the Geriatric Fever Score is a simple and rapid rule for predicting 30-day mortality and classifying mortality risk and disposition in geriatric patients with fever, although external validation should be performed to confirm its usefulness in other clinical settings. It might help preserve medical resources for patients in greater need.

Objective The flood after a typhoon may lead to increase in patients with cellulitis of lower limbs. However, the microbiological features of these cases are rarely reported. We conducted a study of patients with lower extremity cellulitis after a typhoon followed in southern Taiwan to study the risk factors of cellulitis and the bacteriological features of the patients. Methods We reviewed all the medical records of cellulitis at emergency departments of two teaching hospitals in southern Taiwan 30 days before and after the landing of Typhoon Morakot and collected data on the demographic and bacteriological characteristics. In addition, we evaluated the relationship between the daily number of patients and the rainfall in the Tainan area. Results The number of cellulitis patients increased from 183 to 344 during the 30-day period after the typhoon. The number peaked in the third and fourth days and lasted for 3 weeks. The proportion of patients with water immersion of the affected limb was higher after the typhoon (6% vs. 37%, odds ratio [OR]: 9.0, 95% Confidence interval [CI]: 4.7–17.2). We found cultures from the infected limbs with immersion had more polymicrobial (73% vs. 26%, OR: 7.8, 95% CI: 3.2–19.2) and Gram-negative bacilli infection (86% vs. 34%, OR: 11.8, 95% CI: 4.1–34.5). Conclusions Flood arose from Typhoon Morakot caused increases in cellulitis patients, which lasted for 3 weeks. Antibiotic treatment that were effective to both Gram-positive cocci and Gram-negative bacilli are recommended for patients with limbs emerged in the water.