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In the recent years, the business environment for small and medium-sized enterprises (SMEs) in Taiwan has become more difficult due to low-cost competition from Mainland China. In order to cope with uncertainties in the environment, businesses have to focus their attention on customer relationship quality, development of a robust personality in managers, and utilization of management accounting information systems (MAIS). Utilizing MAIS and improving customer satisfaction to create customer royalty are tasks that businesses should work on in marketing. The purpose of this study is to examine whether use of MAIS is a variable mediating the relationship between managers with an internal locus of control and customer relationship quality. The method is based on multiple regression and path analysis. Data were collected using a questionnaire administered to 300 SME managers in central Taiwan who were also members of NCUE EMBA Association by mail. 169 valid responses were obtained, resulting in a response rate of 56.3%. Results showed that personality has a direct effect on customer relationship quality, and personality can also indirectly affect customer relationship quality through use of MAIS. Findings of this study can be a reference for local SMEs when selecting managers.

This study aimed to assess the impact of different methods of draining nontraumatic hemopericardium on outcome from patients with out-of-hospital cardiac arrest (OHCA), identify independent predictors of return of spontaneous circulation (ROSC), and examine the ineffective rate of decompression based on subxiphoid pericardiotomy (SP) and percutaneous pericardial catheter drainage (PCD).Adult patients with OHCA who presented to the ED between May 1, 2000, and October 30, 2006, with moderate to massive nontraumatic hemopericardium were recruited and stratified into 4 groups according to the relieving methods of hemopericardium. Charts were reviewed for various demographic data, resuscitation records, management, and outcome. Patient outcome was recorded as survival to hospital discharge and ROSC, as primary end points. Effective decompression was recorded as a secondary end point. We compared the outcome between the groups.A total of 1491 OHCA resuscitation records were prospective collected. There were 23 OHCA patients with moderate to massive nontraumatic hemopericardium. The overall ROSC rate was 39.1% (9/23). There was a clear difference in the ROSC rate between 4 groups (P.05). The overall rate of survival to hospital discharge was 4.3% (1/23). There was no significant difference in the rate of survival to hospital discharge between the groups. Relieving methods was an independent predictor of ROSC in OHCA patients with nontraumatic hemopericardium (odds ratio, 0.17; 95% confidence interval, 0.4-0.70). There was a significant statistical difference in adequate relief of hemopericardium based on SP and PCD (P.01).The early effective decompression method is associated with an increased rate of ROSC for OHCA patients with nontraumatic hemopericardium. Subxiphoid pericardiotomy has a better effective decompression of hemopericardium than PCD.

Background Rupture of abdominal aortic aneurysm is one of the lifethreatening diseases in Emergency Department (ED) and it can be misdiagnosed. It happens mostly in the people who are in average of age 75 to 84 years.Use of bedside ultrasonography has been became more common in daily practice of emergency physician (EP) for approaching patient in ED, which has chief complaint of acute abdomen.Especially in the life-threatening rupture abdominal aortic aneurysm, bedside sonography can be more safe and adequate time-saving tool for EP for detection, diagnosis and next crucial management. We reviewed the database of an tertiary medical center for collection of first diagnosis of abdominal aortic aneurysm made in Emergency Department.

Current research on the cellular mechanisms of nerve regeneration suggests the application of nerve growth factors at the repair sites to be beneficial. To test the effectiveness of this approach, we performed transections of the C6 and C7 ventral rootlets from their original sites in the spinal cord of 18 rats. We investigated the electrophysiological changes in three groups of rats operated on by different repair strategies. Six rats comprised the control group (G1). In the other 12 rats, 24 rootlets were implanted into the spinal cord by means of an intercostal nerve graft through the pia mater immediately after transection. Six rats (G2) had fibrin glue applied at the incision. The last 6 rats (G3) had grafts with acidic fibroblast growth factor (aFGF) added to the fibrin glue. The rats' functional recovery was evaluated electrophysiologically at 6 weeks and 6 months after the operation. Needle electromyography showed profound fibrillation potentials (Daube's scoring system) in the deltoid, biceps, and triceps of the operated forelimbs in all groups 6 weeks after the operation. After 6 months, there was a significant decrease in the amount of fibrillation potentials in all groups (G1, G2 and G3, p < 0.0001, 0.0001, 0.0009, respectively, generalized estimating equation, repeated measures) and a significantly high probability for motor units present in sampled muscles of G2 and G3 as compared to G1 (log odds ratio in G2 = 51.8316, G3 = 57.4262, generalized estimating equation). We conclude that several cervical roots can regenerate through intercostal nerve grafts applied using fibrin glue. Adding aFGF may increase the efficacy of sprouting.

A 38-year-old man who had been treated with warfarin since mitral valve replacement 10 years earlier presented with acute onset of epigastralgia and melena. Coagulation tests were abnormal with a prolonged prothrombin time of >60 seconds and a prolonged activated partial thromboplastin time of >120 seconds. Abdominal sonographic examination revealed duodenal intramural hematoma that was confirmed on CT. Warfarin therapy was stopped and the patient was treated conservatively with vitamin K and fresh frozen plasma. Recovery was uneventful, and the patient was re-warfarinized 2 weeks later. Duodenal hematoma can be readily diagnosed with bedside sonography.

Background Ultrasound-guided invasive procedures, such as central venous catheter insertion, soft-tissue abscess drainage, and foreign-body removal are essential competencies for Emergency Physicians. Such competencies can be trained using ultrasound phantoms. Objective Our aim is to describe ultrasound phantoms that are easily made, inexpensive, reusable, and can withstand multiple punctures. Methods Previously recommended gelatin-only ultrasound phantoms have inadequate surface tension resulting in surface disruption, and cannot tolerate multiple punctures when simulating cyst drainage. Results By covering the gelatin phantom with a hydrocolloid skin dressing, we are able to minimize physical surface disruption (by transducer or needles) and might reduce biological breakdown due to bacterial propagation. Conclusions The elements required to construct homemade reusable ultrasound phantoms are inexpensive and can be easily obtained.

Objective The management of children with fever of indefinite source still remains controversial. This study aimed to compare different practice patterns between pediatric physicians (PPs) and emergency physicians (EPs) in the management of pediatric fever in the emergency department (ED) and correlate them to existing practice guidelines. Their impact on patient outcomes was also discussed. Methods Medical records of patients 3 to 36 months of age who presented to the ED with fever of indefinite source from June 1 to December 31, 2006, were retrospectively reviewed on day 5 after the patient's first visit. At the same time, telephone follow-up was carried out to determine whether the patient had been visiting or being admitted to another clinic or hospital after discharge. Variation in practice patterns were compared for the number of laboratory tests, ED length of stay (LOS), and the rate of immediate admission. Patient outcomes were measured as the rate of unscheduled revisit within 72 hours and the rate of subsequent admission. Compliance with existing practice guidelines between PPs and EPs were evaluated by dividing all eligible patients into 3 groups: (1) toxic appearing patients (group A), (2) nontoxic patients with body temperature (BT) ≧39°C (group B), and (3) nontoxic patients with BT below 39°C (group C). Results A total of 345 patients who met the inclusion and exclusion criteria were enrolled into this study. Pediatric physicians and EPs treated 163 and 182 febrile children, respectively. In group A, PPs admitted more patients than EPs (41% vs 12 %), whereas more unscheduled revisits were seen in EP-treated patients (44% vs 10%). In group B, PPs ordered more laboratory tests than EPs (2.3 vs 0.7 tests per patient), and their patients also had a longer ED LOS (3.4 ± 3.2 vs 1.5 ± 1.1 hours). However, no difference was found in their rates of immediate admission and unscheduled revisit. In group C, PPs admitted more patients (15% vs 0%) and ordered more laboratory tests (2.0 vs 0.5 tests/patient) than EPs. Longer ED LOS (3.3 ± 3.9 vs 1.0 ± 1.4 hours) was also noted among PP-treated patients. However, no difference was noted in their rates of unscheduled revisit. In all groups, the rates of subsequent admission were similar. Conclusion Compliance with existing practice guidelines (admit the toxic cases and work up those with BT ≧39°C) was higher among PPs, which resulted in a lower rate of unscheduled revisit, but no significant difference was found in the rate of subsequent admission.

To determine the efficacy of the Mortality in Emergency Department Sepsis (MEDS) score in the stratification of patients who presented to the emergency department (ED) with severe sepsis.Adults who presented to the ED with severe sepsis were retrospectively recruited and divided into group A (MEDS score12) and group B (MEDS scoreor =12). Their outcomes were evaluated with 28 day hospital mortality rate, length of hospital stay, Kaplan-Meier survival analysis, and receiver operating characteristic (ROC) analysis. Discriminatory power of the MEDS score in mortality prediction was further compared with the Acute Physiology and Chronic Health Evaluation (APACHE) II model.In total, 276 patients (44.6% men and 55.4% women) were analysed, with 143 patients placed in group A and 133 patients in group B. Patients with MEDS scoreor =12 had a significantly higher mortality rate (48.9% v 17.5%, p0.01) and higher median APACHE II score (25 v 20 points, p0.01). Significant difference in mortality risk was also demonstrated with Kaplan-Meier survival analysis (log rank test, p0.01). No difference in the length of hospital stay was found between the groups. ROC analysis indicated a better performance in mortality prediction by the MEDS score compared with the APACHE II score (ROC 0.75 v 0.62, p0.01).Our results showed that mortality risk stratification of severe sepsis patients in the ED with MEDS score is effective. The MEDS score also discriminated better than the APACHE II model in mortality prediction.

Acute abdominal pain during pregnancy is encountered frequently and the differential diagnosis is extensive. Acute ovarian torsion in a pregnant patient is rare and is difficult to diagnose. Infarction caused by ovarian torsion will result if the twist is not unwound spontaneously or surgically in a timely fashion. The case is described of a 28-year-old primigravida who originally presented to the emergency department with right lower abdominal pain. The patient was ultimately found to have an extremely large cystic teratoma of the right ovary with concomitant torsion. Bedside ultrasonography is a highly accessible tool that can be used in a pregnant woman for screening a mass or ascites. Laparoscopic surgery has now been accepted as a safe modality for definitive diagnosis and therapeutic intervention. Because acute ovarian torsion is not encountered frequently, timely diagnosis is required to prevent mortality and minimise morbidity. It is important to keep ovarian torsion in the differential diagnosis of any pregnant woman with acute abdominal pain. Emergency physicians should be aware of the possibility of acute ovarian torsion in pregnant women and should have a high index of suspicion. Early surgical intervention should be undertaken.

Acute epiglottitis is a true airway emergency in the emergency department (ED). The patient may appear very toxic and rapidly progress to respiratory distress and life-threatening condition. The inflammatory process includes not only epiglottis but also the rest of the supraglottic area including the vallecula, aryepiglottic folds, and arytenoids. Soft tissue swelling over this windpipe area can be very dramatic. The criterion standard of diagnosis is direct inspection of cherry red and swollen epiglottis by laryngoscopy in the operation room with immediate access to anesthetists or ear, nose, and throat specialists. However, before the patients are well prepared, the clinical condition may critically go downhill; and any intention to visualize the throat can result in severe and fatal airway spasm. Thumbprint sign on lateral radiography of neck is typical, but it may be extremely risky to let a patient leave the consulting room for the study if respiratory distress has developed. We demonstrate a safe and practical way to investigate the epiglottis by bedside ultrasonography to visualize the "alphabet P sign" in a longitudinal view through thyrohyoid membrane by emergency physician in the ED.

Patients and methods From January 1 2006 to March 31th 2014, patients who were diagnosed as deep vein thrombosis, either by conventional duplex studies or bedside ultrasound, were included. Medical records were reviewed by a 6-year-trained emergency clinician. Age less than 18, patient who was referred from outpatient department or from other hospital, patient who had the diagnosis of deep vein thrombosis or pulmonary embolism before the visit, patient who use any anti-coagulant before the visit were excluded. Diagnosis of deep vein thrombosis was confirmed by any non-compressible venous vasculature of lower extremities, including common femoral vein, superficial and deep femoral vein, and popliteal vein, under ultrasound. Patient was divided into two group, one group was diagnosed by conventional duplex, and another group was diagnosed by bedside ultrasound. We compared the diagnostic time, treatment time, ED stay time between these two groups. Diagnostic time, treatment time, ED stay time were defined as time between the patient arrived ED and ultrasound-confirmed DVT, time between the patient arrived ED and patient first receive anti-coagulant, time between the patient arrived ED and patient admission or discharge, respectively.