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Background: Indexes of heart rate variability (HRV) appear to reflect severity and may have prognostic value in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We hypothesized that AECOPD without adequate treatment response would demonstrate impaired cardiac autonomic regulation and changes in HRV after emergency department (ED) treatment., Methods: A prospective study of measuring HRV in admitted and discharged patients with AECOPD shortly after ED arrival and again 24 h after treatment., Results: Total consecutive 33 patients (18 admitted and 15 discharged, age 77.1 ± 1.6 years) were enrolled. Among admitted patients, high frequency in normalized unit (HF%) was significantly lower (P < 0.001) while Ratio of LF to HF (LF/HF ratio) was significantly higher (P < 0.001) than discharged. 24 h after treatment, admitted patients had a significantly larger increase in HF% (P < 0.002) and larger decrease in LF/HF ratio (P < 0.05) than discharged. ROC curve analysis show the relative potential of the ΔHF% and ΔLF/HF% in the discrimination of groups. The area under the ROC curve between the 2 groups was 0.807 (P < 0.01) and 0.722 (P < 0.05), respectively. The best cut-off value for the admission between groups was ΔHF% >7.1 and ΔLF/HF% ≦-0.39., Conclusion: Patients with AECOPD requiring admission after ED treatment had a greater increase in HF% and greater decrease in LF/HF ratio compared to those discharged. Our study demonstrates patient with ΔHF% was >7.1 or a ΔLF/HF% ≦-0.39 require admission despite 24 h of ED treatment., (Copyright © 2017. Published by Elsevier Taiwan LLC.)

Objectives: To explore the determinant factors and prognostic significance of emergency department do-not-resuscitate (ED-DNR) orders for patients with spontaneous intracerebral hemorrhage (SICH)., Methods: Consecutive adult SICH patients treated in our ED from January 1, 2012 to December 31, 2016 were selected as the eligible cases from our hospital's stroke database. Patients' information was comprehensively reviewed from the database and medical and nursing charts. ED-DNR orders were defined as DNR orders written during ED stay. Multiple logistic regression analysis was used to identify significant determinants of ED-DNR orders. Thirty- and 90-day neurological outcomes were analyzed to test the prognosis impact of ED-DNR orders., Results: Among 835 enrolled patients, 112 (12.1%) had ED-DNR orders. Significant determinant factors of ED-DNR orders were age, ambulatory status before the event, brain computed tomography findings of midline shift, intraventricular extension, larger hematoma size, and ED arrival GCS ≤8. Patients with and without ED-DNR orders had a similar 30-day death rate if they had the same initial ICH score point. During 30 to 90days, patients with ED-DNR orders had a significantly increased mortality rate. However, the rate of improvement in neurological status between the two groups was not significantly different., Conclusions: Older and sicker SICH patients had higher rate of ED-DNR orders. The mortality rates between patients with and without ED-DNR orders for each ICH score point were not significantly different. During the 30-to-90-day follow-up, the rates of neurological improvement in both groups were similar., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Prolonged endurance exercise is known to cause elevation of cardiac troponin I (cTnI). Previous studies have reported the correlation of several factors with exercise-induced cTnI release. However, the investigation of the predictors for elevated cTnI and postrace kinetics of cTnI after ultramarathon running is lacking, especially in an Oriental population., Methods: Twenty-six participants, including eight hepatitis B virus carrier (HBVc) runners, who finished a 100-km ultramarathon in Taiwan were enrolled. For each participant, blood samples were collected 1 week before the race, as well as immediately and 24 hours after the finish., Results: The results showed that 19 runners (73.1%) had postrace elevated cTnI levels and eight (30.8%) had elevated cTnI values lasting more than 24 hours after the run. A multiple linear regression analysis demonstrated that the HBV status was a factor related to the high level of cTnI after 24 hours of running (β=0.03, p=0.08). The recovery of plasma cTnI levels was delayed in ultramarathon runners with latent HBV infection. Among HBVc runners, multiple linear regression analyses showed age (β=-0.01), previous running experience (β=-0.06), training distance (β=0.37), and 4 hours of running distance (β=-0.04) as significant predictors of higher postrace cTnI levels., Conclusion: For most athletes, cTnI values significantly increased immediately following the race in the absence of adverse clinical sequelae, and HBVc runners had higher and prolonged cTnI levels. While several factors are identified for such HBV effects, the specific causes need further elucidation., (Copyright © 2017. Published by Elsevier Taiwan LLC.)

Background: This study applied a new strategy, termed high-turnover utility bed intervention, to offer early admission chances for emergency department (ED) patients and alleviate ED crowding., Methods: This before-and-after observational cohort study was conducted at the ED of an urban tertiary hospital. On January 1, 2012, 14 utility beds were prepared exclusively for ED patient use. A strict 48-hour course limit for each patient was formulated to govern these high-turnover beds. The primary outcome measure for this study was ED length of stay. Secondary outcome measures were the number of ED admissions, patients who left without being seen, and revisits within 72 hours of discharge, as well as the outcomes of cardiac arrest management and ambulance diversion hours., Results: There were 70,515 adult ED visits enrolled during the preintervention period (January-December 2011), and 69,706 during the postintervention period (July 2012-June 2013). In the postintervention period, this new strategy offered 1401 early admission opportunities. The ambulance diversion hours decreased prominently from 5.4 hours to 1.6 hours per day. A shortening in ED length of stay from 9.7 hours to 8.0 hours was achieved, mainly in cases of nontrauma. More patients (31.2% vs. 29.7%) were admitted to the wards with a lower discharge rate in the postintervention period. Additionally, there was no difference in ED revisit within 72 hours and cardiac arrest management., Conclusion: The high-turnover ED utility bed intervention offered improved admission chance and alleviated ED crowding output. ED efficiency improved, with shortened ED length of stay and fewer ambulance diversion hours., (Copyright © 2017. Published by Elsevier Taiwan LLC.)

Background: We investigated an intensive care model for acute critically cardiovascular emergency patients in the emergency department (ED) as compared with those in the coronary care unit (CCU) after ED visits., Methods: We performed a retrospective cohort analysis of patients with acute cardiovascular emergency admitted to the intensive care unit in the ED (EICU) or CCU from January 1, 2010 to March 31, 2011 in an university-affiliated medical center. All clinical characteristics or predictors possibly related to in-hospital mortality were documented, completed, and measured via electronic medical records review. The clinical independent variables with p < 0.1 in univariate analysis were further analyzed by using multiple logistic regression. Survival analysis of the predictors for hospital mortality was assessed by Kaplan-Meier survival curves., Results: A total of 964 patients were recruited in this study. Of all patients, 328 were enrolled in the EICU group, whereas 636 were enrolled in the CCU group. Multiple regression analysis of both EICU and CCU mortality demonstrated that Acute Physiology and Chronic Health Evaluation II scores were common predictors of mortality in both groups of patients. Based on these scores, Kaplan-Meier survival curves showed no statistically significant differences of cumulative survival rates in both the 7-day and in-hospital survival between both groups., Conclusion: Our study demonstrated a feasible and qualified model of intensive care delivery accomplished by collaboration of emergency physicians and cardiologists for acute critically ill cardiovascular emergency patients after initial ED management. Our results suggest that an expanded multicenter study should be conducted to further test and confirm this intriguing model., (Copyright © 2016. Published by Elsevier Taiwan LLC.)

Background: In-hospital cardiac arrest (IHCA) is a catastrophic complication for patients while admitted in a medical institution. The outcome of IHCA remains poor, and understanding of the prognostic factors for survival outcome after IHCA is lacking, specifically in an oriental population., Methods: A retrospective observational cohort study of 382 patients with IHCA who required resuscitation was conducted in an urban tertiary hospital in Taiwan. Return of spontaneous circulation (ROSC) and survival to hospital discharge were the primary outcome measures., Results: The incidence of IHCA was 3.25 per 1000 admissions. These patients had a mean age of 67.2 ± 21.7 years and were mostly men (66.5%). The rate of successful ROSC was 66%, and the rate of survival to hospital discharge was 11.8%. A stepwise decrease in ROSC was observed with additional resuscitation efforts. Independent predictors for survival to hospital discharge were being female, a resuscitation duration of <20 minutes, and no use of epinephrine during resuscitation. A 68% ROSC success rate and an 84% survival to discharge rate was recorded in patients receiving resuscitation for <30 minutes. Young patients seemed the most likely to benefit from longer resuscitation attempts (>30 minutes), as observed in survival to hospital discharge., Conclusion: Based on data from a single hospital registry in East Asia, a shorter duration of resuscitation was demonstrated to be a predictor of immediate survival with ROSC and survival to hospital discharge., (Copyright © 2015. Published by Elsevier Taiwan LLC.)

Objective: To determine whether on-scene BP is associated with early neurological deterioration (END) in patients with spontaneous intracerebral haemorrhage (SICH)., Methods: This retrospective cohort study enrolled consecutive ambulance-transported adult SICH patients treated at our emergency department (ED) from January 2007 through December 2012. END was defined as a ≥2-point decrease in GCS within 24 h of ED arrival. The exact relationship between on-scene BP and END was assessed using multiple logistic regression analyses for adjusting age, gender, Charlson Index, aspirin use, smoking, elapsed time, consciousness level on ED arrival, haematoma size, intraventricular extension, midline shift and infratentorial ICH. We further calculated the -2 log-likelihood decrease for each regression model incorporated with the BP values measured at different times to compare model fitness., Results: After adjusting for the covariates, on-scene systolic BP (by 10 mm Hg incremental: OR = 1.126, 95% CI 1.015 to 1.265), diastolic BP (by 10 mm Hg incremental: OR=1.146, 95% CI 1.019 to 1.303) and mean arterial pressure (MAP) (by 10 mm Hg incremental: OR=1.225, 95% CI 1.057 to 1.443) were significantly associated with END; adding on-scene MAP into the regression model yielded the highest model fitness increase. Adding on-scene BPs into the regression model yielded higher model fitness increase than adding ED and admission BPs., Conclusions: Few on-scene BP indices were associated with neuroworsening within 24 h after ED arrival in non-comatose SICH patients. Compared with BP measured on ED arrival or admission, on-scene BP had a stronger correlation with END., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Sports anemia is a widely observed phenomenon after prolonged running. There are various factors that contribute to sports anemia, including hemodilution, exercise-induced oxidative stress, iron deficiency, gastrointestinal bleeding, hematuria, and hemolysis resulting from foot-strike and/or from compression of contracting muscles on capillaries. Until now, there has been no published report that describes the overall hematological, urinary, and fecal consequences in Asian male ultramarathoners after a 100-km (62.5-mile) ultramarathon event., Methods: A total of 25 male runners were recruited into our study. Blood was drawn 1 week before, immediately after, and then 24 hours subsequent to the race. Hematological samples were analyzed for the anemia phenomenon. Additionally, urinary and fecal samples were collected before and after the race for detection of occult blood., Results: The blood hemoglobin and erythropoietin values of the recruited runners showed a statistically significant rise in the immediate post-race values and a rapid drop in values at 24 hours post-race. Blood concentrations of red blood cells and hematocrit were significantly lower at 24 hours post-race compared with pre-race. The white blood cell count, interleukin-6, tumor necrosis factor-alpha, high-sensitivity C-reactive protein, and ferritin all showed significant increases both immediately after and 24 hours post-race compared with pre-race hematological values. There were immediate decreases of both haptoglobin and iron, as well as an increase of total iron-binding capacity levels in post-race blood tests. For both urinary and fecal samples, there was a statistically significant difference between the pre- and post-race results in occult blood., Conclusion: Running a 100-km ultramarathon will induce substantial sports anemia, and oxidative stress response, hemolysis, hematuria, and gastrointestinal bleeding are typical factors that contribute to its onset., (Copyright © 2014. Published by Elsevier Taiwan.)

Background: Fewer pauses and better chest compression quality are thought to improve overall survival following cardiac arrest. This study aimed to measure the outcomes of adult nontraumatic out-of-hospital cardiac arrests (OHCAs) treated with 5:1 compressions-to-ventilations (Thumper 1007) or continuous chest compressions with ventilation (Thumper 1008 CCV) mechanical cardiopulmonary resuscitation (CPR) within a specified period of time., Methods: A retrospective observational cohort study of 515 adults with OHCA was conducted at the emergency department of an urban tertiary hospital. There were 307 patients in the Thumper 1007 phase (January 2008 to December 2009) and 208 patients in the Thumper 1008 CCV phase (January 2010 to May 2011). Return of spontaneous circulation (ROSC) and survival to hospital discharge were the primary outcome measures., Results: Patients in the Thumper 1007 and Thumper 1008 CCV phases had comparable results with the following exceptions: less hypertension (42.4% vs. 62.0%), cerebrovascular accidents (11.4% vs. 25.0%), and faster emergency medical service response time intervals (mean, 3.7 vs. 4.5 minutes) with the Thumper 1007. The average ambulance transport time was 6.1 minutes in both phases. The rates of ROSC [35.1% vs. 23.5%; adjusted odds ratio (OR), 1.616; 95% confidence interval (CI), 1.073-2.432] and survival to hospital discharge (10.1% vs. 4.2%; adjusted OR 2.431; 95% CI, 1.154-5.120) were significantly higher with the Thumper 1008 CCV than with the Thumper 1007. Favorable neurologic outcome upon discharge, defined as cerebral performance category scores of 1 (good performance) or 2 (moderate disability), was not significantly different between the two phases [1.6% (5/307) vs. 1.9% (4/208); p = 0.802]. The Thumper 1008 CCV provided significantly faster average chest compression rates and shorter no-chest compression intervals than the Thumper 1007 after activation., Conclusion: In an emergency department with short ambulance transport times, continuous chest compressions with ventilation through mechanical CPR showed improved outcomes, including ROSC and survival to hospital discharge, in an adult with OHCA. However, there are a variety of confounding influences that may affect the validity of conclusions that have been drawn., (Copyright © 2013. Published by Elsevier B.V.)

Rationale and Objectives: To assess the necessity of intravenous contrast medium for abdominopelvic computed tomography (CT) diagnosis of acute appendicitis (APP) among adult patients with right lower quadrant (RLQ) abdominal pain at emergency department (ED)., Materials and Methods: ED patients with clinical suspicion of APP from RLQ pain for a period of 8 months were enrolled retrospectively. Both pre- and postintravenous contrast-enhanced CT scans were performed for these patients. The visibility of vermiform appendix and specific CT findings of APP were recorded separately for noncontrast CT (NCT) and contrast-enhanced CT (CCT) images without knowledge of the patient's identity and final diagnosis. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CT diagnosis for APP were compared between the two groups. The ease of identifying appendix was also compared., Results: Forty-two (42.0%) of the 100 patients (55 males, 45 females; age range, 16-90 years; mean age, 49.3 years) were APP. There was no significant difference for the visibility of appendix (94% vs. 91%; P = .589) and radiological characters between the CCT and NCT groups. There were significant differences between the two groups for sensitivity (100% vs. 90.5%; P = .036), specificity (94.8% vs. 100%; P = .038), PPV (93.3% vs. 100%; P = .021), NPV (100% vs. 93.5%; P = .021), but no significant difference for accuracy (97% vs. 96%; P = 1). The appendix was easier to detect on CCT than NCT images (P = .013)., Conclusion: The diagnostic sensitivity of CCT was significantly better than that of NCT. Intravenous contrast administration could also make doctors easier in indentifying appendixes., (Copyright © 2013 AUR. Published by Elsevier Inc. All rights reserved.)

Introduction: The objective is to evaluate the diagnosis of foreign body (FB) ingestion and report on the endoscopic management in Taiwan., Methods: This retrospective study enrolled 159 adult patients with confirmed diagnosis of upper gastrointestinal FBs who received endoscopic management in the emergency department., Results: The patients' mean age was 57.0 ± 19.2 years, and 66 (37.7%) of the patients were 65 years or older. Majority had a clear history and symptoms of FB ingestion. However, 9 (5.7%) initially ignored the accidental swallowing of FBs and were diagnosed late. The mean time spent for diagnosis was 1.8 days in those with uncertain history. Only 47.1% of those with radiographic studies had positive findings. Fish bones, press-through package and dentures were the most common culprits in this population of Asian elderly. Majority of FBs were located in the esophagus, especially in the upper third. Endoscopic FB extraction was successful in 96.9% of cases, while surgery was required in only 5 patients. The complication rate was 6.9%, including mucosal laceration (n = 10) and suspected perforation (n = 1), all of which were successfully managed conservatively. There was no death due to FB ingestion or endoscopy., Conclusions: In FB ingestion, history usually points toward the diagnosis. Patients with an uncertain history are usually diagnosed late, and plain radiography cannot reliably predict the presence of FB. Endoscopic management is safe and effective for FBs.

Background: Induced pluripotent stem (iPS) cells are novel stem cell populations, but the role of iPS cells in acute lung injury (ALI) is not currently known. We investigated the effect of iPS cells in modifying the pathophysiology of endotoxin-induced ALI., Methods: Male C57BL/6 8- to 12-week-old mice were enrolled in this study. Mouse iPS cells were delivered through the tail veins of mice 4 h after intratracheal instillation of endotoxin. Lung histopathologic findings, the pulmonary levels of cytokines, and functional parameters were analyzed after either 24 h or 48 h., Results: More iPS cells integrated into the lungs of mice with ALI than those of the control mice, as demonstrated by in vivo radionuclide imaging and in vitro Hoechst-labeled fluorescent staining. iPS cells significantly diminished the histopathologic changes of ALI and the lung injury score. There was also a significant reduction in the activity of nuclear factor-κB (NF-κB) and neutrophil accumulation in the lung, confirmed by immunostaining, electrophoretic mobility shift assays, and the decrease of myeloperoxidase activity, in the iPS-cell-treated mice with ALI. These protective effects were not replicated by the control cell therapy with fibroblasts. iPS cells mediated a downregulation of the proinflammatory response to endotoxin (reducing tumor necrosis factor-α, IL-6, and macrophage inflammatory peptide-2). In addition, iPS cells rescued the hypoxemia and pulmonary function of ALI. Treatment with a conditioned medium of iPS cells showed effects similar to those of iPS cells, which may suggest the therapeutic benefits of iPS mediated by paracrine factors., Conclusions: IV delivery of iPS cells provides a beneficial effect to attenuate the severity of endotoxin-induced ALI and improve physiologic impairment, which is partly mediated by a reduction in NF-κB activity and neutrophils accumulation. The conditioned medium of iPS cells demonstrated effects equal to those of iPS cells.

Objectives: The purpose of this study is to investigate the clinical use of inflammatory marker triggering receptor expressed on myeloid cells (TREM)-1 at admission for differentiating between typical and atypical bacterial community-acquired pneumonia (CAP)., Methods: A prospective, noninterventional study of patients with CAP hospitalized through the emergency department was performed. Surface expression of TREM-1 was analyzed using flow cytometry on peripheral blood cells, and soluble TREM-1 (sTREM-1) concentration was determined in plasma., Results: Eighty-eight patients with clinical suspicion of CAP were eligible. The causative pathogen was identified in 39 patients (44.3%). After excluding 4 mixed pneumonia cases, 21 typical and 14 atypical bacterial infections were enrolled. Patients with typical bacterial CAP demonstrated increased TREM-1 surface expression on monocytes and neutrophils. Median plasma sTREM-1 levels at admission were 65.2 pg/mL (range, 17.6-138.1 pg/mL) in patients with typical CAP and 25.9 pg/mL (range, 11.5-54.8 pg/mL) in patients with atypical CAP (P < .001). Soluble TREM-1 had good discriminative value to differentiate typical from atypical pathogens with an area under the receiver operating characteristic curve of 0.87 (95% confidence interval, 0.75-0.98). At a cutoff level of 44.2 pg/mL, sTREM-1 yielded a sensitivity of 81%, a specificity of 79%, a positive likelihood ratio of 3.79, and a negative likelihood ratio of 0.24., Conclusions: In newly admitted patients with CAP, determination of the TREM-1 levels may provide useful additional diagnostic information on the bacterial etiology., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: The aims of the study were to evaluate the incidence of newly diagnosed primary overt hypothyroidism among adults admitted through the emergency department (ED) and to assess how previously undiagnosed hypothyroidism presents., Methods: From July 1, 2002 to June 30, 2006, 56 adult patients were enrolled for further analysis., Results: The incidence of newly diagnosed primary overt hypothyroidism among adults admitted through the ED is 0.1%. The mean age of the patients was 75.8 ± 12.8 years (range, 27-98 years). Most of our patients presented in the winter. Individual symptoms and signs were not sensitive. Drugs (13 patients, 23%), nongoitrogenous autoimmune thyroiditis (12 patients, 21%), and previous surgery or irradiation related (11 patients, 20%) are frequent causes of unrecognized hypothyroidism in this iodine-replete region. Only 21% of patients were admitted with a correct initial impression. Half of myxedema coma patients were missed during the initial ED stay. Thirty-three patients (59%) had cardiomegaly on chest x-ray receiving further echocardiography examination. Pericardial effusion was found in 18 patients. Of these, 7 patients had moderate to large pericardial effusion, but none had cardiac tamponade. Only 6 patients have depressed left ventricular ejection fraction (<40%)., Conclusions: The diagnosis of hypothyroidism is often missed during the ED evaluation of patients at risk for this uncommon disease. Hypothyroidism should always be considered in patients who present with nonspecific symptoms suggestive of the disease, including weakness, cold intolerance, and alterations in mental status, and receive drugs impairing thyroid function or treatment of advanced head and neck cancer. In addition, patients with stable chronic heart failure or unexplained pericardial effusion warrant serum thyroid testing., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objectives: The aims of this study were to assess the diagnostic value of D-dimer in patients with suspected acute mesenteric ischemia (AMI) and to evaluate the correlation between D-dimer levels and the severity of bowel necrosis., Methods: A prospective, noninterventional study of 67 patients with clinical suspicion of AMI was performed. Measurement of D-dimer levels was performed using a latex turbidimetric method., Results: Acute mesenteric ischemia was diagnosed in 23 patients (34.3%) and non-AMI in 44 patients (65.7%). Median D-dimer levels on admission were 6.24 microg fibrinogen equivalent units (FEU)/mL (range, 0.96-53.48 microg FEU/mL) in patients with AMI and 3.45 microg FEU/mL (range, 0.50-44.69 microg FEU/mL) in non-AMI patients (P = .064). D-dimer had poor discriminative value to differentiate the presence from the absence of AMI with an area under the receiver operating characteristic curve of 0.64 (95% confidence interval, 0.50-0.78). A serum D-dimer cutoff value of 1.0 microg FEU/mL had a sensitivity of 96%, a specificity of 18%, a positive likelihood ratio of 1.17, and a negative likelihood ratio of 0.24. Among patients with AMI verified at operation, 8 had resectable bowl necrosis and 9 had unresectable bowel necrosis. There was no difference in serum D-dimer levels between resectable and unresectable bowel necrosis (P = .665)., Conclusions: Detection of serum D-dimer could not help to differentiate patient with AMI from those with non-AMI. We did not find a correlation between serum D-dimer levels and the severity of AMI. However, measurement of D-dimer levels can be of value for a small decrease in the likelihood of AMI, when the result is low.