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To prevent the infection and outbreak of COVID-19, the education method has adjusted the conventional in-person classes to distance learning in recent two years. Most classes were lectures that could go well if the participants were familiar with the online operation and had a stable network environment. Nevertheless, classes such as problem-based learning (PBL) rely on plenty of discussions and still have some limitations for communication and group development. In this research, we surveyed the learning effects of face-to-face (FF) and distance learning (DL) in the medical PBL course at Cheng-Kung University for two individual classes. Tutors and students were requested to give grades for the five key areas (participation, communication, preparation, critical thinking, and group skill). Five factors are used to evaluate the learning effect of face-to-face and distance learning. Compared with FF and DL methods, our research clarified that student learning effects would reduce participation, communication, and group skills by questionnaire survey. The tutors’ perspective regarded participation and communication ability as reduced at distance learning. But for group skills, one of the two classes showed no difference. Our research provides an experience for the PBL class focusing on discussion and communication. In the post-pandemic era, whether face-to-face or distance learning, classes should be adjusted properly to let students conduct effective communication in time.

IntroductionThe standard method of chest compression for adults is a two-handed procedure. One-handed external chest compression (ECC) is used in some situations such as during transport of patients who had an out-of-hospital cardiac arrest, but the quality of one-handed ECC is still not well known. The distribution of force is related to the quality of chest compression and may affect the risk of injury. This study aimed to determine the differences in the quality and potential safety concern between one-handed ECC and two- handed ECC.MethodsIn this randomised crossover study, participants recruited from National Cheng Kung University Hospital and the ambulance team from the fire bureau were asked to perform one-handed and two-handed ECC on the Resusci Anne manikin according to standard 2015 ECC guidelines. The MatScan Pressure Measurement system was used to investigate the compression pressure and force distribution.ResultsTwo-handed ECC had better results than one-handed ECC in terms of the median (IQR) depth (51.00 (41.50–54.75) mm vs 42.00 (27.00–49.00) mm, p=0.018), the proportion of depth accuracy (82.05% (13.95%–99.86%) vs 11.17% (0.00%–42.13%), p=0.028) and the proportion of incomplete recoil (0.23% (0.01%–0.44%) vs 2.42% (0.60%–4.21%), p=0.002). The maximum force (45.72 (36.10–80.84) kgf vs 35.64 (24.13–74.34) kgf, pConclusionThe quality of one-handed ECC, based on depth and recoil, is worse than that of standard two-handed ECC. The pressure and force distribution of one-handed ECC result in greater ulnar pronation of the hand than that of two-handed ECC. One-handed ECC more easily causes operator fatigue. Acknowledging these findings and adjusting training for one-handed ECC would potentially improve the quality of cardiopulmonary resuscitation during transport.

Objective The loading force applied in infant external chest compression (ECC) has not been determined. The objective of this crossover study was to quantify the actual force involved in two-thumb (TT)-encircling hands and two-finger (TF) methods during infant cardiopulmonary resuscitation. Methods A total of 42 emergency medical professionals performed lone rescuer infant external chest compression (ECC) with TF and TT methods. The order of two methods was arranged randomly, with an interval of 30 min in between. The force was collected by MatScan as primary outcomes. The secondary outcomes, quality of chest compressions, and fatigue level were also recorded by SkillReporter and perceived exertion scale. Results Using the TT method, the rescuers performed cardiopulmonary resuscitation (CPR) with higher ECC quality, but more incomplete recoil than they did using the TF method. The mean compression forces delivered in the first and second minutes were 3.53 ± 1.27 kg and 3.22 ± 1.11 kg (P = 0.012) for TF and 4.11 ± 1.80 kg and 4.04 ± 1.83 kg (P = 0.568) for TT, respectively. Pairwise comparison indicates that the compression force delivered through the TF method during the first and second minute of ECC were inferior to that delivered through the TT method. The TF method involved greater perceived exertion than the TT method (5.27 ± 4.69 vs. 4.02 ± 2.31; P = 0.007). The median perceived exertions for the TF and TT methods were 5 and 4, respectively. Conclusion For infant CPR, the TT method involved greater loading force, lower fatigue, and higher overall ECC quality than the TF method. The optimal compression force is about 3.8-4.3 kg.

High-power disk laser welding a steel plate using the Inconel 82 (IN82) filler wire with a 1.2 and 3.0 m/min feeding rate has been investigated in the experiment. The rapid thermal cycle combined with convection induced by the keyhole mechanism in laser welding results in the rapid solidification of the fusion zone (FZ). However, the microstructure of the FZ is not homogeneous at the macroscopic scale. The dilution of the FZ is important in determining the final microstructure of the weldment. For the specimen with a 1.2 m/min wire feeding rate, a lower amount of Ni-based IN82 filler is introduced into the weld pool, and the dilution of the FZ is between 65% and 100%. The BCC structure with high density boundaries dominates the entire FZ. For the specimen with a 3.0 m/min wire feeding rate, part of the filler melt is trapped on the top of the weld pool, and solidified into austenite alloyed with a Ni concentration above 15 at%. The range of dilution in the FZ with a 3.0 m/min wire feeding rate is decreased to 50–90%. There are hot cracks initiated/propagated along interdendritic austenite and in the austenite free of boundaries. Boundaries, especially for high-angle ones, in the BCC structure retard hot crack propagation in the FZ. The application of quantitative chemical analyses of Fe or Ni concentrations in the weldment provides a good approximation in evaluating the dilution of the FZ in laser welding. The methodology proposed in this study shows potential to obtain the dilution of any specific location in the FZ for industrial application in the future.

Background/Purpose: To explore the association of patient injury patterns and entrapped locations inside damaged buildings in the 2016 Taiwan earthquake. Methods: A retrospective analysis was conducted using the Tainan incident registry system. Residents inside nine conjunctive, 16-story (49.3 m in height) reinforced concrete buildings were categorized as non-injured, injured, and dead. Residents were classified into different groups according to their entrapped locations in height and the severity of building damage. The field triage acuity and trauma severity among groups were compared. Statistical significance was set at the level of 0.05. Results: There were 309 enrollees with 76 (24.6%) non-injured, 118 (38.2%) injured, and 115 (37.2%) dead. Residents either in the high floors (odds ratio [OR] = 2.9, 95% CI: 1.5–5.8, p = 0.003) or in the collapsed buildings (OR = 18.2, 95% CI: 7.6–43.6, p

Aim Radiation‐related injury in the general population due to accidents or incidents is a rare but significant event that merits serious study and planning in the health‐care system. Therefore, we developed different levels of training courses targeting medical emergency response and treatment for radiation‐related injury in patients, for different health‐care professionals and medical students. Methods The curriculum, teaching instructions, and objectives were based on the working group consensus of first responders of radiation‐related injury. The working group included different specialists from hospitals, medical schools, and government radiation emergency response agencies. Results Several different course levels, including lectures, group discussions, case and scenario discussions, hands‐on practice, tabletop drills, and drills were included. The curriculums have shown that developing different levels of courses for medical students and health‐care professionals was feasible. Conclusion Through the cooperation of different specialties and different interactive courses, the training programs were able to meet the initial education goals for medical emergency and radiation‐related injury for medical students and health‐care professionals., Different levels of education and training programs for radiation related injury patients with the cooperation from local healthcare facilities, fire department, regional response center, national authorities is feasible. Medical students, healthcare professionals, medical physicists and first responders were able to acquire the knowledge and have practice experiences on the management of radiation related injury.

Electrical impedance tomography (EIT), a noninvasive and radiation-free medical imaging technique, has been used for continuous real-time regional lung aeration. However, adhesive electrodes could cause discomfort and increase the risk of skin injury during prolonged measurement. Additionally, the conductive gel between the electrodes and skin could evaporate in long-term usage and deteriorate the signal quality. To address these issues, in this work, textile electrodes integrated with a clothing belt are proposed to achieve EIT lung imaging along with a custom portable EIT system. The simulation and experimental results have verified the validity of the proposed portable EIT system. Furthermore, the imaging results of using the proposed textile electrodes were compared with commercial electrocardiogram electrodes to evaluate their performance.

The Mortality in Emergency Department Sepsis (MEDS) score can be used to stratify ED patients with suspected infections according to mortality risk. However, it has yet to be externally validated for patients having bloodstream infections.We retrospectively computed clinical information for the MEDS score, Pitt bacteremia score (PBS), Charlson comorbidity index (CCI), and McCabe-Jackson comorbid classification (MJCC) for adults with community-onset bacteremia. The MEDS score was validated by the comparisons with the following scoring systems: the PBS, CCI, MJCC, PBS plus MJCC, and PBS plus CCI. We evaluated goodness-of-fit statistics and c-statistics as measures of model calibration and discrimination, respectively.Of 2328 adults, a good calibration for 28-day crude mortality was obtained only in the MEDS score and PBS plus MJCC; a higher c-statistic (0.870, P 0.001) were achieved by the MEDS score, compared to the PBS, CCI MJCC, PBS plus MJCC, and PBS plus CCI. A high c-statistic was observed in two combinative scoring system: the PBS plus CCI (0.855, P 0.001) and PBS plus MJCC (0.843, P 0.001). According to the Kaplan-Meier curves, 28-day crude mortality significantly differed between patients with scores equal to or higher than selected cutoff values and those with scores lower than selected cutoff values: 10 in the MEDS score and 5 in the PBS plus MJCC, respectively.The MEDS score is an excellent predictor of short-term outcomes in patients with community-onset bacteremia because it provides estimates with higher calibration and discrimination than those of the other scoring systems.

Third-generation cephalosporins (3GCs) [ceftriaxone (CRO) and cefotaxime (CTX)] have remarkable potency against Enterobacteriaceae and are commonly prescribed for the treatment of community-onset bacteraemia. However, clinical evidence supporting the updated interpretive criteria of the Clinical and Laboratory Standards Institute (CLSI) is limited. Adults with community-onset monomicrobial Enterobacteriaceae bacteraemia treated empirically with CRO or CTX were recruited. Clinical information was collected from medical records and CTX MICs were determined using the broth microdilution method. Eligible patients (n=409) were categorised into de-escalation (260; 63.6%), no switch (115; 28.1%) and escalation (34; 8.3%) groups according to the type of definitive antibiotics. Multivariate regression revealed five independent predictors of 28-day mortality: fatal co-morbidities based on McCabe classification [odds ratio (OR)=19.96; P

To investigate the clinical outcomes of patients with septic shock related to community-onset monomicrobial Enterobacteriaceae (CoME) bacteremia as categorized by the strategy of antimicrobial therapy, a retrospective and observational study was conducted. Clinical information on the patients was obtained from medical records. Antibiotic regimens were ranked according to their activity spectrum against Enterobacteriaceae (category IV, highest; I, lowest). De-escalation was defined as a switch to a category with a narrower spectrum of coverage within 5days after the bacteremic onset. Of the 189 eligible patients, 86 (45.5%) patients received de-escalation antibiotic therapy, and most (48, 55.8%) of the patients were empirically treated first with a category IV antibiotic. In a multivariate analysis for 28-day mortality, of several independent predictors, the de-escalation strategy was protective (odds ratio, 0.37; P=0.04). In conclusion, for patients with CoME bacteremia and available susceptibility data, de-escalation of antimicrobial therapy was beneficial for improving clinical outcome.

Objectives The objectives were to investigate the clinical characteristics of community-onset bacteremia in cirrhotic adults visiting the emergency department (ED), as well as the clinical impact of empirical antibiotics on their outcome. Methods Cirrhotic adults with community-onset bacteremia who visited the ED from January 2005 to December 2009 were included retrospectively. Clinical data and outcome were collected from the medical chart. The in vitro susceptibility was measured by the broth microdilution method. Results Of the 246 bacteremic episodes in cirrhotic patients, the major sources of bacteremia included intraabdominal infections (111, 45.1%), primary bacteremia (43, 17.5%), urinary tract infection (39, 15.9%), and soft tissue infection (22, 8.9%). Of the 258 bacteremic pathogens identified, Escherichia coli (83 isolates, 33.7%) and Klebsiella pneumoniae (61, 23.6%) were the most common microorganisms. In the multivariate analysis, delayed appropriate antibiotic therapy (>72 hours; odds ratio [OR], 4.29; P = .003), serum creatinine greater than 1.5 mg/dL at the ED (OR, 3.12; P = .005), severe sepsis (OR, 3.61; P = .01), Pittsburgh bacteremia score of at least 4 (OR, 2.66; P = .04), bacteremia due to pneumonia (OR, 5.44; P = .02), and a comorbidity of diabetes mellitus (OR, 3.54; P = .004) were independently associated with the 28-day mortality. Conclusions Focusing on cirrhotic adults with community-onset bacteremia, we emphasized that the cirrhosis severity is one of the critical factors when choosing empirical antimicrobial therapy and that the strategy of empirical therapy is warranted for cirrhotic adults with severe decompensation (Child's C group). For critically ill patients, especially in those with Child's C group, only piperacillin/tazobactam, ertapenem, or imipenem treatment was warranted because of susceptibility rate of greater than 90%.

Background Increasing chest compression rate during cardiopulmonary resuscitation can affect the workload and, ultimately, the quality of chest compression. This study examines the effects of compression at the rate of as-fast-as-you-can on cardiopulmonary resuscitation (CPR) performance. Methods A crossover, randomized-to-order design was used. Each participant performed chest compressions without ventilation on a manikin with 2 compression rates: 100 per minute (100-cpm) and “push as-fast-as you-can” (PF). The participants performed chest compressions at a rate of either 100-cpm or PF and subsequently switched to the other after a 50-minute rest. Results Forty-two CPR-qualified nonprofessionals voluntarily participated in the study. During the PF session, the rescuers performed CPR with higher compression rates (156.8 vs 101.6 cpm), more compressions (787.2 vs 510.8 per 5 minutes), and more duty cycles (51.0% vs 41.7%), but a lower percentage of effective compressions (47.7% vs 57.9%) and a lower compression depth (35.6 vs 38.0 mm) than they did during the 100-cpm session. The CPR quality deteriorated in numbers and percentile of effective compression since the third minute in the PF session and the fourth minute in the 100-cpm session. The percentile of compressions with adequate depth in the 100-cpm sessions was higher than that in the PF sessions during the second, third, and fourth minutes of CPR. Conclusion Push-fast technique showed a significant decrease in the percentile of effective chest compression compared with the 100-cpm technique during the 5-minute hand-only CPR. The PF technique exhibited a trend toward increased fatigue in the rescuers, which can result in early decay of CPR quality.

The objective of this study is to analyze the differences in clinical presentation and outcome of community-onset bacteremia between human immunodeficiency virus (HIV)-infected adults and HIV-uninfected adults visiting the emergency department (ED).A multicenter, case-control study with a ratio of 1:4 was conducted retrospectively over an 8-year period. Demographic characteristics, severity of illness, and clinical outcomes determined from chart records were analyzed.In total, 74 HIV-infected adults (case patients) and 288 HIV-uninfected adults (control patients) were examined. Significant differences in clinical presentation, severity, and the source of bacteremia as well as bacteremia-causing microorganisms between the case patients and control patients were observed by univariate analyses. Using multivariate analyses, the following variables were positively associated with case patients: male sex (odds ratio [OR], 3.42; P = .01), bacteremia due to endocarditis (OR, 7.68; P = .007), bacteremia due to Salmonella enteritidis (OR, 4.29; P = .03), and comorbidity with chronic hepatitis (OR, 5.65; P.001). Moreover, several independent risk factors of 28-day mortality were discovered, including inappropriate empirical antibiotic therapy after the ED visit (OR, 9.01; P.001), an initial syndrome with septic shock (OR, 5.37; P.001); a Pittsburgh bacteremia score greater than or equal to 4 points at the ED (OR, 4.28; P = .002), severe underlying disease based on McCabe classification (rapid and ultimately fatal; OR, 3.31; P = .002), and bacteremia due to pneumonia (OR, 2.66; P = .03). Of note, HIV infection was not a significant factor affecting 28-day mortality.This study demonstrated that the clinical characteristics, the severity, and the character of bacteremia in HIV-infected and uninfected patients varied among community-onset bacteremic patients visiting the ED, despite the limited impact of HIV infection on short-term outcomes.

Because out-of-hospital cardiac arrests (OHCAs) due to a major trauma rarely present with shockable rhythms, the potential benefits of using automated external defibrillators (AEDs) at the scene of traumatic OHCAs have not been examined.We conducted an observational, retrospective cohort study using an Utstein-style analysis in Tainan city, Taiwan. The enrollees were adult patients with traumatic OHCAs accessed by emergency medical technicians (EMTs) from January 1, 2004 to December 31, 2010. The exposure was the use or non-use of AEDs at the scene, as determined by the clinical judgment of the EMTs. The primary outcome evaluated was a sustained (≥2h) return of spontaneous circulation (ROSC), and the secondary outcomes were prehospital ROSC, overall ROSC, survival to hospital admission, survival at one month and favorable neurologic status at one month.A total of 424 patients (313 males) were enrolled, of whom 280 had AEDs applied, and 144 did not. Only 25 (5.9%) patients had received bystander cardiopulmonary resuscitation (CPR), and merely 21 (7.5%) patients in the AED group presented with shockable rhythms. Compared to the non-AED group, the primary and secondary outcomes of the AED group were not significantly different, except for a significantly lower prehospital ROSC rate (1.1% vs. 4.9%, p0.05). Multivariate analysis showed no significant interactions between the use of AEDs and other key variables. Use of the AED was not associated with sustained ROSC (OR 1.33; 95% CI 0.75-2.38, p=0.33).In a community with a low prevalence of shockable rhythms and administration of bystander CPR in patients with traumatic OHCA, we found no significant differences in the sustained ROSC between the AED and the non-AED groups. Considering scene safety and the possible interruption of CPR, we do not encourage the routine use of AEDs at the scene of traumatic OHCAs.

Although electrolyte abnormalities have been generally considered the major cause of out-of-hospital cardiac arrest (OHCA) in patients with kidney disease (KD), this association has never been prospectively validated.A prospective, observational study was conducted in a tertiary university hospital between January 2008 and December 2009. The study sample consisted of consecutively admitted patients with nontraumatic OHCA. Based on the estimated glomerular filtration rate (eGFR, unit: milliliters per minute per 1.73 m(2)), the enrollees were divided into 3 groups: group A (normal kidney function or mild KD; eGFR, 60.0), group B (moderate KD; eGFR between 15.0 and 59.9), and group C (severe KD; eGFR15.0 or on dialysis). The laboratory findings of the groups were compared. Two-tailed P values less than .005 were considered significant.Two hundred thirty-four enrollees (137 were male) were divided into 3 groups: group A (n = 51; 21.8%), group B (n = 128; 54.7%), and group C (n = 55; 23.5%). Compared with the other 2 groups, group C presented significantly higher serum potassium and magnesium and lower pH and hemoglobin level (all P.005). After stratifications of the significant variables, a post hoc analysis revealed that group C presented significantly higher incidences of hypermagnesemia (Mg2.5 mmol/L) and severe hyperkalemia (K6.5 mmol/L) (both P.005) than the other 2 groups. The odds ratios of the incidence of severe hyperkalemia in group C was 3.37 (95% confidence intervals, 1.46-7.77) compared with group A (50.9% vs 23.5%, P.005).Severe hyperkalemia is common in patients with OHCA who have severe KD and should be considered during resuscitation for these patients.

Outcome prediction for out-of-hospital cardiac arrest (OHCA) is of medical, ethical, and socioeconomic importance. We hypothesized that blood ammonia may reflect tissue hypoxia in OHCA patients and conducted this study to evaluate the prognostic value of ammonia for the return of spontaneous circulation (ROSC).This prospective, observational study was conducted in a tertiary university hospital between January 2008 and December 2008. The subjects consisted of OHCA patients who were sent to the emergency department (ED). The primary outcome was ROSC. The prognostic values were calculated for ammonia levels and the partial pressure of ammonia (pNH(3)), and the results were depicted as a receiver operating characteristics curve with an area under the curve.Among 119 patients enrolled in this study, 28 patients (23.5%) achieved ROSC. Ammonia levels and pNH(3) in the non-ROSC group were significantly higher than those in the ROSC group (167.0 μmol/L vs 80.0 μmol/L, P.05; 2.61 × 10(-5) vs 1.67 × 10(-5) mm Hg, P.05, respectively). The predictive capacity of area under the curve for ammonia and pNH(3) for non-ROSC was 0.85 (95% confidence interval, 0.75-0.95) and 0.73 (95% confidence interval, 0.61-0.84), respectively. The multivariate analysis confirmed that ammonia and pNH(3) are independent predictors of non-ROSC. The prognostic value of ammonia was better than that of pNH(3). The cutoff level for ammonia of 84 μmol/L was 94.5% sensitive and 75.0% specific for predicting non-ROSC with a diagnostic accuracy of 89.9%.Hyperammonemia on ED arrival is independently predictive of non-ROSC for OHCA patients. The findings may offer useful information for clinical management.

Dengue infection is a major health problem in tropical and subtropical countries. A prospective observational study in a university-affiliated hospital was conducted between August 2015 and September 2015. Patients who visited the emergency department (ED) with a presentation of any symptoms of dengue were eligible for the dengue non-structural protein 1 (NS1), IgM/IgG rapid immunochromatographic tests and real-time polymerase chain reaction (RT-PCR) to evaluate the performance of the rapid tests. Considering the RT-PCR as the gold standard for the dengue diagnosis, the ideal primary results of sensitivity (80–100%), specificity (60–84%), positive predicted value(75%-95%), and negative predicted value (70–100%) suggested that the NS1-based test with or without a combination of IgM and IgG tests have good diagnostic performances in detecting dengue infections, even in the afebrile or elderly populations.

Objectives Bacteremia is a severe bacterial infection with significant mortality and morbidity. Clinical parameters that reliably predict the presence of community-onset bacteremia are less elucidated. Methods During 96 randomly selected days between August 2006 and July 2007, a prospective study was conducted to analyze the risk factors of community-onset bacteremia among febrile adults who visited the emergency department (ED) of a medical center. Patients hospitalized in the 30 days prior to the study, patients experiencing consciousness alteration, and nursing facility residents were excluded. Results The mean age of the 396 febrile adults enrolled in the study was 53.8 years (range, 18–95 years), and 60 (15.2%) patients had true bacteremia, with the predominance of monomicrobial Gram-negative pathogens (42 patients). In a multivariate analysis, several factors were independently associated with community-onset bacteremia, including an age of >65 years (odds ratio [OR], 2.81; 95% confidence interval [CI], 1.25–6.33), the presence of rigor (OR, 13.7; 95% CI, 4.47–42.0) or chills (OR, 6.04; 95% CI, 1.10–32.9), a body temperature >39.9 °C (OR, 2.68; 95% CI, 1.03–6.94), blood urea nitrogen >20 mg/dL (OR, 5.56; 95% CI, 2.03–15.7), a blood urea nitrogen/creatinine ratio >16 (OR, 2.29; 95% CI, 1.03–5.11), and thrombocytopenia (OR, 6.09; 95% CI, 1.84–20.0). After scoring each risk factor, a logistic regression model for the prediction of bacteremia was developed, and the area under the receiver operating characteristic curve was 0.91. Conclusions Some easily determined clinical parameters were independently associated with community-onset bacteremia among febrile adults, and the most significant predictor was the presence of rigor. Although the proposed predictive model needs further validation, it may be of use for the early identification of bacteremic episodes in ED practice.

Although increasing consecutive compressions during cardiopulmonary resuscitation (CPR) is beneficial to patients, it possibly affects the workload and, ultimately, the quality of CPR. This study examines the effects of compression-to-ventilation ratio on external chest compression performance of rescuers.Subjects were 17 health care providers. Each participant performed CPR with 3 compression-to-ventilation ratios: 15:2, 30:2, and 50:5. The duration of CPR was 5 minutes in each group, with a rest period of 50 minutes in between. The manikin was equipped with a 6-axis force load cell to measure the force applied. An 8-camera digital motion analysis system was used to collect the 3-dimensional trajectory information. Data were compared using the crossover design. Ratings of perceived exertion and body area discomfort were measured.The mean compression forces (in Newtons) delivered at 1 minute 20 seconds to 1 minute 40 seconds and at 4 minutes 20 seconds to 4 minutes 40 seconds were 494.65 ± 53.58 and 478.64 ± 50.29, respectively (P = .047), for compression-to-ventilation ratios of 15:2; 473.57 ± 49.69 and 435.59 ± 56.79, respectively (P.001), for ratios of 30:2; and 468.44 ± 38.05 and 442.18 ± 43.40, respectively (P = .012), for ratio of 50:5. Diminished compression force in the ratio 50:5 was observed at 1 minute 20 seconds, and in the 30:2 ratio, it was observed at 4 minutes 20 seconds. The mean joint angles in each group did not differ significantly between 1 minute 20 seconds and 4 minutes 20 seconds. The Ratings of Perceived Exertion Scale was 3.38 ± 1.64 in 15:2, 4.06 ± 1.43 in 30:2, and 4.35 ± 1.54 in 50:5 (P = .045). Waist discomfort was noted in 50:5 after 4 minutes 20 seconds of external chest compression.Rescuer fatigue must be considered when raising the consecutive compression during CPR. Switching the compressor every 2 minutes should be followed where possible.

ACADEMIC EMERGENCY MEDICINE 2010; 17:958–964 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives: Scabies is highly contagious and requires prompt diagnosis and implementation of infection control measures to prevent transmission and outbreaks. This study investigated the clinical and administrative correlates associated with missed diagnosis of scabies in an emergency department (ED). Methods: This was a retrospective study of patients with incidental scabies infestations who were admitted to a university hospital via the ED during a 4-year period. Results: A total of 135 inpatients were identified as having scabies; among them, 111 patients (82%) had visited the ED. Scabies were diagnosed during the ED stay in 39 of 111 patients (35%), while the diagnosis was missed in the ED in 72 patients (65%). Although no geographic clusters suggestive of nosocomial scabies transmission were registered, 160 medical workers and one hospitalized patient received prophylactic treatment due to direct skin-to-skin contact with inpatient scabies cases during the study period. Overcrowding (odds ratio [OR] = 8.4; 95% confidence interval [CI] = 1.9 to 38.0) and time constraints (OR = 8.2; 95% CI = 1.9 to 34.7) in the ED were associated with a missed diagnosis of scabies during ED stay. Patients with lower illness severity scores were at higher risk for failure to diagnose and to treat scabies prior to hospital admission (OR = 5.7; 95% CI = 1.6 to 20.9). Conclusions: Missed diagnoses of scabies during ED stay may result in nosocomial spread and increase the unnecessary use of prophylactic treatments. ED overcrowding, time constraints, and less severe illness compromise ED recognition of scabies. Health care workers should be especially alert for signs of scabies infestations under these conditions.

Background Over-the-head cardiopulmonary resuscitation (CPR) is a method of chest compression, which may be easier to perform than standard CPR in a confined space. Purpose The purpose of this study was to evaluate the effects of over-the-head CPR on the kinematics and the force of delivered compressions. Methods The subjects were 21 health care providers who were experienced in CPR. Each participant performed over-the-head CPR (O) and standard CPR (S). The compression-to-ventilation ratio was 30:2. The CPR duration was 2 minutes in each position, with a rest period of 15 minutes between each instance. The order in which positions were adopted was randomized. A manikin was equipped with a 6-axial force load cell to collect 3-dimensional compression forces at a sampling rate of 1000 Hz. An 8-camera digital motion analysis system was used to collect 3-dimensional trajectory information. Data were compared by crossover design analysis of variance ( P Results No significant differences in range of motion of the head, shoulder, lower trunk, hip, and knee were obtained using the 2 methods. The compression forces in O and S were 386.64 ± 47.32 and 397.35 ± 41.89 N, respectively ( P > .05). No significant differences between the compression frequencies, depths, and percentages correct were obtained using the 2 methods. Conclusions There were no differences between the kinematics, compression forces, depths, and frequencies obtained using the O and S CPR methods as practiced by experienced providers.

Aim Back pain is often seen in professional rescuers after carrying out resuscitation. Back loading is known to be affected by the working surface height, but the relationship between the surface height and back loading during cardiopulmonary resuscitation (CPR) is poorly understood. The purpose of this study was to examine how back loading changes in response to CPR posture and surface height. Methods Twenty-two experienced professional rescuers performed CPR using three surface heights; the floor (F), a table at a height of 63 cm (HT) and one at a height of 37 cm (LT). Results The mean and maximal low back moment and compression force at HT were significantly smaller than those at LT and F. Conclusion The results suggest that the HT task of chest compression produces the lowest low back moment and compression force. Thus, HT positioning may decrease the probability of low back pain and is suggested to be optimal height for inexperienced resuscitators, those with back injury, or those requiring a long operating duration.

Poisoning is one of the most common reasons for visiting the emergency department in many countries, and the pattern varies from countries to countries and time to time. To compare the etiology and outcome of poisoning patients in different gender and age groups, we conducted a prospective study at the emergency departments of two medical centers in southern Taiwan between January 2001 and December 2002. All cases of poisoning, excluding patients diagnosed as cases of alcohol or food poisoning, were included, and relevant information was collected. There were 1512 cases of poisoning observed with a male to female ratio of 1:1.2 (684/828). Overall, drugs (49.9%) were the main agents involved, and a suicidal attempt (66.1%) was the predominant etiology. A total of 63 fatalities (4.2%) were observed and pesticides, especially paraquat, resulted in most fatalities. Patients aged 19–30 years constituted the most cases, and significant differences in exposure agents, causes, and fatality rates were found among different age and gender groups. The results are compatible with the trend reported by other Asian countries. This study also shows important differences existing in poisoning patients of different age and gender groups. Therefore, different poisoning-prevention strategies should be applied to different groups.

Depending on the clinical setting, rescuers may provide CPR from a kneeling (if the patient is on the ground) or standing (if the patient is in a bed) position. The rescuer position may affect workload, and hence rate of fatigue and quality of CPR.This study evaluates how three common rescuer positions affect the kinematics of CPR and the force of delivered compressions.Subjects were 18 health care providers experienced in CPR. Each participant performed CPR from three different positions: kneeling beside the Resusci Anne manikin placed on the floor (F); standing beside the manikin placed on a Table 63 cm in height (H), and standing beside the manikin placed on a Table 37 cm in height (L). The compression to ventilation ratio was 15:2. CPR duration was 5 min for each position, with a rest period of 50 min in-between. The order of position was randomised. The manikin was equipped with a six-axial force load cell to collect 3D compression forces at a sampling rate of 1000 Hz. An eight-camera Motion Analysis Digital System was adopted to collect 3D trajectory information. Data were compared using crossover-design analysis of variance (p0.05 was regarded as statistically significant). Ratings of Perceived Exertion (RPE) were measured by modified Borg scale.Significant differences were observed in the head, shoulder, lower trunk, hip and knee angles between the three methods. Lower trunk flexion angle (degrees) for H, L, and F were -14.52+/-1.13, -28.83+/-1.75, and 14.39+/-1.14, respectively. Hip flexion angle for H, L, and F were -16.21+/-3.30, -42.59+/-4.75, and -47.39+/-4.36, respectively. However, compression force (N) in H, L, and F were 455.8+/-17.6, 455.7+/-14.0, 461.5+/-13.5, respectively (p0.05). Compression depths (mm) were: 43.5+/-3.4, 42.0+/-5.4, 44+/-5.2, respectively (p0.05). Compression frequencies (times/min) were: 117.9+/-12.4, 116.6+/-13.4, 108.8+/-11.7, respectively (p0.05). No differences were found between the three positions for RPE.In this study, while the kinematics of CPR differed significantly with varying rescuer position, these differences did not affect the compression force, depth and frequency as performed by experienced providers.

Enterobacteriaceae is a leading pathogen of community-onset bacteremia. This study aims to establish a predictive scoring algorithm to identify adults with community-onset Enterobacteriaceae bacteremia who are at risk for abscesses. Of the total 1262 adults, 152 (12.0%) with abscess occurrence were noted. The 6 risk factors significantly associated with abscess occurrence-liver cirrhosis, diabetes mellitus, thrombocytopenia and high C-reactive protein (>100 mg/L) at bacteremic onset, delayed defervescence, and bacteremia-causing Klebsiella pneumoniae-were each assigned +1 point to form the scoring algorithm. In contrast, the elderly, fatal comorbidity (McCabe classification), and bacteremia-causing Escherichia coli were each assigned -1 point, owing to their negative associations with abscess occurrence. Using the proposed scoring algorithm, a cut-off value of +1 yielded a high sensitivity (85.5%) and an acceptable specificity (60.4%). Although the proposed predictive model needs further validation, this simple scoring algorithm may be useful for the early identification of abscesses by clinicians.

We evaluate the effects of zolpidem use to develop dementia or Alzheimer disease from the Taiwan National Health Insurance Research Database (NHIRD). A retrospective population-based nested case–control study. Newly diagnosed dementia patients 65 years and older and controls were sampled. A total of 8406 dementia and 16,812 control subjects were enrolled from Taiwan NHIRD during 2006 to 2010. The relationships between zolpidem use and dementia were measured using odds and adjusted odds ratios. The relationship between the average cumulative doses for zolpidem and dementia was also analyzed. Zolpidem alone or with other underlying diseases, such as hypertension, diabetes, and stroke, was significantly associated with dementia after controlling for potential confounders, such as age, sex, coronary artery disease, diabetes, anti-hypertension drugs, stroke, anticholesterol statin drugs, depression, anxiety, benzodiazepine, anti-psychotic, and anti-depressant agents’ use (Adjusted OR = 1.33, 95% CI 1.24–1.41). Zolpidem use also has significant dose–response effects for most of the types of dementia. In patient with Alzheimer diseases, the effects of zolpidem among patients with Alzheimer's disease remained obscure. The adjusted OR for patients whose cumulative exposure doses were between 170 and 819 mg/year (adjusted OR: 1.65, 95% CI 1.08–2.51, P = 0.0199) was significant; however, the effects for lower and higher cumulative dose were not significant. Zolpidem used might be associated with increased risk for dementia in elderly population. Increased accumulative dose might have higher risk to develop dementia, especially in patients with underlying diseases such as hypertension, diabetes, and stroke.