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Schizophrenia is associated with increased resting-state large-scale functional network connectivity in the gamma frequency. High-frequency transcranial random noise stimulation (hf-tRNS) modulates gamma-band endogenous neural oscillations in healthy individuals through the application of low-amplitude electrical noises. Yet, it is unclear if hf-tRNS can modulate gamma-band functional connectivity in patients with schizophrenia. We performed a randomized, double-blind, sham-controlled clinical trial to contrast hf-tRNS (N = 17) and sham stimulation (N = 18) for treating negative symptoms in 35 schizophrenia patients. Short continuous currents without neuromodulatory effects were applied in the sham group to mimic real-stimulation sensations. We used electroencephalography to investigate if a five-day, twice-daily hf-tRNS protocol modulates gamma-band (33–45 Hz) functional network connectivity in schizophrenia. Exact low resolution electromagnetic tomography (eLORETA) was used to compute intra-cortical activity from regions within the default mode network (DMN) and fronto-parietal network (FPN), and functional connectivity was computed using lagged phase synchronization. We found that hf-tRNS reduced gamma-band within-DMN and within-FPN connectivity at the end of stimulation relative to sham stimulation. A trend was obtained between the change in within-FPN functional connectivity from baseline to the end of stimulation and the improvement of negative symptoms at the one-month follow-up (r = −0.49, p = 0.055). Together, our findings suggest that hf-tRNS has potential as a network-level approach to modulate large-scale functional network connectivity pertaining to negative symptoms of schizophrenia.

Green tea epigallocatechin gallate (EGCG) and microRNA (miRNA) molecules modulate obesity. Nevertheless, it is still unknown whether EGCG modulates fat cell growth via miRNA-related signaling. In this study, white preadipocytes were used to examine whether the antimitogenic effect of EGCG on fat cells is regulated by the miR-143/MAPK7 pathway. We showed that EGCG upregulated the levels of miR-143, but not miR-155, in 3T3-L1 preadipocytes. Moreover, EGCG downregulated MAPK7 mRNA and protein levels time- and dose-dependently. MAPK7 expression increased during 3T3-L1 cell proliferation. miR-143 overexpression in the absence of EGCG mimicked the effects of EGCG to suppress preadipocyte growth and MAPK7 expression, whereas knockdown of miR-143 antagonized the EGCG-altered levels of miR-143, MAPK7, and pERK1/2 and reversed the EGCG-inhibited cell growth. These findings suggest that EGCG inhibits 3T3-L1 cell growth via miR-143/MAPK7 pathway.

Background Although add-on transcranial direct current stimulation (tDCS) is a promising intervention for treating unipolar (UD) and bipolar depression (BD), its moderate antidepressant efficacy urges research into biomarkers for predicting therapeutic response and achieving highly targeted applications. Methods This open-label trial enrolled UD (N=58) and BD (N=22) patients who had failed 1 or more trials of adequate pharmacologic interventions (ClinicalTrials.gov ID: NCT03287037). Bifrontal tDCS (anode/cathode: F3/F4) was applied using a 2 mA current for 20 min, twice daily, for 5 consecutive weekdays. Depression was measured with Hamilton Depression Rating Scale-17 (HAMD) at baseline, after 10-session stimulation, 1- and 4-week follow-ups. Heart rate (HR) and heart rate variability (HRV) was measured at baseline, during the initial 5 min of the 1st session, after 10-session stimulation, 1- and 4-week follow-ups. Cognitive performance and other outcomes were also assessed. Results Bifrontal tDCS rapidly and equally improved depression in both groups. The effects persisted until the end of the trial. Both groups had similar improvements in cognitive performance, anxiety, and psychosocial functioning. Compared with baseline, increased vagally-mediated HRV was observed one month after tDCS for both groups. A positive correlation was found between HR deceleration within the 1st session and treatment response after 10-session tDCS only among UD patients, explaining 20% of the variance. Conclusion tDCS as an adjunct therapy is effective for both UD and BD. Data suggest that the greater the increase in parasympathetic signaling during the 1st session, the better the clinical response after 10-session tDCS for UD patients.

High-frequency transcranial random noise stimulation (hf-tRNS) is a non-invasive neuromodulatory technique capable of increasing human cortex excitability. There were only published case reports on the use of hf-tRNS targeting the lateral prefrontal cortex in treating negative symptoms of schizophrenia, thus necessitating systematic investigation. We designed a randomized, double-blind, sham-controlled trial in a cohort of stabilized schizophrenia patients to examine the efficacy of add-on hf-tRNS (100-640 Hz; 2 mA; 20 min) using a high definition 4 × 1 electrode montage (anode AF3, cathodes AF4, F2, F6, and FC4) in treating negative symptoms (ClinicalTrials.gov ID: NCT04038788). Participants received either active hf-tRNS or sham twice daily for 5 consecutive weekdays. Primary outcome measure was the change over time in the Positive and Negative Syndrome Scale Factor Score for Negative Symptoms (PANSS-FSNS), which was measured at baseline, after 10-session stimulation, and at one-week and one-month follow-ups. Among 36 randomized patients, 35 (97.2%) completed the trial. Intention-to-treat analysis showed a significantly greater decrease in PANSS-FSNS score after active (-17.11%) than after sham stimulation (-1.68%), with a large effect size (Cohen's d = 2.16, p 0.001). The beneficial effect lasted for up to one month. In secondary-outcome analyses, the authors observed improvements with hf-tRNS of disorganization symptoms, unawareness of negative symptoms, subjective response to taking antipsychotics, and antipsychotic-induced extrapyramidal symptoms. No effects were observed on the neurocognitive performance and other outcome measures. Overall, hf-tRNS was safe and efficacious in improving negative symptoms. Our promising findings should be confirmed in a larger sample of patients with predominant negative symptoms.

Background: Healthcare-associated infections (HAIs) cause increases in length of stay, mortality, and healthcare costs. A previous study conducted in Taiwan obtained similar results to those reported in Korea and Japan in 2015. Changes in microorganisms have been noted in recent years. Understanding the recent condition of HAIs in intensive care units (ICUs) can enable healthcare providers to develop effective infection control protocols to reduce HAIs. Methods: We used the Taiwan Nosocomial Infection Surveillance System to evaluate the incidence densities of HAIs, the proportions of causative pathogens, and the proportions of antimicrobial resistance (AMR). The Poisson regression model was constructed to incidence density, and the chi-square test was used to assess proportion. Results: The incidence density of HAIs decreased 5.7 to 5.4 per 1000 person-days. However, the proportions of Klebsiella pneumoniae and Enterococcus faecium significantly increased. In addition, the proportions of carbapenem-resistant K. pneumoniae and vancomycin-resistant Enterococcus faecium significantly increased over time. Conclusion: Analysis of the microorganisms involved in HAIs in ICUs showed elevated proportions of K. pneumoniae and E. faecium with AMR. Infection control protocols have been implemented for several years and require improvements regarding environmental cleanliness and medical staff prevention.

Negative symptoms represent an unmet need for schizophrenia treatment. The effect of theta frequency transcranial alternating current stimulation (theta-tACS) applied during working memory (WM) tasks on negative symptoms has not been demonstrated as of yet. We conducted a randomized, double-blind, sham-controlled trial of 36 stabilized schizophrenia patients, randomized to receive either twice daily, 6 Hz 2 mA, 20 min sessions of in-phase frontoparietal tACS or sham for five consecutive weekdays. Participants were concurrently engaged in WM tasks during stimulation. The primary outcome measure was the change over time in the Positive and Negative Syndrome Scale (PANSS) negative subscale score measured from baseline through to the 1-month follow-up. Secondary outcome measures were other symptom clusters, neurocognitive performance, and relevant outcomes. The intention-to-treat analysis demonstrated greater reductions in PANSS negative subscale scores at the end of stimulation in the active (−13.84%) than the sham (−3.78%) condition, with a large effect size (Cohen’s d = 0.96, p = 0.006). The positive effect endured for at least one month. Theta-tACS also showed efficacies for cognitive symptoms, WM capacity, and psychosocial functions. Online theta-tACS offers a novel approach to modulate frontoparietal networks to treat negative symptoms of schizophrenia. The promising results require large-scale replication studies in patients with predominantly negative symptoms.

Reduced left-lateralized electroencephalographic (EEG) frontal alpha asymmetry (FAA), a biomarker for the imbalance of interhemispheric frontal activity and motivational disturbances, represents a neuropathological attribute of negative symptoms of schizophrenia. Unidirectional high-frequency transcranial random noise stimulation (hf-tRNS) can increase the excitability of the cortex beneath the stimulating electrode. Yet, it is unclear if hf-tRNS can modulate electroencephalographic FAA in patients with schizophrenia. We performed a randomized, double-blind, sham-controlled clinical trial to contrast hf-tRNS and sham stimulation for treating negative symptoms in 35 schizophrenia patients. We used electroencephalography to investigate if 10 sessions of hf-tRNS delivered twice-a-day for five consecutive weekdays would modulate electroencephalographic FAA in schizophrenia. EEG data were collected and FAA was expressed as the differences between common-log-transformed absolute power values of frontal right and left hemisphere electrodes in the alpha frequency range (8–12.5 Hz). We found that hf-tRNS significantly increased FAA during the first session of stimulation (p = 0.009) and at the 1-week follow-up (p = 0.004) relative to sham stimulation. However, FAA failed to predict and surrogate the improvement in the severity of negative symptoms with hf-tRNS intervention. Together, our findings suggest that modulating electroencephalographic frontal alpha asymmetry by using unidirectional hf-tRNS may play a key role in reducing negative symptoms in patients with schizophrenia.

Background Amyloidosis is a rare and variable disease, characterized by extracellular deposits of amyloid protein in different tissues and organs. Patients may present with a range of symptoms, depending on the extent of involvement. Rapid, accurate diagnosis is still challenging in clinical practice. Case report A 72-y-old woman presented with a 1-y history of droopy upper left eyelid, resulting in decreased visual acuity, and progressive tongue swelling, resulting in dysarthria, dysphagia, and sleep apnea. Physical examination revealed puffy eyes, moderate swelling up to 1 cm of the upper left eyelid, swollen submental region, and protrusion of the tongue, causing an inability to close the mouth. An abnormal serum free light chain ratio implied the presence of monoclonal gammopathies, and Congo red staining revealed amyloid deposits in specimens from both the tongue and left eyelid. Therefore, a diagnosis of systemic light-chain (AL) amyloidosis was confirmed. The patient then received oral melphalan therapy and surgical intervention for macroglossia. Clinical symptoms including dysarthria, dysphagia, and sleep apnea were under control at 6-month follow-up. Conclusions We report an uncommon case presenting initially with both ptosis and macroglossia, for which a final diagnosis of systemic AL amyloidosis was made. Detailed history and laboratory investigation must be implemented on suspicion of amyloidosis, because early recognition of amyloid-associated diseases and appropriate treatment can improve clinical outcomes.

Foreign body (FB) ingestion is a common clinical problem in acute settings. Detecting FBs in the upper digestive tract is challenging. The conventional X-ray is usually the first-line imaging tool to detect FBs. However, its diagnostic performance is inconsistent in the literature. In this study, we performed a systematic review and meta-analysis to determine the diagnostic performance of the conventional X-ray for detecting FBs in the upper digestive tract. We conducted a systematic search of PubMed, Embase, Cochrane Library, Web of Science, and Scopus until 1 August 2020. Prospective or retrospective studies investigating the diagnostic accuracy of conventional X-rays for detecting FBs in the upper digestive tract in patients of all ages were included. The Quality Assessment of Studies of Diagnostic Accuracy-2 tool was used to review the quality of included studies. We used a bivariate random-effects model to calculate diagnostic accuracy parameters. Heterogeneity was assessed using I2 statistics. We included 17 studies (n = 4809) in the meta-analysis. Of the 17 studies, most studies were rated as having a high risk of bias. Conventional X-rays had a pooled sensitivity of 0.58 (95% confidence interval [CI] = 0.36–0.77, I2 = 98.52) and a pooled specificity of 0.94 (95% CI = 0.87–0.98, I2 = 94.49) for detecting FBs in the upper digestive tract. The heterogeneity was considerable. The area under the summary receiver operating characteristic curve was 0.91 (95% CI = 0.88–0.93). Deek’s funnel plot asymmetry test results revealed no significant publication bias (p = 0.41). The overall sensitivity and specificity of conventional X-rays were low and high, respectively, for detecting FBs in the upper digestive tract. Hence, conventional X-rays to exclude patients without upper FBs in the digestive tract are not recommended. Further imaging or endoscopic examinations should be performed for at-risk patients.

Scaphoid fractures are the most common carpal fractures. Diagnosing scaphoid fractures is challenging. Recently, cone-beam computed tomography (CBCT) has been shown to be a promising strategy for diagnosing scaphoid fractures. The diagnostic performance of CBCT remains inconclusive in the literature. Through a systematic review and meta-analysis, our study aims to determine the diagnostic performance of CBCT for diagnosing scaphoid fractures. Five databases were searched up to March 25, 2020. We included prospective and retrospective studies describing the diagnostic accuracy of CBCT for scaphoid fractures in adult patients. QUADAS-2 tool was used to assess the quality of the included studies. Four studies (n = 350) were included in the meta-analysis. Three of the four studies had high bias risk. The result showed that CBCT had a pooled sensitivity of 0.88 and a pooled specificity of 0.99 for scaphoid fracture diagnosis. The heterogeneities of sensitivity and specificity were substantial. The area under the summary receiver operating characteristic curve was 0.98. No significant publication bias was observed. The result suggested that the diagnostic performance of CBCT for scaphoid fracture was excellent. The certainty of current evidence is low. Further well-designed studies with large sample sizes are warranted to confirm this finding.

Prostate cancer (PCa) is a reproductive system cancer in elderly men. We investigated the effects of betel nut arecoline on the growth of normal and cancerous prostate cells. Normal RWPE-1 prostate epithelial cells, androgen-independent PC-3 PCa cells, and androgen-dependent LNCaP PCa cells were used. Arecoline inhibited their growth in dose- and time-dependent manners. Arecoline caused RWPE-1 and PC-3 cell cycle arrest in the G2/M phase and LNCaP cell arrest in the G0/G1 phase. In RWPE-1 cells, arecoline increased the expression of cyclin-dependent kinase (CDK)-1, p21, and cyclins B1 and D3, decreased the expression of CDK2, and had no effects on CDK4 and cyclin D1 expression. In PC-3 cells, arecoline decreased CDK1, CDK2, CDK4, p21, p27, and cyclin D1 and D3 protein expression and increased cyclin B1 protein expression. In LNCaP cells, arecoline decreased CDK2, CDK4, and cyclin D1 expression, increased p21, p27, and cyclin D3 expression, had no effects on CDK1 and cyclin B1 expression. The antioxidant N-acetylcysteine blocked the arecoline-induced increase in reactive oxygen species production, decreased cell viability, altered the cell cycle, and changed the cell cycle regulatory protein levels. Thus, arecoline oxidant exerts differential effects on the cell cycle through modulations of regulatory proteins.

Microplastics (MPs) pollution has become a serious environmental issue worldwide, but its potential effects on health remain unknown. The administration of polystyrene MPs (PS-MPs) to mice for eight weeks impaired learning and memory behavior. PS-MPs were detected in the brain especially in the hippocampus of these mice. Concurrently, the hippocampus had decreased levels of immediate-early genes, aberrantly enhanced synaptic glutamate AMPA receptors, and elevated neuroinflammation, all of which are critical for synaptic plasticity and memory. Interestingly, ablation of the vagus nerve, a modulator of the gut-brain axis, improved the memory function of PS-MPs mice. These results indicate that exposure to PS-MPs in mice alters the expression of neuronal activity-dependent genes and synaptic proteins, and increases neuroinflammation in the hippocampus, subsequently causing behavioral changes through the vagus nerve-dependent pathway. Our findings shed light on the adverse impacts of PS-MPs on the brain and hippocampal learning and memory.

Endothelin (ET)-1 regulates adipogenesis and the endocrine activity of fat cells. However, relatively little is known about the ET-1 signaling pathway in preadipocyte growth. We used 3T3-L1 preadipocytes to investigate the signaling pathways involved in ET-1 modulation of preadipocyte proliferation. As indicated by an increased number of cells and greater incorporation of bromodeoxyuridine (BrdU), the stimulation of preadipocyte growth by ET-1 depends on concentration and timing. The concentration of ET-1 that increased preadipocyte number by 51–67% was ~100 nM for ~24–48 h of treatment. ET-1 signaling time dependently stimulated phosphorylation of ERK, c-JUN, STAT3, AMPK, and PKCα/βII proteins but not AKT, JNK, or p38 MAPK. Treatment with an ETAR antagonist, such as BQ610, but not ETBR antagonist BQ788, blocked the ET-1-induced increase in cell proliferation and phosphorylated levels of ERK, c-JUN, STAT3, AMPK, and PKCα/βII proteins. In addition, pretreatment with specific inhibitors of ERK1/2 (U0126), JNK (SP600125), JAK2/STAT3 (AG490), AMPK (compound C), or PKC (Ro318220) prevented the ET-1-induced increase in cell proliferation and reduced the ET-1-stimulated phosphorylation of ERK1/2, c-JUN, STAT3, AMPK, and PKCα/β. Moreover, the SphK antagonist suppressed ET-1-induced cell proliferation and ERK, c-JUN, STAT3, AMPK, and PKC phosphorylation, and the SMase2 antagonist suppressed ET-1-induced cell proliferation. However, neither the p38 MAPK antagonist nor the CerS inhibitor altered the effect of ET-1. The results indicate that ETAR, JAK2/STAT3, ERK1/2, JNK/c-JUN, AMPK, PKC, SphK, and SMase2, but not ETBR, p38 MAPK, or CerS, are necessary for the ET-1 stimulation of preadipocyte proliferation.

Background: Hymenopteran stings are the most common animal insult injury encountered in the emergency department. With increasing global spread of imported fire ants in recent decades, the rate of Formicidae assault has become a serious problem in many countries. Formicidae-associated injuries gradually increased in Taiwan in recent decades and became the second most common arthropod assault injury in our ED. The present study aimed at comparing the clinical characteristics of Formicidae sting patients with those of the most serious and common group, Vespidae sting patients, in an emergency department (ED) in Taiwan. Methods: This retrospective study included patients who were admitted between 2015 to 2018 to the ED in a local teaching hospital in Taiwan after a Vespidae or Formicidae sting. Cases with anaphylactic reaction were further compared. Results: We reviewed the records of 881 subjects (503 males, 378 females, mean age, 49.09 &plusmn, 17.62 years) who visited our emergency department due to Vespidae or Formicidae stings. A total of 538 (61.1%) were categorized into the Vespidae group, and 343 (38.9%) were sorted into the Formicidae group. The Formicidae group had a longer ED length of stay (79.15 &plusmn, 92.30 vs. 108.00 &plusmn, 96.50 min, p &lt, 0.01), but the Vespidae group had more cases that required hospitalization (1.9% vs. 0.3%, p = 0.04). Antihistamines (76.8% vs. 80.2%, p &lt, 0.01) were more frequently used in the Formicidae group, while analgesics were more frequently used in the Vespidae group (38.1% vs. 12.5%, p &lt, 0.01). The Vespidae group had more local reactions, and the Formicidae group had more extreme, systemic, or anaphylactic allergic reactions. Creatine kinase was significantly higher in the Vespidae group with an anaphylactic reaction. Sting frequency in both groups exhibited the same positive associations with average temperature of the month and weekend days. Conclusion: Formicidae sting patients presented to the ED with higher rate allergic reactions and spent more time in the ED than Vespidae sting patients. However, Vespidae sting patients had more complications and higher rates of admission, especially with anaphylactic reaction. Laboratory data, especially creatine kinase data, were more valuable to check in Vespidae sting patients with an anaphylactic reaction in the ED. Both groups exhibited positive correlations with temperature and a higher rate on weekend days.

Patient: Male, 67 Final Diagnosis: Torsion of a giant antimesenteric lipoma of the ileum Symptoms: Acute abdomen Medication: — Clinical Procedure: En bloc segmental resection with end-to-end anastomosis Specialty: Surgery Objective: Rare disease Background: Torsion of an intra-abdominal lipoma is rarely the cause of acute abdominal pain. Most of the previously reported cases of intra-abdominal lipoma torsion originated in the mesentery or omentum. However, an antimesenteric lipoma of the ileum with torsion has not been reported before. Case Report: A 67-year-old man presented to the emergency department with acute abdominal pain. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis only showed a giant fat-containing, soft-tissue, intra-abdominal tumor, suspected to be a lipoma. Laparotomy was performed, and the presence of torsion of the antimesenteric lipoma of the ileum was confirmed. Beside tumor resection, en bloc segmental resection of the ileum with end-to-end anastomosis was performed to avoid bowel stricture and obtain tumor-free margins. Conclusions: CECT is the modality of choice to detect an intra-abdominal lipoma. Urgent surgical intervention should be considered if the symptoms persist and torsion cannot be excluded. If simple excision is not adequate because of poor accessibility of the tumor stalk, en bloc segmental resection with end-to-end anastomosis should be considered.

Rationale Hemichorea-hemiballism, a rare manifestation of non-ketotic hyperglycemia, characterized by involuntary arrhythmic motions involving one side of the body, results from focal lesions in the contralateral caudate nucleus and putamen. Hyperkinetic disorders can be complications of uncontrolled diabetes mellitus and should not be ignored. Patient concerns We present the case of a 39-year-old woman who presented to the emergency department with a 3-day history of left-sided hemichorea-hemiballism. She had type 2 diabetes mellitus with poor control and maintenance of regular hemodialysis. Diagnoses The patient was diagnosed as hyperglycemia, normal ketone body and hemichorea-hemiballism based on laboratory examination, computed tomography (CT) scan, and brain magnetic resonance image (MRI). Interventions Intensive glycemic control via insulin injection was prescribed for correction of hyperglycemia. Outcomes The unilateral involuntary movements subsided progressively over four weeks. The patient's hemichorea had completely resolved at the three-month follow-up. Lessons This unusual clinical presentation is often accompanied by severe hyperglycemia. Appropriate blood glycemic control is important. If physicians recognize and provide early treatment for this disease, it is usually treatable and has a good prognosis.

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

Hypoglycemia is a common finding in both daily clinical practice and acute care settings. The causes of severe hypoglycemia (SH) are multi-factorial and the major etiologies are iatrogenic, infectious diseases with sepsis and tumor or autoimmune diseases. With the advent of aggressive lowering of HbA1c values to achieve optimal glycemic control, patients are at increased risk of hypoglycemic episodes. Iatrogenic hypoglycemia can cause recurrent morbidity, sometime irreversible neurologic complications and even death, and further preclude maintenance of euglycemia over a lifetime of diabetes. Recent studies have shown that hypoglycemia is associated with adverse outcomes in many acute illnesses. In addition, hypoglycemia is associated with increased mortality among elderly and non-diabetic hospitalized patients. Clinicians should have high clinical suspicion of subtle symptoms of hypoglycemia and provide prompt treatment. Clinicians should know that hypoglycemia is associated with considerable adverse outcomes in many acute critical illnesses. In order to reduce hypoglycemia-associated morbidity and mortality, timely health education programs and close monitoring should be applied to those diabetic patients presenting to the Emergency Department with SH. ED disposition strategies should be further validated and justified to achieve balance between the benefits of euglycemia and the risks of SH. We discuss relevant issues regarding hypoglycemia in emergency and critical care settings.

Purpose Severe hypoglycemia can result in neural damage, impaired cognitive function, coma, seizures, or death. The decision to admit diabetic patients after initial treatment in the emergency department remains unclear. Our purpose is to identify risk factors for developing recurrent hypoglycemia in diabetic patients admitted for severe hypoglycemia. Materials and methods We reviewed the records of 233 subjects (92 males, 141 females; mean age, 74.1 +/- 9.8 years) with type 2 diabetes treated at a tertiary care teaching hospital and hospitalized for severe hypoglycemia. Results Seventy-four (31.8%) patients were categorized with recurrent hypoglycemia and 159 (68.2%) with non-recurrent. Multivariate logistic regression analysis revealed that patients with loss of a recent meal, coronary artery disease, infection, and poor renal function (lower estimated glomerular filtration rate) were at risk for recurrent hypoglycemia. The use of calcium-channel blockers appeared to be a protective factor for the development of recurrent hypoglycemia. Conclusion There may be a subset of patients with severe hypoglycemia and certain risk factors for recurrent hypoglycemia that should be admitted.

Background Diabetes mellitus (DM) is associated with adverse events or complications in various gastrointestinal diseases. In this study, we examined whether diabetic patients had higher risk for the development of complicated acute appendicitis than nondiabetic patients. The relevant risk factors also were determined. Methods A retrospective study enrolling diabetic and nondiabetic patients who acquired acute appendicitis was conducted at a single institution over a 5-year period. Results We identified 1,184 patients with a primary discharge diagnosis of acute appendicitis. Seventy-one patients were found to have DM. Diabetic patients were older, had a higher risk of developing complicated acute appendicitis (CAA), and had a more prolonged hospital stay compared with nondiabetic patients. On further examination by multivariate logistic regression analysis, DM was an independent risk factor for CAA after adjusting for age and sex. Of the 71 diabetic patients, 46 patients (64.8%) were found to have CAA. The mean age of diabetic patients with uncomplicated acute appendicitis (DM/UAA) and CAA (DM/CAA) had no significant difference. The duration from the onset of symptoms to diagnosis was significantly longer in the DM/CAA than in the DM/UAA group. The mean length of hospital stay also was significantly longer in the DM/CAA than in the DM/UAA group. DM/CAA patients were found to have a higher rate of history of diabetic nephropathy as well as a higher serum creatinine level and a lower estimated glomerular filtration rate than DM/UAA patients. There was no statistical significance regarding patients older or younger than 60 years. Conclusions Our study showed that diabetic patients had a higher risk for the development of CAA and a subsequently longer hospital stay than nondiabetic patients. Age was not an independent risk factor for the development of CAA in diabetic patients in our study. Delayed diagnosis, and probably a history of diabetic nephropathy, as well as poorer renal function were risk factors for the development of CAA in diabetic patients. The single most important risk factor was the duration from the onset of symptoms to diagnosis. Once CAA developed, the length of hospital stay was prolonged significantly.

We present a patient who had a 3-day history of epigastric pain and acid regurgitation and was found to have gastroesophageal reflux disease and duodenitis by esophagogastroduodenoscopy. His symptoms were refractory to treatment with a proton pump inhibitor. Peritonitis developed subsequently. Enhanced computed tomography (CT) confirmed a diagnosis of mesenteric venous thrombosis (MVT) with jejunum infarction. Emergency exploratory laparotomy with segmental resectioning of the jejunum was performed. We emphasize that emergency department (ED) physicians should always thoroughly re-evaluate patients with abdominal pain using serial physical examinations in accordance with the chronic nature of the disease. There is a need to be highly alert to pain that is out of the proportion to the physical examination results and/or endoscopic findings, the development of peritoneal irritation signs, the presence of fever, and the presence of leukocytosis among patients with nonspecific endoscopic findings. This will help to differentiate MVT as the true etiology of ischemic duodenitis in a timely manner. ED physicians should also be aware that hyperemic edematous duodenitis can be the finding for MVT using endoscopy.

Central retinal vein occlusion (CRVO) is a common cause of visual impairment at any age, but only 10% to 15% of patients are younger than 40 years. Ocular involvement is not uncommon in patients with leukemia; however, bilateral CRVO as a complication of acute myeloid leukemia has rarely been reported. Here, we report a patient who had simultaneous bilateral CRVO as the initial presentation of acute myeloid leukemia. Thorough examination should be carefully conducted because ocular manifestations may be the initial presentation of life-threatening illness. A prompt search for the underlying systemic illness should be performed in all young patients presenting with CRVO.

Myocarditis can be totally asymptomatic or can manifest with chest pain syndromes, ranging from mild persistent chest pain of acute myopericarditis to severe symptoms that mimic acute myocardial infarction. About 60% of patients may have antecedent arthralgias, malaise, fevers, sweats, or chills consistent with viral infections 1 to 2 weeks before onset. Here, we report a postpartum young woman who developed postural hypotension as the first manifestation of fulminant myocarditis with initially acute "cold and dry" right-sided heart failure and cardiogenic shock. Common causes of postural hypotension include volume depletion, medications, diabetes, alcohol, infection, and varicose veins as well as dysautonomic syndromes. Fulminant myocarditis can cause cardiogenic shock. Myocardial inflammation more frequently affects localized areas of the left ventricle free wall, rarely right ventricle (RV). However, predominant RV involvement with acute right-sided heart failure and low cardiac output syndrome can be easily overlooked due to lack of typical heart failure signs. On reviewing medical literatures, we had found no report regarding the RV involvement with acute right-sided heart failure as the initial presentation of fulminant myocarditis.

Natriuretic peptides (NPs) have been found to be useful markers in differentiating acute dyspneic patients presenting to the emergency department (ED) and emerged as potent prognostic markers for patients with congestive heart failure (CHF). The best-established and widely used clinical application of BNP and NT-proBNP testing is for the emergent diagnosis of CHF in patients presenting with acute dyspnea. Nevertheless, elevated NPs levels can be found in many circumstances involving left ventricular (LV) dysfunction or hypertrophy; right ventricular (RV) dysfunction secondary to pulmonary diseases; cardiac inflammatory or infectious diseases; endocrinology diseases and high output status without decreased LV ejection fraction. Even in the absence of significant clinical evidence of volume overload or LV dysfunction, markedly elevated NP levels can be found in patients with multiple comorbidities with a certain degree of prognostic value. Potential clinical applications of NPs are expanded accompanied by emerging reports regarding screening the presence of secondary cardiac dysfunction; monitoring the therapeutic responses, risk stratifications and providing prognostic values in many settings. Clinicians need to have expanded knowledge regarding the interpretation of elevated NPs levels and potential clinical applications of NPs. Clinicians should recognize that currently the only reasonable application for routine practice is limited to differentiation of acute dyspnea, rule-out-diagnostic-tests, monitoring of therapeutic responses and prognosis of acute or decompensated CHF. The rationales as well the potential applications of NPs in these settings are discussed in this review article.

Lumbar puncture is a commonly practiced bedside technique for acquiring cerebrospinal fluid for the purposes of examination, spinal anesthesia, and as therapeutic trial for normal pressure hydrocephalus. Headache and backache after lumbar puncture are not uncommon. We report an elderly woman who suffered from altered consciousness and acute neurologic deficit after a difficult lumbar puncture. Serial imaging studies revealed active bleeding from the left first lumbar artery with the formation of spinal epidural hematoma and coexisting acute cranial intraventricular hematoma and subarachnoid hemorrhage. Lumbar puncture may rarely associate with life-threatening complications. Acute spinal subdural hemorrhage or subarachnoid hemorrhage after lumbar puncture is a timely diagnosis and needs urgent interventions. Clinicians should be aware of these rare but life-threatening complications after lumbar puncture. A cranial unenhanced CT is mandatory for patients having acute altered consciousness after lumbar puncture. A thorough vascular imaging evaluation from the lumbar spine to the brain is warranted in selected cases.

Purpose Aortic dissection (AoD) is one of the most common catastrophes involving the aorta. Nevertheless, early diagnosis remains to be a challenge in the Emergency Department (ED), particularly in young individuals. In this study, we attempted to identify the characteristics of acute AoD among young individuals, particular in patients with Marfan syndrome. Materials and methods This was an retrospective chart-review study conducted in a tertiary referring hospital. The hospital database was queried for the combination of AoD and patients under age of 40 years. The medical charts were reviewed to obtain demographic data, clinical data and laboratory characteristics by using a standardized data collection sheet. A comparison between Marfan syndrome and non-Marfan syndrome patients was performed. Results During the 10-years period, 18 of 344 patients with acute AoD were younger than 40 years-old. Patients with Marfan syndrome developed acute AoD at a younger age than patients without Marfan syndrome. The mean diastolic blood pressure was significantly lower in patients with Marfan syndrome upon presenting to the ED than those without. Patients with Marfan syndrome had trends toward higher risk of development of type A AoD, increased recurrence rate and higher mortality rate than those without. However, statistical significance was not present. Conclusion ED physicians should have high alert to acute AoD in young patients presenting with severe unexplained chest and back pain, particularly in those patients with a history of heart diseases, hypertension, and Marfan syndrome or featuring Marfanoid habitus. Acute coronary syndrome, unexplained abdominal symptoms, and sudden cardiac arrest could be the initial manifestation of AoD in young patients. A low threshold to perform enhanced computed tomography may facilitate early diagnosis and timely treatment in this patient population.