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OBJECTIVE: To identify the incidence and prehospital predictors of ventricular tachycardia/ventricular fibrillation (VT/VF) as the initial arrhythmia in patients with out-of-hospital cardiac arrest (OHCA) in central Taiwan. PATIENTS AND METHODS: The Taichung Sudden Unexpected Death Registry program encompasses the Taichung metropolitan area in central Taiwan, with a population of 2.7 million and 17 destination hospitals for patients with OHCA. We performed a detailed analysis of demographic characteristics, circumstances of cardiac arrest, and emergency medical service records using the Utstein Style. RESULTS: From May 1, 2013, through April 30, 2014, resuscitation was attempted in 2013 individuals with OHCA, of which 384 were excluded due to trauma and noncardiac etiologies. Of the 1629 patients with presumed cardiogenic OHCA, 7.9% (n=129) had initial shockable rhythm; this proportion increased to 18.8% (61 of 325) in the witnessed arrest subgroup. Male sex (odds ratio [OR], 2.45; 95% CI, 1.46-4.12; P<.001), age younger than 65 years (OR, 2.39, 95% CI, 1.58-3.62; P<.001), public location of arrest (OR, 4.61; 95% CI, 2.86-7.44; P<.001), and witnessed status (OR, 3.98; 95% CI, 2.62-6.05; P<.001) were independent predictors of VT/VF rhythm. CONCLUSION: The proportion of patients with OHCA presenting with VT/VF was generally low in this East Asian population. Of the prehospital factors associated with VT/VF, public location of OHCA was the strongest predictor of VT/VF in this population, which may affect planning and deployment of emergency medical services in central Taiwan.
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Reanimación Cardiopulmonar , Cardioversión Eléctrica , Paro Cardíaco Extrahospitalario/mortalidad , Taquicardia/epidemiología , Fibrilación Ventricular/epidemiología , Distribución por Edad , Anciano , Servicios Médicos de Urgencia/estadística & datos numéricos , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/fisiopatología , Paro Cardíaco Extrahospitalario/terapia , Pronóstico , Estudios Prospectivos , Sistema de Registros/estadística & datos numéricos , Distribución por Sexo , Análisis de Supervivencia , Taquicardia/etiología , Taiwán/epidemiología , Tiempo de Tratamiento/estadística & datos numéricos , Fibrilación Ventricular/etiologíaRESUMEN
BACKGROUND: Percutaneous drainage (PCD) and surgical intervention are two primary treatment options for iliopsoas abscess (IPA). However, there is currently no consensus on when to use PCD or surgical intervention, especially in patients with gas-forming IPA. This study compared the characteristics of patients with gas-forming and non-gas forming IPA and their mortality rates under different treatment modalities. An algorithm for selecting appropriate treatment for IPA patients is proposed based on our findings. METHODS: Eighty-eight IPA patients between July 2007 and February 2013 were enrolled in this retrospective study. Patients < 18 years of age or with an incomplete course of treatment were excluded. Demographic information, clinical characteristics, and outcomes of different treatment approaches were compared between gas-forming IPA and non-gas forming IPA patients. RESULTS: Among the 88 enrolled patients, 27 (31%) had gas-forming IPA and 61 (69%) had non-gas forming IPA. The overall intra-hospital mortality rate was 25%. The gas-forming IPA group had a higher intra-hospital mortality rate (12/27, 44.0%) than the non-gas forming IPA group (10/61, 16.4%) (P < 0.001). Only 2 of the 13 patients in the gas-forming IPA group initially accepting PCD had a good outcome (success rate = 15.4%). Three of the 11 IPA patients with failed initial PCD expired, and 8 of the 11 patients with failed initial PCD accepted salvage operation, of whom 5 survived. Seven of the 8 gas-forming IPA patients accepting primary surgical intervention survived (success rate = 87.5%). Only 1 of the 6 gas-forming IPA patients who accepted antibiotics alone, without PCD or surgical intervention, survived (success rate = 16.7%). In the non-gas forming IPA group, 23 of 61 patients initially accepted PCD, which was successful in 17 patients (73.9%). The success rate of PCD was much higher in the non-gas forming group than in the gas-forming group (P <0.01). CONCLUSIONS: Based on the high failure rate of PCD and the high success rate of surgical intervention in our samples, we recommend early surgical intervention with appropriate antibiotic treatment for the patients with gas-forming IPA. Either PCD or primary surgical intervention is a suitable treatment for patients with non-gas forming IPA.
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Drenaje , Absceso del Psoas/terapia , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Absceso del Psoas/mortalidad , Absceso del Psoas/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: To investigate the reasons for the occurrence of clinically significant adverse events (CSAEs) in emergency department-discharged patients through emergency physicians' (EPs) subjective reasoning and senior EPs' objective evaluation. DESIGN: This was a combined prospective follow-up and retrospective review of cases of consecutive adult non-traumatic patients who presented to a tertiary-care emergency department in Taiwan between 1 September 2005 and 31 July 2006. Data were extracted from 'on-duty EPs' subjective reasoning for discharging patients with CSAEs (study group) and without CSAEs (control group)' and 'objective evaluation of CSAEs by senior EPs, using clinical evidences such as recording history, physical examinations, laboratory/radiological examinations and observation of inadequacies in the basic management process (such as recording history, physical examinations, laboratory/radiological examinations and observation) as the guide'. Subjective reasons for discharging patients' improvement of symptoms, and the certainty of safety of the discharge were compared in the two groups using χ(2) statistics or t test. RESULTS: Of the 20,512 discharged cases, there were 1370 return visits (6.7%, 95% CI 6.3% to 7%) and 165 CSAEs due to physicians' factors (0.82%, 95% CI 0.75% to 0.95%). In comparisons between the study group and the control group, only some components of discharge reasoning showed a significant difference (p<0.001). Inadequacies in the basic management process were the main cause of CSAEs (164/165). CONCLUSION: The authors recommended that EP follow-up of the basic management processes (including history record, physical examination, laboratory and radiological examinations, clinical symptoms/signs and treatment) using clinical evidence as a guideline should be made mandatory.
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Continuidad de la Atención al Paciente/normas , Servicio de Urgencia en Hospital/normas , Errores Médicos , Alta del Paciente/tendencias , Estudios de Casos y Controles , Distribución de Chi-Cuadrado , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Entrevistas como Asunto , Masculino , Estudios Prospectivos , Estudios Retrospectivos , Riesgo , Medición de Riesgo , Taiwán/epidemiologíaRESUMEN
BACKGROUND: Glufosinate-containing herbicides are commonly used worldwide. Data on acute human glufosinate poisoning however remain scarce. METHODS: We retrospectively reviewed the medical records of all glufosinate poisoned cases reported to the Taiwan National Poison Control Center and two medical centers in Taiwan from August 1993 through February 2010. Their demographic and clinical data were then analyzed to identify potential predictors of severe effects following acute glufosinate poisoning. RESULTS: One hundred and thirty-one patients, including 115 oral and 16 non-oral exposures, were eligible for final analysis. Among patients with oral exposure, 25 were asymptomatic, while the others developed gastrointestinal, neurological, cardiovascular, and/or respiratory manifestations. Seven patients (6.1%) died following deliberate glufosinate ingestion. The median dose of glufosinate ingestion was 30.4 grams (interquartile range 18.5-45.6 grams) in the severe/fatal group compared to 6.8 grams (interquartile range 3.7-16.2 grams) in the non-severe group (p <0.001). Older age (≥ 61 years; adjusted OR 4.9, 95% CI 1.3-17.9) and larger amount of glufosinate ingestion (≥ 13.9 grams; adjusted OR 25.2, 95% CI 4.8-132.5) were positively associated with the development of severe toxicity, whereas ethanol consumption (adjusted OR 0.1, 95% CI <0.1-0.5) was inversely associated with the risk of severe toxicity. CONCLUSION: Although glufosinate is generally thought to be of low toxicity to humans, severe effects can occur and may be associated with older age, larger amount of ingestion and absence of concomitant ethanol consumption.
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Aminobutiratos/envenenamiento , Etanol/administración & dosificación , Herbicidas/envenenamiento , Centros de Control de Intoxicaciones/estadística & datos numéricos , Suicidio/estadística & datos numéricos , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Consumo de Bebidas Alcohólicas/epidemiología , Aminobutiratos/administración & dosificación , Relación Dosis-Respuesta a Droga , Femenino , Herbicidas/administración & dosificación , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Taiwán/epidemiologíaRESUMEN
There are very few microbiological data on wound infections following snakebites. The objective of this study was to investigate the treatment of secondary infection following snakebites in central Taiwan. Microbiological data and antibiotic sensitivity of wound cultures were retrospectively analyzed from December 2005 to October 2007 in a medical center in central Taiwan. A total of 121 snakebite patients participated in the study. Forty-nine (40.5%) subjects were bitten by cobra (Naja atra); 34 of them had secondary infection, and 24 of them (70.6%) needed surgical intervention. Cobra bites caused more severe bacterial infection than other snakebites. Morganella morganii was the most common pathogen, followed by Aeromonas hydrophila and Enterococcus. Gram-negative bacteria were susceptible to amikacin, trimethoprim/sulfamethoxazole, cefotaxime, cefepime, ciprofloxacin, and piperacillin/tazobactam. Enterococcus were susceptible to ampicillin, gentamicin, penicillin and vancomycin. It is reasonable to choose piperacillin/tazobactam, quinolone, second- or third-generation cephalosporin for empirical therapy following snakebite. Surgical intervention should be considered for invasive soft tissue infections.(AU)
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Humanos , Mordeduras de Serpientes , Infecciones Bacterianas , Infección de Heridas , Heridas y Lesiones , AntibacterianosRESUMEN
BACKGROUND: Scrub typhus, a mite-transmitted zoonosis caused by Orientia tsutsugamushi, is an endemic disease in Taiwan and may be potentially fatal if diagnosis is delayed. CASE PRESENTATIONS: We encountered a 23-year-old previously healthy Taiwanese male soldier presenting with the right ear pain after training in the jungle and an eleven-day history of intermittent high fever up to 39°C. Amoxicillin/clavulanate was prescribed for otitis media at a local clinic. Skin rash over whole body and abdominal cramping pain with watery diarrhea appeared on the sixth day of fever. He was referred due to progressive dyspnea and cough for 4 days prior to admission in our institution. On physical examination, there were cardiopulmonary distress, icteric sclera, an eschar in the right external auditory canal and bilateral basal rales. Laboratory evaluation revealed thrombocytopenia, elevation of liver function and acute renal failure. Chest x-ray revealed bilateral diffuse infiltration. Doxycycline was prescribed for scrub typhus with acute respiratory distress syndrome and multiple organ failure. Fever subsided dramatically the next day and he was discharged on day 7 with oral tetracycline for 7 days. CONCLUSION: Scrub typhus should be considered in acutely febrile patients with multiple organ involvement, particularly if there is an eschar or a history of environmental exposure in endemic areas. Rapid and accurate diagnosis, timely administration of antibiotics and intensive supportive care are necessary to decrease mortality of serious complications of scrub typhus.
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Dolor de Oído/complicaciones , Insuficiencia Multiorgánica/complicaciones , Síndrome de Dificultad Respiratoria/complicaciones , Tifus por Ácaros/complicaciones , Doxiciclina/uso terapéutico , Conducto Auditivo Externo/fisiopatología , Fiebre/microbiología , Humanos , Masculino , Insuficiencia Multiorgánica/microbiología , Síndrome de Dificultad Respiratoria/microbiología , Tifus por Ácaros/tratamiento farmacológico , Adulto JovenRESUMEN
Pneumoscrotum, the accumulation of air inside the scrotum, is a rare complication associated with blunt chest trauma. We report a case of severe subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium, and pneumoscrotum after blunt chest trauma in a 44-year-old man. He presented with progressive swelling of the neck that descended to the chest, abdomen, both legs, and scrotum. Radiography and computed tomography of the chest and abdomen confirmed the diagnosis of a tracheal injury complicated by severe subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium, and pneumoscrotum. Primary repair of the tracheal injury was performed, and he was weaned successfully from the ventilator by day 5. He was discharged on day 7.
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Enfermedades de los Genitales Masculinos/etiología , Escroto , Traumatismos Torácicos/complicaciones , Heridas no Penetrantes/complicaciones , Adulto , Aire , Humanos , MasculinoAsunto(s)
Anemia Hemolítica/etiología , Histoplasmosis/complicaciones , Enfermedades Pulmonares Fúngicas/complicaciones , Infecciones Oportunistas/complicaciones , Anciano , Resultado Fatal , Femenino , Histoplasma , Histoplasmosis/patología , Humanos , Enfermedades Pulmonares Fúngicas/patología , Infecciones Oportunistas/patología , Tomografía Computarizada por Rayos XRESUMEN
Envenoming by Protobothrops mucrosquamatus and Viridovipera stejnegeri accounts for the majority of venomous snakebites in Taiwan. We conducted a retrospective study to systematically examine the clinical manifestations and responses to antivenom therapy after P. mucrosquamatus and V. stejnegeri envenoming. Information on demographic characteristics, treatments, and systemic/local complications were abstracted from medical charts between 1991 and 2006. One hundred forty-nine patients with P. mucrosquamatus envenoming and 51 with V. stejnegeri envenoming were eligible for the final analysis, and they differed in terms of patient age, bite site, local bruising, proportion of patients needing >/= 3 vials of antivenom, and mean hospital stay. Univariate analysis revealed that P. mucrosquamatus envenoming had a higher risk of developing rhabdomyolysis, cellulitis, necrosis, and skin graft. Our findings suggested that P. mucrosquamatus envenoming was associated with a greater risk of severe clinical events, and monitoring for major clinical complications would be recommended.
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Antivenenos/uso terapéutico , Venenos de Crotálidos , Mordeduras de Serpientes/fisiopatología , Venenos de Víboras , Lesión Renal Aguda/etiología , Adulto , Anciano , Animales , Demografía , Edema/etiología , Eritema/etiología , Femenino , Hemorragia/etiología , Humanos , Tiempo de Internación , Masculino , Registros Médicos , Persona de Mediana Edad , Rabdomiólisis/etiología , Mordeduras de Serpientes/complicaciones , Mordeduras de Serpientes/tratamiento farmacológico , Mordeduras de Serpientes/epidemiología , Taiwán/epidemiología , Trombocitopenia/etiología , Resultado del Tratamiento , Viperidae/anatomía & histologíaRESUMEN
Emphysematous pyelonephritis (EPN) is a rare but life-threatening acute suppurative infection of the kidney, characterised by production of gas within the renal parenchyma, collecting system or perirenal tissue. It has a high mortality rate (70% to 90%), and the majority of patients have diabetes mellitus. The left kidney is most common involved and Escherichia coli is the most common pathogen. EPN complicated with pneumomediastinum (PM) has been reported in only four cases previously. Here, a case of PM as first manifestation of EPN in a non-diabetic 81-year-old man is reported. He had experienced back pain and abdominal fullness for 1 week. A plain radiograph, CT aortography and MRI confirmed the diagnosis of EPN complicated with PM. The patient died on the 22nd day of treatment with antibiotics of cefmetazole, gentamycin and metronidazole.
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INTRODUCTION: Glyphosate-surfactant herbicide (GlySH) is widely used as a non-selective herbicide. Most intoxicated cases are from ingestion, inhalation, and skin exposure. Intramuscular injection of GlySH has never been reported. We present a case of GlySH intoxication via intramuscular injection. CASE REPORT: A 42-year-old woman came to the emergency department complaining of painful swelling of left upper limb for 12 h. She had performed an intramuscular injection of 6 mL of GlySH over the lateral aspect of the left elbow 15 h previously. Physical examination disclosed painful swelling over left distal arm, elbow, and forearm with three needle punctures. CT scan revealed ill-defined areas of heterogeneous high density with marked swelling at subcutaneous tissue over posterior aspect of the elbow. DISCUSSION: The mechanism of toxicity of GlySH is complicated and surfactant was thought to play an important role in GlySH intoxication. Intramuscular GlySH poisoning is different from oral GlySH intoxication. Care should be taken when monitoring acute rhabdomyolysis and compartment syndrome, which may develop rapidly and contribute to the surfactant component of glyphosate formulation.
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Glicina/análogos & derivados , Rabdomiólisis/inducido químicamente , Tensoactivos/envenenamiento , Adulto , Femenino , Glicina/administración & dosificación , Glicina/envenenamiento , Herbicidas/administración & dosificación , Herbicidas/envenenamiento , Humanos , Inyecciones Intramusculares , Intento de Suicidio , GlifosatoRESUMEN
BACKGROUND: Septic pulmonary embolism (SPE) is one of the metastatic foci of pyogenic liver abscess. The purpose of this study was to investigate the clinical presentations of, and management options for patients with pyogenic liver abscess complicated with SPE. METHODS: A retrospective chart review was conducted from January 1, 1999 to December 31, 2005 inclusively, in a medical center in northern Taiwan. We collected and analyzed the clinical presentations, diagnostic modalities, treatment programs and prognoses for all pyogenic liver abscess patients with SPE. RESULTS: The association between liver abscess affected with the complication of SPE and diabetes mellitus was significant. There were 9 patients who had pyogenic liver abscess with SPE. Abnormal chest radiograph (CXR) findings with multiple ill-defined peripheral round densities were noted in all patients. Seven patients were diabetic, fever occurred in 5 patients, respiratory symptoms were noted in 6 patients, and abdominal pain occurred in 3 patients. Endophthalmitis coexisted in 3 patients, meningitis in 1 patient, and necrotizing fasciitis in 2 patients. Microbiological studies revealed Klebsiella pneumoniae in 9 patients. Computed tomography (CT) demonstrated metastatic nodules in both lung lobes, some of which featured cavitation, in all 9 patients. Three patients soon advanced to acute respiratory failure, and later died due to acute respiratory distress syndrome and/or septic shock. The remaining 6 patients survived without complication during their hospital course. CONCLUSION: There is diagnostic value in performing a chest CT scan in diabetic patients who have liver abscess plus abnormal CXR findings with multiple ill-defined peripheral round densities, in order to detect SPE, which has a relatively poor outcome in patients with liver abscess.
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Absceso Piógeno Hepático/etiología , Embolia Pulmonar/complicaciones , Sepsis/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Absceso Piógeno Hepático/diagnóstico , Absceso Piógeno Hepático/terapia , Masculino , Persona de Mediana Edad , Radiografía Torácica , Estudios Retrospectivos , Tomografía Computarizada por Rayos XRESUMEN
Cerebrovascular dysfunction ensuing from severe heatstroke includes intracranial hypertension, cerebral hypoperfusion, and brain inflammation. We attempted to assess whether L-arginine improves survival during experimental heatstroke by attenuating these reactions. Anesthetized rats, 70 min after the start of heat stress (43 degrees C), were divided into two major groups and given the following: vehicle solution (1 mL/kg body weight) or L-arginine (50-250 mg/kg body weight) intravenously. Another group of rats was exposed to room temperature (24 degrees C) and used as normothermic controls. Their physiological and biochemical parameters were continuously monitored. When the vehicle-treated rats underwent heat stress, their survival time values were found to be 20 to 26 min. Treatment with i.v. doses of L-arginine significantly improved the survival rate during heatstroke (54-245 min). As compared with those of normothermic controls, all vehicle-treated heatstroke animals displayed higher levels of core temperature, intracranial pressure, and NO metabolite, glutamate, glycerol, lactate-pyruvate ratio, and dihydroxybenzoic acid in hypothalamus. In addition, hypothalamic levels of IL-1beta and TNF-alpha were elevated after heatstroke onset. In contrast, all vehicle-treated heatstroke animals had lower levels of MAP, cerebral perfusion pressure, cerebral blood flow, and brain partial pressure of oxygen. Administration of L-arginine immediately after the onset of heatstroke significantly reduced the intracranial hypertension and the increased levels of NO metabolite, glutamate, glycerol, lactate-pyruvate ratio, and dihydroxybenzoic acid in the hypothalamus that occurred during heatstroke. The heatstroke-induced increased levels of IL-1beta and TNF-alpha in the hypothalamus were suppressed by L-arginine treatment. In contrast, the hypothalamic levels of IL-10 were significantly elevated by L-arginine during heatstroke. The results suggest that L-arginine may cause attenuation of heatstroke by reducing cerebrovascular dysfunction and brain inflammation.
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Arginina/farmacología , Trastornos Cerebrovasculares/tratamiento farmacológico , Encefalitis/tratamiento farmacológico , Golpe de Calor/tratamiento farmacológico , Hipertensión Intracraneal/tratamiento farmacológico , Animales , Circulación Cerebrovascular/efectos de los fármacos , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/metabolismo , Citocinas/metabolismo , Encefalitis/etiología , Encefalitis/metabolismo , Ensayo de Inmunoadsorción Enzimática , Ácido Glutámico/metabolismo , Glicerol/metabolismo , Golpe de Calor/complicaciones , Hipotálamo/efectos de los fármacos , Hipotálamo/metabolismo , Interleucina-10/metabolismo , Interleucina-1beta/metabolismo , Hipertensión Intracraneal/etiología , Hipertensión Intracraneal/metabolismo , Presión Intracraneal/efectos de los fármacos , Ácido Láctico/metabolismo , Óxido Nítrico/metabolismo , Ácido Pirúvico/metabolismo , Ratas , Ratas Sprague-Dawley , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
Snake envenoming in pregnancy may cause fetal death and maternal mortality or morbidity. However, little is known about the toxic effects and optimal management of snake envenoming because of the rarity of cases. We report three cases in Taiwan in the past 15 years of pregnant women who were treated successfully after being bitten by Trimeresurus stejnegeri with local envenoming. Two of the three patients received treatment with equine-derived hemotoxic bivalent F(ab')(2) antivenom without development of any adverse effects. All three women recovered uneventfully and subsequently had normal deliveries. Telephone follow-up of the three children 6-10 years later showed no developmental delay of the children.
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Antivenenos/uso terapéutico , Complicaciones del Embarazo , Mordeduras de Serpientes/complicaciones , Mordeduras de Serpientes/tratamiento farmacológico , Trimeresurus , Adulto , Animales , Femenino , Humanos , EmbarazoRESUMEN
BACKGROUND: The aim of this study was to investigate the outcome of patients of unexpected cardiac arrest initially resuscitated by first responders with dissimilar experiences under the support of cardiac arrest team (CAT). METHODS: All unexpected cardiac arrest patients receiving in-hospital resuscitation with the activation of CAT in a tertiary-care teaching hospital over a 12-month period were recorded according to the Utstein criteria. We prospectively recorded various factors at resuscitation and retrospectively evaluated the outcome. Outcome measures included return of spontaneous circulation (ROSC), survival longer than 24 hours, and survival to discharge. RESULTS: Altogether, 76 emergency calls were registered, and among these, 44 calls (58%) were cardiac arrests, including 8 ventricular tachycardia/fibrillation, 15 pulseless electrical activity, and 21 asystole. The rate of ROSC was 61%, the rate of survival longer than 24 hours was 37%, and the rate of survival to discharge was 18%. The response time of our CAT was 271 seconds (4 minutes and 31 seconds) on average. The patients who collapsed in the wards experienced in resuscitation effort received higher rates of appropriate basic and advanced cardiac life support interventions before CAT arrival (79% vs. 44%; p = 0.019), had an increased chance of ROSC (75% vs. 38%; p = 0.014), survival longer than 24 hours (54% vs. 13%; p = 0.007), and survival to discharge (29% vs. 0%; p = 0.036). CONCLUSION: Hospital wards with more than 5 cardiac arrests per year have a better patient survival rate than those with fewer arrests. This is despite all ward staff receiving the same level of training.
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Reanimación Cardiopulmonar , Paro Cardíaco/mortalidad , Anciano , Femenino , Hospitales de Enseñanza , Humanos , Masculino , Pronóstico , Análisis de Regresión , Tasa de SupervivenciaRESUMEN
BACKGROUND: Adopting thrombolytic therapy with tissue plasminogen activator (tPA) in clinical practice presents many challenges. One major factor is the restrictive time window of 0-3 hours after symptom onset, for the commencement of treatment. OBJECTIVE: To test the efficacy of a newly developed plasminogen activator (human tissue urokinase type plasminogen activator [HTUPA]) for the treatment of acute ischaemic stroke within 5 hours of symptom onset. DESIGN: An open-label, dose escalation trial. The initial dose was 0.3 mg/kg and could be increased or decreased depending on tolerability. SETTING: Three teaching hospitals in Taiwan. PARTICIPANTS: Thirty-three patients who presented with National Institute of Health Stroke Scale (NIHSS) scores of between 9 and 20, who had evidence of ischaemic stroke confirmed by CT. MAIN OUTCOMES MEASURES: Efficacy was assessed by the NIHSS, the Modified Rankin Scale (MRS), the Barthel Index and the Glasgow Outcome Scale. Preliminary efficacy endpoints included major neurological improvement at 24 hours and favourable outcome at 90 days after administration of HTUPA. RESULTS: Of the 33 patients who received HTUPA, 29 received 0.3 mg/kg, 3 received 0.35 mg/kg and 1 received 0.4 mg/kg. Major neurological improvement, defined as improvement of > or =4 points on the NIHSS 24 hours after treatment, was observed in 45% of all patients treated (15/33) and in 48% (14/29) of those treated with 0.3 mg/kg. Ninety days after symptom onset, in those who received HTUPA 0.3 mg/kg, the proportion of patients with a favourable outcome was 34% on the NIHSS (< or =1), 45% on the MRS (0 or 1), 41% on the Barthel Index (> or =95) and 45% on the Glasgow Outcome Scale (1). Eighty six percent of the patients treated with 0.3 mg/kg within 0-3 hours of symptom onset reached scores of 0-1 on both the NIHSS and the MRS. CONCLUSIONS: Approximately 50% of patients treated with HTUPA 0.3 mg/kg within a 5-hour window after symptom onset experienced major neurological improvement within 24 hours of drug administration. Thrombolytic agents, in this case HTUPA, may be suitable for Taiwanese or Asian patients with acute ischaemic stroke who meet the inclusion criteria.
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Isquemia Encefálica/tratamiento farmacológico , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/métodos , Activador de Plasminógeno de Tipo Uroquinasa/uso terapéutico , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/complicaciones , Hemorragia Cerebral/inducido químicamente , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Factores de Riesgo , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del Tratamiento , Activador de Plasminógeno de Tipo Uroquinasa/efectos adversosRESUMEN
BACKGROUND AND OBJECTIVES: Previous studies have shown little or no improvement in pulmonary function and arterial blood oxygenation after therapeutic thoracocentesis. This study investigated changes in pulmonary function, arterial blood gases and dyspnoea after therapeutic thoracocentesis in patients with paradoxical movement (PM) of a hemidiaphragm due to pleural effusion. METHODS: Twenty-one patients with pleural effusion and PM of a hemidiaphragm and 41 patients with pleural effusion but without paradoxical movement (NPM) were studied before and 24 h after thoracocentesis. Lung function measurements included lung mechanics, blood gas exchange and the Borg dyspnoea scale. RESULTS: At thoracocentesis a mean of 1,220 mL of pleural fluid was removed from the PM group and 1,110 mL from the NPM group. Post-thoracocentesis the PM group showed small but significant improvement (P < 0.05) in FEV(1) (63% vs 73%), FVC (67% vs 77%), PaO(2) (66 mm Hg vs 73 mm Hg), A-a O(2) gradient (38 mm Hg vs 30 mm Hg), and the Borg scale (5.1 vs 2.1). The NPM group showed no significant change in any parameter. CONCLUSIONS: Statistically significant improvement in pulmonary function following thoracocentesis was observed in patients with pleural effusion and PM of the hemidiaphragm. Patient selection may therefore explain the different outcomes of thoracocentesis reported in previous studies.
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Derrame Pleural/fisiopatología , Derrame Pleural/terapia , Pleurodesia , Respiración , Adulto , Anciano , Anciano de 80 o más Años , Análisis de los Gases de la Sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pruebas de Función RespiratoriaRESUMEN
OBJECTIVE: The objective of the study was to investigate initial clinical characteristics that can suggest an early diagnosis of patients with acute renal infarction presenting with flank and/or abdominal pain in the emergency department (ED). METHODS: From January 1, 1996, through December 31, 2005, 20 adult patients with renal infarction diagnosed by contrast-enhanced computed tomography in the ED were enrolled. Medical records, including demographic data, risk factors for thromboembolism, initial clinical presentations, laboratory data, treatment programs and outcomes, were retrospectively reviewed and analyzed. RESULTS: Mean patient age was 60.3 years (range, 21-80). The estimated incidence of renal infarction was 0.004% (20 of 481,540) among the ED census. The median time of onset of symptoms before the ED visit was 31 hours (range, 1-285). Eighteen patients (90%) had a history of more than 1 risk factor for thromboembolic events. In clinical presentations, all the patients had either abdominal or flank pain and tenderness. Nineteen patients (95%) had an elevated serum lactate dehydrogenase level with a mean +/- SD of 812.1 +/- 569.4 U/L. Sixteen patients (80%) presented with the triad--persisting flank or abdominal pain/tenderness, elevated serum lactate dehydrogenase level, and proteinuria. Among all 20 patients, 10 patients (50%) were diagnosed as having renal infarction at the initial ED visit. No specific clinical characteristics could be identified to distinguish those patients diagnosed early and those with delayed diagnosis. All 20 patients received medical treatment with coumadin, which was given in combination with heparin treatment in 11, peripheral intravenous and/or local intra-arterial thrombolytics with urokinase in 5, and mitral valve replacement in 1. No patient died. Although 4 patients had a mildly elevated serum creatinine level (>1.5 mg/dL) during hospitalization, none of them needs dialysis after more than 1 year of follow-up. CONCLUSIONS: In this study, we delineated specifically clinical features for emergency physicians to raise their suspicion index for an early diagnosis of patients with renal infarction, a disease which is uncommon and is usually delayed or missed at initial ED presentation.
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Dolor Abdominal/etiología , Servicio de Urgencia en Hospital , Dolor en el Flanco/etiología , Infarto/complicaciones , Infarto/diagnóstico , Riñón/irrigación sanguínea , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Infarto/terapia , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Tomografía Computarizada por Rayos XAsunto(s)
Contrapulsador Intraaórtico , Infecciones Meningocócicas/complicaciones , Miocarditis/terapia , Neisseria meningitidis Serogrupo B , Sepsis/complicaciones , Choque Cardiogénico/terapia , Adulto , Femenino , Humanos , Infecciones Meningocócicas/diagnóstico , Infecciones Meningocócicas/terapia , Miocarditis/diagnóstico , Miocarditis/microbiología , Sepsis/diagnóstico , Sepsis/terapia , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/microbiologíaRESUMEN
Crotaline snakebites (Protobothrops mucrosquamatus and Trimeresurus stejnegeri) are a common medical emergency in Taiwan that can be effectively treated by a bivalent F(ab)2 antivenom. We investigated the differences in the clinical outcomes of patients who received different therapeutic regimens of antivenom in a medical center where clinical toxicologists followed the poison control center (PCC) guidelines (medical group) and surgeons did not (surgical group). The medical records of inpatients with crotaline snakebites between 1991 and 2005 were reviewed and information on demographics, treatments, adverse effects of antivenom, and complications was abstracted and analyzed. A total of 179 patients (90 medical, 89 surgical) were eligible for study. There was no significant intergroup difference in baseline characteristics except that the dose of antivenom and the probability of antibiotic use were both higher in the surgical group (5.9 +/- 4.2 vials vs. 2.7 +/- 1.6 vials; 93% vs. 60%). Multiple logistic regression adjusting for age, gender, calendar year of envenomation, severity of envenomation, and antibiotic use did not disclose evidence of any difference in various clinical outcomes between medical and surgical patients. The lower dose of antivenom recommended by the PCC may be as effective and safe as the higher dose used in the surgical group for the treatment of crotaline snakebites.