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In some cases, the conventional C-arm fluoroscopy can barely identify anatomical landmarks such as the dorsal sacral foramen. A fully endoscopic rhizotomy under three-dimensional (3D) provides satisfactory results in the treatment of sacroiliac (SI) joint pain. The workflow of a fully endoscopic rhizotomy under 3D robotic C-arm navigation system is introduced. The presented technique is novel, effective, and safe for the treatment of SI joint pain. The 3D navigation system guides the operator to easily locate the target points for finding the medial branches of L5 and sacral lateral branches from S1, S2, and S3 dorsal foramina under endoscopic visualization.

With the evolution of endoscopic instruments and techniques, full-endoscopic spine surgery has attracted more attention worldwide in recent years. At the initial stage, surgeons conducted endoscopic lumbar discectomy using the transforaminal approach. Next, interlaminar endoscopic lumbar discectomy was developed to treat a herniation disc at the L5-S1 level. The progression in interlaminar endoscopic techniques has further broadened the indications for full-endoscopic spine surgery. However, the steep learning curve of endoscopic procedures has remained challenging. The use of interlaminar endoscopic lumbar discectomy entails many essential skills to manage the different anatomical structures of the spine. From the perspective of successful and safe interlaminar endoscopic lumbar discectomy, we have discussed the technical considerations for endoscopic procedures.

Due to the aging population, patients required spinal surgery for degenerative spondylopathy is increasing. With the advent of surgical instruments and techniques, minimally invasive spine surgery is prevalent worldwide. Besides microscopic techniques, endoscopic spine surgery has gotten attention gradually in this surgical field for the past two decades. There are two essential approaches developed currently, including transforaminal and interlaminar approach. These innovative equipment and skills promote the progression of endoscopic surgery from discectomy to decompression of spinal stenosis. Meanwhile, they also opened up the application of endoscopic surgery in a complicated situation. From the perspective of emerging technologies and techniques, the authors will review the evolution and describe the prospects of the interlaminar endoscopic spine surgery (IESS).

Backgroun:This study proposed an algorithm to improve resuscitation outcomes in the emergency department (ED) for patients with traumatic out-of-hospital cardiac arrest (TOHCA). We also performed a retrospective chart review of patient outcomes before and after implementing the algorithm and sought to define factors that might influence patient outcomes.Methods: In September 2018, we implemented an algorithm for patients with TOHCA. This algorithm rapidly identifies possible causes of TOHCA and recommends appropriate interventions. We retrospectively reviewed the outcomes of all patients with TOHCA during a 5-year period and compared the results before and after the implementation of the algorithm.Results:After this algorithm was implemented, the use of the ED interventions of blood transfusion, placement of a large-bore central venous catheter, and thoracostomy increased significantly. Return of spontaneous circulation (ROSC), hospital admission, and survival rates also increased (before vs. after: ROSC: 23.6% vs. 41.5%, P = 0.035; hospital admission: 18.2% vs. 24.6%, P = 0.394; survival: 0.0% vs. 4.6%, P = 0.107). Admitted patients exhibited a higher end-tidal CO2 level than nonadmitted patients [admitted vs. nonadmitted: 41.5 (33.3–52.0) vs. 12.0 (7.5–18.8), P = 0.001].Conclusion:Our algorithm prioritizes the three major treatable causes of TOHCA: impedance of venous return, hypovolemia, and hypoxia. We found that ROSC, hospital admission, and survival rates increased with the increasing implementation of the ED interventions recommended by the algorithm.

Accurate stratification of sepsis can effectively guide the triage of patient care and shared decision making in the emergency department (ED). However, previous research on sepsis identification models focused mainly on ICU patients, and discrepancies in model performance between the development and external validation datasets are rarely evaluated. The aim of our study was to develop and externally validate a machine learning model to stratify sepsis patients in the ED. We retrospectively collected clinical data from two geographically separate institutes that provided a different level of care at different time periods. The Sepsis-3 criteria were used as the reference standard in both datasets for identifying true sepsis cases. An eXtreme Gradient Boosting (XGBoost) algorithm was developed to stratify sepsis patients and the performance of the model was compared with traditional clinical sepsis tools, quick Sequential Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS). There were 8296 patients (1752 (21%) being septic) in the development and 1744 patients (506 (29%) being septic) in the external validation datasets. The mortality of septic patients in the development and validation datasets was 13.5% and 17%, respectively. In the internal validation, XGBoost achieved an area under the receiver operating characteristic curve (AUROC) of 0.86, exceeding SIRS (0.68) and qSOFA (0.56). The performance of XGBoost deteriorated in the external validation (the AUROC of XGBoost, SIRS and qSOFA was 0.75, 0.57 and 0.66, respectively). Heterogeneity in patient characteristics, such as sepsis prevalence, severity, age, comorbidity and infection focus, could reduce model performance. Our model showed good discriminative capabilities for the identification of sepsis patients and outperformed the existing sepsis identification tools. Implementation of the ML model in the ED can facilitate timely sepsis identification and treatment. However, dataset discrepancies should be carefully evaluated before implementing the ML approach in clinical practice. This finding reinforces the necessity for future studies to perform external validation to ensure the generalisability of any developed ML approaches.

Background Percutaneous radiofrequency trigeminal rhizotomy (RF-TR) is a well-established treatment for patients suffering from trigeminal neuralgia (TN) as a primary modality or for those refractory to medical treatment. However, few existing studies have identified intraoperative parameter or navigation technique that can be used to predict the rates of short-term or long-term pain relief. In this study, we analyzed patient characteristics, intraoperative parameters and technical factors, and postoperative changes in relation to immediate and long-term pain relief. Method This study included a total 252 patients in which 340 RF-TR were performed under the guidance of intraoperative computed tomography (iCT) alone or with magnetic resonance image (MRI) and iCT fusion imaging. Result The immediate pain relief of RF-TR with iCT alone and iCT with MR image guidance with or without cerebrospinal fluid (CSF) outflow were all above 90.4%. The 2-year pain relief rate of RF-TR using iCT alone and iCT with MR images guidance with or without CSF outflow were 47.8%, 39.8%, 71.7%, and 53.9% respectively. Significant factors for 2-year pain relief were CSF outflow, iCT with MR image fusion, non-recurrent TN, and presence of postoperative facial numbness. Conclusion This preliminary study demonstrated foramen ovale cannulation under the aid of iCT with MR image guidance could improve 2-year pain relief.

With the trend of minimally invasive spine surgery, full-endoscopic lumbar discectomy (FELD) has evolved with the advancement of the optics and instruments. Regarding the techniques, the transforaminal and interlaminar approach remain the major accesses in FELD. Transforaminal endoscopic lumbar discectomy (TELD) is an effective and safe treatment for herniation of the lumbar disc. More and more evidence supports the TELD in enhancing recovery and decreasing surgical complications. However, the learning curve of TELD remains steep, especially at the L5-S1 level. The iliac crest height is an essential factor in the operability of TELD at the L5-S1 level. In the situation of the high iliac crest, TELD is technically challenging even for an experienced surgeon. Therefore, the authors report their techniques of TELD with foraminoplasty step-by-step and the preliminary results in this report.

Background: After the main shock of a major earthquake, casualties cluster in a short period and may overwhelm the capacities of health care facilities. An earthquake with a magnitude of 6.4 on the Richter scale struck Tainan City causing 117 fatalities and 513 injuries. Objectives: We conducted a retrospective study to review the medical records of emergency department after the attack of earthquake. The aim of this study was delineating the medical resource requirements after the disaster. Methods: We reviewed the medical records of patients admitted to the emergency department of Chi Mei Medical Center. Each chart indicating that the emergency department visit was earthquake-related was reviewed. After the earthquake struck, the Chi Mei Medical Center mobilized off-duty staff through a preset 333 code. Subsequently, routine surgeries and nonurgent admissions were postponed to reserve the maximal capacity for wounded patients. Results: A total of 150 patients were reviewed during the study period. In all, 25 cases (23.8%) required admission, and 9 of them (8.6%) were admitted to the intensive care unit. Patients with earthquake-related injuries constituted 62.8% of all traumatic patients in the 24-h aftermath. The requirements for wound sutures, blood component transfusion, numbers of radiographic/computed tomographic scans, and invasive procedures increased dramatically (earthquake-related/total: 66.0%, 30.0%, 72.1%/57.4%, and 47.7%, respectively). Conclusion: Patients with earthquake-related injuries arrived at the emergency department soon after the earthquake occurred and substantial emergency department resources were utilized in the 24-h aftermath. Each hospital should have a preset mobilization signal to call in off-duty workers to treat casualties resulting from the main shock of an earthquake. Subsequently, hospital-based mobilization should be initiated to provide comprehensive care to severely injured patients.

Background: Acute epiglottitis is a potentially life-threatening condition, but its clinical manifestations are usually nonspecific. Objectives: We investigated the clinical differences between patients with and those without acute epiglottitis and identified the risk factors of patients with acute epiglottitis who may develop airway compromise. Methods: We studied patients suspected of having acute epiglottitis in the emergency department. All patients received fibre-optic laryngoscopy performed by an otorhinolaryngologist and were subsequently divided into two groups: patients with acute epiglottitis and those without. Results: Of the 311 adult patients, 108 were diagnosed with acute epiglottitis. In the nonepiglottitis group, more complaints of fever (p < 0.001), cough (p < 0.001), and rhinorrhoea (p = 0.048) and more systemic comorbidities were reported. People with acute epiglottitis generally had a higher prevalence of head and neck tumours (p = 0.015), odynophagia (p = 0.037) and an elevated white blood cell level (p < 0.001). The proportion of patients with cardiovascular disease (p = 0.014) or diabetes mellitus (p = 0.019), drooling (p = 0.026) or sore throat (p = 0.042), a high respiratory rate (p = 0.009), an elevated white blood cell level (p = 0.002) and a higher C-reactive protein level (p = 0.005) was higher among those who required airway intervention. Conclusion: Clinical manifestations alone were insufficiently reliable for diagnosing acute epiglottitis but could predict disease severity. Laryngoscopy should be performed as soon as possible once a patient is suspected of having acute epiglottitis.

The pain of acute compression fracture in the lumbar spine may be refractory to conservative treatment, and surgery is not an optimal choice for the elderly or infirm individuals. Moreover, even vertebroplasty can cause many side effects such as chemical leak, adjacent segment instability, and residual pain. Percutaneous dorsal root ganglion block (PDRGB) possibly is an alternative therapeutic option. In this study, we evaluated the efficacy of pain relief and the rate of adjacent level compression fracture in patients with acute compression fracture of the lumbar spine. We retrospectively reviewed 40 patients with lumbar compression fracture from 2013 to 2015. The patients were treated with navigation-assisted CT-guided PDRGB with steroid at the pathological level and at the adjacent level above and below. Therapeutic response was evaluated using the Numerical Rating Scale (NRS); and an optimal, acceptable, and unfavorable outcome were analyzed. Among the 40 patients treated, initial pain relief on the first day was dramatic, and the average NRS did not change significantly up to the first-year follow-up. The highest percentage of a good outcome, at 90% (37.5% with an optimal outcome, 52.5% with an acceptable outcome), was reported at 1 week postoperatively. The percentage of optimal outcomes increased even at the 1-year follow-up. No adjacent compression fracture was found in the group treated with PDRGB alone at the 1-year follow-up. PDRGB is a simple, safe, and minimally invasive procedure that showed immediate and prolonged improvement of pain in lumbar osteoporotic compression fracture patients who failed conservative treatment or had residual pain after vertebroplasty. However, continuous medication for osteoporosis was still required.

Emergency physicians may overlook spinal cord injury in patients when the direct impact of a gunshot on the spine is lacking. A 30-year-old man who was shot on his right chest wall was brought to the emergency department. He arrived in a state of shock and underwent emergent thoracotomy for massive hemothorax. After surgery, he was found to be paraplegic. Magnetic resonance imaging of the spine showed T4 spinal cord contusion. The penetrating bullet dissipates energy to the surrounding tissue and contuses the spinal cord. Another assumption of the spinal cord injury is the impairment of blood supply to the cord. No effective treatment exists for gunshot-related indirect injury to the spinal cord. These reported cases reminded emergency physicians that after stabilization of the patient with a gunshot wound, a complete neurologic examination should be performed to discover occult spinal cord injury.

Full-endoscopic lumbar discectomy has been an alternative in minimally invasive spine surgery to treat lumbar disc herniation. For the transforaminal approach, high-grade down-migrated disc below the suprapedicular border remains technically challenging and leads to a higher failure rate. Different full-endoscopic techniques regarding the issue have been proposed, including the transforaminal approach with foraminoplasty, contralateral transforaminal approach, and interlaminar or translaminar approach. In terms of anatomy, the pedicle is a barrier to reach the migrated fragment through the posterolateral trajectory. The full-endoscopic instruments allow surgeons to achieve fragmentectomy by creating a “keyhole” on the pedicle. The nerve roots are free of manipulation through the tract toward the target directly. Therefore, a full-endoscopic transpedicular approach can be a solution to treat high-grade downward disc migration. In this chapter, the authors will introduce the techniques of full-endoscopic transpedicular approach step by step.

BACKGROUND Endoscopic spine surgery is an alternative to the traditional treatment of lumbar disc herniation. However, the traditional technique of interlaminar endoscopic approach is challenging and risky in patients with concomitant spinal stenosis. OBJECTIVE To report a modified technique called hybrid interlaminar endoscopic lumbar decompression as an effective treatment. METHODS Patients with combined lumbar disc herniation and lateral recess stenosis undergoing full-endoscopic interlaminar lumbar discectomy were retrospectively studied. The hybrid interlaminar endoscopic discectomy technique, as well as the use of 2 endoscopes with different diameters, is described in detail. The large endoscope is used for the laminotomy procedure, while the small endoscope is used for the discectomy procedure. The demographics and clinical outcomes of the patients are presented. RESULTS A total of 19 patients were included in this study. The mean age was 46.7 yr. The visual analog scale for back and leg pain improved from 5.6 ± 3.4 and 7.5 ± 2.3 to 1.8 ± 1.3 and 1.8 ± 1.6, respectively (P

The interlaminar contralateral endoscopic lumbar foraminotomy (ICELF) provides access to the foraminal pathology with less violation to facet than the ipsilateral approach. However, it is technically challenging even for an experienced surgeon. We introduce the step-by-step workflow of the interlaminar contralateral endoscopic lumbar foraminotomy assisted with O-arm navigation system. The ICELF assisted with O-arm navigation is safe, accurate, and efficient for the treatment of lumbar foraminal stenosis. The CT-based navigation reshapes the learning curve of the advanced endoscopic technique, reducing the risk of facet joint violation, and minimizes radiation exposure to surgeons.

An ocular jellyfish sting is an ophthalmic emergency and is rarely reported in the medical literature. With the evolution of aquatic activities and entertainment in recent decades, we anticipate that more patients with ocular jellyfish stings may be taken to the emergency department. However, most physicians are unaware of the typical presentations, suitable treatments, prognosis, and possible complications of ocular jellyfish stings. We reported 2 cases with ocular jellyfish stings and collected cases series from literature review. The most common clinical features of ocular jellyfish stings were pain, conjunctival injection, corneal lesion, and photophobia. All patients who sustained ocular stings did so during aquatic activities, and the best management at the scene was proper analgesics and copious irrigation of affected eyes with seawater or saline. The ocular lesions were treated with topical cycloplegics, topical steroids, topical antibiotics, topical antihistamines, and removal of nematocysts. The prognosis was good, and all patients recovered without any permanent sequelae. However, symptoms in some patients may last longer than 1 week. Reported complications included iritis, increased intraocular pressures, mydriasis, decreased accommodation, and peripheral anterior synechiae.

Introduction: Severe accidental hypothermia in trauma patients is rarely encountered in tropical areas. However, unnoticed hypothermia may lead to deleterious consequences and even sudden death.Case report: We report the case of a middle-aged patient who sustained hemorrhagic shock secondary to a traffic accidentinduced severe intraabdominal injury, followed by prolonged exposure to a cold and wet environment. Thereafter, the patient was sedated and paralyzed and was administered large infusion volumes of fluid and blood components. In the emergency department, profound hypothermia could not be detected using an infrared forehead thermometer. Subsequently, the patient had a sudden cardiac arrest during the emergency surgery.Conclusion: This case report highlights that even in a tropical city, fatal severe hypothermia may occur in severe trauma patients. Therefore, to avoid accidental hypothermia, emergency physicians and trauma surgeons should use invasive temperature monitoring, and aggressive rewarming should be performed for correcting hypothermia in severe trauma patients

In Taiwan, legal migrant workers and almost all citizens are covered under the National Health Insurance program. Work-related injuries and various traumatic events constitute 2 major reasons for seeking medical care among migrant workers. Therefore, we conducted this retrospective study to delineate the clinical features of migrant workers with trauma and determine differences in trauma management between migrant workers and citizens under the current medical care and insurance system. We retrospectively reviewed the data of all patients with trauma who were discharged from adult wards between January 1, 2015 and December 31, 2016. We identified 5854 citizens and 110 migrant workers during the chart review. Data related to the prehospital period, emergency department, hospital course, and prognosis were collected and compared between migrant workers and citizens. More than half of the traumatic events among migrant workers occurred at factory, farm, or mine locations (migrant workers vs all citizens: 57.3% vs 11.5%), whereas most traumatic events among citizens occurred at street and home or dormitory locations (street: migrant workers vs all citizens: 17.3% vs 52.5%; home or dormitory: migrant workers vs all citizens: 0.9% vs 14.3%). Compared with citizens, migrant workers had lower scores in injury severity scores and new injury severity scores, but higher scores in revised trauma score and trauma and injury severity scores. The hospital course and prognosis were similar between migrant workers and citizens. Compared with citizens, migrant workers had a higher incidence of work-related injury and sustained less severe injuries. Under the coverage of the current health care and insurance system in Taiwan, migrant workers with trauma and work-related injuries receive comparable medical care and prognoses to citizens.

High-grade gliomas (HGGs) are a rapidly progressive and highly recurrent group of primary brain tumors. Despite aggressive surgical resection with chemoradiotherapy, prognoses remained poor. Valproic acid (VPA), a histone deacetylase inhibitor has shown the potential to inhibit glioma cell growth in vitro through several diverse mechanisms. However clinical studies regarding the effect of VPA on HGGs are limited. This study aimed to investigate whether using VPA in patients with HGGs under temozolomide (TMZ) would lead to a better overall survival (OS).We used the Taiwan National Health Insurance Research database to conduct this population-based cohort study. A total of 2379 patients with HGGs under TMZ treatment were included and were further classified into VPA (n = 1212, VPA ≥ 84 defined daily dose [DDD]) and non-VPA (n = 1167, VPA < 84 DDD) groups. Each patient was followed from 1998 to 2013 or until death. A Cox proportional hazard regression was performed to evaluate the effect of VPA and OS.The VPA group had a longer mean OS time compared with the non-VPA group (OS: 50.3 ± 41.0 vs 42.0 ± 37.2 months, P < .001). In patients between 18 and 40 years old, the difference is most significant (OS: 70.5 ± 48.7 vs 55.1 ± 46.0, P = .001). The adjusted hazard ratio is 0.81 (95% confidence interval, 0.72-0.91) for the VPA group relative to the non-VPA group.VPA at over 84 DDD improved OS in HGGs TMZ treatment.

Background People sometimes siphon fuel to fill their tanks. However, this is a potentially dangerous procedure and may cause hydrocarbon pneumonitis. We present the case of a patient with severe hydrocarbon pneumonitis after siphoning fuel. The patient underwent artificial ventilation and was admitted to hospital for 97 days. Methods We review the relevant literature for a better understanding of clinical features and management strategies for hydrocarbon pneumonitis following fuel siphonage. Results We reviewed 15 articles, which included 3 original articles and 12 case reports that reported the clinical features of fuel siphonage. In addition, we added our presented case for data analysis. A total of 40 cases were included in this review. The literature review found that hydrocarbon pneumonitis caused by fuel siphonage occurs worldwide and that most patients (80%) became symptomatic within 1 day of aspiration. Cough (70%), chest pain (62.5%), dyspnoea (55%), and fever (52.5%) presented in more than half of all patients. The right middle lobe (80%) was the predominantly involved lung field; more than one-third of patients (36.7%) showed the involvement of two lobes. Conclusion Patient history, computed tomographic scans of the chest, and bronchoalveolar lavage are the commonly used diagnostic tools. Supportive care remains the foundation of treatment, whereas antibiotics, steroids, and bronchoalveolar lavage are practical therapies. Patients' clinical improvement precedes the resolution of lesions on chest X-ray. Most complications arise from pulmonary lesions. The prognosis of patients suffering from hydrocarbon pneumonitis following fuel siphonage might be improved by accurate diagnosis and appropriate care.

Percutaneous radiofrequency trigeminal rhizotomy (RF-TR) has been an effective treatment modality for medically refractory trigeminal neuralgia. Our group has established a protocol for this procedure that includes intraoperative computed tomography (iCT) navigation. The depth of the puncture needle in our protocol was based on cadaveric studies, and anatomical localization was mainly by electric stimulation test. The limitation of the invisibility of the trigeminal cistern on CT imaging and bias from the patient’s subjective expression during neurophysiologic stimulation might affect the accuracy of the needle tip and the treatment effect.This study aimed to evaluate the feasibility and preliminary results of the application of magnetic resonance imaging (MRI) and iCT fusion imaging in RF-TR. The study included 13 patients who received RF-TR with iCT navigation and with recurrence within 3 years. Repeated RF-TR was performed with real-time guidance by MRI and iCT fusion imaging. A pain-free or partial satisfactory response was reported with 12 patients (92 %). There was a statistically significant difference in the depth of the needle tip before and after application of MRI and iCT fusion imaging. This preliminary study demonstrated that the application of MRI and iCT fusion could help with anatomical localization of the trigeminal cistern intraoperatively. The improvement in neuronavigation provides a choice in the treatment of recurrent or persistent trigeminal neuralgia after previous intervention. Long-term follow-up of the result is necessary to evaluate the benefit in terms of durability of therapeutic efficacy.

Not available.

Introduction Neurogenic pulmonary edema (NPE) is a life-threatening condition caused by various significant central nervous system injuries. It is characterized by an abrupt increase in fluids within the alveoli and interstitium of the lungs. The mechanism underlying NPE remains unclear. Few pathophysiological causes — including neurocardiac factors, neurohemodynamic factors, blast theory, and pulmonary venule adrenergic hypersensitivity — have been proposed Case report We report the case of a patient with NPE associated with subarachnoid hemorrhage (SAH) and stress-hemoconcentration. Adrenergic responses have been reported to play a crucial role in both NPE and stress-hemoconcentration. We believe that SAH induces an adrenergic surge, which causes a cascade of reactions and leads to both NPE and stress-hemoconcentration. Conclusion Central nervous system (CNS) injuries are crucial and common causes of adrenergic stimulation; therefore, any subtle signs indicating CNS injuries should be carefully investigated. The distress of NPE may mask the initial symptoms of CNS injuries . If the patient is intubated and under mechanical ventilation to treat NPE, the inciting neurological injury may be overlooked and result in a delayed diagnosis.

BackgroundDengue is one of the most important mosquito-borne diseases. Taiwan is located in an epidemic area for dengue, and several dengue outbreaks have been reported in southern Taiwan. Therefore, we conducted this study to determine the incidence and clinical manifestations of symptomatic dengue infection.MethodsWe reviewed the medical records of 177 pediatric patients (age < 16 years) who underwent serum tests for dengue (polymerase chain reaction or capture enzyme-linked immunosorbent assay for dengue immunoglobulin M and immunoglobulin G antibodies) in the pediatric outpatient clinic, the pediatric ward, or the emergency department of the Chi-Mei Medical Center from January 1, 2007 to December 31, 2007. We evaluated the differences in the clinical characteristics and laboratory data between the dengue and nondengue patients.ResultsMost of the dengue cases appeared starting in July and peaked during November. In the dengue group, there were more school-age patients (age > 7 years) and a more frequent history of mosquito contact. There was no difference in the sex distribution. Most of the dengue patients had obvious symptoms including skin rash (79.0%), nausea/vomiting (47.4%), high fever (> 39°C; 44.7%), diarrhea (26.3%), abdominal pain (23.7%), and petechiae (15.8%). Leukopenia, thrombocytopenia, elevated aspartate aminotransferase levels, and elevated alanine aminotransferase levels were found in 78.4%, 79.3%, 34.5%, and 29.0% of the patients, respectively. Nondengue patients showed elevated C-reactive protein levels (57.5%).ConclusionDengue is commonly found in older pediatric patients and is rare in infants. High fever and skin and gastrointestinal manifestations were usually found in dengue patients. The laboratory findings of leukopenia, thrombocytopenia, elevated levels of liver enzymes, and low C-reactive protein levels were common in dengue patients, and these markers could help confirm the suspicion of pediatric dengue infection.

The flood after a typhoon may lead to increase in patients with cellulitis of lower limbs. However, the microbiological features of these cases are rarely reported. We conducted a study of patients with lower extremity cellulitis after a typhoon followed in southern Taiwan to study the risk factors of cellulitis and the bacteriological features of the patients.We reviewed all the medical records of cellulitis at emergency departments of two teaching hospitals in southern Taiwan 30 days before and after the landing of Typhoon Morakot and collected data on the demographic and bacteriological characteristics. In addition, we evaluated the relationship between the daily number of patients and the rainfall in the Tainan area.The number of cellulitis patients increased from 183 to 344 during the 30-day period after the typhoon. The number peaked in the third and fourth days and lasted for 3 weeks. The proportion of patients with water immersion of the affected limb was higher after the typhoon (6% vs. 37%, odds ratio [OR]: 9.0, 95% Confidence interval [CI]: 4.7-17.2). We found cultures from the infected limbs with immersion had more polymicrobial (73% vs. 26%, OR: 7.8, 95% CI: 3.2-19.2) and Gram-negative bacilli infection (86% vs. 34%, OR: 11.8, 95% CI: 4.1-34.5).Flood arose from Typhoon Morakot caused increases in cellulitis patients, which lasted for 3 weeks. Antibiotic treatment that were effective to both Gram-positive cocci and Gram-negative bacilli are recommended for patients with limbs emerged in the water.

Objective To test the accuracy of capnography in the differential placement of feeding tubes into the trachea versus the oesophagus. Method Nineteen pigs were anesthetised, and feeding tubes were placed into their tracheas and oesophagi. A naïve examiner attached a capnography to the tube and evaluated the presence or absence of flow waveforms on the capnography. In the next step experiment, we gave 20 intentional oesophageal ventilations to the animals to create a distended stomach. The feeding tubes were reinserted, and examined by a naïve examiner by capnography. Results Capnography demonstrated continuous flow waveforms for the feeding tubes placed in the tracheas, but no waveforms were observed for those placed in the oesophagi. In the next step experiment, we found the same results. Conclusion Capnography can be used to accurately determine the placement of tracheal versus oesophageal feeding tubes based on the presence or absence of flow waveforms.

Venous thromboembolism caused by prolonged sitting during air travel has been recognised as economy-class syndrome for more than 30 years. Since 2003, the term “eThrombosis” has been proposed to describe the 21st Century variant of venous thromboembolism associated with immobilisation. We reported a case of cerebral venous sinus thrombosis presenting with severe headache after a prolonged period of sitting for over 12 hours in front of a computer for recreational purpose. We described this case as cerebral “eThrombosis”. Considering the widespread use of computers for many purposes including working, recreation and communications in the present digital era, we would like to put forward that prolonged immobilisation associated with computer use is a possible provoking risk factor of cerebral venous sinus thrombosis.

Objective The β-adrenergic effects of tracheal adrenaline include a decrease in initial arterial pressure, and those of tracheal vasopressin include bradycardia. Both of these deleterious effects influence the outcome of resuscitation. We conducted an animal study to test whether tracheal administration of adrenaline and vasopressin results in synergic effects and abolishes the undesirable individual effects of each drug. Methods Twenty-four pigs were intubated, anesthetized, and divided into four groups. The control group received 5 mL of water. Group A received 0.05 mg/kg adrenaline. Group V received 0.8 U/kg vasopressin. Group AV received 0.05 mg/kg adrenaline plus 0.8 U/kg vasopressin. For all animals, the heart rate and arterial pressure were recorded before drug administration, at 0.25, 0.5, 0.75, and 1 minute after administration, and then every 0.5 minutes for 14 minutes. Results The heart rate decreased from 4 to 15 minutes postinjection in group V. In contrast, Groups A and AV had increases in heart rate. In Group A, the arterial pressure decreased initially after adrenaline administration and then gradually increased. Group V demonstrated an increase in arterial pressure postinjection that then plateaued. Group AV initially demonstrated a nonsignificant arterial pressure decrease and then an elevation in arterial pressure. Conclusions A combination of adrenaline and vasopressin eliminates the bradycardic effects of tracheal vasopressin and minimizes the β-adrenergic effects of tracheal adrenaline. In addition, simultaneous administration of these drugs results in higher arterial pressures, which would have a positive influence on resuscitation.

Summary Background Malpositioned feeding tubes carry the risk of serious complications. However, common bedside methods of differentiating tracheal from gastric feeding tube placement are neither accurate nor practical. Therefore, we conducted an animal study to verify feeding tube placement by syringe aspiration test. Methods A total of 26 pigs were anesthetized and intubated with tracheal tubes in the trachea and the esophagus. The animals were divided into two groups. The animals in the mechanical ventilation group were paralysed and received mechanical ventilation. The animals in the spontaneous breathing group maintained spontaneous breathing. The feeding tubes were then inserted through the tracheal tubes, into the trachea and esophagus, so that the anterior openings of the feeding tubes were located in the trachea and esophagus. A feeding syringe was then attached and 30 ml of air was aspirated into the syringe. The ability to aspirate air without resistance was defined as a positive syringe aspiration test. If there was resistance as air was aspirated, it was defined as a negative syringe aspiration test. In the next step, 20 esophageal ventilations were given to create a distended stomach in the experimental animals, and the syringe aspiration test was repeated in the same manner described above. Results The syringe aspiration test was positive for feeding tubes placed in the trachea and was negative for feeding tubes located in the esophagus in both the mechanical ventilation group and the spontaneous breathing group. Conclusion The syringe aspiration test is an effective method of differentiating tracheal from esophageal feeding tube placement.

Background The objective of this study was to describe the characteristics of patients presenting to the emergency department with cardiac symptoms subsequently diagnosed to have systemic lupus erythematosus (SLE). Methods The authors performed a review of newly diagnosed SLE patients at 2 hospitals in Tainan city between January 2010 and December 2013. Patients initially presenting with cardiac symptoms were included. Demographic data, presenting symptomatology, laboratory data, and imaging studies were obtained and analyzed. Results Eight cases, including 5 female and 3 male patients, were identified during the 4-year study period. The mean age was 37 (range, 15-54) years. Pericardial effusion (63%) and mitral regurgitation (63%) were the most common cardiac abnormalities, followed by impairment of left ventricular systolic function (25%) and tricuspid regurgitation (13%). Most patients showed signs of increased generalized inflammation and immunological activity with elevated levels of C-reactive protein (100%) and anti-dsDNA (88%) and decreased complement levels (63%). The median duration from admission to the diagnosis of SLE was 6.3 (range, 1-13) days, and all patients showed multiple-organ involvement in addition to the cardiovascular system. Conclusions Patients presenting to the emergency department with cardiac symptoms without a history of cardiopulmonary disease or traditional cardiovascular disease risk factors should be assessed for an underlying cause of cardiac decompensation. If the patients exhibit extracardiac manifestations or their illnesses involve multiple-organ systems, screening tests for autoimmune diseases such as SLE are mandatory.

The standard treatment of peritoneal dialysis peritonitis (PD peritonitis) is intraperitoneal antibiotic therapy. In patients with PD peritonitis complicated by bacteremia, intraperitoneal antibiotics combined with elective removal of the infected intraperitoneal catheter may be inadequate. We collected data of all patients with PD peritonitis admitted to Chi-Mei Medical Center during a 4-year period. We reviewed the medical records of the study cohort and collected their in-hospital details. Patients with positive blood culture results were assigned to the bacteremia group, whereas those with negative blood culture results were assigned to the peritonitis-only group. We discovered that 11.0% of patients with PD peritonitis had bacteremia complications, and immunocompromised comorbidities were more common in the bacteremia group than in the peritonitis-only group (66.7% vs 37.2%, P = .022). Additionally, the bacteremia group exhibited higher temperatures, greater respiratory rates, and lower serum sodium levels than the peritonitis-only group (temperature, 37.7 vs 37.2 °C, P = .014; respiratory rate, 19.1 vs 17.9 rate/min, P = .008; serum sodium level, 130.3 vs 132.7 mEq/L, P = .031). No mortality was found in patients with PD peritonitis complicated by bacteremia after intravenous and intraperitoneal antibiotic therapy. More than 1 in 10 patients with PD peritonitis was complicated by bacteremia, which resulted in extensive systemic derangements. Patients with immunocompromised comorbidities carried a higher risk of developing bacteremia, resulting in prolonged hospital stays. Combination of intraperitoneal and intravenous antibiotics therapies achieved fair prognoses in patients with PD peritonitis complicated by bacteremia.

We determined the validity of serumaspartate aminotransferase (AST) and alanine aminotransferase(ALT) as screening tests in the identificationof liver injuries in pediatric torso trauma patients.We conducted a retrospective study inpediatric patients17 years of age who sustainedblunt trauma and were admitted to an urban traumacenter during a 39-month period. The serum AST andALT levels, injury severity scores (ISS), lengths of hospitaland intensive care unit stays, laparotomy andvascular embolization requirement, mortality rate, andconcomitant injuries were compared betweenpatients with and without liver injury.Of the 40 patients reviewed, 16 patients hadliver injuries. The mean serum AST and ALT levels weremarkedly higher in the liver injury (LI) group than inthe non-liver injury (NLI) group (773.4 IU/l ± 781.3 [SD]and 613.6 IU/l ± 640.0 [SD], respectively, and (67.2IU/l ± 63.2 [SD] and 55.5 IU/l ± 62.6 [SD], respectively;p0.01). One of the 16 LI patients and 20 of the 24 NLIpatients had AST levels200 IU/l or ALT levels125IU/l. The sensitivity, specificity, and positive and negativepredictive values were 94, 83, 79, and 95%,respectively.A serum AST200 IU/l or an ALT125 IU/l are strong predictors of liver injury in childrensustaining blunt torso trauma. We recommend theroutine use of serum transaminase levels as screeningtests in hemodynamically stable patients.

Renal artery embolism (RAE) is a rare disease, and its clinical features and diagnostic tools are mysterious to most physicians. Anticoagulants, surgery, and thrombolytic therapies have been used to treat patients with RAE. However, there is no universal protocol for the proper management of RAE and the timing of treatment. This variation in treatment management further impairs the comparison of different therapies, complications and prognoses. We reported a RAE patient who underwent intra-arterial urokinase treatment. A detailed literature search found that the most common presentations of RAE are localized pain in the flank/abdomen, nausea and vomiting, and fever. A few laboratory abnormalities, including elevations of lactic dehydrogenase, C-reactive protein, and white cell count, as well as unexplained proteinuria and hematuria, are useful screening tools for RAE. A contrast-enhanced computed tomographic scan of the abdomen is currently the best diagnostic tool. Anticoagulants are an effective and safe treatment, resulting in a fair prognosis for RAE cases. The rates of mortality and long-term hemodialysis are low. Surgery and intra-arterial thrombolytic therapy should be reserved in cases where the aggressive preservation of residual renal function is necessary in patients with deteriorated renal function or only one functional kidney. In addition, concurrent and subsequent thrombolytic events in other organs are common in patients with RAE.

Foreign body-induced epiglottitis is rare and may not display typical manifestations of infectious epiglottitis. Besides, except for airway management and antibiotics treatment, the foreign body should be removed and accompanied complications, such as epiglottic abscess, also require adequate drainage. We reported on a patient admitted for epiglottitis and airway obstruction. Computed tomographic scan of the neck revealed an epiglottitis and a suspected retained epiglottic foreign body. The patient recovered completely after the removal of the foreign body and drainage of the abscess surgically. In the discussion, we describe the usefulness and limitations of laryngoscopic examination and computed tomographic scan of the neck for the evaluation of airway obstruction. If there is any suspicion of non-infectious causes of epiglottitis, or the response to treatment is inadequate, we suggest using varied diagnostic tools liberally to discover the accurate etiologies of epiglottitis.

A previously fit 32-year-old woman was presented to the emergency department for left abdominal pain for two days. The pain is dull in character and is not accompanied by nausea, diarrhoea, fever, dysuria, or haematuria. She is a virgin with a regular menstrual cycle and her last menstrual period started 2 weeks ago. The physical examination revealed mild left lower quadrant tenderness only. The initial impression of her illness was urolithiasis and she underwent intramuscular piroxicam for analgesia. However, the urine analysis showed neither haematuria nor pyuria. Her pregnancy test was negative for pregnancy and hydronephrosis was not exhibited on the sonogram of her bilateral kidneys.

In the adult population, the occurrence of cerebral venous thrombosis (CVT) had been related to a number of risk factors, including genetic and acquired prothrombotic conditions, infections, inflammatory diseases, hematologic disorders, trauma, and drug use. However, dehydration has never been reported as a predisposing factor. We reported a man with CVT that was provoked by acute gastroenteritis-induced dehydration. Notably, headache was the only sign of CVT. This rare case presentation is a reminder to emergency physicians that, in both pediatric and adult patients, severe dehydration might induce CVT. In addition, we discuss the direct signs of CVT as revealed by noncontrast computed tomography and report that a subtle subarachnoid hemorrhage may develop secondary to CVT.

Background: It is uncommon for emergency physicians to discover a patient with circulatory failure resulting from chronic diarrhea. Objectives: We describe McKittrick-Wheelock syndrome, a rare disorder characterized by volume and electrolyte depletion and caused by colonic neoplasm. Case Report: The case of a 30-year-old woman who came to the Emergency Department with hypovolemic shock, hyponatremia, and hypokalemia with a background of chronic diarrhea is reported. The hypokalemia and dehydration were refractory to aggressive replacement therapy. Her condition was the result of fluid and electrolyte hypersecretion caused by a colonic adenocarcinoma and colonic polyposis. Surgical removal of the colon and subsequent volume and electrolyte replacement therapy resulted in complete recovery. Conclusion: This case is presented to increase awareness among emergency physicians of the rare disorder of McKittrick-Wheelock syndrome.

Carotid blowout syndrome refers to the rupture of the carotid artery and its branches. Carotid blowout syndrome is a dangerous medical emergency typically resulting from complications of treatments for head and neck cancer. A patient without a prior history of head or neck cancer presented to the emergency department with a painless, enlarging neck mass was reported in this study. The mass progressed to acute airway obstruction during imaging of the lesion and necessitated emergency cricothyrotomy to secure the airway. The patient underwent four endovascular treatments to manage repeated bleeding thus producing the neurological complication of right middle cerebral artery infarction. Clinical manifestations, varied treatments, and common complications of carotid blowout syndrome were discussed.

A 23-year-old male presented with a parasellar lesion which was suspected as disseminated intracranial germ cell tumour. The diagnosis of germinoma was made using immunohistochemistry from percutaneous trans-foramen ovale biopsy. This report describes the role of neuronavigation-guided biopsy through the foramen ovale for lesions in the parasellar region.

Introduction This study aimed to assess the differences in the clinical characteristics, management, and outcomes of supraglottitis between geriatric and nongeriatric adults over a 30-month period. Methods All adult patients admitted to the emergency department with suspected supraglottitis and who underwent laryngoscopy for confirmation were included. We collected the clinical characteristics, management, and outcomes of these patients and compared geriatric (≥60 years old) and nongeriatric (12-59 years old) groups in terms of these data. Results Eighty-one geriatric patients and 205 nongeriatric patients were reviewed during the study period. The accuracies of the clinical suspicions of supraglottitis were lower in the geriatric group (geriatric vs nongeriatric, 29.4% vs 47.3%, P = .008). The geriatric group constituted 19.8% of all supraglottitis patients. Comorbidities were discovered in 74.1% of the geriatric group and 25.4% of the nongeriatric group ( P = .000). The complication rate in the geriatric patients was almost twice that of the nongeriatric patients (20.8% vs 10.8%). Additionally, the geriatric patients exhibited tendencies toward longer periods of intubation, hospitalization, and stay in the intensive care unit. Conclusions The clinical characteristics and management were similar between the geriatric and nongeriatric supraglottitis patients. Nevertheless, the comorbidities altered the clinical presentations of the geriatric patients and resulted in lower diagnostic accuracy. Additionally, the elevated complication rates of the geriatric patient might have negatively affected their outcomes.

We present a patient who visited emergency department owing to the skin manifestation of disseminated intravascular coagulation. Recent anterior myocardial infarction induced congestive heart failure and left ventricular thrombus, which were considered to be the cause of disseminated intravascular coagulation. Anticoagulant therapy with heparin and warfarin was used successfully to treat the disseminated intravascular coagulation and left ventricular thrombus.

Acute onset of hemiparesis is a common initial presentation of cerebral vascular accidents, but many differential diagnoses should be considered. Hemiparesis results from an upper motor neuron lesion above the midcervical spinal cord, and the absence of cranial nerve signs or facial palsy suggests a lesion in the high cervical spinal cord. Most spinal cord lesions, however, result in quadriparesis or paraparesis, but not hemiparesis. We present a rare case of acute spontaneous cervical spinal epidural hematoma, with initial presentation of right hemiparesis and mild neck pain.

BACKGROUND Accurate diagnosis of infected aortic and iliac aneurysms is often delayed, hampering timely treatment and potentially resulting in a fatal consequence. The aim of this study was to discover useful clinical features that can help physicians to identify these patients. METHODS We reviewed the discharge notes from two hospitals and identified all patients who had a diagnosis of infected aneurysms of the thoracoabdominal aorta and iliac arteries between July 2009 and December 2013. Eighteen patients, aged from 41 to 93, were reviewed. Only 6 patients were diagnosed accurately in their first visit to our ED. RESULTS Most patients had at least one underlying illness, and it took 1 to 30 (9.9±6.5) days for physicians to diagnose their infected aneurysm. Localized pain and fever were the two most commonly presented symptoms. The majority (92%) of isolated microorganisms were gram-negative bacilli, including Salmonella spp, Klebsiella pneumoniae, and Escherichia coli. Two of the 3 patients who underwent non-operative therapy died, and all of the patients who underwent a combination of medical and operative therapies survived. CONCLUSION We suggest that physicians liberally use computed tomography scans on patients with unknown causes of pain and inflammatory processes. A combination of surgical and medical treatments is indicated for all patients with infected aortic and iliac aneurysms.

We reported on a hypnotic overdose young female who was taken to the emergency department because of abdominal pain, acute kidney injury, and an unexplained massive ascites. The final diagnosis was spontaneous urinary bladder rupture due to hypnotic-induced semi-coma. Hypontics overdose greatly influenced the patient’s ability to urinate and contributed to prolonged urinary retention, which resulted in the rupture of urinary bladder. However, the history and physical examinations of these intoxicated patients are usually questionable. As a result, we proposed a triad of clinical manifestations – abdominal pain, acute kidney injury and a massive ascites. The presence of these clinical findings together should prompt physicians to consider spontaneous urinary bladder rupture.