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Background The need for patients to wear compression stockings after varicose vein surgery and the duration of compressions tocking therapy has been debated. This study isa meta-analysis of randomized controlled trials (RCTs) to determine the optimal duration of compression stocking therapy after endovenous thermal ablation (ETA) of the great saphenous vein. Methods The PubMed, Embase, and Cochrane Library databases were searched before January 2019. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate the pooled effect size by using a random effects model. The primary outcome was the severity of pain in the postoperative period. Secondary outcomes were quality of life (QoL), leg volume, bruising scores, consumptionof analgesic agents, recovery time off work, satisfaction, and the incidence rates of postoperative complications including paresthesia and phlebitis. Results Five RCTsinvolving775 patients were reviewed. The long-duration (1–2 weeks) group significantly reduced postoperative pain at 1 week (mean difference [MD] 1.19; 95% confidence interval [CI]: 0.58–1.80) and recovery time off work (MD: 1.01 day, 95% CI: 0.06–1.96)when compared with the short-duration (24–48 h) group. However, the mean pain scores at 2 (0.1; 95% CI: 0–0.2) and 6 weeks postoperatively (−0.3; 95% CI: −1.09-0.49) did not differ significantly between the two groups. Moreover, the incidence rates of complication, paresthesia, and phlebitis did not differ significantly between the short-duration and long-duration groups. Conclusion The use of compression therapy for a long time (1–2 weeks) is better than short-term (24–48 h) use in terms of postoperative pain at 1 week and recovery off work. Hence, we recommend the prescription of 1-week compression stocking therapy after ETA in routine clinical practice. However, the available evidence is of variable quality, further well-structured RCTs with improved standardization of compression treatment, types of stockings, and target populations are warranted.

Introduction: Seizure is a common poisoning-related neurological presentation in the emergency department (ED). Although brain computed tomography (CT) is recommended in patients presenting with first seizures, its role in patients with a suspected drug/substance-induced seizure (DSS) remains inconclusive. This study evaluated whether brain CT examination changes the management and outcome of DSS patients. Methods: We retrospectively reviewed adult patients presenting to the ED with a DSS in Linkou and Taipei Chang Gung Memorial Hospital, Taiwan, from January 2008 to December 2015. We also analyzed whether the brain CT examinations found meaningful acute abnormalities and their impact on subsequent management. We compared the differences between DSS patients undergoing CT scans or not to identify factors that affect the decision to arrange brain CT. Results: The study enrolled 97 patients (69 males). The most common cause of DSS was alcohol withdrawal (58.76%), followed by carbon monoxide (12.37%) and stimulants (8.25%). Eight (8.25%) patients developed status epilepticus, 15 (15.46%) were intubated, and 37 (37.76%) were admitted, including 12 (12.26%) to the intensive care unit. Brain CT was performed in 64 (66.0%) patients and four had abnormal reports that led to further imaging studies. The abnormal findings ultimately had no significant clinical impact. Patients who underwent CT scans had a worse Glasgow Coma Scale score (p = 0.024) and higher rate of status epilepticus (p = 0.031). Conclusion: Brain CT does not provide substantial information for the care of DSS patients. Multi-center prospective studies are needed to obtain stronger evidence.

Naja atra envenomation is one of the most significant clinical snakebite concerns in Taiwan. Taiwanese freeze-dried neurotoxic antivenom (FNAV) is currently used clinically for the treatment of cobra snakebite, and has been shown to limit the mortality of cobra envenomation to less than 1%. However, more than half of victims (60%) require surgery because of local tissue necrosis, a major problem in patients with cobra envenomation. Although the importance of evaluating the neutralizing effect of FNAV on this pathology is recognized, whether FNAV is able to prevent the local necrosis extension induced by N. atra venom has not been investigated in detail. Cytotoxins (CTXs) are considered as the major components of N. atra venom that cause necrosis. In the current study, we isolated CTXs from whole cobra venom and used both whole venom and purified CTXs to develop animal models for assessing the neutralization potential of FNAV against venom necrotizing activity. Local necrotic lesions were successfully produced in mice using CTXs in place of whole N. atra venom. FNAV was able to rescue mice from a subcutaneously injected lethal dose of cobra venom; however, it was unable to prevent CTX-induced dermo-necrosis. Furthermore, using the minimal necrosis dose (MND) of CTXs and venom proteome data, we found a dose of whole N. atra venom suitable for FNAV and developed a workable protocol for inducing local necrosis in rodent models that successfully imitated the clinical circumstance of cobra envenoming. This information provides a more comprehensive understanding of the pathophysiology of N. atra envenomation, and serves as a guide for improving current antivenom strategies and advancing clinical snakebite management in Taiwan., Author summary Naja atra envenomation is an important public health issue in Taiwan. Although the mortality rate of cobra snakebite is controlled using antivenom, more than half of victims develop symptoms of local necrosis and require surgical intervention. Whether the Taiwanese freeze-dried neurotoxic antivenom (FNAV) currently in clinical use is able to prevent the local necrosis extension induced by N. atra venom is still unclear. In this study, we developed a dermo-necrosis animal model using purified cytotoxins (CTXs), the major necrosis-related proteins from N. atra venom. We found that FNAV was able to neutralize the lethality of whole cobra venom, but was unable to neutralize the necrosis induced by CTXs in vivo. This finding introduced an example that supplementary quality control assays may be necessary to determine the effectiveness of antivenoms in neutralizing specific pathology induced by the venom; only evaluating the rodent lethality prevention is insufficient. Our results provide insights that should help improve current antivenoms and advance cobra snakebite management in Taiwan.

We previously reported that, in rodents, a diet with a high oxidised frying oil (OFO) content leads to glucose intolerance associated with a reduction in insulin secretion. The present study aimed at investigating the impairment of pancreatic islets caused by dietary OFO. C57BL/6J mice were divided into three groups to receive a low-fat basal diet containing 5 g/100 g of fresh soyabean oil (LF group) or a high-fat diet containing 20 g/100 g of either fresh soyabean oil (HF group) or OFO (HO group). After 8 weeks, mice in the HO group showed glucose intolerance and hypoinsulinaemia, and their islets showed impaired glucose-stimulated insulin secretion (P v. LF and HF groups). Significantly higher oxidative stress and a lower mitochondrial membrane potential were observed in the islets in the HO group compared with the LF and HF groups. Immunoblots showed that the reduction in insulin levels in HO islets was associated with activation of the c-Jun NH2-terminal kinase and a reduction in levels of pancreatic and duodenal homeobox factor-1. In a second study, when dietary OFO-induced tissue vitamin E depletion was prevented by large-dose vitamin E supplementation (500 IU(1·06 mmol all-rac-α-tocopherol acetate)/kg diet; HO+E group), the OFO-mediated reduction in islet size and impairment of glucose tolerance and insulin secretion were significantly attenuated (P v. HO+E group). We conclude that a high level of dietary OFO ingestion impairs glucose metabolism by causing oxidative damage and compromising insulin secretion in pancreatic islets, and that these effects can be prevented by vitamin E supplementation.

The liquid precipitation method using zinc acetate dihydrate was applied for the synthesis of uniform and spherical ZnO nanoparticles. The ultrafine zinc oxid was prepared in a water-ethanol mixture solution. The solution containing zinc cation was soluble in water. The surface-active agent triethanolamine (TEA) was soluble in ethanol. Then alkali precipitated by adding n-propylamine. The spherical zinc oxide particle morphology was found to be highly dependent on the zinc salt concentration, ethanol-water ratio, and the surface-active agent additive. The process can produce white ZnO powder of 50-90 nm in size. The morphology of zinc oxide showed a powder shape by transmission electron microscopy (TEM), the crystallization phase structure of zinc oxide by X-ray diffraction (XRD), and the zinc oxide remaining by using an organic analysis by infrared spectroscopy (IR).

OBJECTIVE: We have previously shown that bitter melon seed oil (BMSO), which is rich in cis-9, trans-11, trans-13 conjugated linolenic acid, is more potent than soybean oil in attenuating body fat deposition in high-fat diet-induced obese C57BL/6J mice. The aim of this study was to obtain a comprehensive insight into how white adipose tissue (WAT) is affected by BMSO administration and to explore the underlying mechanisms of the anti-adiposity effect of BMSO. METHODS AND RESULTS: A proteomic approach was used to identify proteins differentially expressed in the WAT of mice fed diets with or without BMSO for 11 wks. The WAT was also analyzed histologically for morphological changes. Two-dimensional gel electrophoresis (pH 4-7) revealed 32 spots showing a statistically significant difference (P2-fold change). Combined with histological evidence of macrophage infiltration and brown adipocyte recruitment, the proteomic and immunoblotting data showed that the WAT in mice subjected to long-term high dose BMSO administration was characterized by reduced caveolae formation, increased ROS insult, tissue remodeling/repair, mitochondria uncoupling, and stabilization of the actin cytoskeleton, this last change being putatively related to an increased inflammatory response. CONCLUSION: The anti-adiposity effect of BMSO is associated with WAT delipidation, inflammation, and browning. Some novel proteins participating in these processes were identified. In addition, the BMSO-mediated WAT browning may account for the increased inflammation without causing adverse metabolic effects.

Clinical introduction A 60-year-old man had a long history of chronic hepatitis C. He presented to the emergency department with 2 days of progressive dyspnoea. Clinical manifestations included respiratory distress, cyanosis, digital clubbing, spider naevi on the upper chest and shifting dullness in the abdomen (see online supplementary figure S1). The ECG showed sinus tachycardia and left axis deviation. The chest radiography depicted blunting of right costophrenic angle with small pleural effusions and bilateral prominent pulmonary vascular markings (see online supplementary figure S2). The dyspnoea was exacerbated by upright posture and improved with recumbency. The hypoxaemia could not be corrected with administration of 100% oxygen. Contrast-enhanced transthoracic echocardiography was performed with injection of agitated saline (see figure 1 and online supplementary video). CT scan of the chest revealed some vascular abnormalities (see online supplementary figure S3–S6). Question Which of the following is the next best step in management? Catheter-based closure of intracardiac shunt Liver transplantation Pulmonary angiography and embolisation Thoracentesis Transjugular intrahepatic portosystemic shunt

A 76-year-old woman with a history of hypertension and diabetes mellitus presented to the ED with abdominal pain for 1 week. On physical examination, the patient was found to have epigastric and bilateral costovertebral angle tenderness. Laboratory tests reported elevations of white blood cell count, creatinine and serum lipase. A chest radiograph was obtained (figure 1). Figure 1 A chest radiograph of the patient. What is …

Received 2 April 2012; returned 27 May 2012; revised 28 October 2012; accepted 31 October 2012Background: Studies on the effect of inadequate empirical antibiotic therapy on the outcome of patients withsystemic infection have led to inconsistent results.Methods: We analysed data from a comprehensive clinical database collected prospectively in a university hos-pital between 2008 and 2009. All adult patients who registered in the emergency department (ED) with abloodstream infection (BSI) were enrolled. Empirical therapy was considered adequate if it included antimicro-bials to which the specific isolate displayed in vitro susceptibility and that were administered within 24 h of EDadmission. The propensity score (PS) was created by a logistic regression model predicting inadequate empiricaltherapy. PS-adjusted multivariate analysis was performed by the Cox regression model. The Mortality in Emer-gency Department Sepsis (MEDS) score was used for the adjustment of residual confounding due to differencesin the baseline clinical severity of disease.Results: Out of 937 episodes of bacteraemia, 255 (27.2%) patients received inadequate empirical antimicrobialtherapy. A crude analysis showed that inadequate antibiotic therapy was associated with higher mortality rates(hazard ratio 1.78, 95% CI 1.30–2.45). PS-adjusted multivariate analyses also showed a significant adverseimpact (hazard ratio 1.59, 95% CI 1.14–2.28). The clinical disease severity significantly modified the effectof inadequate antibiotic therapy on survival. The magnitude of the adverse impact of inadequate antibiotictherapy decreased with the increasing severity of sepsis (P¼0.009).Conclusions: Inadequate empirical antimicrobial therapy for community-onset BSI was associated with higher30 day mortality rates. Study populations with different clinical severities may have different results, which mayhelp to partly explain the heterogeneous findings in many similar studies.Keywords: mortality, effect modification, propensity score

The aim of this study was to investigate the antiadiposity effect of bitter melon seed oil (BMSO), which is rich in the cis-9, trans-11, trans-13 isomer of conjugated linolenic acid. In Expt. 1, C57BL/6J mice were fed a butter-based, high-fat diet [HB; 29% butter + 1% soybean oil (SBO)] for 10 wk to induce obesity. They then continued to receive that diet or were switched to an SBO-based, high-fat diet alone (HS; 30% SBO) or containing bitter melon seed oil (BMSO) (HBM; 15% SBO + 15% BMSO) for 5 wk. The body fat percentage was significantly lower in mice fed the HBM diet (21%), but not the HS diet, compared with mice fed the HB diet. In Expt. 2, mice were fed an SBO-based, high-fat diet containing 0 (HS), 5 (LBM), 10 (MBM), or 15% (HBM) BMSO for 10 wk. In the LBM, MBM, and HBM groups, the body fat percentage was significantly lower by 32, 35, and 65%, respectively, compared with the HS control. The reduction in the HBM group was significantly greater than that in the LBM or MBM group. BMSO administration increased phosphorylation of acetyl-CoA carboxylase, cAMP-activated protein kinase (PKA), and signal transducer and activator of transcription 3 in the white adipose tissue (WAT), suggesting that PKA and leptin signaling might be involved in the BMSO-mediated reduction in lipogenesis and increase in thermogenesis and lipolysis. However, compared with the HS control, the HBM group had a significantly higher TNFα concentration in the WAT accompanied by TUNEL-positive nuclei. We conclude that BMSO is effective in attenuating body fat accumulation through mechanisms associated with PKA activation and programmed cell death in the WAT, but safety concerns need to be carefully addressed.

Spontaneous rupture of a hepatocellular carcinoma is a rare and lethal complication in the emergency department. A cau-date lobe hepatoma rupture is even rarer. It can be treated with vascular embolization, surgical intervention or supportive care. A 70-year-old woman with underlying hepatocellular carcinoma presented to our emergency department with severe abdominal pain encompassing the entire region for half a day. Abdominal computer tomography scans with and without contrast medium revealed a large hematoma confined to the lesser sac of the abdomen. It was initially diagnosed as a ruptured aneurysm. A ruptured caudate lobe hepatoma with acute hemorrhage into the lesser sac was diagnosed after reviewing and discussing the imaging findings with the radiologist. The patient was treated with supportive care without vascular embolization or surgical intervention because there was no imaging evidence of active contrast extravasation and the vital signs were within the normal range. After reviewing the literature, our case appears to be the second only case treated with supportive care and discharged without complications.

Background High-energy blunt chest injury will bring out severe cardiac and pulmonary injuries. It may cause cardiac contusion, rupture, cardiac valve dysfunction, and aortic laceration [1]. As traumatic hemopericardium occurs, ultrasound is a convenient and reliable tool for diagnosis. We presented a 55-year-old male victim of blunt chest trauma complicated with hemopericardium, cardiac tamponade, cardiac contusion and epicardial hematoma.

A 34-year-old man presented with a 1 day history of upper abdomen pain. Physical examination showed epigastric tenderness and rebounding pain. There was no abnormality in standing chest radiography. The plain abdomen revealed vertical oriented …