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Chronic kidney disease (CKD) has become a burden of health care globally. However, data on epidemiology, clinical features, and outcomes of urinary tract infection (UTI) in this population are scarce. This study aims to retrospectively review such data. Materials and methods: A retrospective cohort study was conducted from 1 January 2005 to 31 December 2011 in patients with CKD requiring hospitalization. Patients who had upper and lower UTIs were compared for demography and clinical data. Logistic regression was used to assess which variables were associated with upper UTI. Results: A total of 276 bacteriuria patients were admitted to our ward with upper and lower UTIs. The average ages of the upper and lower UTI patients were 59.21 ± 16.54 and 71.18 ± 14.77 years, respectively. The results of logistic regression analysis showed that age (OR 0.946, P < 0.001), female sex (OR 4.695, P < 0.001), and renal stones (OR 8.232, P < 0.001) were independently associated with upper UTI. Conclusion: This study shows that patients with CKD and UTIs were elderly, and that females were prone to have more bacteriuria and upper UTIs than males. In addition, patients who had renal stones were more prone to have upper UTI than other bacteriuria patients. Aggressive treatment of renal stones should be considered in these patients.

Background: In motorcycle accidents, especially in an urban area with lightweight motorcycles, the belly of the motorcyclist is not protected, and this makes this type of trauma a cause of blunt hepatic injuries. This study investigated the effect and safety of using nonoperative management and selective early angioembolization to treat patients with blunt liver injuries as a result of motorcycle accident. Methods: This was a retrospective study of the hepatic injuries sustained by motorcyclists involved in traffic accidents. We collected patient demographic information, the severity of total injuries, grade of liver injury, associated concomitant injuries, management scheme, and outcome of patients from 2006 to 2007. These patients were treated nonoperatively with selective early angioembolization and close monitoring in our intensive care unit (ICU). Results: We reviewed the cases of 266 patients sustaining blunt abdominal injuries. Thirty-four patients (12.78%) had hepatic injuries. All survived with no obvious morbidity, and no further invasive procedures were performed after admission to ICU. There was no significant association between grade of injury and ICU length of stay (P = .073), but there was a significant association between grade and in-patient length of stay on our regular ward (P = .001). Conclusion: Most patients with hepatic injury caused by motorcycle accidents can be treated safely by nonoperative management. Early selective angioembolization improved the success of nonoperative management of blunt liver injury without other surgical intervention. Routine follow-up with computed axial tomography scans and endoscopic retrograde cholangiopancreatography may not be necessary because complications associated with hepatic injuries were rare.

Blunt abdominal contusion is common in children, but isolated injury with gallbladder hematoma is rarely observed. Examining children can be difficult because they may not cooperate or understand procedures, and therefore, radiography is helpful for diagnosis. However, there are still limitations in applying radiographic examinations in diagnosing intra-abdominal injuries, especially in children with peritoneal signs or an unstable hemodynamic status. In these circumstances, invasive intervention with laparoscopy should be applied for further evaluation. We report here a 6-year-old girl with blunt abdominal trauma in whom hepatobiliary injury was noted on computed tomography and magnetic resonance imaging. Because the patient was unconscious, had unstable vital signs, and the radiographic study was ambiguous, peritonitis could not be excluded. A laparoscopy was then performed and isolated gallbladder hematoma was diagnosed. The patient was discharged after laparoscopic intervention and orthopedic fixation.

ObjectiveHead nurses in a hospital setting work to maintain the quality of nursing care and ensure that staff nursing skills are up-to-date. Although cardiopulmonary resuscitation (CFR) is most often performed by physicians in a hospital, nurses play crucial assistance roles, including the administration of medication, record-keeping, obtaining intravenous access, and helping with intubation. Patient outcome is therefore related to nurses' skill level in CFR. We hypothesized that the more senior head nurses would be more skillful at assisting with CFR.Materials and MethodsWe conducted an observational study of 55 head nurses, who were asked to perform a 4-minute simulation in which they assisted with CFR using a resuscitation manikin. We collected demographic data, including age and years since becoming a nurse and becoming a head nurse, together with a stress score, which assessed the stress felt by the nurses while taking the test. These measures were analyzed along with the accuracy of the nurses' skills while performing CFR.ResultsTwenty-two skills were evaluated, with each skill graded as either a pass or fail. Only 30/55 (54.5%) of the head nurses passed all 22 skills. There was a significant difference in the numbers of skills with a pass rating (p = 0.043) in relation to the units where the head nurses were employed. Their performance also showed a strong negative correlation with age (p = 0.001), work experience (p = 0.028), and time since becoming head nurse (p

Aortic rupture is a critical condition in trauma patients. Most patients are killed at the scene of the accident. A patient who survives long enough to reach hospital also has a high risk of rupture during management. We report a patient who was transferred from a municipal hospital with the emergency complex of blunt head trauma and chest and abdominal contusion. Chest computed tomography scan revealed aortic rupture. Liver laceration with hemodynamic stability and brain concussion were also diagnosed in the emergency room. She was admitted to the trauma intensive care unit without emergency surgery. She received aorta repair after 5 days of observation. After the operation, the patient recovered very well. Delayed surgery for aortic rupture as a treatment choice may be of benefit in selected complex trauma cases.

Background. Blunt spleen injury is generally taken as major trauma which is potentially lethal. However, the management strategy has progressively changed to noninvasive treatment over the decade. This study aimed to (1) find out the incidence and trend of strategy change; (2) investigate the effect of change on the mortality rate over the study period; and (3) evaluate the risk factors of mortality.Materials and Methods. We utilized nationwide population-based data to explore the incidence of BSI during a 12-year study period. The demographic characteristics, including gender, age, surgical intervention, blood transfusion, availability of CT scans, and numbers of coexisting injuries, were collected for analysis. Mortality, hospital length of stay, and cost were as outcome variables.Results. 578 splenic injuries were recorded with an estimated incidence of 48 per million per year. The average 12-year overall mortality rate during hospital stay was 5.28% (29/549). There is a trend of decreasing operative management in patients (X2,P=0.004). The risk factors for mortality in BSI from a multivariate logistic regression analysis were amount of transfusion (OR 1.033,P<0.001, CI 1.017–1.049), with or without CT obtained (OR 0.347,P=0.026, CI 0.158–0.889), and numbers of coexisting injuries (OR 1.346,P=0.043, CI 1.010–1.842).Conclusion. Although uncommon of BSI, management strategy is obviously changed to nonoperative treatment without increasing mortality and blood transfusion under the increase of CT utilization. Patients with more coexisting injuries and more blood transfusion had higher mortality.

Summary Blunt abdominal injuries are not uncommon; however, ileal perforation caused by blunt trauma, especially when associated with an inguinal hernia, is a very rare event, and a difficult diagnosis. We present the case of a 63-year-old male who had sustained a blunt abdominal injury on his left inguinal hernia in a bicycle versus motorcycle accident. Computed tomography (CT) scans on arrival at hospital showed the left inguinal hernia with partial protrusion of the small intestine, without categorical inflammatory changes of the mesenteric tissue or intraperitoneal fluid. During observation, he sustained intermittent lower abdominal pain. About 8 hours later, hypotension and fever ensued. The repeated CT scans showed adjacent bowel edema with free air, and a hernia sac, in the left lower quadrant of the abdomen. Emergency laparotomy revealed ileal perforation. Segmental resection with end-to-end anastomosis was performed. The patient made an uneventful recovery and was discharged 2 weeks later. Although the CT scan has become the gold standard in evaluating abdominal trauma, delayed perforation of the intestine with blunt injuries may escape early detection. Serial physical examinations with a high index of suspicion are mandatory in susceptible patients to avoid time-related complications. The imaging findings from a single examination should not be depended upon solely.

Subarachnoid hemorrhage (SAH) is a critical illness that may result in patient mortality or morbidity. In this study, we investigated the outcomes of patients treated in medical center and nonmedical center hospitals and the relationship between such outcomes and hospital and surgeon volume. Patient data were abstracted from the National Health Insurance Research Database of Taiwan in the Longitudinal Health Insurance Database 2000, which contains all claims data of 1 million beneficiaries randomly selected in 2000. The International Classification of Diseases, Ninth Revision, subarachnoid hemorrhage (430) was used for the inclusion criteria. We identified 355 patients between 11 and 87 years of age who had subarachnoid hemorrhage. Among them, 32.4% (115/355) were men. The median Charlson comorbidity index (CCI) score was 1.3 (SD ± 0.6). Unadjusted logistic regression analysis demonstrated that low mortality was associated with high hospital volume (OR = 3.21; 95% CI: 1.18–8.77). In this study, we found no statistical significances of mortality, LOS, and total charges between medical centers and nonmedical center hospitals. Patient mortality was associated with hospital volume. Nonmedical center hospitals could achieve resource use and outcomes similar to those of medical centers with sufficient volume.

Alcohol is found to have neuroprotection in recent studies in head injuries. We investigated the association of blood alcohol concentration (BAC) with mortality of patients with blunt head injury after traffic accident. All patients sustaining blunt head injury caused by traffic accident brought to our emergency department who had obtained a brain computed tomography scans and BAC were analyzed. Patients with unknown mechanisms, transfers from outside hospitals, and incomplete data were excluded. Logistic regression was used to identify independent predictors of mortality. During the study period, 3,628 patients with brain computed tomography (CT) were included. Of these, BAC was measured in 556 patients. Patients with the lowest BAC (less than 8 mg/dl) had lower mortality; intoxicated patients with BAC between 8 and less than 100 mg/dl were associated with significantly higher mortality than those patients in other intoxicated groups. Adjusted logistic regression demonstrated higher BAC group and Glasgow coma scale (GCS) scores, and lower ISS and age were identified as independent predictors of reduced mortality. In our study, we found that patients who had moderate alcohol intoxication had higher risk of mortality. However, higher GCS scores, lower ISS, and younger age were identified as independent predictors of reduced mortality in the study patients.

To investigate the longitudinal trend of nontraumatic subarachnoid haemorrhage (SAH), we analyzed the annual population-based incidence and mortality rate of nontraumatic subarachnoid hemorrhage in Taiwan. Logistic regression was used to identify independent predictors of mortality. The average incidence rate (IR) of nontraumatic SAH was6.25±0.88per 100,000 per year. The prevalence of female patients was higher than in the male population (54.5% versus 45.5%). The average age of these patients was55.78±17.09and females were older than males (58.50±15.9versus52.45±18.50,P<0.001). Of these patients, 97.6% (611/626) were treated with surgical intervention with clipping procedure and 2.9% (18/626) with coiling. Total mortality of these patients was 13.4% (84/626). In adjusted analysis, age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.98-0.98;P<0.001) and Charlson comorbidity index (OR, 0.709; 95% CI, 0.57–0.88;P=0.002) remained independent predictors of the mortality. Patients with nontraumatic SAH had a much higher prevalence in older age groups and in females than in the general population. Patients with old age and more comorbidity have higher mortality. Aggressive management of patients might reduce the initial mortality; however, patient outcome still remains poor.

Objectives. Restraint of patients on a spine board has been used in the past to prevent further spinal cord injury after rescue of patients from the scene of an accident. Removal from the spine board is a routine protocol in many hospitals once the patient has been cleared of spinal injury. However, the benefit of using a spine board, in light-weight motorcycle-related accident victims, has never been studied before.Materials and methods. A retrospective observational study enrolled patients who had sustained motorcycle-related acci-dents and were brought to our emergency department (ED). Patients with a Glasgow Coma Scale score lower than 15 and those who died at the ED, or had incomplete data, were excluded. The diagnosis of spinal injury was based upon clinical evaluation and was confirmed by computed tomography, magnetic resonance imaging or X-ray reports, as interpreted by a qualified radiologist. A neurological examination was performed, according to the Standard Neurological Classification of Spinal Cord Injury, directly after arrival and again before leaving the ED. Results. During the study period, from January 2007 to December 2010, 91 patients with spinal injuries who met the inclusi-on criteria, consisting of 35 male and 56 female patients with a mean age of 45.44±18.12 years, were enrolled in our study. The scores of the motor and sensory neurological exams did not show any significant change during the ED stay after being placed in a gurney without a spine board (p=0.432). Conclusions. Removal of the spine board and placement on a hospital gurney sponge is safe in alert patients whose primary examination is completed at the ED.

Pneumothorax, whether spontaneous, iatrogenic or traumatic, frequently requires drainage, especially in the face of positive pressure ventilation or general anesthesia. The traditional approach with large-bore, rigid chest tube is associated with significant pain and various complications. Recently, less invasive modalities such as pigtail catheter or fine-needle aspira-tion have been used in selected patients. We report a case of delay-onset pneumothorax after trauma and the patient was treated successfully with the easily available central venous catheter for drainage.

Cysts of the omentum are rare and most frequently discovered in children. These cysts may cause abdominal distension, pain, or vomiting. Omental cysts with right lower quadrant pain are found even more rarely in adults. We describe a 44-year-old male who had a 2-day history of abdominal pain localized in the right lower quadrant. Before surgery, acute appendicitis with intra-abdominal abscess was suspected, but during the operation, an infected cyst of the omentum, adjacent and adherent to the redundant transverse colon, was found to have been causing these symptoms. Despite the fact that cysts of the omentum have been reported rarely, the operator should be aware that the cyst is a benign entity and the surgical strategy should be different from that for malignancy. We should keep the possibility of omental cyst in mind to avoid unnecessary bowel resection and potentially harmful inappropriate treatment.

It is sometimes difficult to decide whether to perform abdominal computed tomographic (CT) scans for possible liver laceration in patients who have sustained less severe or minor blunt abdominal trauma. This study was conducted to find out whether the basic laboratory workup could provide information of possible liver laceration in blunt abdominal trauma patients and act as an indication for CT scans.In this retrospective case-control study, we included 289 patients who had sustained blunt abdominal injury for which they received abdominal CT scans in our emergency department. Of the 289 patients, the study group (n = 42) included patients who had been found to have liver lacerations after obtaining the CT; the controls (n = 42) were those not found to have such injuries by the same method with matching of age and sex.In patients with blunt abdominal injuries, there is a strong difference in liver laceration between elevation of white blood cell (WBC) counts (P = .001), aspartate aminotransferase (AST) (P.001), and alanine aminotransferase (ALT) (P.001). A logistic regression model demonstrated that WBC count and AST were independently associated with liver laceration. With elevations of serum AST greater than 100 IU/L, ALT greater than 80 IU/L, and WBC count greater than 10 000/mm(3), we found a sensitivity and specificity of 90.0% and 92.3%, respectively, in the 42 liver laceration victims.In patients with blunt abdominal trauma, elevated WBC counts together with elevated AST and ALT are strongly associated with liver laceration and warrant further imaging studies and management.

Pancreatic cancer is sometimes called a “silent disease” because it often causes no symptoms in the early stage. The symptoms can be quite vague and various depending on the location of cancer in the pancreas. The anatomic site distribution is 78% in the head of the pancreas, 11% in the body, and 11% in the tail. Pancreatic cancer is rarely detected in the early stage, and it is very uncommon to diagnose pancreatic tail cancer during an emergency department visit. The manifestation of pancreatic tail cancer as left flank pain is very rare and has seldom been identified in the literature. We present a case of pancreatic tail cancer with the sole manifestation of dull left flank pain. Having negative findings on an ultrasound study initially, this female patient was misdiagnosed as having possible acute gastritis, urolithiasis or muscle strain after she received gastroendoscopy and colonofiberscopy. Her symptoms persisted for several months and she visited our emergency department due to an acute exacerbation of a persistent dull pain in the left flank area. Radiographic evaluation with computed tomography was performed, and pancreatic tail tumor with multiple metastases was found unexpectedly. We review the literature and discuss this rare presentation of pancreatic tail cancer.

Background: Splenic artery embolization (SAE) has been used as an adjunct to the nonsurgical treatment of blunt splenic injuries since 1981. It is imperative to define the role of SAE in the management of splenic trauma and to establish a guideline for its use. Methods: In this study, 39 consecutive patients with blunt splenic ruptures were evaluated. All the patients were treated according to the authors' protocol, which included SAE as an adjunct. Angiographic study was performed for patients with any of the following presentations: recurrent hypotension despite fluid resuscitation, significant hemoperitoneum or extravasation of contrast media on computed tomography, grade 4 or 5 splenic injury, or progressive need for blood transfusion. Laparotomy was reserved for patients with unstable hemodynamics or failure of SAE. Results: Four patients were excluded from the study, and 6 of the 35 remaining patients (male-to-female ratio, 22:13) received SAE. One of the six SAE patients underwent operation because of persistent hemorrhage after SAE. Nonoperative treatment was successful for 31 patients. Splenic artery embolization increased the success rate for nonsurgical management from 74% (26 of 35 patients) to 89% (31 of 35 patients). Conclusions: Judicious use of SAE for patients with blunt splenic injury avoids unnecessary surgery and expands the number of patients who can retain their spleen.

Closed degloving injury is characterized by the development of soft tissue separated from underlying structure without outer skin disruption. “Empty toe” is one of the most unique types of closed degloving injuries. Only 4 such injuries have been reported previously. We demonstrate a case of this entity in a 20-year-old scooter passenger. She presented to our emergency department with apparent deformity of the left fifth toe with intact skin. Radiographic examination showed no skeletal fracture or dislocation, but the skin of the injured toe was detached from the underlying bony structure. Despite repositioning the phalangeal bone into the empty toe, the skin was nonviable, and surgical site gangrene developed thereafter. The fifth toe was eventually amputated. An empty toe implies that the injured site has experienced severe compressive and shearing force with potential neurovascular damage. Health care providers should be fully aware of the high risk of the probability of vascular insufficiency, and the viability would be associated with vascular capability.

Patient sustained cardiac tamponade caused by rupture of type A aortic dissection may result in sudden death. Pericardio-centesis is a lifesaving procedure; nevertheless, blood may occlude the catheter and fail to relieve the pressure. However, open-chest cardiac massage in resuscitation has been studied in animal models by some medical centers and laboratories with inspiring results. We report a 58-year-old woman who was transferred from a local hospital with the diagnosis of cardiac tamponade caused by ruptured type A aortic dissection. Pulseless electrical activity followed by cardiac arrest occurred thereafter. Successful resuscitation in the emergency department was achieved using open cardiac massage through the sub-xyphoid region by opening a pericardial window. Therefore, in unstable patients with cardiac tamponade due to aortic dissection, this resuscitative procedure is feasible, safe and efficient.

In the emergency department, we frequently manage patients with multiple contusions and bruise over the trunk without severe injuries. Emergency department discharge is a common option for these patients, and we may neglect the existence of closed internal degloving injury, which is a soft tissue injury with pelvic trauma, combining the subcutaneous tissue torn away from the underlying fascia followed by a cavity being filled with hematoma and liquefied fat created in the next few days (Harefuah 2006;145:111-3:66, J Trauma 1997;42:1046). We report the unusual occurrence of this entity in an 18-year-old man. He encountered a scooter accident and experienced a few days of hospitalization because of thoracispinal (T10 and T11) process fracture. He was discharged, but a fluctuating mass developed at the lumbar area 10 days later. The comprehensive survey excluded the cerebrospinal fluid leakage associated with spinal fracture, and internal degloving injury was diagnosed. Percutaneous drainage with compressive bondage was aggressively used. Even though the treatment course was time consuming, the lesion eventually disappeared 10 months after his first visit.

Objective Hepatic enzymes can be used as a predictor of hepatic injury. The present study investigated the relationship between blood alcohol concentration (BAC) and hepatic enzymes in patients intoxicated with ethanol at an emergency department (ED). Materials and Methods To determine whether BAC is an independent predictor of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels, we retrospectively reviewed the medical data for patients who were intoxicated and whose BAC and hepatic enzyme levels were measured. Patients who had hepatitis caused by viruses or traumatic hepatic injury, as well as patients with a normal BAC, were excluded. Results Of the 1432 patients, 298 were female and 1134 were male. The average age of males was 41.4 ± 11.7 years and that of females was 35.6 ± 11.8 years. Mean serum AST and ALT levels were 78 ± 88 IU/L and 51 ± 67 IU/L in males, while those in females were 63 ± 110 IU/L and 40 ± 83 IU/L, respectively. Mean BACs were 199.6 ± 99.0 mg/dL for males and 175.1 ± 101.1 mg/dL for females. Log BAC had a high positive correlation with log ALT ( r = 0.208; p r = 0.086; p = 0.001) when BAC was above 50 mg/dL (0.05%). Multivariate linear regression showed that BAC was an independent predictor of AST and ALT ( r 2 = 0.057 and 0.056, respectively). Conclusion The high correlation of BAC with serum AST and ALT levels in patients intoxicated with ethanol when their BAC was above 50 mg/dL can be used to predict serum AST and ALT levels. However, a high BAC only appears to be associated with a slight elevation in hepatic enzymes. Therefore, in patients with acute alcohol intoxication at the ED, an elevation in AST and ALT levels should be considered as a result of hepatic injury rather than an effect of alcohol.

BackgroundManagement of critically injured patients is usually complicated and challenging. A structured team approach with comprehensive survey is warranted. However, delayed diagnosis of co-existing injuries that are less severe or occult might still occur, despite a standard thorough approach coupled with advances in image intervention. Clinicians are easily distracted or occupied by the more obvious or threatening conditions. We hypothesised that the major area of injured body regions might contribute to this unwanted condition.MethodsA retrospective study of all trauma patients admitted to our surgical intensive care units (ICU) was performed to survey the incidence of delayed diagnosis of injury (DDI) and the association between main body region injured and possibility of DDI. Demographic data and main body regions injured were compared and statistically analysed between patients with and without DDI.ResultsDuring the two-year study period, a total 976 trauma patients admitted to our surgical ICU were included in this study. The incidence of DDI was 12.1% (118/976). Patients with DDI had higher percentages of thoracic, abdominal, and pelvic injuries (30.5%, 16.1%, and 7.6% respectively) than the non-DDI group (14.7%, 7.5%, and 3.0% respectively) (p

Stings by honeybees are not uncommon and most cases cause pain but no significant medical problems. Some patients, however, have lethal complications such as acute anaphylactic shock. Cellulitis caused by honeybee sting is very rare and can be a late complication in some patients. We report a 45-year-old female patient who was stung by a honeybee, and whose right forearm showed progressive swelling with bullous formation after the sting. She was sent to our emergency department with the diagnosis of right hand cellulitis. After treatment with antibiotics for 5 days, the lesions showed no response. Then, systemic steroid was used and the lesion gradually resolved. Diagnosis of Wells' syndrome was made according to clinical appearance, course and characteristic histopathological findings.