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Abstract Background The reverse shock index (rSI) combined with the Simplified Motor Score (sMS), that is, the rSI-sMS, is a novel and efficient prehospital triage scoring system for patients with COVID-19. In this study, we evaluated the predictive accuracy of the rSI-sMS for general ward and intensive care unit (ICU) admission among patients with COVID-19 and compared it with that of other measures, including the shock index (SI), modified SI (mSI), rSI combined with the Glasgow Coma Scale (rSI-GCS), and rSI combined with the GCS motor subscale (rSI-GCSM). Methods All patients who visited the emergency department of Taipei Tzu Chi Hospital between January 2021 and June 2022 were included in this retrospective cohort. A diagnosis of COVID-19 was confirmed through a SARS-CoV-2 reverse-transcription polymerase chain reaction test or SARS-CoV-2 rapid test with oropharyngeal or nasopharyngeal swabs and was double confirmed by checking International Classification of Diseases, Tenth Revision, Clinical Modification codes in electronic medical records. In-hospital mortality was regarded as the primary outcome, and sepsis, general ward or ICU admission, endotracheal intubation, and total hospital length of stay (LOS) were regarded as secondary outcomes. Multivariate logistic regression was used to determine the relationship between the scoring systems and the three major outcomes of patients with COVID-19, including. The discriminant ability of the predictive scoring systems was investigated using the area under the receiver operating characteristic curve, and the most favorable cutoff value of the rSI-sMS for each major outcome was determined using Youden’s index. Results After 74,183 patients younger than 20 years (n = 11,572) and without COVID-19 (n = 62,611) were excluded, 9,282 patients with COVID-19 (median age: 45 years, interquartile range: 33–60 years, 46.1% men) were identified as eligible for inclusion in the study. The rate of in-hospital mortality was determined to be 0.75%. The rSI-sMS scores were significantly lower in the patient groups with sepsis, hyperlactatemia, admission to a general ward, admission to the ICU, total length of stay ≥ 14 days, and mortality. Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS exhibited a significantly higher accuracy for predicting general ward admission, ICU admission, and mortality but a similar accuracy to that of the rSI-GCS. The optimal cutoff values of the rSI-sMS for predicting general ward admission, ICU admission, and mortality were calculated to be 3.17, 3.45, and 3.15, respectively, with a predictive accuracy of 86.83%, 81.94%%, and 90.96%, respectively. Conclusions Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS has a higher predictive accuracy for general ward admission, ICU admission, and mortality among patients with COVID-19.

Uremic toxins play a crucial role in the development of low bone turnover disease in chronic kidney disease (CKD) through the induction of oxidative stress. This oxidative stress disrupts the delicate balance between bone formation and resorption, resulting in a decline in both bone quantity and quality. Reactive oxygen species (ROS) activate nuclear factor kappa-B and mitogen-activated protein kinase signaling pathways, promoting osteoclastogenesis. Conversely, ROS hinder osteoblast differentiation by facilitating the binding of Forkhead box O proteins (FoxOs) to β-catenin, triggering apoptosis through FoxOs-activating kinase phosphorylation. This results in increased osteoblastic receptor activator of nuclear factor kappa-B ligand (RANKL) expression and decreased nuclear factor erythroid 2-related factor 2 levels, compromising antioxidant defenses against oxidative damage. As CKD progresses, the accumulation of protein-bound uremic toxins such as indoxyl sulfate (IS) and p-cresyl sulfate (PCS) intensifies oxidative stress, primarily affecting osteoblasts. IS and PCS directly inhibit osteoblast viability, induce apoptosis, decrease alkaline phosphatase activity, and impair collagen 1 and osteonectin, impeding bone formation. They also reduce cyclic adenosine 3',5'-monophosphate (cAMP) production and lower parathyroid hormone (PTH) receptor expression in osteoblasts, resulting in PTH hyporesponsiveness. In summary, excessive production of ROS by uremic toxins not only reduces the number and function of osteoblasts but also induces PTH hyporesponsiveness, contributing to the initiation and progression of low bone turnover disease in CKD.

Background: Research on the impact of reduced time to emergent surgery in trauma patients has yielded inconsistent results. Therefore, this study investigated the relationship between waiting emergent surgery time (WEST) and outcomes in trauma patients. Methods: This retrospective, multicenter study used data from the Tzu Chi Hospital trauma database. The primary clinical outcomes were in-hospital mortality, intensive care unit (ICU) admission, and prolonged hospital length of stay (LOS) of ≥30 days. Results: A total of 15,164 patients were analyzed. The median WEST was 444 min, with an interquartile range (IQR) of 248–848 min for all patients. Patients who died in the hospital had a shorter median WEST than did those who survived (240 vs. 446 min, p < 0.001). Among the trauma patients with a WEST of p < 0.001). Multivariable logistic regression analysis revealed that WEST was not associated with an increased risk of in-hospital mortality (adjusted odds ratio [aOR] = 1.05, 95% confidence interval [CI] = 0.17–6.35 for 30 min ≤ WEST < 60 min; aOR = 1.12, 95% CI = 0.22–5.70 for 60 min ≤ WEST < 90 min; and aOR = 0.60, 95% CI = 0.13–2.74 for WEST ≥ 90 min). Conclusions: Our findings do not support the “golden hour” concept because no association was identified between the time to definitive care and in-hospital mortality, ICU admission, and prolonged hospital stay of ≥30 days.

Background and Objectives: The Taiwan Triage and Acuity Scale (TTAS) is reliable for triaging patients in emergency departments in Taiwan; however, most triage decisions are still based on chief complaints. The reverse-shock index (SI) multiplied by the simplified motor score (rSI-sMS) is a more comprehensive approach to triage that combines the SI and a modified consciousness assessment. We investigated the combination of the TTAS and rSI-sMS for triage compared with either parameter alone as well as the SI and modified SI. Materials and Methods: We analyzed 13,144 patients with trauma from the Taipei Tzu Chi Trauma Database. We investigated the prioritization performance of the TTAS, rSI-sMS, and their combination. A subgroup analysis was performed to evaluate the trends in all clinical outcomes for different rSI-sMS values. The sensitivity and specificity of rSI-sMS were investigated at a cutoff value of 4 (based on previous study and the highest score of the Youden Index) in predicting injury severity clinical outcomes under the TTAS system were also investigated. Results: Compared with patients in triage level III, those in triage levels I and II had higher odds ratios for major injury (as indicated by revised trauma score < 7 and injury severity score [ISS] ≥ 16), intensive care unit (ICU) admission, prolonged ICU stay (≥14 days), prolonged hospital stay (≥30 days), and mortality. In all three triage levels, the rSI-sMS < 4 group had severe injury and worse outcomes than the rSI-sMS ≥ 4 group. The TTAS and rSI-sMS had higher area under the receiver operating characteristic curves (AUROCs) for mortality, ICU admission, prolonged ICU stay, and prolonged hospital stay than the SI and modified SI. The combination of the TTAS and rSI-sMS had the highest AUROC for all clinical outcomes. The prediction performance of rSI-sMS < 4 for major injury (ISS ≥ 16) exhibited 81.49% specificity in triage levels I and II and 87.6% specificity in triage level III. The specificity for mortality was 79.2% in triage levels I and II and 87.4% in triage level III. Conclusions: The combination of rSI-sMS and the TTAS yielded superior prioritization performance to TTAS alone. The integration of rSI-sMS and TTAS effectively enhances the efficiency and accuracy of identifying trauma patients at a high risk of mortality.

Objectives: Trauma is one of the leading causes of death and its incidence increases annually. The “weekend effect” and “holiday season effect” on traumatic injury mortality remain controversial, whereby traumatic injury patients admitted during weekends and/or holiday season have a higher risk of in-hospital death. The present study is aimed to explore the association between “weekend effect” and “holiday season effect” and mortality in traumatic injury population. Materials and Methods: This retrospective descriptive study included patients from the Taipei Tzu Chi Hospital Trauma Database between January 2009 and June 2019. The exclusion criterion was age of < 20 years. The primary outcome was the in-hospital mortality rate. The secondary outcomes included intensive care unit (ICU) admission, ICU re-admission, length of stay (LOS) in the ICU, ICU admission duration ≥ 14 days, total hospital LOS, total hospital LOS ≥ 14 days, need for surgery, and re-operation rate. Results: In this study, 11,946 patients were included in the analysis, and 8143 (68.2%) patients were admitted on weekdays, 3050 (25.5%) on weekends, and 753 (6.3%) on holidays. Multivariable logistic regression revealed that the admission day was not associated with an increased risk of in-hospital mortality. In other clinical outcome analyses, we found no significant increase in the risk of in-hospital mortality, ICU admission, ICU LOS ≥ 14 days, or total LOS ≥ 14 days in the weekend and holiday season groups. The subgroup analysis showed that the association between holiday season admission and in-hospital mortality was noted only in the elderly and shock condition populations. The holiday season duration did not differ in terms of in-hospital mortality. Longer holiday season duration was also not associated with an increased risk of in-hospital mortality, ICU LOS ≥14 days, and total LOS ≥14 days. Conclusion: In this study, we did not find any evidence that weekend and holiday season admissions in the traumatic injury population were associated with an increased risk of mortality. In other clinical outcome analyses, there was no significant increase in the risk of in-hospital mortality, ICU admission, ICU LOS ≥ 14 days, or total LOS ≥ 14 days in the weekend and holiday season groups.

Background: Characteristics of children with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Taiwanese households is nascent. We sought to characterize SARS-CoV-2 infection, and estimate the relative risk of infection among children within households during school closures in Taipei and New Taipei City. Methods: We reviewed consecutive children below 18 years presenting to our emergency department from May 18, 2021 to July 12, 2021 who underwent real-time reverse-transcription polymerase chain reaction (rRT-PCR) for SARS-CoV-2 from respiratory swabs. Demographics, symptoms, and contacts were captured from medical records. Household contact was defined as an individual with confirmed COVID-19 living in the same residence as the child. Results: Among 56 children with SARS-CoV-2, twenty-five (45%) were male with mean age of 7.9 years. Symptoms were nonspecific, with 29% having fever, 32% having cough, and 48% were asymptomatic. The median cycle threshold (Ct) value of SARS-CoV-2 rRT-PCR was 25 (range 11–38). All 56 children reported 94 contacts with a COVID-19 patient, of which 99% were household contacts. The relative risk of infection was 8.5 (95% CI 5.0–14.7) for children whose parent(s) were COVID-19 patients, and 7.3 (95% CI 4.9–11.0) for children whose household grandparent(s) were patients, as compared to children without respective contacts. Children without COVID-19 contacts were all tested negative. Conclusions: During school closures in Taipei and New Taipei City, children with SARS-CoV-2 infection in our cohort had one or more COVID-19 contacts, mostly within their households. While diagnosing pediatric COVID-19 is challenging as children were often asymptomatic, those without contacts were likely uninfected.

Background and Objectives: In the context of prehospital care, spinal immobilization is commonly employed to maintain cervical stability in head and neck injury patients. However, its use in cases of unclear consciousness or major trauma patients is often precautionary, pending the exclusion of unstable spinal injuries through appropriate diagnostic imaging. The impact of prehospital C-spinal immobilization in these specific patient populations remains uncertain. Materials and Methods: We conducted a retrospective cohort study at Taipei Tzu Chi Hospital from January 2009 to May 2019, focusing on trauma patients suspected of head and neck injuries. The primary outcome assessed was in-hospital mortality. We employed multivariable logistic regression to investigate the relationship between prehospital C-spine immobilization and outcomes, while adjusting for various factors such as age, gender, type of traumatic brain injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and activation of trauma team. Results: Our analysis encompassed 2733 patients. Among these, patients in the unclear consciousness group (GCS ≤ 8) who underwent C-spine immobilization exhibited a higher mortality rate than those without immobilization. However, there was no statistically significant difference in mortality among patients with alert consciousness (GCS > 8). Multivariable logistic regression analysis revealed that advanced age (age ≥ 65), unclear consciousness (GCS ≤ 8), major traumatic injuries (ISS ≥ 16 and RTS ≤ 7), and the use of neck collars for immobilization (adjusted OR: 1.850, 95% CI: 1.240–2.760, p = 0.003) were significantly associated with an increased risk of mortality. Subgroup analysis indicated that C-spine immobilization was significantly linked to an elevated risk of mortality in older adults (age ≥ 65), patients with unclear consciousness (GCS ≤ 8), those with major traumatic injuries (ISS ≥ 16 and RTS ≤ 7), and individuals in shock (shock index > 1). Conclusions: While our findings do not advocate for the complete abandonment of neck collars in all suspected head and neck injury patients, our study suggests that prehospital cervical and spinal immobilization should be applied more selectively in certain head and neck injury populations. This approach is particularly relevant for older individuals (age ≥ 65), those with unclear consciousness (GCS ≤ 8), individuals experiencing major traumatic injuries (ISS ≥ 16 or RTS ≤ 7), and patients in a state of shock (shock index ≥ 1). Our study employs a retrospective cohort design, which may introduce selection bias. Therefore, in the future, there is a need for confirmation of our results through a two-arm randomized controlled trial (RCT) arises, as this design is considered ideal for addressing this issue.

Background: Data on Taiwanese adolescents with self-inflicted injuries are limited. We describe the epidemiology of children and adolescents visiting the emergency department for self-inflicted injuries in two geographically distinct teaching hospitals. Methods: Medical records of children 0–18 years old who visited the emergency department of Taipei Tzu Chi Hospital and Chi Mei Medical Center, Tainan between 2016 and 2019 coded with relevant diagnoses were reviewed. Visits with documented self-inflicted injury were included. Results: During the 4-year period, 62 children made 74 emergency visits for self-inflicted injury. A total of 88% of visits were made by children with a psychiatric diagnosis, with depressive disorders being the most common (57%). Interpersonal relationship issue was cited as a trigger for self-harm in 49% of visits. Adjusted for annual visit volumes, self-harm visits per 10,000 pediatric emergency visits increased nearly 5 fold between 2016 and 2019, with the most prominent increase in the final year. Poisoning was the most common mechanism of injury and was frequently used by females, as compared to males who tended to jump from heights. Up to 96% of adolescents with previous self-harm seen at the emergency department had sought psychiatric help in the past year. Urban-rural inequity in mental health resource utilization was observed. Conclusions: Visits to the emergency department for self-inflicted injuries among children and adolescents increased, most remarkably in 2019, for both hospitals. Intentional poisoning with prescription and over-the-counter medications was the most common method. There was a high prevalence of psychiatric disorders in our study population. As the emergency department is likely the first point of medical contact for such visits, emergency personnel should be trained appropriately on managing such patients.

ObjectivesEarly identification of traumatic brain injury (TBI) patients at a high risk of mortality is very important. This study aimed to compare the predictive accuracy of four scoring systems in TBI, including shock index (SI), modified shock index (MSI), age-adjusted shock index (ASI), and reverse shock index multiplied by the Glasgow Coma Scale (rSIG).Patients and methodsThis is a retrospective analysis of a registry from the Taipei Tzu Chi trauma database. Totally, 1,791 patients with TBI were included. We investigated the accuracy of four major shock indices for TBI mortality. In the subgroup analysis, we also analyzed the effects of age, injury mechanism, underlying diseases, TBI severity, and injury severity.ResultsThe predictive accuracy of rSIG was significantly higher than those of SI, MSI, and ASI in all the patients [area under the receiver operating characteristic curve (AUROC), 0.710 vs. 0.495 vs. 0.527 vs. 0.598], especially in the moderate/severe TBI (AUROC, 0.625 vs. 0.450 vs. 0.476 vs. 0.529) and isolated head injury populations (AUROC 0.689 vs. 0.472 vs. 0.504 vs. 0.587). In the subgroup analysis, the prediction accuracy of mortality of rSIG was better in TBI with major trauma [Injury Severity Score (ISS) ≥ 16], motor vehicle collisions, fall injury, and healthy and cardiovascular disease population. rSIG also had a better prediction effect, as compared to SI, MSI, and ASI, both in the non-geriatric (age < 65 years) and geriatric (age ≥ 65 years).ConclusionrSIG had a better prediction accuracy for mortality in the overall TBI population than SI, MSI, and ASI. Although rSIG have better accuracy than other indices (ROC values indicate poor to moderate accuracy), the further clinical studies are necessary to validate our results.

Objective: Emergency air medical services (EAMS) share a common helicopter system for prehospital care and transfer in several countries. In Penghu, two systems are involved in EAMS: the helicopter and C130 systems. Given their features and limitations, patients using the two systems have significantly different characteristics. Materials and Methods: To clearly understand the disease patterns and dynamic changes in transferred patients, we studied 1228 patients transported from Penghu to Taiwan between January 2009 and December 2017. Results: Our findings show that the helicopter group had more acute diseases, while the C130 system group had more chronic diseases. Cardiovascular disease was the most common diagnosis (328 patients, 26.71%), followed by cerebrovascular disease (263 patients, 21.41%) and gastrointestinal disease (221 patients, 17.99%). Following interventions to support local medicine by Tri-Service General Hospital and the establishment of a cardiac catheterization laboratory, the annual number of transported patients decreased, especially those with cardiovascular diseases. The disease pattern also shifted from acute to chronic disease. Conclusion: Current data indicate that the local medical system is developing the ability to manage chronic diseases and care problems. This article analyzes dynamic changes in the disease patterns of transferred patients in both EAMS groups, providing a strong foundation for developing local medical systems.

Internal jugular vein thrombosis is a rare critical cardiovascular emergency, which has potential catastrophic clinical outcomes by resulting in stroke and pulmonary embolism. Several etiologies have been reported; however, there are limited data on Lemierre's and Trousseau's syndromes, which are both rare conditions with advanced disease progression and poor clinical outcomes. Lemierre's syndrome may present with typical progressively infectious symptoms and signs, including sore throat, neck mass, and fever, whereas Trousseau's syndrome may present with thrombophlebitis and painful edema. Without antibiotic agents controlling the infection, the condition of patients with Lemierre's syndrome may progress to sepsis or septic shock. The infection pattern plays an important role for differential diagnosis. Herein, we describe the case of a 46-year-old woman presenting with atypical symptoms of Trousseau's syndrome mimicking Lemierre's syndrome. Laboratory analysis including protein C, protein S, rheumatoid factor, and antinuclear antibody ruled out hypercoagulopathy and autoimmune vasculitis. Abdominal computed tomography and panendoscopy revealed ulcerative tumor at the antrum. Pathological examination confirmed the presence of signet-ring cell adenocarcinoma. We highlight the clinical features and etiologies of internal jugular vein thrombosis, especially in Lemierre's syndrome and Trousseau's syndrome, to aid physicians in making an early diagnosis and providing timely management.

Vomiting-induced pneumomediastinum is a rare presentation and can be a result of alveolar rupture (Mackler effect) or Boerhaave syndrome. Patients diagnosed with Boerhaave syndrome may present with the classic Mackler triad of vomiting, chest pain, and subcutaneous emphysema. However, there exists a large overlap of symptoms accompanying Boerhaave syndrome and the Macklin effect, including retrosternal chest pain, neck discomfort, cough, sore throat, dysphagia, dysphonia, and dyspnea. Boerhaave syndrome is a dangerous condition. Delayed diagnosis of Boerhaave syndrome may worsen sepsis and cause mortality. Therefore, early diagnosis and timely management are important to prevent further complications. Here, we present a case of vomiting-induced pneumomediastinum, which supports the use of bedside ultrasonography to aid in the diagnosis and rapid differentiation of etiology of pneumomediastinum.

Aging processes, including immunosenescence, inflammation, inflammasome formation, genomic instability, telomeric attrition, and altered autophagy, are involved in viral infections and they may contribute to increased pathophysiological responses to the SARS-CoV-2 infection in the elderly; this poses additional risks of accelerated aging, which could be found even after recovery. Aging is associated with oxidative damage. Moreover, SARS-CoV-2 infections may increase the production of reactive oxygen species and such infections will disturb the Ca++ balance via an endoplasmic reticulum (ER) stress-mediated unfolded protein response. Although vaccine development and anti-inflammation therapy lower the severity of COVID-19, the prevalence and mortality rates are still alarming in some countries worldwide. In this review, we describe the involvement of viral proteins in activating ER stress transducers and their downstream signals and in inducing inflammation and inflammasome formation. Furthermore, we propose the potential of melatonin as an ER stress modulator, owing to its antioxidant, anti-inflammatory, and immunoregulatory effects in viral infections. Considering its strong safety profile, we suggest that additive melatonin supplementation in the elderly could be beneficial in treating COVID-19.

Bipolar disorder is a complex psychiatric trait that is also recognized as a high substantial heritability from a worldwide distribution. The success in identifying susceptibility loci for bipolar disorder (BPD) has been limited due to its complex genetic architecture. Growing evidence from association studies including genome-wide association (GWA) studies points to the need of improved analytic strategies to pinpoint the missing heritability for BPD. More importantly, many studies indicate that BPD has a strong association with dementia. We conducted advanced pathway analytics strategies to investigate synergistic effects of multilocus within biologically functional pathways, and further demonstrated functional effects among proteins in subnetworks to examine mechanisms underlying the complex nature of bipolarity using a GWA dataset for BPD. We allowed bipolar susceptible loci to play a role that takes larger weights in pathway-based analytic approaches. Having significantly informative genes identified from enriched pathways, we further built function-specific subnetworks of protein interactions using MetaCore. The gene-wise scores (i.e., minimum p-value) were corrected for the gene-length, and the results were corrected for multiple tests using Benjamini and Hochberg’s method. We found 87 enriched pathways that are significant for BPD; of which 36 pathways were reported. Most of them are involved with several metabolic processes, neural systems, immune system, molecular transport, cellular communication, and signal transduction. Three significant and function-related subnetworks with multiple hotspots were reported to link with several Gene Ontology processes for BPD. Our comprehensive pathway-network frameworks demonstrated that the use of prior knowledge is promising to facilitate our understanding between complex psychiatric disorders (e.g., BPD) and dementia for the access to the connection and clinical implications, along with the development and progression of dementia.

Background: Early trauma team activation (TTA) may improve clinical outcomes through early diagnosis and timely intervention by a dedicated multidisciplinary team. Controversy seems to exist about the effect of establishing trauma team systems in traumatic injury populations. Our aim was to identify factors that may be associated with clinical outcomes in trauma injury and to investigate the effect of trauma team activation. Method: This retrospective descriptive study included all traumatic patients from the Taipei Tzu Chi Hospital Trauma Database. All prehospital vital signs, management, injury type, injury mechanisms, hospitalization history, and clinical outcomes were analyzed, and multivariable logistic regression was used to investigate the association between trauma team activation and clinical outcomes. Subgroups of TTA in minor injury and non-TTA in major injury were also analyzed. Result: In this study, a total of 11,946 patients were included, of which 10,831 (90.7%) patients were minor injury (ISS < 16), and 1115 (9.3%) patients were major injury (ISS ≥ 16). In the minor injury population, TTA had a higher intensive care unit (ICU) admission rate, operation rate, re-operation rate, and prolonged total length of stay (LOS). In the major injury population, TTA had a higher mortality rate, prolonged total LOS, and prolonged ICU LOS. After adjusting for mechanism of injury and injury severity, there was no association between in-hospital mortality and TTA, compared with the non-TTA group. However, the TTA group had a higher risk of ICU admission, prolonged ICU LOS, and prolonged total LOS. The subgroup analysis showed trauma team activation had a higher risk of mortality in the 60- to 80-year-old population, major injury (ISS ≥ 16), consciousness clear population, and non-head injury group. Conclusions: We found there was no significant association between in-hospital mortality and TTA. However, in the TTA group, there was a higher risk of ICU admission, prolonged total, LOS, and prolonged ICU LOS. In the subgroup analysis, TTA had a higher risk of mortality in the 60- to 80-year-old population, major injury (ISS ≥ 16), consciousness clear population, and non-head injury group. Our results reflect TTA-criteria-selected patients with greater ISS and a high risk of mortality.

Post-snakebite compartment syndrome (PSCS) is an uncommon but dangerous condition. Compartment syndrome-like symptoms after snakebite by Protobothrops mucrosquamatus (P. mucrosquamatus) are not effective in guiding fasciotomy. Objective evaluation of intracompartmental pressure measurements in patients with suspected PSCS is recommended. However, there is a lack of consensus regarding PSCS and indications for surgical intervention, including the threshold value of chamber pressure. In addition, intracompartmental pressure measurements may not be readily available in all emergency service settings. Measuring intracompartmental pressure in all snakebite patients for early diagnosis of PSCS is impractical. Therefore, identifying risk factors, continuous real-time monitoring tools, and predictive factors for PSCS are important. Sonography has proved useful in identifying the location and extension of edema after a snakebite. In this study, we attempted to use point-of-care ultrasound to manage PSCS in real-time. Here, we describe a rare case of snakebite from P. mucrosquamatus. PSCS was considered as diastolic retrograde arterial flow (DRAF) was noted in the affected limb with a cobblestone-like appearance in the subcutaneous area, indicating that the target artery was compressed. The DRAF sign requires physicians to aggressively administer antivenom to salvage the limb. The patient was administered 31 vials of P. mucrosquamatus antivenom, and fasciotomy was not performed. DRAF is an early sign of the prediction of PSCS.

Difficult airway management in critically ill patients remains a difficult task associated with high morbidity and mortality rates. In difficult airway populations, prompt effective intubation is more important to prevent hypoxia and neurological injury. During the ongoing COVID-19 pandemic, prolonged intubation time and repeated intubation can lead to an increase in the risk of infection. Therefore, digital devices can shorten intubation times and decrease the risk of infection among clinical staff. The advantages of the Trachway videolight intubating stylet suit these conditions. Trachway stylet intubation is an effective method for video laryngoscopy to enhance patient safety and improve the intubation success rate. However, a few studies have focused on the effect of stylet intubation by reducing repeated intubation and oxygen desaturation. In this study, we reviewed current data of Trachway intubation and shared our four major training scenarios in Taipei Tzu Chi Hospital via the Trachway videolight intubating stylet system for emergency intubation, comparing them with other modes of intubation.

Background: We investigated the clinical signs to establish a method for rapid identification of patients with the National Institute of Health Stroke Scale (NIHSS) score ≥ 8 eligible for direct brain CTA study; Methods: We retrospectively enrolled 2895 in patients with acute ischemic stroke (AIS). Four items in the NIHSS were selected as the main clinical signs of stroke; Results: A total of 922 (31.8%) patients had an initial NIHSS score of ≥8. The average door-to-CT time and door-to-CTA time were 13.4 ± 1.8 and 75.5 ± 44.5 min, respectively. Among 658 patients who had the priority signs, namely dense hemiplegia (D), aphasia with right arm drop (AR), and eyeball forced deviation (E), 634 patients (96.4%) with an NIHSS score ≥ 8 were identified. By using a classification and regression tree analysis, 153 patients with an NIHSS ≥ 8 were identified among 175 patients (87.4%) who had the secondary signs, namely hemiparesis with limb falls (P), aphasia (A), drowsy or worse consciousness (C), and eyeball limitation (E). The sensitivity, specificity, and accuracy were 85.4%, 97.7%, and 95.3%, respectively. Conclusions: The DARE-PACE assessment involving a checkbox list provides excellent accuracy for rapid identification of AIS patients with an NIHSS score ≥ 8 for direct CTA study to reduce the time delay for endovascular thrombectomy.

Distant metastases are the major cause of mortality in cancer patients. Bone metastases may cause bone fractures, local pain, hypercalcemia, bone marrow aplasia, and spinal cord compression. Therefore, the management of bone metastases is important in cancer treatment. Normal bone remodeling is regulated by osteoprotegerin ligand (OPGL), receptor activator of NF-κB ligand (RANKL), parathyroid hormone-related protein (PTHrP), and other cytokines. In the tumor microenvironment, tumor cells induce a vicious cycle that promotes osteoblastic and osteolytic lesions. Studies support the idea that distant metastases may occur due to the immunosuppressive function of myeloid-derived suppressor cells (MDSCs). These cells inhibit T cells and natural killer (NK) cells and differentiate into tumor-associating macrophages (TAMs), monocytes, and dendritic cells (DCs). In this review, we summarize studies focusing on the role of MDSCs in bone metastasis and provide a strong foundation for developing anticancer immune treatments and anticancer therapies, in general.

Ischemia-reperfusion injury is associated with serious clinical manifestations, including myocardial hibernation, acute heart failure, cerebral dysfunction, gastrointestinal dysfunction, systemic inflammatory response syndrome, and multiple organ dysfunction syndrome. Ischemia-reperfusion injury is a critical medical condition that poses an important therapeutic challenge for physicians. In this review article, we present recent advances focusing on the basic pathophysiology of ischemia-reperfusion injury, especially the involvement of reactive oxygen species and cell death pathways. The involvement of the NADPH oxidase system, nitric oxide synthase system, and xanthine oxidase system are also described. When the blood supply is re-established after prolonged ischemia, local inflammation and ROS production increase, leading to secondary injury. Cell damage induced by prolonged ischemia-reperfusion injury may lead to apoptosis, autophagy, necrosis, and necroptosis. We highlight the latest mechanistic insights into reperfusion-injury-induced cell death via these different processes. The interlinked signaling pathways of cell death could offer new targets for therapeutic approaches. Treatment approaches for ischemia-reperfusion injury are also reviewed. We believe that understanding the pathophysiology ischemia-reperfusion injury will enable the development of novel treatment interventions.

Spiked helmet sign is a novel electrocardiogram marker that reflects a poor prognosis, and may mimic myocardial infarction, especially in patients with an acute alteration of mental status or out-of-hospital cardiac arrest. In cases where a spiked helmet sign is missed, there may be a delay in surgical intervention for the underlying conditions because of unnecessary cardiac catheterization. In addition, antiplatelet agents for acute coronary syndrome in such cases can lead to catastrophic complications. Therefore, early recognition of spiked helmet sign is useful for timely correction of the underlying disease and prevention of poor outcomes. Herein, we describe a rare case of a patient with internal bleeding and subarachnoid hemorrhage presenting with spiked helmet sign on an electrocardiogram.

The shock index (SI) is a useful tool for predicting the injury severity and mortality in patients with trauma. However, pediatric physiology differs from that of adults. In the pediatric trauma population, the shock status may be obscured within the normal range of vital signs. Pediatric age-adjusted SI (SIPA) is reported more accurately compared to SI. In our study, we conducted a 10 year retrospective cohort study of pediatric trauma population to evaluate the SI and SIPA in predicting mortality, intensive care unit (ICU) admission, and the need for surgery. This retrospective cohort study included 1265 pediatric trauma patients from January 2009 to June 2019 at the Taipei Tzu Chi Hospital, who had a history of hospitalization. The primary outcome of this investigation was in-hospital mortality, and the secondary outcomes were the length of hospital and ICU stay, operation times, and ICU admission times. The SIPA group can detect changes in vital signs early to reflect shock progression. In the elevated SIPA group, more severe traumatic injuries were identified, including high injury severity score (ISS), revised trauma score (RTS), and new injury severity score (NISS) scores than SI > 0.9. The odds ratio of elevated SIPA and SI (>0.9) to predict ISS ≥ 16 was 3.593 (95% Confidence interval [CI]: 2.175–5.935, p < 0.001) and 2.329 (95% CI: 1.454–3.730, p < 0.001). SI and SIPA are useful for identifying the compensatory phase of shock in prehospital and hospital settings, especially in corresponding normal to low-normal blood pressure. SIPA is effective in predicting the mortality and severity of traumatic injuries in the pediatric population. However, SI and SIPA were not significant predictors of ICU admission and the need for surgery analysis.

Antiphospholipid syndrome (APS) is an autoimmune disorder with characteristics of arterial and/or venous thrombosis due to hypercoagulation status. Although deep vein thrombosis is common, the involvement of arterial thrombosis is more dangerous and poses a high risk of complications. Acute aorto-iliac occlusive disease (AIOD, known as Leriche syndrome) is severe arterial thrombosis that is associated with high morbidity and mortality rates. Severe acute occlusion may cause spinal cord ischemia, leading to neurological defects, such as acute onset of paraplegia. Co-occurrence of acute aorto-iliac occlusive disease and antiphospholipid syndrome is rare and may present with atypical symptoms mimicking other diseases, including chronic ulcers, musculoskeletal events, and pulmonary diseases. In patients with weak femoral pulses and recurrent thrombotic events, co-occurrence of APS and AIOD should be taken into consideration. Here, we describe a rare case of co-occurrence of APS and AIOD presenting with acute lower leg weakness and numbness. Timely thrombectomies and bilateral common iliac artery stentings rescued distal blood flow. We highlight the clinical features and early diagnosis of co-occurrence of APS and AIOD in order to prevent catastrophic complications. The detailed mechanism and pathogenesis of antiphospholipid syndrome-induced acute aorto-iliac occlusive disease are also discussed.

Neisseria meningitidis-induced acute systemic meningococcal disease is an emergency and a fatal condition that has a high mortality rate. In patients with a fulminant infection, a maculopapular petechial eruption, purpura fulminans, or an ecchymotic lesion are worrisome signs reflecting disseminated intravascular coagulation (DIC) and hint at Waterhouse−Friderichsen syndrome (WFS). Here, we describe a rare case of a patient with a fulminant Neisseria meningitidis-induced acute systemic meningococcal disease presenting with high-grade fever without meningitis symptoms. Fatal septicemia with DIC and multiple organ failure was noted. WFS was chiefly suspected. We highlight the clinical features and pathogenesis of Neisseria meningitidis-induced meningococcemia and WFS. We propose that they should be kept in mind, especially in patients presenting with a petechial eruption and purpura fulminans.

Kounis syndrome is a rare anaphylactic reaction leading to coronary spasm, acute plaque rupture, or intrastent stenosis. Many types of medicine or environmental factors can potentially trigger Kounis syndrome by mast cell allergic reactions. In severe Kounis syndrome, reduced blood pressure or cardiac arrest may be accompanying symptoms. The treatment strategy for Kounis syndrome is usually difficult due to both cardiac dysfunction and allergic reactions. The delay to intervention to break the vicious circle may cause catastrophic complications. Therefore, early diagnosis is critical for physicians to outline detailed etiology for prevention and treat the cardiac and allergic symptoms in a timely manner. Here, we describe a case presenting rare severe Kounis syndrome with cardiac arrest which occurred after the administration of a contrast media.

A spontaneous rupture of the spleen is a rare but critical diagnosis of an acute abdomen, which may accompany unspecific symptoms mimicking acute pancreatitis, rupture of aortic aneurism, or acute coronary syndrome, delaying diagnosis and treatment. In patients that have experienced a severe spleen rupture, hypovolemic shock may cause catastrophic clinical outcomes. Therefore, early diagnosis is very important in order for physicians to declare the etiology for prevention and timely correction of the shock status. Several causes of spontaneous splenic rupture have been reported, including infection, vasculitis, pancreatitis, or hematological malignancies. Acute lymphoblastic leukemia (ALL) remains a rare but important cause of non-traumatic splenic rupture that physicians are required to assess for. Here, we describe a case presenting an acute abdomen due to spontaneous spleen rupture as the first manifestation. The purpose of this case report was to highlight the importance of considering spontaneous ruptures of the spleen as a rare but critical differential diagnosis of an acute abdomen, especially in patients with acute lymphoblastic leukemia.

The transforming growth factor-β (TGF-β) signaling pathway plays multiple regulatory roles in the tumorigenesis and development of cancer. TGF-β can inhibit the growth and proliferation of epithelial cells and induce apoptosis, thereby playing a role in inhibiting breast cancer. Therefore, the loss of response in epithelial cells that leads to the inhibition of cell proliferation due to TGF-β is a landmark event in tumorigenesis. As tumors progress, TGF-β can promote tumor cell invasion, metastasis, and drug resistance. At present, the above-mentioned role of TGF-β is related to the interaction of multiple signaling pathways in the cell, which can attenuate or abolish the inhibition of proliferation and apoptosis-promoting effects of TGF-β and enhance its promotion of tumor progression. This article focuses on the molecular mechanisms through which TGF-β interacts with multiple intracellular signaling pathways in tumor progression and the effects of these interactions on tumorigenesis.

Intracranial hemorrhage (ICH) is a catastrophic complication in patients with acute myeloid leukemia (AML). AML cells, especially in the acute promyelocytic leukemia subtype, may release microparticles (MPs), tissue factor (TF), and cancer procoagulant (CP) to promote coagulopathy. Hyperfibrinolysis is also triggered via release of annexin II, t-PA, u-PA, and u-PAR. Various inflammatory cytokines from cancer cells, such as IL-1β and TNF-α, activate endothelial cells and promote leukostasis. This condition may increase the ICH risk and lead to poor clinical outcomes. Here, we present a case under a unique situation with acute ICH detected prior to the diagnosis of AML. The patient initially presented with two episodes of syncope. Rapidly progressive ICH was noted in follow-up computed tomography (CT) scans. Therefore, we highlight that AML should be among the differential diagnoses of the etiologies of ICH. Early diagnosis and timely intervention are very important for AML patients.

Minocycline is a tetracycline group antibiotic that is known to cause significant antibacterial and anti-inflammatory effects. Minocycline has been widely used to treat systemic infection, acne, dermatitis, and rosacea. However, various dose-related side effects of hyperpigmentation in whole body tissues have been reported. Three main types of minocycline-induced hyperpigmentation have been identified. In rare severe hyperpigmentation cases, drug-induced hyperpigmentation can mimic local cellulitis or peripheral arterial occlusive disease (PAOD). These processes require different therapeutic strategies. Therefore, early diagnosis is extremely important for physicians to determine the etiology of the hyperpigmentation, and subsequently discontinue the minocycline if indicated. We describe a rare case presenting a severe form of type III minocycline-induced hyperpigmentation mimicking peripheral arterial occlusive disease in a bullous pemphigoid patient.