Adrenal insufficiency in critically ill emergency department patients: a Taiwan preliminary study.

OBJECTIVE: Unrecognized adrenal insufficiency can have serious consequences in critically ill emergency department (ED) patients. This prospective pilot study of adrenal function in patients with severe illness was undertaken to determine the prevalence of adrenal dysfunction and any relation to prior herbal drug use. METHODS: In a high-volume urban tertiary care ED, adult patients with sepsis or acute myocardial infarction (AMI) were eligible for the study. Over a two-month period, a convenience sample was enrolled by the authors on arrival to the ED. Inclusion criteria were systemic inflammatory response syndrome (SIRS) criteria plus evidence of at least one organ dysfunction or cardiac marker plus electrocardiogram-proven AMI. Exclusion criteria included known corticosteroid use. Serum cortisol was measured on arrival and for those patients with a level of <15 microg/dL (<414 nmol/L), an adrenocorticotropic hormone (ACTH) stimulation test was performed. RESULTS: Of the 30 enrolled patients, 23 (77%) were suffering from severe sepsis and the other seven (23%) had an AMI. Thirteen of the 30 patients (43%; 95% CI = 25% to 65%) had serum cortisol levels of <15 microg/dL, consistent with adrenal insufficiency, nine with severe sepsis and four with an AMI. Eight (62%; 95% CI = 32% to 86%) of the 13 patients with low cortisol levels reported using herbal medications, while only two (12%; 95% CI = 1% to 36%) of the 17 with normal cortisol levels reported taking herb drugs (p = 0.01). Only two (15%; 95% CI = 2% to 45%) of the patients with low cortisol levels failed their corticotropin stimulation test, suggestive of true adrenocortical insufficiency. Both reported using herbal preparations. CONCLUSIONS: These results indicate that adrenal dysfunction is common among a group of critically ill patients seen in this Taiwanese ED. Moreover, the use of herbal drugs was high in the patients with low serum cortisols. Further studies are required to both confirm these findings and clarify whether a number of herbal medications contain corticosteroids.

Periaortic contrast medium extravasation on chest CT in traumatic aortic injury: a sign for immediate thoracotomy.

Traumatic aortic injury (TAI) after blunt chest trauma is potentially a lethal condition. The injury must be diagnosed promptly and accurately. Evaluation for traumatic aortic injury begins with an assessment of mechanism of injury, a physical examination and chest radiography. In recent years, chest computed tomography (CT) has been advocated as a better screening tool to detect TAI but there is still controversial over the confirmatory diagnostic value of CT. For hemodynamically unstable patients in whom chest CT had shown direct sign of aortic injury and with periaortic contrast medium extravasation, we advocate that these patients should be operated on immediately without aortogram to avoid unnecessary delay. Herein, we describe a case of TAI with direct signs and periaortic contrast extravasation and discuss if chest CT can substitute an aortogram as a diagnostic tool when direct signs of TAI are revealed.

Rotavirus gastroenteritis in children: 5-year experience in a medical center.

Rotavirus infection is the leading cause of childhood gastroenteritis. We retrospectively reviewed cases of rotavirus gastroenteritis at National Taiwan University Hospital from January 1993 to December 1997. During the study period there were 429 patients with rotavirus infection with ages ranging from 1 day to 16 years with a median of 13 months. The male-to-female ratio was 1.2:1. Infection occurred before the age of 2 years old in 76% of patients. The seasonal peak occurred in the late winter and early spring during 1993 to 1996, but the case number increased in late spring and summer in 1997. The G serotype of the rotavirus was identified in 302 patients (70%). Vomiting and dehydration developed more frequently following infection with G1 rotaviruses, while an increased frequency of seizures was noted following G2 infection; the differences were not statistically significant. One patient had two episodes of infection; the first one was caused by G1 rotavirus, and the strain causing the second infection could not be typed. In conclusion, the results suggest that there is a strong seasonal variation in the incidence and characteristics of rotavirus infection in Taipei area. The infections caused by G1 and G2 rotaviruses were clinically indistinguishable.

Enteric adenovirus infection in children in Taipei.

Enteric adenoviruses (EAds), including type 40 (Ad40) and 41 (Ad41), can cause acute and severe diarrhea in young children. To delineate the epidemiological features of pediatric EAds infection in Taiwan, we conducted a retrospective study of all cases of EAds gastroenteritis in children treated at National Taiwan University Hospital for the period from July 1993 to December 1997. Stool samples were tested for the presence of Ad40 or Ad41 by enzyme immunoassay (EIA). A total of 64 cases of EAds infection in 63 children aged from 8 days to 81 months old with a median age of 9.5 months treated during the study period were identified. The male-to-female ratio was 1.63 (39/24). No obvious seasonal clustering of EAds cases was noted. Most patients (76.6%) were infected before the age of 2 years. Clinical features included diarrhea (96.9%), fever (54.7%), vomiting (45.3%), mild dehydration (43.8%), symptoms of upper respiratory tract infection (21.9%), and abdominal pain (12.5%). Analysis of fecal samples in patients with diarrhea showed watery diarrhea in 72.2%, diarrhea with mucus in 20%, diarrhea with blood in 3.1% and diarrhea with mucus and blood in 1.6 % of all patients. Nearly one-half (43.5%) of the patients had diarrhea for more than 7 days. Thirty-seven patients (57.8%) were hospitalized due to gastroenteritis or other unrelated diseases, and 11 patients (17.2%) acquired enteric adenovirus infection during hospitalization for other underlying disease. Twelve patients (18.8%) had mixed infections, which included rotavirus, respiratory syncytial virus (RSV) and Salmonella species. There were no deaths in this series. The findings of this study suggest that EAds are important etiologic microbes of pediatric gastroenteritis.

Risk of immediate effects from F(ab)2 bivalent antivenin in Taiwan.

OBJECTIVE: To evaluate the incidence of immediate adverse effects from equine fragment antigen binding F(ab)2 bivalent antivenin produced by the National Institute of Preventive Medicine (NIPM) in Taiwan. METHODS: A retrospective chart review of patients presenting to a 600-bed general hospital over a 3-year period with snakebite who were treated with NIPM antivenin. RESULTS: A total of 130 snakebite victims presented to the emergency department over the study period, and 159 vials of antivenin were given. One hundred two patients (78.5%; 95% CI: 70, 85) received only hemorrhagic bivalent antivenin, 2 (1.5%; 95% CI: 0, 5) received only neurotoxic bivalent antivenin, and the remaining 26 (20.0%; 95% CI: 13, 28) received both kinds of bivalent antivenin. Three received a second vial of hemorrhagic antivenin because of progression of symptoms. Forty-two patients (32.3%; 95% CI: 24, 41) had positive skin tests, but following pretreatment with diphenhydramine and hydrocortisone, only 1 patient developed a skin rash thought to be related to antivenin. No patient developed an anaphylactic reaction. CONCLUSIONS: The use of NIPM F(ab)2 antivenin in snakebite victims in Taiwan has a very low risk of acute adverse reactions.

Differences of disease characteristics between genders in emergency department elderly of a community hospital in Taiwan.

BACKGROUND: The purpose of this study was to catalog the chief complaints and diagnoses of elderly patients visiting to a Taiwanese emergency department (ED), and to compare gender differences. METHODS: ED computer log data of patients 65 years and older, who visited the ED from July 1995 to June 1996, were retrospectively reviewed. The computer log data for each patient was entered prospectively by the doctor providing the ED care. All patient data were separated by gender, and then subdivided into trauma and non-trauma groups for analysis. RESULTS: There were 8038 elderly patients treated during the study period. The most common male chief complaint was dyspnea, and for females, it was abdominal pain, followed by injuries for both genders. Falls were the most common mechanism of injury for both genders, but they were more common among females (63.2% vs. 46.1%, p < 0.001). Motorbike accidents, however, were 3 times as frequent among males (16.05% vs. 5.45%, p < 0.001). Males presented most commonly with COPD (12.2%), compared to only 4.16% for females (p < 0.001), with urinary retention the second most common diagnosis (5.04% vs. 0.72%, p < 0.001). Females suffered a greater number of urinary tract infections (5.42% vs. 2.03%, p < 0.001), presentations for renal failure (2.98% vs. 1.56% p < 0.001), and diabetes-associated problems (4.58% vs. 2.48%, p < 0.001). CONCLUSION: Elderly females presented to the ED more frequently with urinary tract and diabetic problems; while their male counterparts presented with complications of COPD, urinary retention, and motorbike accidents.

Pertussis seroepidemiology in Taipei.

PURPOSE: We evaluated the seroprevalence of pertussis among apparently healthy Taipei residents. METHODS: From January 1992 through December 1994, we recruited subjects from a well baby clinic (children < 3 years), kindergartens, primary, and secondary schools and colleges (3-20 years), a health exam clinic (> 20 years), and obstetric clinics (pregnant women). Subjects were stratified into 12 groups according to age and pregnant women were considered separately. The serum antibody titers against filamentous hemagglutinin (FHA) and pertussis toxin (PT) were measured by enzyme-linked immunosorbent assay. RESULTS: The anti-PT and anti-FHA titers were elevated in the 4 to 6-month and 19 to 20-month age groups, coinciding with regular pertussis vaccinations. The anti-PT titers rose again in the 3 to 4-year age group, reflecting a higher prevalence of natural pertussis infection. The anti-PT titers gradually decreased among older age groups, although a peak occurred in the 11 to 15-year age group. The sequential changes in anti-FHA titers followed those of anti-Pt titers in the younger age groups, but the anti-FHA titers were persistently elevated beyond 15 years of age. The antibody levels were similar in the two sexes, except that anti-PT titers were higher in males of 19 to 20 months and 21 to 30 years of age. Anti-PT titers were equivalent between neonates (0-2 months) and pregnant women, but anti-FHA titers were much lower in neonates. CONCLUSIONS: The seroprevalence patterns in this study indicate that young children, adolescents, and even adults remain at risk of pertussis, despite the current immunization program. Booster vaccinations after completion of the current four-dose immunization schedule, possibly continuing into adolescence, should be considered to block the transmission of infection.

Treatment of poisonous snakebites in northern Taiwan.

PURPOSE: We evaluated the epidemiology and outcomes of snakebites in northern Taiwan, and the effect of local antivenom injection to speed neutralization and reduce the spread of venom. METHODS: We retrospectively reviewed the medical records of 130 venomous snakebite patients treated in a general hospital in northern Taiwan during a 3-year period (1991-1994). Patients received either combined local and intravenous injection of antivenom or intravenous administration only, according to the physicians' decision. The species of snake involved, time of bite, and outcome of the patient were recorded. The effect sof local and systemic antivenom administration were analyzed using the duration of emergency department (ED) stay among patients discharged from the ED with medical approval as a treatment index. RESULTS: Most (76.1%) venomous snakebites were attributed to the green habu (68 patients) and the Taiwan habu (31 patients). All bites were to the extremities: 74 (57%) to the feet and 56 (43%) to the hands or arms. Most bites (n = 70, 53.9%) occurred between 2 PM and 9 PM. The peak months for snakebites were June through October (n = 84, 64.6%). Eighteen patients (13.8%) were admitted for further treatment after being cared for in the ED. The other 112 patients were discharged from the ED (86.2%), although three of these were admitted later because of infection. No patients died, but eight developed wound infections. Of the 93 patients discharged from the ED with medical approval, 26 (28.0%) received local injection plus systemic administration of antivenom. The duration of ED stay did not differ significantly between patients with local plus systemic administration and those who received systemic administration alone (23.7 +/- 19.5 hours vs 27.0 +/- 12.5 hours, p = 0.19). CONCLUSIONS: Most snakebites in northern Taiwan were due to habus and caused mild symptoms. Local antivenom injection plus intravenous administration of antivenom had no benefit over intravenous administration alone.

Clinical presentations of elderly patients at emergency departments: a comparison between a medical center and a community hospital.

BACKGROUND: The utilization of emergency services is expected to increase in parallel with an increase of the elderly population. This article compares the elderly patient Emergency Department (ED) utilization at a 3500-bed medical center with that of a 600-bed community hospital serviced by the same group of emergency physicians. METHODS: We retrospectively reviewed all patients over 64 years old who presented to Linkou Chang Gung Memorial Hospital (CGMH) and Keelung CGMH between July 1, 1995 and June 30, 1996 by using the 2 ED's real-time computer logs. Data comparisons included age, gender, mode of arrival, arriving source, triage category, chief complaint, impression, and final disposition. RESULTS: There were 18,285 patients in the Linkou ED and 8038 in Keelung. Significant differences in arrival mode, arriving source, triage category, disease pattern, and final disposition were observed between the Linkou and Keelung CGMH EDs. CONCLUSION: Significant differences reflected the different roles between the Linkou and Keelung CGMH EDs. Hospital EDs should be prepared to adapt to meet the needs of the elderly based on their roles in the medical care system, at the elderly population grows in the 21st century.

Croup syndrome in children: five-year experience.

To investigate the etiology and clinical features of croup syndrome, clinical records of hospitalized children with a diagnosis of croup syndrome were reviewed from April 1990 to January 1996. There was a total of 132 children, aged between three months and seven years with a mean age of 21.3 +/- 16.8 months. A diagnosis of laryngotracheobronchitis was made in 123 (93.2 percent) children. Twenty-three pathogens were identified in twenty-two of them, including seven parainfluenza viruses, five respiratory syncytial viruses, four influenza A viruses, four Mycoplasma pneumoniae, and three adenoviruses. Bacterial tracheitis was confirmed by bronchoscopic examination in seven cases (5.3 percent). Cultures of the respiratory secretions yielded viridans streptococci in six and Staphylococcus aureus in one child. Two children (1.5 percent) had spasmodic croup. No case with epiglottitis was noted in the present study. A fever lasting for more than three days was noted in five (71 percent) children with bacterial tracheitis and thirty-five (28 percent) children with laryngotracheobronchitis (p = 0.048). Among children with laryngotracheobronchitis, an associated diagnosis of pneumonia, acute otitis media, or paranasal sinusitis was more frequently observed in those with fever > 3 days (40 percent) than those with a shorter duration of fever (17 percent, p = 0.013). In conclusion, a child with a longer duration of fever and more severe manifestations of airway obstruction probably has a bacterial cause of croup syndrome or a bacterial complication. Bacterial tracheitis is more common than epiglottitis in Taiwan.

Immunogenicity of oral poliovirus vaccine in Taiwan.

Previous studies have shown that the immune response to trivalent oral poliovirus vaccine (OPV) varies widely from country to country. However, there has been no report on the immunogenicity of this vaccine in Taiwanese children. In this study, 98 children were followed up for 17 months to study the antibody responses following four doses of trivalent OPV. The results showed that, after two doses of vaccine, all children were protected against poliovirus type 1 and 2. All except two children also developed protective antibodies against poliovirus type 3. After three doses, the antibody levels in all subjects were above protective concentrations. The fourth dose, given at 18 months of age, further boosted the antibody titers. These findings show that the OPV currently used in Taiwan is highly immunogenic in Taiwanese children.

Penicillin-nonsusceptible Streptococcus pneumoniae infections in children.

The emergence of penicillin-nonsusceptible Streptococcus pneumoniae (PNSSP) has brought a new clinical challenge. In Taiwan, reports of the prevalence and clinical features of PNSSP infections in children are limited. This study reviewed the resistance patterns of all clinical isolates of S. pneumoniae obtained from patients under 17 years of age from January 1993 through July 1998 in a medical center. Their clinical features and treatment responses were analyzed, with special attention paid to those patients with invasive PNSSP infections. Totally, 170 clinical isolates of S. pneumoniae were obtained from 168 patients aged under 17 years. Among those infections, there were 56 sinusitis (including 4 sinusitis with bacteremia), 44 pneumonia (including 23 pneumonia with bacteremia or empyema), 23 otitis media (including 5 otitis media with bacteremia), 9 simple bacteremia, 9 conjunctivitis, 8 meningitis, 4 peritonitis, 3 skin infections and the other 14 isolates were colonization. One hundred eleven isolates (65.3%) showed reduced penicillin susceptibility by the disk diffusion method. A trend of increasing percentiles of PRSP was noted: 27.3% (3/11) in 1993, 37.5% (9/24) in 1994, 55.5% (10/18) in 1995, 77.5% (31/40) in 1996, 66.0% (31/47) in 1997, and 87.1% (27/31) in 1998. Minimum inhibitory concentration (MIC) determinations by the E-test showed some of the isolates were intermediately resistant. Prior antibiotic usage was associated with a higher incidence of PNSSP infections. However, most children responded well to antimicrobial treatment.

Profiling expression patterns and isolating differentially expressed genes by cDNA microarray system with colorimetry detection.

A high-density cDNA microarray with colorimetry detection system to simultaneously monitor the expression of many genes on nylon membrane is described and characterized. To quantify the expression of genes and to isolate differentially expressed genes, the southern hybridization process on filter membranes was employed. The levels of gene expression were represented by color intensities generated by colorimetric reactions in place of hazardous radioisotopes or costly laser-induced fluorescence detection. The gene expression patterns on nylon membranes were digitized by devices such as an economical flatbed scanner or a digital camera. The quantitative information of gene expression was retrieved by image analysis software. Quantitative comparison of the northern dot-blotting method with the microarray system is described. Applications employing single-color detection as well as dual-color detection to isolate differentially expressed genes among thousands of genes are demonstrated.

Comparison of once daily cefpodoxime proxetil suspension and thrice daily cefaclor suspension in the treatment of acute otitis media in children.

An open-labeled and randomized trial was conducted to compare the efficacy and safety of once daily cefpodoxime proxetil suspension (10mg/kg/day) and thrice daily cefaclor (45mg/kg/day) in the treatment of acute otitis media in children. A total of 57 children aged from 6 months to 9 years were enrolled; 23 were treated with cefpodoxime and 34 with cefaclor. Satisfactory clinical outcome, either cure or improvement, was achieved at the end of treatment in 90% of patients in the cefaclor group and 95% of patients in the cefpodoxime group (p > 0.05). Clinical recurrence was identified at the follow-up visits in one case of the cefaclor group (3%), and none in the cefpodoxime group (p > 0.05). These drugs were well tolerated by 14/21 (67%) in the cefpodoxime-treated group and 27/32 (84%) in the cefaclor-treated group. The incidence of adverse events was slightly higher in the cefpodoxime group than in the cefaclor group, however the difference did not reach statistical significance (p > 0.05). The daily cost of once-daily cefpodoxime was lower than that of thrice-daily cefaclor. We conclude that cefpodoxime administered once daily is as effective and safe as cefaclor administered thrice daily in the treatment of acute otitis media in children. The less dosing frequency and lower daily price of cefpodoxime provide additional benefits.

Rapid life-threatening hyperkalemia after addition of amiloride HCl/hydrochlorothiazide to angiotensin-converting enzyme inhibitor therapy.

STUDY OBJECTIVE: To highlight the dangers of a precipitous rise in serum potassium levels in patients at risk for renal insufficiency, already receiving an angiotensin-converting enzyme (ACE) inhibitor, who are given a potassium-sparing diuretic. METHODS: We conducted a retrospective chart review of five patients who were taking the above combination of medications who were seen in our ED with hyperkalemia. RESULTS: All five patients had diabetes and were older than 50 years of age. Except for one patient, they had some degree of renal impairment and all were receiving an ACE inhibitor. Each had amiloride HCl/hydrochlorothiazide added to their therapeutic regimen 8 to 18 days before presenting to our ED with hyperkalemia. Potassium levels were between 9.4 and 11 mEq/L in 4 of the patients; 2 did not respond to resuscitation measures. CONCLUSION: The concomitant use of ACE inhibitor and potassium-sparing diuretic therapy should be avoided. If impossible, weekly monitoring of both renal function and serum potassium should be performed. In the ED patients who are receiving such a combination should receive immediate ECG monitoring.

Adult respiratory distress syndrome and late death following imipramine overdose: a case report.

Adult respiratory distress syndrome (ARDS) after tricyclic antidepressant (TCA) overdose has been reported, but has not received as much attention in the literature as hemodynamic instability, cardiac arrhythmias or seizures. This report concerns a 33-year-old female who ingested a large amount of imipramine in an attempted suicide. She developed deep coma, hypotension, cardiac dysrhythmias and seizures. Although she survived initially, ARDS developed and she died of severe hypoxia nine days later. Her lung injury may have been the result of a variety of factors including prolonged hypotension, aspiration pneumonia, sepsis or a direct action on the lung parenchyma by imipramine. The literature pertaining to etiology, epidemiology, pathophysiology and management of TCA-induced lung injury has been reviewed. In one series of severe TCA overdose, an ARDS rate of 9% was reported. The risk of developing pulmonary edema and ARDS should be considered in severe TCA-poisoned patients. To try to prevent this complication, early intubation should be considered to avoid aspiration, and cautious volume loading, plus judicious use of alpha-adrenergic agonists, is indicated to prevent protracted hypotension.