Comorbid asthma is associated with rhinitis severity in children exposed to air pollutants.

BACKGROUND: The impact of asthma on the severity of rhinitis when children with allergic rhinitis (AR) are exposed to air pollutants has not been studied. METHODS: Children with AR (65 with asthma, 208 without asthma), aged 6-13 years, were recruited from a hospital in Taichung, Taiwan, between 2007 and 2011. Correlations between Pediatric-Rhinoconjunctivitis-Quality-of-Life score, nasal peak expiratory flow, and air pollutants were compared. With the same age, research time, and form the same city, children with AR (660 with asthma, 3174 without asthma) were selected from a database. Correlations between clinical visit times for AR and air pollutants were compared. RESULTS: In male children with AR and asthma, both clinical and database studies revealed a correlation between higher rhinitis discomfort (quality-of-life score), higher visit times for AR, and higher PM10, PM2.5, NO2, NMHC concentrations. Correlations between higher nasal inflammation/obstruction (lower expiratory flow) and higher air pollutant concentrations were observed in male children with AR and asthma. CONCLUSION: In children with AR, comorbid asthma was associated with increased rhinitis severity when they were exposed to air pollutants, and the association was only noted in males. Increased nasal obstruction/inflammation from exposure to air pollutants may be the mechanisms underlying this association. IMPACT STATEMENT: The influence of asthma on the severity of rhinitis when children with allergic rhinitis (AR) are exposed to air pollutants has not been studied. In children with AR, the correlation between higher rhinitis discomfort, higher number of clinical visits for AR, and higher PM10, PM2.5, NO2, NMHC concentrations were only noted in those who also had asthma. The correlation was only noted in male. Comorbid asthma was associated with higher rhinitis severity when children with AR are exposed to air pollutants The association was only noted in male.

Usage of point-of-care Ultrasonography for Rapid Diagnosis of Cardiac Perforation by Pacemaker Lead.

Cardiac perforation after pacemaker placement is a rare form of cardiovascular emergency. A case of an elderly adult undergoing hemodialysis that contributed to this emergency is presented. The history, clinical imaging findings, and surgical procedures for clinical assessment are briefly described. Point-of-care ultrasonography (POCUS) was used to identify, locate, and perform ultrasonography-guided pericardiocentesis. The role of POCUS in cases of tamponade has been emphasized in clinical settings.

Risk of atrial fibrillation in patients with pneumonia.

BACKGROUND: Cardiac arrhythmias have a strong association with pneumonia due to the cardiovascular response to infection. Electrocardiographic (ECG) changes in patients with pneumonia are associated with greater disease severity. Atrial fibrillation (AF) is the most common type of cardiac arrhythmia. OBJECTIVE: This population-based cohort study investigated the incidence of AF among Taiwanese adults with pneumonia using data from the National Health Insurance Research Database in Taiwan. METHODS: A total of 34,883 patients with pneumonia and an equal number of individuals without pneumonia were eligible after excluding those with a previous diagnosis of AF and matching 1:1 by age, sex, and comorbidities. The Cox proportional hazards model was used to estimate hazard ratios for AF in both groups. RESULTS: Patients were more likely to develop AF throughout the 1-year follow-up period after the diagnosis of pneumonia. The incidence of AF was 1.2 (414/334,746) per 1000 person-months. Patients with pneumonia had a 4.08-fold (95% confidence interval 3.37-4.95) increased risk for AF compared to patients without pneumonia. CONCLUSION: Patients with pneumonia exhibited an increased risk for AF, especially in the early period after diagnosis of pneumonia.

Usage of Point-of-care Ultrasonography for Rapid Diagnosis of Acute Renal Infarction: Two Case Reports.

Acute renal infarction is a rare form of vascular emergency. Although major risk factors of renal infarction are due to cardio-embolic events such as atrial fibrillation, valvular or ischemic heart disease, renal artery thrombosis/dissection, and coagulopathy, the prevalence of idiopathic acute renal infarction can be as high as 59%. Two cases that contributed to this emergency are presented. The history, physical examination, and clinical imaging findings for clinical assessment are briefly described. Point-of-Care Ultrasonography (POCUS) was used to exclude other etiology and identify the pathological changes. The role of POCUS in rapid rule in acute renal infarction has been emphasized in clinical settings.

Rapid Detecting Brachial Plexus Injury by Point-of-Care Ultrasonography.

Brachial plexus injury (BPI) is regarded as one of the most devastating injuries of the upper extremity. Brachial plexus neuropathy can have a high morbidity by seriously affecting the motor function and sensation of upper limbs with loss of activities of daily living. The use of computed tomography myelogram and/or magnetic resonance imaging (MRI) assessing brachial plexus offers valuable details including the location, morphology, and severity of preganglionic and postganglionic injuries during the preoperative period. High-field-strength MRI with specific coil and specialized MRI sequences might be not available in every emergency setting and is time-consuming. Point-of-care ultrasonography (POCUS) comes in handy and offers good image resolution of muscles and nerves that makes early detection of neuromuscular injury possible. Here, we present a case report of BPI that POCUS provides indirect evidence of cervical root injury and expedite time to MRI.

CHA2DS2-VASc Score for Major Adverse Cardiovascular Events Stratification in Patients with Pneumonia with and without Atrial Fibrillation.

BACKGROUND: Recent studies have shown an association between CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category) score and outcome of acute myocardial infarction, stroke, and chest pain. As pneumonia can affect the cardiovascular system, this study aimed to investigate the performance of the CHA2DS2-VASc score for major adverse cardiovascular events (MACEs) risk stratification in patients with pneumonia. METHODS: A retrospective population-based cohort study including 61,843 patients with pneumonia. These patients were divided into two cohorts that were stratified based on the presence or absence of underlying atrial fibrillation (AF). We calculated the CHA2DS2-VASc score and incidence density rates of MACEs in each cohort. Cox regression was conducted to calculate hazard ratio of MACEs in pneumonia patients. The diagnostic performance of CHA2DS2-VASc with regard to MACEs was tested using the receiver operator characteristic curve. RESULTS: Pneumonia patients with higher CHA2DS2-VASc score were more likely develop MACEs in both the AF and non-AF groups. In the AF group, the areas under the curve (AUC), sensitivity, and specificity were 0.824 (0.7773-0.8708), 0.7, and 0.84 respectively. In the non-AF group, the AUC, sensitivity, and specificity were 0.8185 (0.8152-0.8217), 0.75, and 0.83 respectively. CONCLUSIONS: The CHA2DS2-VASc score showed good performance in the prediction of MACE in patients with pneumonia.

Non-Contrast-Enhancing Glioma Mimicking Acute Ischemic Stroke Within Three Hours of Onset.

Intravenous thrombolytic therapy is recommended within 3 hours of onset of acute ischemic stroke. However, stroke mimics create challenges because of time pressures. We describe a case of an undiagnosed glioma, a rarely reported condition, that was nearly treated with thrombolytic therapy. A 71-year-old man presented to the emergency department with sudden left gaze preference, right-sided hemiplegia, and global aphasia, which suggested a large infarction in the left hemisphere. The thrombolytic protocol was started at once. However, noncontrast computed tomography (CT) of the brain, CT angiography, and CT perfusion were essentially normal. Later, magnetic resonance imaging of the brain demonstrated a diffuse intracerebral lesion. The patient was found to have an undiagnosed diffuse glioma, whose initial neurologic symptoms mimicked acute stroke within 3 hours of onset. Cerebral neoplasms are an absolute contraindication for thrombolysis therapy. Several brain tumors are rarely seen on a brain CT scan. The mismatch between neurologic examination and brain perfusion imaging may suggest a stroke mimic in some cases.

Pre- and Post-Implementation of One-Hour Rule for the Boarding of Referral of Critically Ill Patients in the Emergency Department.

In 2017, the Taiwan Ministry of Health and Welfare established a regional electronic referral system in Central Taiwan to streamline transfers of critically ill patients from the intensive care unit (ICU) of a regional hospital to a medical hospital center. Moreover, in 2018, a one-hour rule for the boarding of referral of critically ill patients from emergency department (ED) to ICU was implemented. This pre- and post-implementation study enrolled consecutive critically ill referral patients from a single academic medical center hospital from January 1, 2017 to December 31, 2018. After implementation of the one-hour rule, two interventions, namely, active bed management before patient arrival and no requirement for laboratory test results to be completed before ICU admissions, were used to improve patient flow in the ED. After implementation of one-hour rule, the proportion of patients transferred to the ICU within 1 hour increased from 3.1% to 65.9% (p < 0.001). Median ED length of stay (LOS) reduced from 129.5 minutes to 52.0 minutes (p < 0.001). The overall mortality rate decreased from 34.4% to 26.8%, without a significant difference. In conclusion, the implementation of the one-hour rule for the boarding of referral of critically ill patients in the ED is safe and possible. Achieving the target significantly reduced ED LOS by 77.5 minutes without an increase in patient mortality rate.

Epidemiology and factors associated with mortality of thyroid storm in Taiwan: a nationwide population-based study.

Thyroid storm is a rare and life-threatening disease. However, its prevalence, incidence, and mortality rate in Chinese population are unknown. We performed a retrospective study using the Taiwan Health and Welfare Data. Patients admitted owing to thyrotoxicosis were divided into thyroid storm group and non-thyroid storm group. We assessed thyroid storm prevalence, incidence, complications, and mortality rate. Multiple Cox regression was performed to estimate the hazard ratio for the mortality risk. Overall, 1244 thyroid storm patients and 83,874 thyrotoxicosis patients without thyroid storm were included. Most thyroid storm patients were female (67.9%) with ages ranging from 30 to 44 years (33.4%), and most thyroid storm cases occurred during the summer season. The prevalence of thyroid storm was 1.48% (1244/83,874). The incidence rate of thyroid storm was 0.55 per 100,000 persons per year and 6.28 per 100,000 hospitalized patients per year. The overall 14-, 28-, and 90-day mortality rates of thyroid storm patients were 5.23%, 6.59%, and 8.12%, respectively. Thyroid storm, older age, male, and underlying ischemic stroke, myocardial infarction, heart failure, kidney disease, atrial fibrillation, depression, chronic obstructive pulmonary disease, diabetes mellitus, cancer, end stage renal diseases were associated with a significantly higher risk of mortality. In conclusion, the 90-day mortality rate of thyroid storm was high and was commonly associated with multiorgan failure and shock. Therefore, clinical physicians should identify thyroid storm and treat it accordingly.