Examining patient flow in a tertiary hospital's emergency department at a low coronavirus prevalence region.

BACKGROUND: Taiwan's successful containment of the COVID-19 outbreak prior to 2021 provided a unique environment for the surveillance of unnecessary emergency medical use. The aim of the study is to examine the impact of the coronavirus disease (COVID-19) pandemic on the patient flow in the emergency department (ED) of a tertiary hospital over 1 year in southern Taiwan, a region with low COVID-19 prevalence. METHODS: Cross-sectional observational study was conducted from January to December 2020. Essential parameters of patient flow in the ED between January and February 2020 and the subsequent 11-month period were compared to data from 2019. Data were analyzed with descriptive statistics, using an independent sample t-test or Mann-Whitney U test, as applicable. RESULTS: The ED census showed an acute decline (- 30.8%) from January to February 2020, reaching its nadir (- 40.5%) in April 2020. From February to December 2020, there was an average decrease of 20.3% in ED attendance (p < 0.001). The impact was most significant in ambulatory visits, lower-urgency acuity (level III) visits, and pediatric visits, without change in the acuity proportion. The length of stay shortened mainly in the adult division, which typically had an overcrowding problem (median, 5.7-4.4 hours in discharge; 24.8-16.9 hours in hospitalization; p < 0.001). The incidence of 72-hour unscheduled return visits was also reduced (4.1-3.5%, p = 0.002). CONCLUSIONS: In contrast to devastated regions, the impact on the ED patient flow in regions having low COVID-19 prevalence highlights a remodeling process of emergency medical care that would improve overcrowding.

Syphilis and ischemic stroke: Old question revisited by a nationwide cohort study.

BACKGROUND AND PURPOSE: In the era of easily available antibiotic use, this study provides epidemiological evidence for a re-examination of the relationship between syphilis and ischemic stroke (IS). METHODS: Patients aged 18 years and older with newly diagnosed syphilis were included (n = 1585) from 2000 to 2012, and participants without syphilis in the control group (n = 6340) were matched by propensity score (age, sex, index year, insured amount, urbanization, seasons, and comorbidities). The Cox proportional hazard model was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) of IS. Five different Cox regression models, sensitivity analyses, and negative control were conducted to test our findings. RESULTS: In all, 1585 patients (1055 (66.56%) men; mean (SD) age, 49.59 (20.32) years) had syphilis, and 3.8% had new-onset IS. The syphilis group had a higher risk of IS than the controls (adjusted HR, 1.35; 95% CI, 1.01-1.80; p value < 0.05) after full adjustment. Serial sensitivity analyses yielded consistent results. CONCLUSION: Syphilis patients have higher risk of IS, and our data raise the question of implementation of prophylactic treatment for IS.

Laryngopharyngeal reflux image quantization and analysis of its severity.

Laryngopharyngeal reflux (LPR) is a prevalent disease affecting a high proportion of patients seeking laryngology consultation. Diagnosis is made subjectively based on history, symptoms, and endoscopic assessment. The results depend on the examiner's interpretation of endoscopic images. There are still no consistent objective diagnostic methods. The aim of this study is to use image processing techniques to quantize the laryngeal variation caused by LPR, to judge and analyze its severity. This study proposed methods of screening sharp images automatically from laryngeal endoscopic images and using throat eigen structure for automatic region segmentation. The proposed image compensation improved the illumination problems from the use of laryngoscope lens. Fisher linear discriminant was used to find out features and classification performance while support vector machine was used as the classifier for judging LPR. Evaluation results were 97.16% accuracy, 98.11% sensitivity, and 3.77% false positive rate. To evaluate the severity, quantized data of the laryngeal variation was used. LPR images were combined with reflux symptom index score chart, and severity was graded using a neural network. The results indicated 96.08% accuracy. The experiment indicated that laryngeal variation induced by LPR could be quantized by using image processing techniques to assist in diagnosing and treating LPR.

Occurrence and distribution of pharmaceutical compounds in the Danshuei River Estuary and the Northern Taiwan Strait.

Ten pharmaceutically active compounds (PhACs) were determined in northern Taiwan estuarine waters and Taiwan Strait (TS) seawater. The ecological risk of these PhACs was assessed using risk quotient (RQ), which is the ratio of the measured maximum concentration to the predicted no-effect concentration. Six PhACs were detected within the estuarine waters. Caffeine concentration (130-718 ng l-1) was the highest among the analyzed PhACs. The distribution of PhACs in the Danshuei River Estuary generally exhibited addition behavior, except that caffeine showed conservative behavior. Carbamazepine, gemfibrozil, caffeine, and ketoprofen were detected in TS seawaters. Their concentrations follow the sequence: gemfibrozil > ketoprofen > caffeine > carbamazepine. The caffeine concentrations in TS seawaters were 2-3 orders of magnitude lower than those in Danshuei estuarine waters. With few exceptions for caffeine, erythromycin, and sulfadiazine posing low risk in some estuarine waters, most of the RQ values were <0.01, suggesting no adverse effects on aquatic organisms.

Disseminated Nocardiosis with Lung, Liver and Spleen Abscesses in Sweet Syndrome: A Case Report.

Hepatic abscesses are rarely encountered in disseminated nocardia infections. We report a rare case of idiopathic Sweet syndrome (SS) who responded well to steroid therapy. However, he developed multiple abscesses in the lung, liver and spleen after 6 months of systemic steroid therapy. The culture result from liver abscess and sputum was diagnostic of disseminiated nocardiosis. Intravenous sulfamethoxazole/trimethoprim was given and follow-up computed tomography (CT) scan revealed resolution of abscess. To conclude, nocardiosis should be suspected as a likely cause of lung, liver and spleen abscesses in patients undergoing long-term steroid treatment. A high index of clinical suspicion in patients with defects in cell-mediated immunity and prompt management by appropriate image studies are needed to prevent delay in diagnosis.

The role of autonomic nervous system function in hypothermia-mediated sepsis protection.

OBJECTIVE: The objective of this study is to determine whether hypothermia will lessen decreases in heart rate variability and improve outcome in a rat model of sepsis. METHODS: Thirty-six male Sprague-Dawley rats were randomized into 3 groups: control, low sepsis, and high sepsis groups. These groups were each subdivided into a normothermia (37°C) (n = 6) and a hypothermia group (34°C) (n = 6). Cyclophosphamide (100 mg/kg) was administered 5 days before Staphylococcus aureus injection to produce conditions in which sepsis could be induced reliably. Hypothermic rats received temperature reduction for 1 hour post injection. Electrocardiogram was recorded before, after, and 1 day after staphylococcal injection, and the low frequency, high frequency (HF), and LF/HF ratio measurements of heart rate variability and the frequencies of arrhythmia were recorded. The effects of time, sepsis severity, and hypothermia on these variables were analyzed using a multivariate generalized estimation equation mode. RESULTS: Four deaths occurred in the normothermic group, and none, in the hypothermic group. Sepsis of both low and high severity increased low frequency and HF 1 day after sepsis induction. Hypothermia significantly decreased HF in low, but not high sepsis severity. CONCLUSIONS: Hypothermia decreased mortality in septic rats. The influence of hypothermia on HF depended on the severity of the sepsis.

Clinical manifestations of nontyphoid salmonellosis in children younger than 2 years old--experiences of a tertiary hospital in southern Taiwan.

BACKGROUND: Few published studies have explored the clinical manifestations of nontyphoid salmonellosis in children <2 years of age. The aim of this study was to investigate the clinical manifestations, microbiological features, complications, fecal excretion time, and responses to treatment in children <2 years of age with nontyphoid salmonellosis. METHODS: Between January 2005 and December 2009, pediatric patients who were admitted to Kaohsiung Veterans General Hospital with positive cultures for nontyphoid Salmonella were enrolled. The following data were recorded: demographic, clinical, and microbiological features, underlying diseases, treatment regimen, complications, responses to treatment, and fecal excretion time. The clinical manifestations were compared between patients <2 years of age and patients >2 years of age. RESULTS: Of a total 279 enrolled patients, 179 were >2 years of age. Compared with the patients who were ≥2 years of age, patients <2 years of age demonstrated a significantly higher incidence of bloody stool, mixed infection, extraintestinal infection, longer course of antibiotics, longer course of diarrhea after admission, and more days spent in the hospital. The rates of insusceptibility of nontyphoid Salmonella to ampicillin, chloramphenicol, trimethoprim/sulfamethoxazole, ceftriaxone, and ciprofloxacin in patients <2 years of age were 37.87%, 29.09%, 23.73%, 3.26%, and 2.25%, respectively. Younger patients were generally more susceptible to antibiotics than patients ≥2 years of age, although this result was not statistically significant. CONCLUSION: The clinical manifestations of nontyphoid salmonellosis are more severe in younger children <2 years of age than older children. Local susceptibility patterns could serve as a guide for the prescription of antibiotics by clinicians.

Isolated pathogens and clinical outcomes of adult bacteremia in the emergency department: a retrospective study in a tertiary Referral Center.

BACKGROUND: Approximately two-thirds of the patients with severe sepsis or septic shock are first encountered in the emergency departments (EDs) of western countries, in which bacteremia is present in about 50% of patients with severe sepsis. The situation of bacteremia presenting to the EDs in Taiwan is not well documented. The objective of this study was to examine the epidemiology and microbiology of bacteremia in adult patients who visited the ED of a medical center in southern Taiwan. METHODS: A retrospective observational study of the epidemiology and microbiology of bacteremia was conducted in the ED of a medical center involving 6,137 adult patients and 13,903 blood cultures. RESULTS: A total of 831 consecutive patients with 890 episodes of bacteremia were obtained from January 1 to December 31, 2004, indicating a positive culture rate of 13.5% (1,872/13,903). Among these episodes, 525 (59%) were defined as true community-acquired infections followed by 263 (29.5%) as health care-associated infections and 102 (11.5%) as nosocomial infections. Of the 972 isolates, 289 (29.7%) were gram-positive species and 683 (70.3%) were gram-negative species. Urinary tract infections (32.2%, 287/890) were most common in these patients, with Escherichia coli (30.8%, 299/972) being the most common pathogen. Bacteremia caused by Staphylococcus aureus was more common in nosocomial than true community-acquired infections (31.3% vs. 12%) and had significantly higher possibility of resistance to methicillin in infections not purely acquired from community (odds ratio = 24.92; 95% confidence interval, 9.88-62.87). The overall crude mortality rate was 21% and nearly half of the mortalities occurred within 3 days of visiting the ED. All patients discharged inadvertently were uneventful (n = 65, two lost at follow-up). CONCLUSIONS: Categories of bacteremia acquisition was associated with different distribution of pathogens, antimicrobial resistance, and clinical outcome. Traditional classification might overestimate the problem of drug resistance in community-acquired infections. The concept of health care-associated infection should be introduced to avoid overemphasis of drug-resistant problem in true community-acquired infection.

Pyogenic liver abscess caused by Burkholderia pseudomallei in Taiwan.

Pyogenic liver abscess in Taiwan is a well-known disease entity, commonly associated with a single pathogen, Klebsiella pneumoniae. Melioidosis is an endemic disease in Taiwan that can manifest as multiple abscesses in sites including the liver. We report three cases of liver abscesses caused by Burkholderia pseudomallei. The first patient was a 54-year-old diabetic woman, who presented with liver abscess and a left subphrenic abscess resulting from a ruptured splenic abscess, co-infected with K. pneumoniae and B. pseudomallei. The second patient, a 58-year-old diabetic man, developed bacteremic pneumonia over the left lower lung due to B. pseudomallei with acute respiratory distress syndrome, and relapsed 5 months later with bacteremic abscesses of the liver, spleen, prostate and osteomyelitis, due to lack of compliance with prescribed antibiotic therapy. The third patient was a 61-year-old diabetic man with a history of travel to Thailand, who presented with jaundice and fever of unknown origin. Liver and splenic abscesses due to B. pseudomallei were diagnosed. A high clinical alertness to patients' travel history, underlying diseases, and the presence of concomitant splenic abscess is essential to early detection of the great mimicker, melioidosis. The treatment of choice is intravenous ceftazidime for at least 14 days or more. An adequate duration of maintenance oral therapy, with amoxicillin-clavulanate or trimethoprim-sulfamethoxazole for 12-20 weeks, is necessary to prevent relapse. Liver abscess in Taiwan is most commonly due to K. pneumoniae, but clinicians should keep in mind that this may be a presenting feature of melioidosis.

Human metapneumovirus as a causative agent of lower respiratory tract infection in four patients: the first report of human metapneumovirus infection confirmed by RNA sequences in Taiwan.

Human metapneumovirus (HMPV) has been described as a human pathogen associated with respiratory disease in most parts of the world from all age groups. This report presents the first 4 cases of HMPV disease confirmed by the sequences of PCR products in Taiwan.

Abbreviated duration of superheat-and-flush and disinfection of taps for Legionella disinfection: lessons learned from failure.

One medical center in southern Taiwan faced an outbreak of nosocomial Legionnaires' disease; a total of 81 suspected cases were detected during an 8-month period. Baseline environmental surveillance showed that 80% of the distal sites in intensive care units (ICUs) were positive for Legionella pneumophila. Superheat-and-flush was selected for hospital water supply disinfection because it required no special equipment, and it can be initiated expeditiously. We conducted 2 episodes of superheat-and-flush based on the published recommendations from the Department of Health, Taiwan; US Centers for Disease Control and Prevention; and American Society of Heating, Refrigerating, and Air-Conditioning Engineers. Both flushes failed to control colonization of Legionella in the hospital water supply. The rate of distal sites positive for Legionella in wards and ICUs was 14% and 66%, respectively, 10 days after the second flush. The effect of replacement of faucets and showerheads in ICUs appeared to be insignificant in colonization of Legionella. The application of superheat-and-flush for flush duration of 5 minutes was ineffective. Superheat-and-flush may not be economic for a large medical center because it could be costly and labor intensive.

Characteristics of a dengue hemorrhagic fever outbreak in 2001 in Kaohsiung.

A dengue outbreak occurred in Kaohsiung City starting in July in 2001. We studied the clinical profile of all patients admitted to Kaohsiung Veterans General Hospital during this outbreak from July 2001 to January 2002. A total of 25 cases of clinically suspected dengue fever were treated during this period, and 13 of them were confirmed by laboratory results (13/25; 52%). Eleven of the 25 patients (11/25; 44%) were admitted. The mean age of the patients with laboratory confirmation of infection was 53 years (range, 7 to 85 years). Headache (7/13; 53.8%), bone pain (8/13; 61.5%), myalgia (10/13; 76.9%), abdominal pain (7/13; 53.8%), and skin rash (9/13; 69.2%) were the most common presentations. A high proportion of patients were classified as having dengue hemorrhagic fever (DHF) [6/13; 46.2%] and 2 of these patients had dengue shock syndrome (DSS) based on the World Health Organization criteria. Pretibial petechia (6/13; 46.1%), gastrointestinal bleeding (6/13; 46.1%), and hemoptysis (4/13; 30.8%) were the most common hemorrhagic manifestations. The average hospital stay was 7.1 days. Thrombocytopenia was very common and 84.6% patients had a platelet count less than 100,000/mm3. Monocytosis was found in all patients. Few patients required blood or platelet concentrate transfusion. The 2 patients who developed DSS both survived. All patients recovered completely without any obvious sequela. In conclusion, there was a high percentage of DHF among patients in the dengue outbreak in 2001. Increasing rates of DHF compared to previous reports from Taiwan may be a sign of hyperendemicity (multiple serotypes present) of the dengue virus in Kaohsiung City and its greater likelihood elsewhere in Taiwan. Prevention and control of both dengue fever and DHF have thus become increasingly important.

Outbreak of aseptic meningitis among adults in southern Taiwan.

A total of 38 adult cases of aseptic meningitis were diagnosed based on clinical manifestations as well as examination of cerebrospinal fluid at Kaohsiung Veterans General Hospital in 2001. The majority (31 cases, 82%) of cases occurred between June and August, and most (33 cases, 87%) of them aged from 18 to 35 years (median age, 25 years). The male-to-female ratio was 2.16:1. Common clinical presentations included headache, fever, nausea or vomiting, and symptoms of common cold. On initial cerebrospinal fluid examination, white cell counts were above 500 cells/mm3 in 7 (18%) cases, and neutrophils predominated in 10 (28%) of 36 cases. The cerebrospinal fluid protein concentration was below 100 mg/dL in 29 (77%) of 38 cases, and hypoglycorrhachia (cerebrospinal fluid/serum glucose ratio <0.5) was seen in 9 (24%) cases. Enterovirus as a definite etiology was confirmed by isolation from cerebrospinal fluid in 17 (45%) of 38 cases and was the presumptive etiology by isolation from the stool or throat swab in 2 (5%) cases. Of the 19 cases with positive viral isolation, echovirus serotype 30 accounted for the majority (15 cases, 79%), followed by echovirus serotype 6 (3 cases, 16%), with one (5%) case undetermined. The viral isolation rate from cerebrospinal fluid correlated to the day of cerebrospinal fluid sampling after disease onset (chi2 = 12.05, p = 0.007). All patients were discharged uneventfully without receiving antibiotic therapy.

Mycobacteriosis in patients with fever of unknown origin.

Fever of unknown origin (FUO) is a common syndrome. A total of 94 patients (57 men and 37 women; mean age, 56.3 +/- 19 years, range, 18-86 years) who met the criteria of FUO were included in this study. Mycobacteriosis was diagnosed in 22 (23%) of these patients (13 men and 9 women), including 9 with disseminated disease and 13 with pulmonary disease. There was no significant statistical difference in age, sex, short-term survival status (3 months), and other clinical parameters between patients with and without mycobacteriosis. Clinical manifestations may be specific or nonspecific. The most common initial presentations in patients with mycobacteriosis were respiratory tract symptoms, mainly of cough and dyspnea, observed in 11 (50%) patients, and disturbance of consciousness in 6 (27%). The associated conditions included malnutrition (4 patients, 18%), diabetes mellitus (3, 14%), and renal failure (3, 14%). Four (18%) patients had a history of pulmonary tuberculosis or tuberculous spondylitis in their early adulthood. The 2 most common findings on chest radiograph were interstitial (41%) and nonspecific infiltrative (32%) patterns. In conclusion, mycobacteriosis remains the leading cause of FUO in southern Taiwan and it is important to screen for this treatable disease in all cases of FUO.