Challenges in the diagnosis of Boerhaave syndrome: A case report.

RATIONALE: Acute chest pain remains one of the most challenging complaints of patients presenting to emergency departments (EDs). The diverse etiologies of chest pain frequently lead to diagnostic and therapeutic challenges. Esophageal perforation is a rare but potentially life-threatening disease. It results in delayed diagnosis and an estimated mortality risk of 20% to 40%. Prompt diagnosis and immediate therapeutic interventions are key factors for a good prognosis. PATIENT CONCERNS: Case 1 involved a 66-year-old man who presented to the ED with acute chest pain radiating to the back and hematemesis. Emergent contrast thoracic computerized tomography (CT) indicated the presence of a massive pneumothorax with pleural effusion. The continuous drainage of a dark-red bloody fluid following emergent thoracic intubation led to the discovery that the patient had experienced severe vomiting after whiskey consumption before admission to the hospital. Re-evaluation of the CT indicated spontaneous pneumomediastinum, whereas barium esophagography confirmed the presence of an esophageal perforation. Case 2 involved an 18-year-old Vietnamese man admitted to our ED with acute chest pain and swelling of the neck after vomiting due to beer consumption. A chest x-ray indicated diffuse subcutaneous emphysema of the neck and upper thorax. Contrast CT indicated pneumomediastinum with extensive emphysema and air in the paraspinal region and spinal canal. DIAGNOSES: Both of the 2 cases were diagnosed as spontaneous perforation of the esophagus (Boerhaave syndrome [BS]). INTERVENTIONS: Case 1 received surgical interventions, whereas case 2 decided not to avail our medical services. OUTCOMES: Case 1 was discharged after a good recovery. Case 2 lost to follow-up. LESSONS: We recommend all physicians in the ED to raise their index of suspicion for BS when dealing with patients having acute chest pain, dyspnea, confirmed pneumothorax, or newly-developed pleural effusion.

Risk of aortic dissection, congestive heart failure, pneumonia and acute respiratory distress syndrome in patients with clinical vertebral fracture: a nationwide population-based cohort study in Taiwan.

OBJECTIVE: Studies on the association between clinical vertebral fractures (CVFs) and the subsequent risk of cardiopulmonary diseases, including aortic dissection (AD), congestive heart failure (CHF), pneumonia and acute respiratory distress syndrome (ARDS) are scarce. Therefore, we used the National Health Insurance Research Database to investigate whether patients with CVF have a heightened risk of subsequent AD, CHF, pneumonia and ARDS. DESIGN: The National Health Insurance Research Database was used to investigate whether patients with CVFs have an increased risk of subsequent AD, CHF, pneumonia and ARDS. PARTICIPANTS: This cohort study comprised patients aged ≥18 years with a diagnosis of CVF and were hospitalised at any point during 2000-2010 (n=1 08 935). Each CVF patient was frequency-matched to a no-CVF hospitalised patients based on age, sex, index year and comorbidities (n=1 08 935). The Cox proportional hazard regressions model was used to estimate the adjusted effect of CVF on AD, CHF, pneumonia and ARDS risk. RESULTS: The overall incidence of AD, CHF, pneumonia and ARDS was higher in the CVF group than in the no-CVF group (4.85 vs 3.99, 119.1 vs 89.6, 283.3 vs 183.5 and 9.18 vs 4.18/10 000 person-years, respectively). After adjustment for age, sex, comorbidities and Charlson comorbidity index score, patients with CVF had a 1.23-fold higher risk of AD (95% CI=1.03-1.45), 1.35-fold higher risk of CHF (95% CI=1.30-1.40), 1.57-fold higher risk of pneumonia (95% CI=1.54-1.61) and 2.21-fold higher risk of ARDS (95% CI=1.91-2.57) than did those without CVF. Patients with cervical CVF and SCI were more likely to develop pneumonia and ARDS. CONCLUSIONS: Our study demonstrates that CVFs are associated with an increased risk of subsequent cardiopulmonary diseases. Future investigations are encouraged to delineate the mechanisms underlying this association.

Risk of Dementia in Patients with Leptospirosis: A Nationwide Cohort Analysis.

BACKGROUND: Studies have linked some bacterial infections with an increased likelihood for development of dementia. However, there is a paucity of data on the relationship between dementia and leptospirosis. In view of this, we conducted a retrospective cohort study to determine whether leptospirosis is a risk factor for dementia. METHODS: Data were collected from the Taiwan National Health Insurance Research Databases (2000-2010) to investigate the incidence of and risk factors for dementia in patients with leptospirosis. Patients with leptospirosis who did not have a history of dementia were enrolled in the study. For each leptospirosis patient, four controls were randomly selected after frequency matching of age, sex, and index date. Cox proportional hazard regression models were used for the analyses of dementia risk. RESULTS: A greater risk of dementia was observed in the leptospirosis cohort than in the non-leptospirosis cohort both in patients without any comorbidity (adjusted HR (aHR) = 1.23, 95% CI = 1.06-1.43) and with a comorbidity (aHR = 2.06, 95% CI = 1.7-2.5). Compared with the non-leptospirosis cohort without these comorbidities, the leptospirosis cohort with ≥2 comorbidities exhibited a significantly increased risk of dementia (aHR = 6.11, 95% CI = 3.15-11.9), followed by those with any one comorbidity (adjusted HR = 3.62, 95% CI = 1.76-7.46). CONCLUSIONS: Patients with leptospirosis were at a 1.89-fold greater risk of subsequent dementia, but potential genetic susceptibility bias in the study group is a major confound.

Scrub typhus and depression: a nationwide cohort analysis.

BACKGROUND: Studies on the relationship between depression and scrub typhus are limited. We conducted a retrospective cohort study to investigate whether scrub typhus is a risk factor for depression. METHODS: Using Taiwan's National Health Insurance Research Database, this study investigated the incidence of depression, and its risk factors, in patients diagnosed with scrub typhus between 2000 and 2010. Scrub typhus patients who did not have a history of depression before the index date were enrolled. For each patient with scrub typhus, four controls without a history of scrub typhus and depression were randomly selected and frequency matched by sex, age, year of the index date, and comorbidities. The follow-up period was from the time of initial scrub typhus diagnosis to the date of diagnosis of depression, censoring, or December 31, 2010. Cox proportional hazards regression models were used to analyze the risk of depression according to sex, age, and comorbidities. RESULTS: The study comprised a 5238-patient scrub typhus group and a 20,952-patient non-scrub typhus group with similar sex and age distributions. During the follow-up period, the cumulative incidence of depression was higher in the scrub typhus than the non-scrub typhus group (log-rank test P < 0.001). In the scrub typhus group, 45 patients developed depression, yielding an incidence rate of 1.67 per 1000 person-years, and in the non-scrub typhus group, 117 patients developed depression, yielding an incidence rate of 1.08 per 1000 person-years. This yielded a crude hazard ratio (HR) of 1.55 (95% confidence interval [CI] 1.41-1.70) and adjusted HR (aHR) of 1.56 (95% CI 1.42-1.71). Compared with the non-scrub typhus group, the risk of depression in the scrub typhus group was higher in patients of both sexes (men: aHR = 1.46, 95% CI 1.29-1.64; women: aHR = 1.68, 95% CI 1.45-1.96), in patients aged younger than 65 (≤ 49 years: aHR = 1.95, 50-64 years: aHR = 1.73), and in patients without comorbidities (aHR = 2.06, 95% CI 1.85-2.29). CONCLUSIONS: The risk of depression was 1.56-fold higher in patients with scrub typhus than in the general population.

Increased risk of deep vein thrombosis and pulmonary thromboembolism in patients with aortic aneurysms: A nationwide cohort study.

Studies on the association between aortic aneurysm (AA) and the subsequent risk of venous thromboembolism (VTE) are limited to a few case reports and investigations which only focused on surgical effects. Therefore, we used the National Health Insurance Research Database to clarify whether patients with AAs have a heightened risk of subsequent VTEs, including deep vein thrombosis (DVT) and pulmonary embolism (PE). Our retrospective cohort study comprised patients aged ≥ 18 years who received a diagnosis of an AA and were hospitalized at any point during 2000-2010 (n = 16,630). Each AA patient was frequency-matched to 4 non-AA hospitalized patients based on age, sex, and index year (n = 66,453). The Cox proportional hazard regressions model was used to estimate the adjusted effect of AAs on VTE risk. The overall incidence of DVT and PE was higher in the patients with AA than in the non-AA group patients (23.5 versus 13.2 and 13.5 versus 7.98/1,000 person-years). After adjustment for age, sex, duration of hospitalization in the study period, and comorbidities, patients with AAs were associated with a 1.88-fold higher risk of DVT and 1.90-fold higher risk of PE compared to the non-AA cohort. Patients with abdominal AAs were more likely to develop DVT, whereas thoracic AA patients were more likely to develop PE. A diagnosis of a ruptured AA was associated with a substantially increased risk of DVT. Surgical treatment of AAs was associated with a heightened risk of VTE within 6-months post-operation. Our study demonstrates that AAs are associated with an increased risk of subsequent VTE. Future investigations are encouraged to delineate the mechanisms underlying this association and to evaluate the cost-effectiveness of screening for VTEs in patients with AAs.

Leptospirosis and Depression: A Nationwide Cohort Analysis.

OBJECTIVE: We conducted a retrospective cohort study to investigate whether leptospirosis is a risk factor for depression. METHOD: From the Taiwan National Health Insurance Research Database between 2000 and 2010, patients with leptospirosis (ICD-9 code 100) who did not have a history of depression (ICD-9-CM codes 296.2, 296.3, 300.4, and 311) before the index date were enrolled (leptospirosis cohort). For each patient with leptospirosis, 1 control without a history of leptospirosis and depression was randomly selected (nonleptospirosis cohort). Cox proportional hazards regression models were used to analyze the risk of depression according to sex, age, and comorbidities. RESULTS: In the leptospirosis and nonleptospirosis cohorts, we observed 34 patients with depression, with the incidence rate of 2.87 per 1,000 person-years, and 25 patients with depression, with the incidence rate of 1.93 per 1,000 person-years, respectively, yielding a crude hazard ratio (HR) of 1.49 (95% confidence interval [CI], 1.25-1.77) and an adjusted HR (aHR) of 1.58 (95% CI, 1.34-1.88). Compared with the nonleptospirosis cohort, the leptospirosis cohort had a risk of depression stratified by sex, age, and comorbidity that was higher in female patients (aHR = 2.08; 95% CI, 1.54-2.80), patients younger than 49 years old (aHR = 3.19; 95% CI, 2.39-4.27), and patients without comorbidity (aHR = 2.14; 95% CI, 1.68-2.71). The risk of depression was higher in women than in men (aHR = 1.90; 95% CI, 1.61-2.25) and in patients with comorbidities, namely hyperlipidemia (aHR = 1.80; 95% CI, 1.40-2.31), coronary artery disease (aHR = 2.47; 95% CI, 1.96-3.12), stroke (aHR = 1.77; 95% CI, 1.39-2.24), and septicemia (aHR = 2.06; 95% CI, 1.64-2.58). CONCLUSIONS: Patients with leptospirosis have a 1.58-fold higher risk of depression than that in the general population. Physicians should be alert to the emotional condition and depression symptoms of people who had been suffering from leptospirosis.

Leptospirosis and Peripheral Artery Occlusive Disease: A Nationwide Cohort Analysis.

Data on the association between peripheral artery occlusive disease (PAOD) and leptospirosis are limited. We conducted a retrospective cohort study for determining whether leptospirosis is one of the possible risk factors for PAOD. Patients diagnosed with leptospirosis by using 2000 to 2010 data from the Taiwan National Health Insurance Research Database. Patients with leptospirosis without a history of PAOD were selected. For each leptospirosis patient, 4 controls without a history of leptospirosis and PAOD were randomly selected and frequency-matched for sex, age, the year of the index date, and comorbidity diseases. The follow-up period was from the time of the initial diagnosis of leptospirosis to the diagnosis date of PAOD, or December 31, 2011. The Cox proportional hazard regression models were used for analyzing the risk of PAOD. During the follow-up period, the cumulative incidence of PAOD was higher among the patients from the leptospirosis cohort than among the nonleptospirosis cohort (log-rank test, P < 0.001). In total, 29 patients with PAOD from the leptospirosis cohort and 81 from the nonleptospirosis cohort were observed with the incidence rates of 2.1 and 1.3 per 1000 person-years, respectively, yielding a crude hazards ratio (HR) of 1.62 (95% confidence interval [CI] = 1.44-1.81) and adjusted HR (aHR) of 1.75 (95% CI = 1.58-1.95).The risk of PAOD was 1.75-fold higher in the patients with leptospirosis than in the general population.

Organophosphate Poisoning and Subsequent Acute Kidney Injury Risk: A Nationwide Population-Based Cohort Study.

Small numbers of the papers have studied the association between organophosphate (OP) poisoning and the subsequent acute kidney injury (AKI). Therefore, we used the National Health Insurance Research Database (NHIRD) to study whether patients with OP poisoning are associated with a higher risk to have subsequent AKI.The retrospective cohort study comprised patients aged ≥20 years with OP poisoning and hospitalized diagnosis during 2000-2011 (N = 8924). Each OP poisoning patient was frequency-matched to 4 control patients based on age, sex, index year, and comorbidities of diabetes, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, coronary artery disease, and stroke (N = 35,696). We conducted Cox proportional hazard regression analysis to estimate the effects of OP poisoning on AKI risk.The overall incidence of AKI was higher in the patients with OP poisoning than in the controls (4.85 vs 3.47/1000 person-years). After adjustment for age, sex, comorbidity, and interaction terms, patients with OP poisoning were associated with a 6.17-fold higher risk of AKI compared with the comparison cohort. Patients with highly severe OP poisoning were associated with a substantially increased risk of AKI.The study found OP poisoning is associated with increased risk of subsequent AKI. Future studies are encouraged to evaluate whether long-term effects exist and the best guideline to prevent the continuously impaired renal function.

Carbon monoxide poisoning and subsequent cardiovascular disease risk: a nationwide population-based cohort study.

Carbon monoxide (CO) poisoning is considered one of the most crucial health concerns. Few studies have investigated the correlation between CO poisoning and the risk of developing cardiovascular diseases (CVDs). Therefore, we conducted a population-based, longitudinal cohort study in Taiwan to determine whether patients with CO poisoning are associated with higher risk of developing subsequent CVDs, including arrhythmia, coronary artery disease (CAD) and congestive heart failure (CHF). This retrospective study used the National Health Insurance Research Database. The study cohort comprised all patients aged ≥20 years with a diagnosis of CO poisoning and hospitalized during 2000 to 2011 (N = 8381), and the comparison cohort comprised randomly selected non-CO-poisoned patients (N = 33,524) frequency-matched with the study cohort by age, sex, and the year of index date. Each patient was individually tracked to identify those who develop CVD events during the follow-up period. Cox proportional hazards regression model was performed to calculate the hazard ratios of CVDs after adjusting for possible confounders. The overall incidences of arrhythmia, CAD, and CHF were higher in the patients with CO poisoning than in the controls (2.57 vs 1.25/1000 person-years, 3.28 vs 2.25/1000 person-years, and 1.32 vs 1.05/1000 person-years, respectively). After adjusting for age, sex, and comorbidities, the patients with CO poisoning were associated with a 1.83-fold higher risk of arrhythmia compared with the comparison cohort, and nonsignificantly associated with risk of CAD and CHF. CO-poisoned patients with coexisting comorbidity or in high severity were associated with significantly and substantially increased risk of all 3 CVDs. CO poisoning is associated with increased risk of subsequent development of arrhythmia. Future studies are required to explore the long-term effects of CO poisoning on the cardiovascular system.