Functional identification of specialized diterpene synthases from Chamaecyparis obtusa and C. obtusa var. formosana to illustrate the putative evolution of diterpene synthases in Cupressaceae.

Chamaecyparis obtusa and C. obtusa var. formosana of the Cupressaceae family are well known for their fragrance and excellent physical properties. To investigate the biosynthesis of unique diterpenoid compounds, diterpene synthase genes for specialized metabolite synthesis were cloned from C. obtusa and C. obtusa var. formosana. Using an Escherichia coli co-expression system, eight diterpene synthases (diTPSs) were characterized. CoCPS and CovfCPS are class II monofunctional (+)-copalyl diphosphate synthases [(+)-CPSs]. Class I monofunctional CoLS and CovfLS convert (+)-copalyl diphosphate [(+)-CPP] to levopimaradiene, CoBRS, CovfBRS1, and CovfBRS3 convert (+)-CPP to (-)-beyerene, and CovfSDS converts (+)-CPP to (-)-sandaracopimaradiene. These enzymes are all monofunctional diterpene syntheses in Cupressaceae family of gymnosperm, and differ from those in Pinaceae. The discovery of the enzyme responsible for the biosynthesis of tetracyclic diterpene (-)-beyerene was characterized for the first time. Diterpene synthases with different catalytic functions exist in closely related species within the Cupressaceae family, indicating that this group of monofunctional diterpene synthases is particularly prone to the evolution of new functions and development of species-specific specialized diterpenoid constituents.

Effectiveness of Blended Versus Traditional Refresher Training for Cardiopulmonary Resuscitation: Prospective Observational Study.

BACKGROUND: Generally, cardiopulmonary resuscitation (CPR) skills decline substantially over time. By combining web-based self-regulated learning with hands-on practice, blended training can be a time- and resource-efficient approach enabling individuals to acquire or refresh CPR skills at their convenience. However, few studies have evaluated the effectiveness of blended CPR refresher training compared with that of the traditional method. OBJECTIVE: This study investigated and compared the effectiveness of traditional and blended CPR training through 6-month and 12-month refresher sessions with CPR ability indicators. METHODS: This study recruited participants aged ≥18 years from the Automated External Defibrillator Donation Project. The participants were divided into 4 groups based on the format of the CPR training and refresher training received: (1) initial traditional training (a 30-minute instructor-led, hands-on session) and 6-month traditional refresher training (Traditional6 group), (2) initial traditional training and 6-month blended refresher training (an 18-minute e-learning module; Mixed6 group), (3) initial traditional training and 12-month blended refresher training (Mixed12 group), and (4) initial blended training and 6-month blended refresher training (Blended6 group). CPR knowledge and performance were evaluated immediately after initial training. For each group, following initial training but before refresher training, a learning effectiveness assessment was conducted at 12 and 24 months. CPR knowledge was assessed using a written test with 15 multiple-choice questions, and CPR performance was assessed through an examiner-rated skill test and objectively through manikin feedback. A generalized estimating equation model was used to analyze changes in CPR ability indicators. RESULTS: This study recruited 1163 participants (mean age 41.82, SD 11.6 years; n=725, 62.3% female), with 332 (28.5%), 270 (23.2%), 258 (22.2%), and 303 (26.1%) participants in the Mixed6, Traditional6, Mixed12, and Blended6 groups, respectively. No significant between-group difference was observed in knowledge acquisition after initial training (P=.23). All groups met the criteria for high-quality CPR skills (ie, average compression depth: 5-6 cm; average compression rate: 100-120 beats/min; chest recoil rate: >80%); however, a higher proportion (98/303, 32.3%) of participants receiving blended training initially demonstrated high-quality CPR skills. At 12 and 24 months, CPR skills had declined in all the groups, but the decline was significantly higher in the Mixed12 group, whereas the differences were not significant between the other groups. This finding indicates that frequent retraining can maintain high-quality CPR skills and that blended refresher training is as effective as traditional refresher training. CONCLUSIONS: Our findings indicate that 6-month refresher training sessions for CPR are more effective for maintaining high-quality CPR skills, and that as refreshers, self-learning e-modules are as effective as instructor-led sessions. Although the blended learning approach is cost and resource effective, factors such as participant demographics, training environment, and level of engagement must be considered to maximize the potential of this approach. TRIAL REGISTRATION: IGOGO NCT05659108; https://www.cgmh-igogo.tw.

Effects of Dispatcher-Assisted Public-Access Defibrillation Programs on the Outcomes of Out-of-Hospital Cardiac Arrest: A Before-and-After Study.

BACKGROUND: Public access defibrillation (PAD) programs have been implemented globally over the past decade. Although PAD can substantially increase the survival of cardiac arrest, PAD use remains low. This study aimed to evaluate whether drawing upon the successful experiences of dispatcher-assisted cardiopulmonary resuscitation programs would increase the use of PAD in dispatcher-assisted PAD programs. METHODS AND RESULTS: This study using a before-and-after design was conducted in Taoyuan City using a local out-of-hospital cardiac arrest registry system and data of dispatcher performance derived from audio recordings. The primary outcomes were the rate of bystander PAD use, sustained return of spontaneous circulation, survival to discharge, and favorable neurological outcomes. The secondary outcomes were the performance of dispatchers in terms of PAD instruction and dispatcher-assisted cardiopulmonary resuscitation administration, the time interval indicators of dispatcher-assisted cardiopulmonary resuscitation. A total of 1159 patients were included and divided into 2 groups: the before-run-in group (502 patients) and the after-run-in group (657 patients). No significant difference was observed between the 2 groups in terms of baseline characteristics. The rate of PAD use in the after-run-in group significantly increased from 5.0% to 8.7% (P=0.015). The rate of favorable neurological outcomes increased from 4.4% to 5.9%, which was not a statistically significant difference. Compared with the before-run-in group, the rate of successful automated external defibrillator acquisition was 13.5% in the after-run-in group (P<0.001). CONCLUSIONS: Implementing a dispatcher-assisted PAD protocol in a municipality setting significantly increased bystander PAD use without affecting dispatcher performance in out-of-hospital cardiac arrest recognition, cardiopulmonary resuscitation instruction, or dispatcher-assisted cardiopulmonary resuscitation time indicators.

Tree-Based Algorithms and Association Rule Mining for Predicting Patients' Neurological Outcomes After First-Aid Treatment for an Out-of-Hospital Cardiac Arrest During COVID-19 Pandemic: Application of Data Mining.

Objective: The authors performed several tree-based algorithms and an association rules mining as data mining tools to find useful determinants for neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients as well as to assess the effect of the first-aid and basic characteristics in the EMS system. Patients and Methods: This was a retrospective cohort study. The outcome was Cerebral Performance Categories grading on OHCA patients at hospital discharge. Decision tree-based models inclusive of C4.5 algorithm, classification and regression tree and random forest were built to determine an OHCA patient's prognosis. Association rules mining was another data mining method which we used to find the combination of prognostic factors linked to the outcome. Results: The total of 3520 patients were included in the final analysis. The mean age was 67.53 (±18.4) year-old and 63.4% were men. To overcome the imbalance outcome issue in machine learning, the random forest has a better predictive ability for OHCA patients in overall accuracy (91.19%), weighted precision (88.76%), weighted recall (91.20%) and F1 score (0.9) by oversampling adjustment. Under association rules mining, patients who had any witness on the spot when encountering OHCA or who had ever ROSC during first-aid would be highly correlated with good CPC prognosis. Conclusion: The random forest has a better predictive ability for OHCA patients. This paper provides a role model applying several machine learning algorithms to the first-aid clinical assessment that will be promising combining with Artificial Intelligence for applying to emergency medical services.

Learning Effectiveness Assessment between Primary School Students and Adults in Basic Life Support Education.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a big issue of critical care. It is well known that bystander cardiopulmonary resuscitation (CPR) with an automated external defibrillator (AED) used did improve the survival rate. Therefore, CPR education including basic life support (BLS) and AED has been advocated for years. It showed significant improvement of knowledge and willingness to perform CPR through adolescents after the course. However, little is known regarding the ability and learning effectiveness of school students who attend such courses. Therefore, this study aimed to evaluate the CPR effectiveness of both adolescents (12 years old) and adults who undergo the same course of BLS and AED. METHODS: This is a retrospective study. Sixth-grade elementary school students in Northern Taiwan were selected to compare with the adult group. Both took 90 minutes of the BLS and AED course by the doctor with BLS instructor qualification. The primary outcomes were CPR quality and passing or failing the skill examination parameters. The secondary outcome was the posttraining written test and questionnaire of CPR willingness. RESULTS: In the written test, there was a statistical difference in the pretest score except AED knowledge, but no difference was revealed in the posttest score. No statistical difference in CPR quality was noted. In the skill examination, only checking breathing status had statistical difference (elementary group (71%) vs. adult group (86%) (p=0.003)). CONCLUSION: We revealed that sixth-grade elementary students' performance in CPR and AED was similar to that of adults after completing the current 90-minute course. Therefore, we strongly advocate offering CPR and AED courses to 12-year-old children, and these courses should emphasize checking the victim's breathing status.

Traditional versus blended CPR training program: A randomized controlled non-inferiority study.

Cardiopulmonary resuscitation (CPR) training and its quality are critical in improving the survival rate of cardiac arrest. This randomized controlled study investigated the efficacy of a newly developed CPR training program for the public in a Taiwanese setting. A total of 832 adults were randomized to either a traditional or blended (18-minute e-learning plus 30-minute hands-on) compression-only CPR training program. The primary outcome was compression depth. Secondary outcomes included CPR knowledge test, practical test, quality of CPR performance, and skill retention. The mean compression depth was 5.21 cm and 5.24 cm in the blended and traditional groups, respectively. The mean difference in compression depth between groups was -0.04 (95% confidence interval -0.13 to infinity), demonstrating that the blended CPR training program was non-inferior to the traditional CPR training program in compression depth after initial training. Secondary outcome results were comparable between groups. Although the mean compression depth and rate were guideline-compliant, only half of the compressions were delivered with adequate depth and rate in both groups. CPR knowledge and skill retained similarly in both groups at 6 and 12 months after training. The blended CPR training program was non-inferior to the traditional CPR training program. However, there is still room for improvement in optimizing initial skill performance as well as skill retention. Clinical Trial Registration: NCT03586752; www.clinicaltrial.gov.

Impact of Transport Time and Cardiac Arrest Centers on the Neurological Outcome After Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Study.

Background Should all out-of-hospital cardiac arrest (OHCA) patients be directly transported to cardiac arrest centers (CACs) remains under debate. Our study evaluated the impacts of different transport time and destination hospital on the outcomes of OHCA patients. Methods and Results Data were collected from 6655 OHCA patients recorded in the regional prospective OHCA registry database of Taoyuan City, Taiwan, between January 2012 and December 2016. Patients were matched on propensity score, which left 5156 patients, 2578 each in the CAC and non-CAC groups. Transport time was dichotomized into <8 and ≥8 minutes. The relations between the transport time to CACs and good neurological outcome at discharge and survival to discharge were investigated. Of the 5156 patients, 4215 (81.7%) presented with nonshockable rhythms and 941 (18.3%) presented with shockable rhythms. Regardless of transport time, transportation to a CAC increased the likelihoods of survival to discharge (<8 minutes: adjusted odds ratio [aOR], 1.95; 95% CI, 1.11-3.41; ≥8 minutes: aOR, 1.92; 95% CI, 1.25-2.94) and good neurological outcome at discharge (<8 minutes: aOR, 2.70; 95% CI, 1.40-5.22; ≥8 minutes: aOR, 2.20; 95% CI, 1.29-3.75) in OHCA patients with shockable rhythms but not in patients with nonshockable rhythms. Conclusions OHCA patients with shockable rhythms transported to CACs demonstrated higher probabilities of survival to discharge and a good neurological outcome at discharge. Direct ambulance delivery to CACs should thus be considered, particularly when OHCA patients present with shockable rhythms.

Inflammatory macrophages switch to CCL17-expressing phenotype and promote peritoneal fibrosis.

Peritoneal fibrosis remains a problem in kidney failure patients treated with peritoneal dialysis. Severe peritoneal fibrosis with encapsulation or encapsulating peritoneal sclerosis is devastating and life-threatening. Although submesothelial fibroblasts as the major precursor of scar-producing myofibroblasts in animal models and M2 macrophage (Mϕ)-derived chemokines in peritoneal effluents of patients before diagnosis of encapsulating peritoneal sclerosis have been identified, attenuation of peritoneal fibrosis is an unmet medical need partly because the mechanism for cross talk between Mϕs and fibroblasts remains unclear. We use a sodium hypochlorite-induced mouse model akin to clinical encapsulated peritoneal sclerosis to study how the peritoneal Mϕs activate fibroblasts and fibrosis. Sodium hypochlorite induces the disappearance of CD11bhigh F4/80high resident Mϕs but accumulation of CD11bint F4/80int inflammatory Mϕs (InfMϕs) through recruiting blood monocytes and activating local cell proliferation. InfMϕs switch to express chemokine (C-C motif) ligand 17 (CCL17), CCL22, and arginase-1 from day 2 after hypochlorite injury. More than 75% of InfMϕs undergo genetic recombination by Csf1r-driven Cre recombinase, providing the possibility to reduce myofibroblasts and fibrosis by diphtheria toxin-induced Mϕ ablation from day 2 after injury. Furthermore, administration of antibody against CCL17 can reduce Mϕs, myofibroblasts, fibrosis, and improve peritoneal function after injury. Mechanistically, CCL17 stimulates migration and collagen production of submesothelial fibroblasts in culture. By breeding mice that are induced to express red fluorescent protein in Mϕs and green fluorescence protein (GFP) in Col1a1-expressing cells, we confirmed that Mϕs do not produce collagen in peritoneum before and after injury. However, small numbers of fibrocytes are found in fibrotic peritoneum of chimeric mice with bone marrow from Col1a1-GFP reporter mice, but they do not contribute to myofibroblasts. These data demonstrate that InfMϕs switch to pro-fibrotic phenotype and activate peritoneal fibroblasts through CCL17 after injury. CCL17 blockade in patients with peritoneal fibrosis may provide a novel therapy. © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Impact of the caller's emotional state and cooperation on out-of-hospital cardiac arrest recognition and dispatcher-assisted cardiopulmonary resuscitation.

OBJECTIVE: This study determined the impact of the caller's emotional state and cooperation on out-of-hospital cardiac arrest (OHCA) recognition and dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) performance metrics. METHODS: This was a retrospective study using data from November 2015 to October 2016 from the emergency medical service dispatching centre in northern Taiwan. Audio recordings of callers contacting the centre regarding adult patients with non-traumatic OHCA were reviewed. The reviewers assigned an emotional content and cooperation score (ECCS) to the callers. ECCS 1-3 callers were graded as cooperative and ECCS 4-5 callers as uncooperative and highly emotional. The relation between ECCS and OHCA recognition, time to key events and DA-CPR delivery were investigated. RESULTS: Of the 367 cases, 336 (91.6%) callers were assigned ECCS 1-3 with a good inter-rater reliability (k=0.63). Dispatchers recognised OHCA in 251 (68.4%) cases. Compared with callers with ECCS 1, callers with ECCS 2 and 3 were more likely to give unambiguous responses about the patient's breathing status (adjusted OR (AOR)=2.6, 95% CI 1.1 to 6.4), leading to a significantly higher rate of OHCA recognition (AOR=2.3, 95% CI 1.1 to 5.0). Thirty-one callers were rated uncooperative (ECCS 4-5) but had shorter median times to OHCA recognition and chest compression (29 and 122 s, respectively) compared with the cooperative caller group (38 and 170 s, respectively). Nevertheless, those with ECCS 4-5 had a significantly lower DA-CPR delivery rate (54.2% vs 85.9%) due to 'caller refused' or 'overly distraught' factors. CONCLUSIONS: The caller's high emotional state is not a barrier to OHCA recognition by dispatchers but may prevent delivery of DA-CPR instruction. However, DA-CPR instruction followed by first chest compression is possible despite the caller's emotional state if dispatchers are able to skilfully reassure the emotional callers.

The effectiveness of teaching chest compression first in a standardized public cardiopulmonary resuscitation training program.

Effectiveness of bystander cardiopulmonary resuscitation (CPR) is known to provide emergency medical services which reduce the number of deaths in patients with out-of-hospital cardiac arrest. The survival at these patients is affected by the training level of the bystander, but the best format of CPR training is unclear. In this pilot study, we aimed to examine whether the sequence of CPR instruction improves learning retention on the course materials.A total of 95 participants were recruited and divided into 2 groups; Group 1: 49 participants were taught firstly how to recognize a cardiac arrest and activate the emergency response system, and Group 2: 46 participants were taught chest compression first. The performance of participants was observed and evaluated, the results from 1 pre-test and 2 post-tests between 2 groups were then compared.There was a significantly better improvement of participants in Group 2 regarding the recognition of a cardiac arrest and the activation of the emergency response system than of those in Group 1. At the post-test, participants in Group 2 had an improvement in chest compression compared to those in Group 1, but the difference was not statistically significant.Our study had revealed that teaching CPR first in a standardized public education program had improved the ability of participants to recognize cardiac arrest and to activate the emergency response system.

Comatose patient with hypothermia, dyspnea, and general edema in the emergency department: a case report.

Patients presenting to the emergency department with hypothermia are rare and often require prompt diagnosis and management. Myxedema coma, which may cause severe hypothermia, is a true endocrine emergency requiring early and appropriate treatment. We report on a 47-year-old woman with a history of hyperthyroidism who underwent thyroidectomy 5 years previously, with no regular medication or examinations. She presented to the emergency department with a 1-month history of progressive dyspnea associated with general weakness. She also showed hypothermia, decreased mental status, and general edema. Echocardiography revealed increased pericardial effusion without tamponade. Laboratory examination suggested myxedema coma and hypothyroidism. She received thyroxine, glucocorticoid supplement, and intensive supportive care, after which she gradually improved and was discharged. This case suggests that myxedema coma should be considered in patients with hypothyroidism or a history of thyroidectomy who present with change in consciousness, hypothermia, or other symptoms related to critical or slow presentation in multiple organs. Moreover, long-standing hypothyroidism or precipitating acute events such as sepsis, cerebrovascular accidents, gastrointestinal bleeding, cold exposure, trauma, and some medications may also cause myxedema coma. Myxedema coma is associated with a high mortality, and patients suspected to be suffering from this condition should be treated without delay.

Metastatic Malignancy to the Colon and Rectum: A Report of 14 Cases from One Single Institute.

BACKGROUND: Metastatic malignancy occurs rarely in the colon or rectum. We presented 14 patients with colorectal metastasis (CRM). METHODS: A retrospective review was conducted on a computerized colorectal tumor database at the Taipei Veterans General Hospital from January 2000 to June 2013. RESULTS: The incidence of CRM was 0.19% (14 in 7,524 patients). There were 6 males and 8 females with a mean age of 66.9 ± 13.6 years. Origins of the CRM included lung cancers (n = 3), prostate cancers (n = 2), and others (n = 1, respectively). Clinical presentations were not specific and colonoscopic pictures were indistinguishable from primary colorectal cancers; 5 of the 9 biopsies identified metastasis. Eight patients had extracolonic metastasis and 6 patients had CRM only. Significantly better survival was observed in the CRM-only group (p = 0.037). The mean interval from the treatment of primary tumor to the diagnosis of CRM was 30.2 ± 49.0 months. The mean survival time after CRM was 24.9 ± 30.8 months. CONCLUSION: Clinical features and colonoscopic findings of CRM were indistinguishable from primary colorectal cancer. Histopathological review of the biopsy could be helpful in identifying the primary lesion. Surgical resection with curative intent provided longer survival in CRM-only patients.

Losartan reduces ensuing chronic kidney disease and mortality after acute kidney injury.

Acute kidney injury (AKI) is an important risk factor for incident chronic kidney disease (CKD). Clinical studies disclose that ensuing CKD progresses after functional recovery from AKI, but the underlying mechanisms remain illusive. Using a murine model representing AKI-CKD continuum, we show angiotensin II type 1a (AT1a) receptor signaling as one of the underlying mechanisms. Male adult CD-1 mice presented severe AKI with 20% mortality within 2 weeks after right nephrectomy and left renal ischemia-reperfusion injury. Despite functional recovery, focal tubular atrophy, interstitial cell infiltration and fibrosis, upregulation of genes encoding angiotensinogen and AT1a receptor were shown in kidneys 4 weeks after AKI. Thereafter mice manifested increase of blood pressure, albuminuria and azotemia progressively. Drinking water with or without losartan or hydralazine was administered to mice from 4 weeks after AKI. Increase of mortality, blood pressure, albuminuria, azotemia and kidney fibrosis was noted in mice with vehicle administration during the 5-month experimental period. On the contrary, these parameters in mice with losartan administration were reduced to the levels shown in control group. Hydralazine did not provide similar beneficial effect though blood pressure was controlled. These findings demonstrate that losartan can reduce ensuing CKD and mortality after functional recovery from AKI.

Is 15 minutes an appropriate resuscitation duration before termination of a traumatic cardiac arrest? A case-control study.

BACKGROUND: Previous guidelines suggest up to 15 minutes of cardiopulmonary resuscitation (CPR) accompanied by other resuscitative interventions before terminating resuscitation of a traumatic cardiac arrest. The current study evaluated the duration of CPR according to outcome using the model of a county-based emergency medical services (EMS) system in Taiwan. METHODS: This study was performed as a prospectively defined retrospective review from EMS records and cardiac arrest registration between June 2011 and November 2012 in Taoyuan, Taiwan. RESULTS: A total of 396 patients were enrolled. Among the blunt injuries, most incidents were traffic accidents (66.5%) followed by falls (31.5%). Bystander CPR was performed in 34 patients (8.6%). Of the patients, 18.4% were sent to intermediate to advanced level traumatic care hospitals. Although 4.8% of patients survived for 24 hours, only 2.3% survived to discharge, and 0.8% achieved cerebral performance category 1 or 2. Among all patients who developed return of spontaneous circulation (ROSC), 14.3% of ROSC was achieved within 15 minutes since CPR. Except for 1, most patients who developed ROSC over 24 hours but did not survive to discharge received CPR more than 15 minutes. Four of 6 patients who survived to discharge achieved ROSC after CPR for more than 15 minutes (16, 18, 22, and 24 minutes). Three patients discharged with cerebral performance category 1 or 2 received CPR for 6, 16, and 18 minutes, respectively. CONCLUSIONS: Fifteen minutes of CPR before terminating resuscitation is inappropriate for patients undergoing traumatic cardiac arrsests, as longer duration resuscitation increases ROSC and survival.

Rescuer factors predict high-quality CPR--a manikin-based study of health care providers.

BACKGROUND: In the provision of high-quality cardiopulmonary resuscitation (CPR) by health care providers, factors associated with high-quality CPR should be explored. METHODS: This is a post hoc analysis using data from a manikin-based survey of CPR quality among volunteer emergency medical technicians (EMTs) from 2 county fire departments in northern Taiwan. RESULTS: Among the 95 enrolled EMTs, 36 (37.9%) performed high-quality CPR on a manikin. The baseline characteristics that differed significantly between groups were board-certified EMT levels (P = .010), body mass index (BMI, P = .029), average exercise frequency (P = .001), and average exercise duration (P = .005). Average total exercise time per week, which uses frequency times exercise duration, was independently associated with high-quality CPR performance after adjusting for variables via logistic regression analysis (odds ratio, 1.004; P = .044). An index was developed (BMI × ExeTime) based on the product of BMI and average total exercise time per week. A comparison of the area under curve for the different indices showed that BMI × ExeTime was a significant predictor of high-quality CPR, with an area under curve of 0.718 (95% confidence interval, 0.613-0.824; P < .001; Fig. 2) and a cutoff value of 4136.7 kg·min/m(2) (sensitivity, 0.722; specificity, 0.678). CONCLUSIONS: This study identified factors associated with the performance by health care providers of high-quality CPR, including BMI and exercise habits. To optimize CPR quality, a program of exercise frequency and duration adjusted according to individual's BMI should be considered in such populations.

Comparison of 3 scoring systems to predict mortality from unstable upper gastrointestinal bleeding in cirrhotic patients.

OBJECTIVE: We aimed to compare the performance of Glasgow-Blatchford, preendoscopic Rockall, and model for end-stage liver disease (MELD) scores in cirrhotic patients with unstable upper gastrointestinal bleeding (UGIB) in the emergency department (ED). METHODS: This was a retrospective cohort study conducted at a university-affiliated teaching hospital. Adult cirrhotic patients who presented with acute UGIB and unstable vital signs (heart rate >100 beats/min or systolic blood pressure <100 mm Hg) between January 2009 and February 2011 were included. Patients who were transferred from another hospital, received no emergency endoscopy study, or had incomplete medical records were excluded. Data were retrieved from the admission list of the ED critical zone using international classification of disease code via computer registration. RESULTS: Among enrolled visits, the initial median hemoglobin level was 8.6 (interquartile range, 7.2-10.1) mg/dL in the ED. The median heart rate and systolic blood pressure were 111.0 beats/min and 94.0 mm Hg, respectively. The endoscopic diagnosis of variceal bleeding accounted for 86.6% of the events. The mortality rate was 16.0% (19/119). Model for end-stage liver disease score performed better with an area under the curve (AUC) of 0.736 (95% confidence interval [CI], 0.629-0.842; P = .001) compared with other scoring systems (Glasgow-Blatchford score: AUC, 0.527; 95% CI, 0.393-0.661; P = .709; preendoscopic Rockall score: AUC, 0.591; 95% CI, 0.465-0.717; P = .208). CONCLUSION: Model for end-stage liver disease score performed better in terms of predicting mortality of unstable UGIB in cirrhotic patients compared with Glasgow-Blatchford and preendoscopic Rockall scores in the ED.

Can procalcitonin tests aid in identifying bacterial infections associated with influenza pneumonia? A systematic review and meta-analysis.

OBJECTIVE: To summarize evidence for the diagnostic accuracy of procalcitonin (PCT) tests for identifying secondary bacterial infections in patients with influenza. METHODS: Major databases, including MEDLINE, EMBASE, and the Cochrane Library, were searched for studies published between January 1966 and May 2009 that evaluated PCT as a marker for diagnosing bacterial infections in patients with influenza infections and that provided sufficient data to construct two-by-two tables. RESULTS: Six studies were selected that included 137 cases with bacterial coinfection and 381 cases without coinfection. The area under a summary ROC curve was 0·68 (95% CI: 0·64-0·72). The overall sensitivity and specificity estimates for PCT tests were 0·84 (95% CI: 0·75-0·90) and 0·64 (95% CI: 0·58-0·69), respectively. These studies reported heterogeneous sensitivity estimates ranging from 0·74 to 1·0. The positive likelihood ratio for PCT (LR+ = 2·31; 95% CI: 1·93-2·78) was not sufficiently high for its use as a rule-in diagnostic tool, while its negative likelihood ratio was reasonably low for its use as a rule-out diagnostic tool (LR- = 0·26; 95% CI: 0·17-0·40). CONCLUSIONS: Procalcitonin tests have a high sensitivity, particularly for ICU patients, but a low specificity for identifying secondary bacterial infections among patients with influenza. Because of its suboptimal positive likelihood ratio and good negative likelihood ratio, it can be used as a suitable rule-out test but cannot be used as a standalone rule-in test.

Outcome of inadequate empirical antibiotic therapy in emergency department patients with community-onset bloodstream infections.

BACKGROUND: Studies on the effect of inadequate empirical antibiotic therapy on the outcome of patients with systemic infection have led to inconsistent results. METHODS: We analysed data from a comprehensive clinical database collected prospectively in a university hospital between 2008 and 2009. All adult patients who registered in the emergency department (ED) with a bloodstream infection (BSI) were enrolled. Empirical therapy was considered adequate if it included antimicrobials to which the specific isolate displayed in vitro susceptibility and that were administered within 24 h of ED admission. The propensity score (PS) was created by a logistic regression model predicting inadequate empirical therapy. PS-adjusted multivariate analysis was performed by the Cox regression model. The Mortality in Emergency Department Sepsis (MEDS) score was used for the adjustment of residual confounding due to differences in the baseline clinical severity of disease. RESULTS: Out of 937 episodes of bacteraemia, 255 (27.2%) patients received inadequate empirical antimicrobial therapy. A crude analysis showed that inadequate antibiotic therapy was associated with higher mortality rates (hazard ratio 1.78, 95% CI 1.30-2.45). PS-adjusted multivariate analyses also showed a significant adverse impact (hazard ratio 1.59, 95% CI 1.14-2.28). The clinical disease severity significantly modified the effect of inadequate antibiotic therapy on survival. The magnitude of the adverse impact of inadequate antibiotic therapy decreased with the increasing severity of sepsis (P=0.009). CONCLUSIONS: Inadequate empirical antimicrobial therapy for community-onset BSI was associated with higher 30 day mortality rates. Study populations with different clinical severities may have different results, which may help to partly explain the heterogeneous findings in many similar studies.