Jejunojejunum intussusception as the single initial manifestation of Henoch-Schönlein purpura in a teenager.

We described a 14-year-old boy with initial presentation of recurrent intermittent abdominal pain, with subsequent development of jejunojejunum intussusception. The characteristic purpuric skin rash of Henoch-Schönlein purpura appeared later after the surgical manual reduction. When abdominal pain is the single initial manifestation in patients with undiagnosed Henoch-Schönlein purpura, emergency physicians should evaluate if the patient required early surgical intervention such as intussusception or perforation and always keep Henoch-Schönlein purpura as a possibility in mind.

Circadian variation of acute myocardial infarction in young people.

AIMS: The aim was to investigate the circadian and weekly variation in Chinese young patients with acute myocardial infarction (AMI). METHODS: This was a 10-year retrospective cohort study. We studied patients (>18 to <45 years of age) with a first attack of AMI from the emergency departments of 3 university teaching hospitals in Taiwan from January 1, 2001, to December 31, 2010. We analyzed patients in the standard circadian fashion using 6-hour intervals (00:01-06:00, 06:01-12:00, 12:01-18:00, and 18:01-24:00). We also did an analysis by day of week. RESULTS: The database had 505 patients with AMI with complete data. The percentage of total AMIs that occurred in the 6-hour intervals were as follows: 00:01 to 06:00, 30.9%; 06:01 to 12:00, 23.4%; 12:01 to 18:00, 25.9%; and 18:01 to 24:00, 19.8%. The percentage of AMIs between 00:01 and 06:00 was significant higher compared with that in the other three 6-hour intervals (df = 3, χ(2) = 91.7, P < .001). However, there was no significant weekly variation for these patients in the present study. CONCLUSIONS: There was a significant circadian variation with a peak from 00:01 to 06:00 in Chinese young patients with AMI. However, there was no significant weekly variation in these patients. The circadian periodicity may create new possibilities for disease prevention and medication prescription.

Postresuscitation autonomic nervous modulation after cardiac arrest resembles that of severe sepsis.

INTRODUCTION: This study explored whether post-resuscitation status resembles severe sepsis in terms of autonomic nervous modulation by using heart rate variability (HRV) analysis. METHODS: Successfully resuscitated nontraumatic out-of-hospital cardiac arrest (OHCA) adult patients in an emergency department were prospectively enrolled as the study group. Age- and sex-matched patients with severe sepsis with and without mechanical ventilation were included as positive controls, while sepsis patients and healthy volunteers were included as negative controls. The HRV measures obtained from 10-minute electrocardiogram were compared among 5 groups of subjects. RESULTS: Sixty-four successfully resuscitated OHCA patients were studied. There were no significant differences in all HRV measures (standard deviation of R-R intervals [SD(RR)], coefficient of variation of R-R intervals [CV(RR)], total power [TP], very-low-frequency component [VLF], low-frequency component [LF], high-frequency component [HF], normalized LF [LF%], normalized HF [HF%], and LF/HF) among the successfully resuscitated OHCA patients and severe sepsis patients with and without mechanical ventilation. Also, no significant differences in all HRV measures were found between nonsurvivors of OHCA group and nonsurvivors of severe sepsis group. In the nonsurvivors of OHCA group and severe sepsis group, the LF% and LF/HF were significantly lower, whereas the HF and HF% were significantly higher, as compared with the survivors of these 2 groups. CONCLUSIONS: The autonomic nervous modulation in the initial phase of OHCA patients resembles that of severe sepsis in that both groups of patients have decreased global HRV (TP, SD(RR), and CV(RR)), sympathovagal balance (LF% and LF/HF), and renin-angiotensin-aldosterone modulation (VLF), as compared to healthy subjects.

Diagnostic performance of initial salivary alpha-amylase activity for acute myocardial infarction in patients with acute chest pain.

BACKGROUND: To rule out acute myocardial infarction (AMI) in chest pain patients constitutes a diagnostic challenge to emergency department (ED) physicians. STUDY OBJECTIVES: To evaluate the diagnostic value of measuring salivary alpha-amylase (sAA) activity for detecting AMI in patients presenting to the ED with acute chest pain. METHODS: sAA activity was measured in a prospective cohort of 473 consecutive adult patients within 4 h of onset of chest pain. Comparisons were made between patients with a final diagnosis of AMI and those with non-AMI. Univariate analysis and multiple logistic regression model were used to identify independent clinical predictors of AMI. RESULTS: Initial sAA activity in the AMI group (n = 85; 266 ± 127.6 U/mL) was significantly higher than in the non-AMI group (n = 388; 130 ± 92.8 U/mL, p < 0.001). sAA activity levels were also significantly higher in patients with ST elevation AMI (n = 53) compared to in those with non-ST elevation AMI (n = 32) (300 ± 141.1 vs. 210 ± 74.1 U/mL, p < 0.001). The area under the receiver operating characteristic curve of sAA activity for predicting AMI in patients with acute chest pain was 0.826 (95% confidence interval [CI] 0.782-0.869), with diagnostic odds ratio 10.87 (95% CI 6.16-19.18). With a best cutoff value of 197.7 U/mL, the sAA activity revealed moderate sensitivity and specificity as an independent predictor of AMI (78.8% and 74.5%). CONCLUSIONS: High initial sAA activity is an independent predictor of AMI in patients presenting to the ED with chest pain.

Initial salivary α-amylase activity predicts malignant ventricular arrhythmias and short-term prognosis after ST-segment elevation myocardial infarction.

BACKGROUND: Ventricular arrhythmias (VA), including ventricular tachycardia and ventricular fibrillation, are the most common remediable cause of death in patients with acute myocardial infarction. Augmented sympathetic neural activity to the heart and myocardial catecholamine release may be the primary factors in the generation of VA. The aim of this study was to assess the predictive value of salivary α-amylase (sAA) activity, an indicator of sympathetic activity, for malignant VA occurrence and for short-term outcome in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: Patients with STEMI (n=91) were recruited from the Emergency Department during the period 1 December 2008 to 31 April 2010. Correlations of initial sAA activity at presentation with VA, as well as 1-month prognosis were analysed. RESULTS: sAA activity was significantly increased in the VA group (395±173.7; n=9) as compared with the non-VA group (283±89.3; n=82) (p=0.014). The adjusted OR for malignant ventricular arrhythmia occurrence was 1.010 (95% CI 1.001 to 1.018). Eight patients (8.8%) died and 24 (26.4%) had at least one short-term adverse event within the first month after STEMI. Simple logistic regression analysis showed that sAA is an independent predictor for short-term prognosis (p=0.049, OR 1.005, 95% CI 1.000 to 1.009). CONCLUSIONS: Although a prospective study with a large cohort is required, the present results suggest that high initial sAA activity is associated with increased risk of malignant VA and predicts short-term prognosis in patients with STEMI.

Diagnostic performance of mean platelet volume for patients with acute coronary syndrome visiting an emergency department with acute chest pain: the Chinese scenario.

OBJECTIVES: To assess the ability of mean platelet volume (MPV) to detect acute coronary syndromes (ACS) in Chinese patients within 4 h of chest pain onset. METHODS: Consecutive adult Chinese patients who arrived at an emergency department (ED) with acute chest pain (onset within 4 h) between May and August 2009 were recruited. The MPV was checked for all enrolled patients on arrival at the ED, and further comparisons between the patients in different groups were made. RESULTS: 282 patients (136 men and 146 women) were enrolled and 69 were diagnosed as having ACS (24.5%). As compared with the non-ACS group, the ACS group had significantly higher MPV values (10.8±0.86 fl vs 9.8±0.76 fl, p<0.001). Moreover, we found that the MPV values were higher in patients with acute myocardial infarction (AMI) (n=28) as compared with patients with unstable angina (UA) (n=41) (11.0±0.79 fl vs 10.6±0.87 fl, p=0.027). Multiple logistic regression analysis yielded the fact that the initial MPV was an independent predictor of ACS attack in patients with acute chest pain (OR 8.866). The corresponding area under the receiver operating characteristic curve (ROC) for MPV in predicting ACS in patients with acute chest pain was 0.800 (95% CI 0.736 to 0.864) and the best cut-off value was 10.35 fl (sensitivity 78.3%; specificity 74.6%). CONCLUSIONS: MPV is significantly associated with ACS in patients with acute chest pain and is an early and independent predictor.

Life-threatening episode after ingestion of toad eggs: a case report with literature review.

It is known that the toad possesses several toxic substances in the skin and parotid glands. In the past, toad-venom poisoning has been reported from ingestion of toad soup, Kyushin and aphrodisiac pills, but poisoning from toad eggs is observed for the first time. The case of a healthy female who had previously eaten toad soup twice without any discomfort is reported. She developed gastrointestinal symptoms and life-threatening cardiac rhythm after ingestion of toad eggs. A transvenous temporary pacemaker was used promptly to prevent from lethal bradyarrhythmia. Hyperkalaemia was managed with insulin, glucose water and sodium bicarbonate. A digoxin-specific Fab fragment was administered to this young woman 4 h subsequent to her admission.

Life-threatening episode after ingestion of toad eggs: a case report with literature review.

It is known that toad possesses several toxic substances in the skin and parotid glands. In the past, toad-venom poisoning had been reported from ingestion of toad soup, Kyushin and aphrodisiac pills, but the poisoning from toad eggs is observed for the first time. The case of a healthy female who had previously eaten toad soup twice without any discomfort is reported. She developed gastrointestinal symptoms and life-threatening cardiac rhythm after ingestion of toad eggs.

Initial serum glucose level as a prognostic factor in the first acute myocardial infarction.

STUDY OBJECTIVE: We assess the prognostic role of initial glucose levels in patients with a first acute myocardial infarction in the emergency department (ED). METHODS: We conducted a 3-year retrospective cohort study. Patients with a first acute myocardial infarction were recruited from the ED of a tertiary hospital from January 1, 2001, to December 31, 2003. Initial glucose levels in the ED were stratified into 3 levels (normal < 140 mg/dL; intermediate 140 to 200 mg/dL; and high > or = 200 mg/dL). Logistic and Cox regression models were applied to estimate the 1-month short-term and 1-year long-term adverse prognoses, respectively. RESULTS: A total of 198 eligible subjects (159 men and 39 women; mean age 63.1+/-14.2 years) were recruited. The estimated survival curves among the 3 initial glucose levels were significantly different (P=.0002). After adjustment for sex, age, diabetic status, reperfusion therapy, and infarct subtype, the adjusted odds ratio for short-term prognosis progressed with higher levels when compared with the normal level (intermediate level: odds ratio 3.87; 95% confidence interval [CI] 1.71 to 8.78; high level: odds ratio 5.16; 95% CI 1.97 to 13.51). High initial glucose level was an important risk factor for long-term adverse prognosis (hazard ratio 3.08; 95% CI 1.59 to 5.98). CONCLUSION: A high initial glucose level in the ED is an important and independent predictor of short- and long-term adverse prognoses in patients with first acute myocardial infarction.

Fatal hemoptysis after suction through endotracheal tube in a patient with pneumoconiosis--a case report.

A 76-year-old man, with a history of pneumoconiosis, developed massive hemoptysis after suction through endotracheal tube. Emergent bronchial artery angiography revealed that rupture of an aneurysm was the suspected culprit and coil embolization was performed. However, the bleeding persisted and he eventually succumbed. Here we bring forward the clinical evaluation and management of massive hemoptysis for discussion. It is note worthy that in patients with chronic inflammatory lung diseases, such as pneumoconiosis, massive hemoptysis may develop in the act of trachcobronchial toilet with suction.