Retrospective one-million-subject fixed-cohort survey of utilization of emergency departments due to traumatic causes in Taiwan, 2001-2010.

BACKGROUND: Epidemiological study was needed to evaluate trends in emergency department (ED) utilization that could be taken into account when making policy decisions regarding the delivery and distribution of medical resources. METHODS: A retrospective fixed-cohort study of emergency medical utilization from 2001 to 2010 was performed based on one-million people sampled in 2010 in Taiwan. Focusing on traumatic cases, the annual incidences in various groups split according to sex and age were calculated, and further information regarding location of trauma and type of trauma was obtained. RESULTS: In 2010, significantly greater proportions of male and younger subjects were visitors to EDs with a traumatic injury. During 2001-2010, the number of both traumatic cases and non-traumatic cases presenting at EDs significantly increased (average annual percentage change, AAPC 4.7 and 3.6, respectively) and a significantly greater direct medical cost associated with traumatic cases than non-traumatic cases was noted. Focusing on traumatic cases, most of these cases were directed to highest-level hospitals, accounting for 73.5-78.8 % of all traumatic cases, with a significant AAPC of 5.6. The traumatic ED visit annual incidence in males was 58.63 in 2001, which significantly increased to 69.35 per 1000 persons in 2010 (AAPC 1.5); and in females was 38.96 in 2001, which significantly increased to 50.73 per 1000 persons in 2010 (AAPC 2.5). Most of the traumatic cases treated in EDs were minor injuries, such as contusion with the skin intact, open wound of the upper limbs, open wound of the head, neck, or trunk, and other superficial injury (accounting for about 60 % of all cases). The traumatic categories of sprains/strains of joints and adjacent muscles, fractures of upper limbs, fractures of lower limbs, and fractures of the spine/trunk required greater medical resources and significantly positive AAPC values (4.3, 4.0, 4.5 and 6.8, respectively). CONCLUSIONS: Increased ED utilization due to traumatic causes, as assessed by the annual number of cases and incidence, average direct medical cost and highest-level hospital utilization, was observed from 2001 to 2010. Orthopedic-related injuries, including soft tissue trauma of extremities and various fractures, were the categories with the greatest increase in incidence.

Molecular typing and epidemiology of Clostridium difficile in respiratory care wards of central Taiwan.

BACKGROUND/PURPOSE: In industrialized countries, Clostridium difficile is the major cause of nosocomial diarrhea. This study involved a broad overview of baseline epidemiology for C. difficile in Taiwan. MATERIALS AND METHODS: Point prevalence was estimated from a prospective survey conducted in the respiratory care wards of six hospitals in central Taiwan. Polymerase chain reaction (PCR) ribotyping and multiple-locus variable-number tandem-repeat analysis (MLVA) were performed on all toxigenic C. difficile isolates, including asymptomatic and symptomatic strains. RESULTS: A total of 149 patients were screened for C. difficile; the point prevalence for C. difficile infection (CDI) and C. difficile colonization was 4% and 19%, respectively. CDI cases were significantly related to end-stage renal disease, and C. difficile colonization cases were significantly associated with previous admission to an acute-care facility. No hypervirulent PCR ribotype 027 strain was found. MLVA detected two clusters of CDI-related and three clusters of asymptomatic C. difficile strains circulating in wards. CONCLUSION: Our results demonstrate a high prevalence of toxigenic C. difficile colonization in hospitals. Infection control personnel should pay attention to the increasing numbers of CDI cases, and molecular typing for C. difficile should be performed when necessary.

Epidemiology of orthopedic fractures and other injuries among inpatients admitted due to traffic accidents: a 10-year nationwide survey in Taiwan.

To investigate the major injury patterns associated with traffic accidents and evaluate the risk factors of the main injury, a survey of Taiwan's national insurance admission data between 2002 and 2011 was performed. The incidence of traffic-accidents-related hospitalization was between 9.17% and 11.54% and the average mortality rate of the inpatients admitted due to traffic accidents was 0.68%. Of all inpatients due to road traffic accidents in Taiwan, orthopedic fractures were the most common injuries that accounted for 29.36% of them. There were a total of 391,197 cases of three orthopedic fracture groups that were divided into (1) fracture of upper limb, (2) fracture of lower limb, and (3) fracture of spine and trunk. An increase in national medical cost used for inpatients with orthopedic fractures was noted and ranged from US$ 45.6 million to US$ 86 million annually. These orthopedic fracture patterns were frequently associated with other injuries especially head injuries (ranged from 14% to 26%). A significant relation to male gender, older age, low income, and admission to high-level hospital to the observed fracture patterns was observed.

Invasively-treated incidence of lower extremity peripheral arterial disease and associated factors in Taiwan: 2000-2011 nationwide hospitalized data analysis.

BACKGROUND: Lower extremity (LE) peripheral artery disease (PAD), which is associated with a reduced quality of life and increased mortality from atherosclerotic cardio-/cerebro-vascular occlusion, is a significant public health problem, especial for an aging society such as that of Taiwan. METHODS: Specific datasets of the 2000-2011 nationwide inpatient databases were analyzed. Two inclusion criteria, including one of the major diagnosis codes of PAD and one of three categorical invasive treatments of LE PAD, were used consecutively to select cases diagnosed as LE PAD and receiving invasive treatment. The epidemiology of invasively-treated PAD in Taiwan was estimated, and the influences of potential confounders on these invasively-treated methods were evaluated. RESULTS: In general, the invasively-treated incidence of PAD in Taiwan doubled, from 3.73/10,000 (in 2000) to 7.48/10,000 (in 2011). On average, the total direct medical cost of one hospitalized and invasively-treated PAD case ranged from $US 4,600 to $US 5,900. The annual cases of bypass surgery for the PAD cases averaged 1,000 and the cases for limb amputation ranged from 4,100 to 5,100 annually. However, the number of percutaneous transluminal angioplasty (PTA) procedures remarkably increased by 15 times, from 600/year to 9,100/year, from 2000 to 2011. 51.3% of all the enrolled cases were treated with limb amputations, and female, young and middle-aged people (30-65 years of age), DM patients and those on a low income had a tendency to undergo amputation due to PAD. 37.6% of all the enrolled cases were treated with PTAs related to hypertension, cardiovascular disease, hyperlipidemia and catastrophic Illness. 2-year PTA failure rates of 22.13%, 11.91% and 10.61% were noted among the first (2000-2001), second (2004-2005) and the third (2008-2009) cohort groups, respectively. CONCLUSIONS: In Taiwan, a gender difference and age and period effects on the invasively-treated incidence of LE PAD were observed. Female, young and middle-aged people (30-50 and 50-65 years of age), DM patients and those on a low income had a tendency to undergo amputation. The number of PTA procedures remarkably increased, but the 2-year failure rate of PTAs reduced from 2000 to 2011.

Nationwide retrospective cohort survey of orthopedic injuries in members of the Taiwanese population with psychiatric disorders, 2000-2005.

BACKGROUND: The relationship between psychiatric disorders and musculoskeletal injuries is interesting but has not been investigated in depth. STUDY DESIGN: A retrospective cohort study, based on a large-sample nationwide database, was performed during 2000-2005 in Taiwan. METHODS: All subjects matching the inclusion criteria of psychiatric-associated ICD9-CM diagnostic codes in 2000 were selected as the inception cohort population. Another cohort-based case-control study was designed, and one sex-matched and age-matched (1:1) control group randomly selected from the population without any prevalent psychiatric disorder in 2000 and incident psychiatric disorder in 2001-2005 was used for comparison. RESULTS: 64,662 Taiwanese people with any prevalent psychiatric disorder were enrolled in this study in 2000. The 6-year cumulative incidences of orthopedic injuries were 13.61/10,000 for femoral neck/femur fracture and 4.64/10,000, 3.40/10,000, 3.25/10,000, and 3.09/10,000 for radius/ulna or hand fracture, tibia/fibula or patella fracture, ankle or foot fracture, and humeral fracture, respectively. Compared with the control group, this Taiwanese population with prevalent psychiatric disorders had fewer incidences of all orthopedic injuries during the 6 years since 2000, and their cumulative incidence ratios ranged from 0.04 to 0.4 for the different injury sites. For lower-limb fractures, compared with the age stratum of less than 20-years-old, the odds ratios (OR) for the age strata 80-years-old or more and 60-79-years-old were 15.84 (95 % CI 4.55-55.20) and 6.11 (95 % CI 1.92-19.49), respectively. The people with organic psychotic conditions had a significantly greater tendency to suffer upper-limb and lower-limb fractures than those with other psychiatric diagnoses (the ranges of ORs were 3.23-16.67 and 2.13-25.00, respectively). CONCLUSION: Subjects with prevalent psychiatric disorders had fewer occurrences of orthopedic injuries than the general population. Among this specific population, an organic psychotic condition and old age were risk factors for suffering fracture of a limb.

Characterization of Staphylococcus lugdunensis endocarditis in patients with cardiac implantable electronic devices.

OBJECTIVES: Although the application of cardiac implantable electronic devices (CIED) has greatly increased over the past few decades, CIED endocarditis is becoming a challenging scenario in clinical practice. Recently, Staphylococcus lugdunensis has emerged as a pathogen in CIED endocarditis. However, a detailed phenotypic characterization has not been addressed. METHODS: We conducted a systematic literature review covering the period between 1989 and 2011 using the PubMed, Medline, Cochrane, and Embase databases. All cases included had a CIED in use and met the modified Duke criteria for infective endocarditis, and all had isolates of S. lugdunensis. The clinical features, predisposing conditions, echocardiographic findings, and therapeutic strategies/outcomes were evaluated. Polymorphonuclear neutrophil functions were examined to test whether the defect of innate immunity may play a permissive role in host susceptibility to tissue destruction in S. lugdunensis endocarditis. RESULTS: Eleven patients with CIED endocarditis caused by S. lugdunensis were identified. Their mean age was 61.7±11.2 years, and there was a male preponderance (72.7%). Six patients (54.5%) had undergone re-manipulation of the pacing system within a few months to years before the occurrence of clinical symptoms. The median time of symptoms before the diagnosis of CIED endocarditis was 60 days. On echocardiography, vegetations in the CIED were detected in nine cases (81.8%). Nine patients (81.8%) underwent surgical removal of the entire device, and one patient received medical treatment alone. The overall mortality rate was 18.2%. One patient had a septic perforation of the ventricular septum, with a high serum level of N-terminal prohormone of brain natriuretic peptide (NT-pro-BNP) in the absence of pump failure. The assessment of polymorphonuclear neutrophil (PMN) functions revealed normal PMN responses to the various stimuli and normal oxidative burst responses. CONCLUSIONS: Identification and differentiation of staphylococcal species in a timely manner would allow us to intervene more aggressively at an earlier stage to prevent unfavorable outcomes. Clinicians should never consider the isolation of S. lugdunensis as contamination. In selected individuals, therapeutic abstention may be preferable to exposing patients to a high risk of S. lugdunensis CIED endocarditis due to re-manipulation of the pacing system. The prognostic value of NT-pro-BNP warrants further investigations.

Severe hypercalcemia in nonobstructive pyelonephritis with acute renal failure: hit or miss?

Severe hypercalcemia in the course of renal failure is quite unusual. If unrecognized, irreversible inexorable attrition of renal function takes place, carrying a substantial morbidity and mortality. In particular, acute nonobstructive pyelonephritis is barely considered in the primary differential diagnosis of renal failure. Without urinary obstruction, kidney hypoperfusion, or exposure to nephrotoxic agents, a significant decline in glomerular filtration rate generally does not occur. We report a case with severe hypercalcemia after acute renal failure caused by fulminating bacterial pyelonephritis. To obviate unnecessary intervention, preserve organ function, and achieve better outcomes, clinicians should not miss this entity.

Surviving a crisis of HIV-associated immune reconstitution syndrome.

The management of life-threatening complications in HIV-associated immune reconstitution syndrome is becoming a challenging scenario in emergency practice, especially in the era of highly active antiretroviral therapy paralleled by increased worldwide incidence of HIV infection. Here, we described a 37-year-old woman with acute hypoxic respiratory failure, acute renal failure, and hypercalcemic crisis as the presenting features of HIV-associated immune reconstitution syndrome. In this patient, the restored granulomatous host response toward isolated pulmonary Mycobacterium avium complex infection led to a near-fatal catastrophe. This report reinforces the importance of introducing a rapid, systematic approach of hypercalcemia at the emergency department and the need for clinicians to maintain awareness of this distinct manifestation.