Association between ambient PM2.5 and emergency department visits for psychiatric emergency diseases

BackgroundWhether or not short-term exposure to particulate matter <2.5 μm in diameter (PM_2.5) increases the risk of psychiatric emergency diseases is unclear.MethodsThe study was performed in a metropolis from January 2015 to December 2016. The exposure was PM_2.5, and the confounders were weather (temperature and humidity) and other pollutants (PM₁₀, SO₂, CO, O₃, and NO₂). The outcomes were emergency department (ED) visits with psychiatric disease codes (F00-F99 in ICD10 codes). General additive models were used for the statistical analysis to calculate the adjusted relative risks (ARRs) and 95% confidence intervals (95% CIs) for the daily number of ED visits with a lag of 1 to 3 days following a 10 μg/m³ increase in PM_2.5.ResultsDuring the study period, a total of 67,561 ED visits for psychiatric diseases were identified and tested for association with PM_2.5. Daily ED visits for all psychiatric diseases were not associated with PM_2.5 in the model that was not adjusted for other pollutants. The ARR (95% CI) in the model adjusted for SO₂ was 1.011 (1.002–1.021) by 10 μg/m³ of PM_2.5 on Lag 1 for all psychiatric diseases (F00-F99). The ARR (95% CI) in the model adjusted for O₃ was 1.015 (1.003–1.029) by 10 μg/m³ of PM_2.5 on Lag 1 for F40-F49 (Neurotic, stress-related and somatoform disorders).ConclusionAn increase in PM_2.5 showed a significant association with an increase in ED visits for all psychiatric diseases (F00-F99) and for neurotic, stress-related and somatoform disorders (F40-F49) on lag day 1.     

Transient loss of A1 phenotype in a patient with passenger lymphocyte syndrome after ABO minor incompatible liver transplantation: The first case report

Passenger lymphocyte syndrome (PLS) is a well-known cause of antibody mediated hemolysis after minor ABO mismatched transplantations. In most cases, PLS is mild and self-limited and easily recovered through transfusion. We report an unusual case of transient loss of A1 phenotype in AB blood type patient with PLS after ABO minor incompatible liver transplantation from B blood type deceased donor.     

Impact of bacteremia prediction rule in CAP: Before and after study

Objective

In cases of community acquired pneumonia (CAP), it has been known that blood cultures have low yields and rarely affect clinical outcomes. Despite many studies predicting the likelihood of bacteremia in CAP patients, those results have been rarely implemented in clinical practice, and use of blood culture in CAP is still increasing. This study evaluated impact of implementing a previously derived and validated bacteremia prediction rule.

The ratio of N-terminal pro-B-type natriuretic peptide to troponin I for differentiating acute coronary syndrome

IntroductionIt is difficult to differentiate whether coronary or non-coronary causes in patients with elevated troponin I (TnI) in emergency department (ED). The aim of this study was to develop a clinical decision tool for differentiating a coronary cause in the patients with elevated TnI.MethodsThis was a retrospective observational study that enrolled consecutive ED patients. Patients were included in the study if they were ≥16 years of age, had admitted through ED with a medical illness, and TnI levels at initial evaluation in the ED were ≥0.2 ng/mL. Patients diagnosed with ST elevation myocardial infarction or congestive heart failure were excluded. Coronary angiography, electrocardiogram, laboratory results, echocardiography, and clinical characteristics were analyzed.ResultsAmong the included 1441 patients, 603 and 838 patients were categorized into an acute coronary syndrome (ACS) group and non-acute coronary syndrome (non-ACS) group, respectively. The ratio of N-terminal pro-Btype natriuretic peptide (NT-proBNP) to TnI was significantly higher in the non-ACS group compared to the ACS group. The AUC of NT-proBNP/TnI (0.805, 95% CI, 0.784-0.826) was significantly superior to that of NT-proBNP/creatinine kinase-MB, TnI, and NT-proBNP. The patients of the non-ACS group with high levels of TnI and BNP showed more critically ill manifestation at the time of presentation and higher mortality.ConclusionNT-proBNP/TnI may help to distinguish medical patients with elevated TnI whether the elevated TnIs were caused from ACSs or from conditions other than ACS.     

The impact of recommended percutaneous coronary intervention care on hospital outcomes for interhospital-transferred STEMI patients

Background

Timely transfer and percutaneous coronary intervention (PCI) with or without thrombolysis are recommended by the American Heart Association (AHA) to care for ST-segment elevation myocardial infarction (STEMI) patients who present first to a non–PCI-capable hospital. This study was to evaluate the impact on in-hospital mortality of the compliance with guidelines regarding to the time of PCI for patients with STEMI who were transferred to a capable PCI hospital.

Seizure in code stroke: Stroke mimic and initial manifestation of stroke

BackgroundAlthough seizure is one of the common causes of stroke mimics and can be an initial manifestation of acute stroke, accurate diagnosis of seizure during acute stroke management is frequently difficult. The objective of this study was to analyze the frequency, characteristics and results of neuroimaging including CT perfusion in patients with seizures manifesting initially as stroke-like symptoms.MethodsWe retrospectively reviewed the medical records of patients who were treated with code stroke alarming system. We studied the frequency and characteristics of patients who were finally diagnosed with seizures and further correlated their clinical features with the results of neuroimaging including CT perfusion.ResultsAmong the 4673 patients who were treated with code stroke alarming system, seizure was the third most frequent diagnosis (188 patients, 4.0%) among the causes of stroke mimics including 27 patients who manifested seizure as an initial manifestation of acute stroke. CT perfusion showed perfusion changes in more than 25% of them (49 of 188 patients, 26.1%). Thrombolysis was not performed in six patients who presented with seizure as an initial presentation of stroke for delayed diagnosis while one patient underwent thrombolysis for misdiagnosis of seizure.ConclusionsSeizure is a frequent final diagnosis in acute stroke management. However, careful interpretation of clinical features and results of perfusion imaging is necessary to avoid unnecessary thrombolysis in patients with seizure as a stroke mimic and thrombolysis failure due to delayed diagnosis of seizure as an initial manifestation of stroke.     

Hemodialysis in metformin-associated lactic acidosis due to acute overdose in a metformin-naïve patient

Metformin is a common and generally well-tolerated medication in the treatment of diabetes but rarely has been implicated as the cause for metformin-associated lactate acidosis. This is usually caused by decreased elimination from renal dysfunction but is rarely described after an acute ingestion. We present a case of an acute intentional overdose of metformin in a metformin-naïve patient without renal dysfunction. The patient gradually developed altered mental status, tachypnea, hypotension, hyperglycemia, hypoglycemia, hypothermia, and vasoplegic shock unresponsive to vasopressor support. Despite attempts at alkalinization, the patient developed a lactic acidosis with a pH of 6.9 and lactate of 33?mmol/L. Hemodialysis was performed with rapid improvement of clinical status. This case provides a clinical context in the acute setting and illustrates the rare need for extracorporeal support in this setting, which may be lifesaving.     

Efficacy of low-dose nebulized epinephrine as treatment for croup: A randomized,placebo-controlled,double-blind trial

ObjectiveCroup treatment usually involves a single dose of systemic dexamethasone combined with nebulized epinephrine. However, the optimal dose of l-epinephrine remains unclear. We examined whether a low dose (0.1 mg/kg) was inferior to the conventional dose (0.5 mg/kg) of 1:1000 nebulized l-epinephrine in patients with moderate to severe croup.MethodsThis randomized double-blind clinical non-inferiority trial was conducted in three pediatric emergency departments from May 2015 to October 2017. Children 6 months to 5 years old with moderate to severe croup (Westley scale scores 3–11) were eligible. Subjects were randomly assigned to the conventional dose (0.5 mg/kg: maximum 5 mg) or low dose (0.1 mg/kg; maximum 1 mg) group. All subjects received 0.6 mg/kg dexamethasone. Croup scores and other vital signs were measured before and at 30, 60, 90, and 120 min after nebulized l-epinephrine administration. The primary outcome was the change in croup score after 30 min.ResultsThe final analysis included 84 patients. The groups did not differ significantly in terms of demographic parameters. At 30 min after treatment with nebulized l-epinephrine, the croup scores in both groups were significantly reduced from the baseline values (p < 0.05) and did not differ between the two groups (p = 0.42). Neither blood pressure nor heart rate differed between the two groups.ConclusionsLow-dose 1:1000 l-epinephrine was not inferior in croup score reduction to the conventional dose in patients with moderate to severe croup.Clinical trial No: NCT01664507, KCT0002318.     

Characterizing the impact of snowfall on patient attendance at an urban emergency department in Toronto,Canada

ObjectivesWe sought to determine whether addition of a snowfall variable improves emergency department (ED) patient volume forecasting. Our secondary objective was to characterize the magnitude of effect of snowfall on ED volume.MethodsWe used daily historical patient volume data and local snowfall records from April 1st, 2011 to March 31st, 2018 (2542 days) to fit a series of four generalized linear models: a baseline model which included calendar variables and three different snowfall models with an indicator variable for either any snowfall (>0 cm), moderate snowfall (≥1 cm), or large snowfall (≥5 cm). To evaluate model fit, we examined the Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC). Incident rate ratios were calculated to determine the effect of snowfall in each model.ResultsAll three snowfall models demonstrated improved model fit compared to the model without snowfall. The best fitting model included a binary variable for snowfall (<1 cm vs. ≥1 cm). This model showed a statistically significant decrease in daily ED volume of 2.65% (95% CI: 1.23%–4.00%) on snowfall days.DiscussionThe addition of a snowfall variable results in improved model performance in short-term ED volume forecasting. Snowfall is associated with a modest, but statistically significant reduction in ED volume.     

Long-term outcomes and prognostic factors in patients with mild hemoptysis

Objective

The aim of this retrospective study was to observe the long-term outcomes of conservative treatment and bronchial artery embolization (BAE) in patients with mild hemoptysis and to analyze the risk factors associated with hemoptysis recurrence.

The effects of case management program completion on suicide risk among suicide attempters: A 5-year observational study

BackgroundA prior suicide attempt is known to be the most important risk factor for suicide. Case management programs provide psychosocial support and rehabilitation for suicide attempters. This study aimed to determine whether case management completion is associated with good clinical outcomes for suicide attempters visiting the emergency department (ED).MethodsA cross-sectional observational study was conducted using risk assessment records for suicide attempters visiting the ED from October 2013 to December 2017. We created two groups according to completion of the case management program. The primary outcome was a decrease in suicide risk. The secondary and tertiary outcomes were untreated stressors and lack of a support system. We calculated the adjusted odds ratio (AOR) of the case management completion for study outcomes adjusting for potential confounders.ResultsAmong 439 eligible suicide attempters, only 277 (63.1%) participants completed the case management program. Participants who completed the case management program were more likely to have decreased suicide risk (65.3% vs. 46.9%, AOR: 2.13 (1.42–3.20)) and less untreated stressors (49.8% vs. 61.1%, AOR: 0.64 (0.43–0.96)). However, there was no significant difference in lack of a support system (35.4% vs. 45.7%, AOR: 0.68 (0.45–1.03)).ConclusionCompletion of a case management program was associated with reduction of suicide risk. Multicomponent strategies to increase compliance with a case management program are needed to prevent suicide reattempt and reduce the health burden of suicide.     

Moderate brain hypothermia started before resuscitation improves survival and neurobehavioral outcomes after CA/CPR in mice

Aim of the studyNo definitive experimental or clinical evidence exists whether brain hypothermia before, rather than during or after, resuscitation can reduce hypoxic-ischemic brain injury following cardiac arrest/cardiopulmonary resuscitation (CA/CPR) and improve outcomes. We examined the effects of moderate brain hypothermia before resuscitation on survival and histopathological and neurobehavioral outcomes in a mouse model.MethodsAdult C57BL/6 male mice (age: 8–12 weeks) were subjected to 8-min CA followed by CPR. The animals were randomly divided into sham, normothermia (NT; brain temperature 37.5 °C), and extracranial hypothermia (HT; brain temperature 28–32 °C) groups. The hippocampal CA1 was assessed 7 day after resuscitation by histochemical staining. Neurobehavioral outcomes were evaluated by the Barnes maze (BMT), openfield (OFT), rotarod, and light/dark (LDT) tests. Cleaved caspase-3 and heat shock protein 60 (HSP70) levels were investigated by western blotting.ResultsThe HT group exhibited higher survival and lower CA1 neuronal injury than did the NT group. HT mice showed improved spatial memory in the BMT compared with NT mice. NT mice travelled a shorter distance in the OFT and tended to spend more time in the light compartment in the LDT than did sham and HT mice. The levels of cleaved caspase-3 and HSP70 were non-significantly higher in the NT than in the sham and HT groups.ConclusionsModerate brain hypothermia before resuscitation improved survival and reduced histological neuronal injury, spatial memory impairment, and anxiety-like behaviours after CA/CPR in mice.