Background: Recent advancements in artificial intelligence have led to increased adoption of machine learning in disease identification, particularly for challenging diagnoses like necrotizing fasciitis and Vibrio vulnificus infections. This shift is driven by the technology's efficiency, objectivity, and accuracy, offering potential solutions to longstanding diagnostic hurdles in clinical practice. Methods: This investigation incorporated 180 inpatients suffering from soft tissue infections. The participants were categorized into groups: cellulitis, non-Vibrio necrotizing fasciitis (NF), or V. Vulnificus NF. To predict the three relevant outcomes, we employed Light Gradient Boosting Machine (LightGBM) and 5-fold cross-validation methodologies for the development of a multi-class categorization model. Moreover, we applied the SHapley Additive exPlanations (SHAP) methodology to decipher the model's predictions. Results: The multi-classification model possesses substantial predictive capacity, with a weighted-average AUC of 0.86, sensitivity of 87.2%, specificity of 74.5%, NPV of 81.6%, and PPV of 85.4%. The model's calibration was assessed using the Brier score, yielding a weighted mean of 0.084. This low value demonstrates a strong correlation between predicted probabilities and actual outcomes, indicating high predictive accuracy and reliability in the model's forecasts. Conclusions: We effectively developed a multiclassification model aimed at forecasting the occurrence of cellulitis, non-Vibrio NF, or V. Vulnificus NF in patients suffering from soft tissue infection, and we further described the model's predictions using the SHAP algorithm.

Background Pneumonia poses a major global health challenge, necessitating accurate severity assessment tools. However, conventional scoring systems such as CURB-65 have inherent limitations. Machine learning (ML) offers a promising approach for prediction. We previously introduced the Blood Culture Prediction Index (BCPI) model, leveraging solely on complete blood count (CBC) and differential leukocyte count (DC), demonstrating its effectiveness in predicting bacteremia. Nevertheless, its potential in assessing pneumonia remains unexplored. Therefore, this study aims to compare the effectiveness of BCPI and CURB-65 in assessing pneumonia severity in an emergency department (ED) setting and develop an integrated ML model to enhance efficiency. Methods This retrospective study was conducted at a 3400-bed tertiary medical center in Taiwan. Data from 9,352 patients with pneumonia in the ED between 2019 and 2021 were analyzed in this study. We utilized the BCPI model, which was trained on CBC/DC data, and computed CURB-65 scores for each patient to compare their prognosis prediction capabilities. Subsequently, we developed a novel Cox regression model to predict in-hospital mortality, integrating the BCPI model and CURB-65 scores, aiming to assess whether this integration enhances predictive performance. Results The predictive performance of the BCPI model and CURB-65 score for the 30-day mortality rate in ED patients and the in-hospital mortality rate among admitted patients was comparable across all risk categories. However, the Cox regression model demonstrated an improved area under the ROC curve (AUC) of 0.713 than that of CURB-65 (0.668) for in-hospital mortality (p<0.001). In the lowest risk group (CURB-65=0), the Cox regression model outperformed CURB-65, with a significantly lower mortality rate (2.9% vs. 7.7%, p<0.001). Conclusions The BCPI model, constructed using CBC/DC data and ML techniques, performs comparably to the widely utilized CURB-65 in predicting outcomes for patients with pneumonia in the ED. Furthermore, by integrating the CURB-65 score and BCPI model into a Cox regression model, we demonstrated improved prediction capabilities, particularly for low-risk patients. Given its simple parameters and easy training process, the Cox regression model may be a more effective prediction tool for classifying patients with pneumonia in the emergency room.

Necrotizing soft tissue infections (NSTI) are rapidly progressing and life-threatening conditions that require prompt diagnosis. However, differentiating NSTI from other non-necrotizing skin and soft tissue infections (SSTIs) remains challenging. We aimed to evaluate the diagnostic value of the biochemical analysis of soft tissue infectious fluid in distinguishing NSTIs from non-necrotizing SSTIs. This cohort study prospectively enrolled adult patients between May 2023 and April 2024, and retrospectively included patients from April 2019 to April 2023. Patients with a clinical suspicion of NSTI in the limbs who underwent successful ultrasound-guided aspiration to obtain soft tissue infectious fluid for biochemical analysis were evaluated and classified into the NSTI and non-necrotizing SSTI groups based on their final discharge diagnosis. Common extravascular body fluid (EBF) criteria were applied. Of the 72 patients who met the inclusion criteria, 10 patients with abscesses identified via ultrasound-guided aspiration were excluded. Based on discharge diagnoses, 39 and 23 patients were classified into the NSTI and non-necrotizing SSTI groups, respectively. Biochemical analysis revealed significantly higher albumin, lactate, lactate dehydrogenase (LDH), and total protein levels in the NSTI group than in the non-necrotizing SSTI group, and the NSTI group had significantly lower glucose levels and pH in soft tissue fluids. In the biochemical analysis, LDH demonstrated outstanding discrimination (area under the curve (AUC) = 0.955; p < 0.001) among the biochemical markers. Albumin (AUC = 0.884; p < 0.001), lactate (AUC = 0.891; p < 0.001), and total protein (AUC = 0.883; p < 0.001) levels also showed excellent discrimination. Glucose level (AUC = 0.774; p < 0.001) and pH (AUC = 0.780; p < 0.001) showed acceptable discrimination. When the EBF criteria were evaluated, the total scores of Light’s criteria (AUC = 0.925; p < 0.001), fluid-to-serum LDH ratio (AUC = 0.929; p < 0.001), and fluid-to-serum total protein ratio (AUC = 0.927; p < 0.001) demonstrated outstanding discrimination. Biochemical analysis and EBF criteria demonstrated diagnostic performances ranging from acceptable to outstanding for NSTI when analyzing soft tissue infectious fluid. These findings provide valuable diagnostic insights into the recognition of NSTI. Further research is required to validate these findings.

Abdominal pain frequently leads to emergency department (ED) visits, with non-specific abdominal pain (NSAP) being a common diagnosis. Patients with severe mental illness (SMI) face higher risks due to atypical disease presentations and elevated comorbidity rates. Studies show that patients with both SMI and NSAP have increased ED revisit rates and delayed diagnoses. This study examines ED management, unscheduled ED revisit rates, and short-term adverse outcomes in patients with both SMI and NSAP using data from the Chang Gung Research Database from 01 January 2007, to 31 December 2017. Diagnoses were confirmed through the International Classification of Diseases (ICD) codes and medical records, with a 1:3 matching ratio for the non-SMI group using a Greedy algorithm. The outcomes assessed were ED management, 72-hour unscheduled ED revisits, and 7-day adverse events. From seven hospitals, 233,671 patients were initially included over 11 years; 98,722 were excluded, leaving 134,949 for analysis. The SMI group showed higher comorbidity rates, more frequent 72-hour unscheduled ED revisits, and greater use of analgesics but were less likely to receive laboratory tests or CT scans. Non-SMI patients were more likely to be admitted to the hospital and receive invasive procedures within 7 days after index discharge. There were no significant differences in intensive care unit (ICU) admissions, abdominal surgery, or in- hospital mortality between the groups. This study indicates that while patients with SMI and NSAP have higher 72-hour ED revisit rates, they do not experience higher shortterm adverse outcomes. Although NSAP is generally safe for all patients, the higher unscheduled revisit rate highlights the need for tailored healthcare interventions to reduce health disparities in this vulnerable group. Future efforts should focus on strategies to improve healthcare for individuals with SMI and NSAP.

Background and Objectives: The aim of this study is to compare the performance of six clinical physiological-based scores, including the pre-endoscopy Rockall score, shock index (SI), age shock index (age SI), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS), in predicting in-hospital mortality in elderly and very elderly patients in the emergency department (ED) with acute upper gastrointestinal bleeding (AUGIB). Materials and Methods: Patients older than 65 years who visited the ED with a clinical diagnosis of AUGIB were enrolled prospectively from July 2016 to July 2021. The six scores were calculated and compared with in-hospital mortality. Results: A total of 336 patients were recruited, of whom 40 died. There is a significant difference between the patients in the mortality group and survival group in terms of the six scoring systems. MEWS had the highest area under the curve (AUC) value (0.82). A subgroup analysis was performed for a total of 180 very elderly patients (i.e., older than 75 years), of whom 27 died. MEWS also had the best predictive performance in this subgroup (AUC, 0.82). Conclusions: This simple, rapid, and obtainable-by-the-bed parameter could assist emergency physicians in risk stratification and decision making for this vulnerable group.

Shock index (SI) and national early warning score (NEWS) are more frequently used as assessment tools in acute illnesses, patient disposition and early identification of critical condition. Both they are consisted of common vital signs and parameters including heart rate, systolic blood pressure, respiratory rate, oxygen saturation and level of conscious, which made it easy to evaluate in medical facilities. Its ability to predict mortality in patients with necrotizing fasciitis (NF) in the emergency department remains unclear. This study was conducted to compare the predictive capability of the risk scores among NF patients. A retrospective cohort study of hospitalized patients with NF was conducted in 2 tertiary teaching hospitals in Taiwan between January 2013 and March 2015. We investigated the association of NEWS and SI with mortality in NF patients. Of the 395 NF patients, 32 (8.1%) died in the hospital. For mortality, the area under the receiver curve value of NEWS (0.81, 95% confidence interval 0.76–0.86) was significantly higher than SI (0.76, 95% confidence interval 0.73–0.79, P = .016). The sensitivities of NEWS of 3, 4, and 5 for mortality were 98.1%, 95.6%, and 92.3%. On the contrast, the sensitivities of SI of 0.5, 0.6, and 0.7 for mortality were 87.8%, 84.7%, and 81.5%. NEWS had advantage in better discriminative performance of mortality in NF patients. The NEWS may be used to identify relative low risk patients among NF patients.

A bedridden 88-year-old woman with a remote right total hip arthroplasty and Child-Pugh B liver cirrhosis with ascites presented to the emergency department with progressive nontraumatic right leg swelling for 1 month (Figure 1). She was afebrile, and examination revealed painful right hip movement with mild right lower abdominal tenderness. Laboratory test results showed a WBC count of 10.3 × 103/μL, C-reactive protein level of 28.7 mg/dL, hemoglobin level of 8.3 g/dL, and international normalized ratio of 1.1. Point-of-care ultrasonography was performed (Figure 2, Video E1 [available at http://www.annemergmed.com]), and pelvic computed tomography confirmed the diagnosis (Figure 3, Video E2 [available at http://www.annemergmed.com]).Figure 2Point-of-care ultrasonography showing a mixed hyperechoic and hypoechoic oval lesion around the right hip and right lower pelvic area. The lesion compressing the right external iliac vein (arrowhead). The arrow indicates the right external iliac artery, and the asterisk indicates metal femoral head.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Axial computed tomography showing a heterogeneous cystic 15 × 10 × 9 cm lesion (white star) compressing the right external iliac vein (arrowhead). The arrow indicates the right external iliac artery, and the black star indicates metal-on-metal hip implant.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Right external iliac vein compression as a result of right hip hemarthrosis. Computed tomography–guided drainage was unsuccessful, and the patient underwent joint debridement. The synovial fluid culture showed no bacterial growth, and pathology showed fibrosis without evidence of a tumor. Symptomatic iliac vein compression typically presents with unilateral leg swelling, intermittent claudication, chronic ulceration, varicosities, deep venous thrombosis, and hyperpigmentation.1Mukarram O. Dahal K. Azrin M. et al.A case of isolated external iliac vein compression syndrome and the role of advanced imaging.Vasc Endovascular Surg. 2020; 54: 536-539Crossref Scopus (1) Google Scholar,2Radaideh Q. Patel N.M. Shammas N.W. Iliac vein compression: epidemiology, diagnosis and treatment.Vasc Health Risk Manag. 2019; 15: 115-122Crossref PubMed Scopus (27) Google Scholar The most common mechanism is the right external and internal iliac arteries “sandwiching” the iliac vein, but ganglion and synovial cysts, bursitis, and pelvic masses are also culprits, and coagulopathies can also contribute.3Chen F. Deng J. Hu X.M. et al.Compression of the right iliac vein in asymptomatic subjects and patients with iliofemoral deep vein thrombosis.Phlebology. 2016; 31: 471-480Crossref PubMed Scopus (6) Google Scholar,4Chen Z. Zhang X.C. Sun Y. et al.Diagnosis and treatment of nonthrombotic right iliac vein compression syndrome.Ann Vasc Surg. 2019; 61: 363-370Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The treatment of hemarthrosis includes ice packing, immobilization, arthrocentesis, management of underlying causes such as hemophilia, and surgery for refractory cases.5Hanley J. McKernan A. Creagh M.D. et al.Guidelines for the management of acute joint bleeds and chronic synovitis in haemophilia: a United Kingdom Haemophilia Centre Doctors’ Organisation (UKHCDO) guideline.Haemophilia. 2017; 23: 511-520Crossref PubMed Scopus (50) Google Scholar The authors would like to thank all of the participants in this study. The publication of this report was approved by the institutional review board of Chang Gung Memorial Hospital (No.: 202100958B0). https://www.annemergmed.com/cms/asset/9a196507-4164-4508-b33d-f11f493c5533/mmc1.mp4Loading ... Download .mp4 (10.79 MB) Help with .mp4 files Video 1https://www.annemergmed.com/cms/asset/6dc8a253-8345-4f10-a94d-3bcb59cd90f2/mmc2.mp4Loading ... Download .mp4 (13.71 MB) Help with .mp4 files Video 2

Background Patients with severe mental illness (SMI) have a shorter life expectancy and have been considered by the World Health Organization (WHO) as a vulnerable group. As the causes for this mortality gap are complex, clarification regarding the contributing factors is crucial to improving the health care of SMI patients. Acute appendicitis is one of the most common indications for emergency surgery worldwide. A higher perforation rate has been found among psychiatric patients. This study aims to evaluate the differences in appendiceal perforation rate, emergency department (ED) management, in-hospital outcomes, and in-hospital expenditure among acute appendicitis patients with or without SMI via the use of a multi-centre database. Methods Relying on Chang Gung Research Database (CGRD) for data, we selectively used its data from January 1st, 2007 to December 31st, 2017. The diagnoses of acute appendicitis and SMI were confirmed by combining ICD codes with relevant medical records. A non-SMI patient group was matched at the ratio of 1:3 by using the Greedy algorithm. The outcomes were appendiceal perforation rate, ED treatment, in-hospital outcome, and in-hospital expenditure. Results A total of 25,766 patients from seven hospitals over a span of 11 years were recruited; among them, 11,513 were excluded by criteria, with 14,253 patients left for analysis. SMI group was older (50.5 vs. 44.4 years, p < 0.01) and had a higher percentage of females (56.5 vs. 44.4%, p = 0.01) and Charlson Comorbidity Index. An analysis of the matched group has revealed that the SMI group has a higher unscheduled 72-hour revisit to ED (17.9 vs. 10.4%, p = 0.01). There was no significant difference in appendiceal perforation rate, ED treatment, in-hospital outcome, and in-hospital expenditure. Conclusions Our study demonstrated no obvious differences in appendiceal perforation rate, ED management, in-hospital outcomes, and in-hospital expenditure among SMI and non-SMI patients with acute appendicitis. A higher unscheduled 72-hour ED revisit rate prior to the diagnosis of acute appendicitis in the SMI group was found. ED health providers need to be cautious when it comes to SMI patients with vague symptoms or unspecified abdominal complaints.

Background It remains unclear whether Vibrio vulnificus necrotizing soft tissue infection (NSTI) is associated with higher mortality compared with non- Vibrio NSTI. This study’s objective was to compare outcomes including in-hospital mortality and prognosis between patients with V. vulnificus NSTI and those with non- Vibrio NSTI. Method A retrospective 1:2 matched-pair cohort study of hospitalized patients with NSTI diagnosed by surgical finding was conducted in two tertiary hospitals in southern Taiwan between January 2015 and January 2020. In-hospital outcomes (mortality, length of stay) were compared between patients with and without V. vulnificus infection. We performed multiple imputation using chained equations followed by multivariable regression analyses fitted with generalized estimating equations to account for clustering within matched pairs. All-cause in-hospital mortality and length of stay during hospitalization were compared for NSTI patients with and without V. vulnificus . Result A total of 135 patients were included, 45 in V. vulnificus NSTI group and 90 in non- Vibrio group. The V. vulnificus NSTI patients had higher mortality and longer hospital stays. Multivariable logistic regression analysis revealed that V. vulnificus NSTI was significantly associated with higher in-hospital mortality compared with non- Vibrio NSTI (adjusted odds ratio = 1.52; 95% confidence interval 1.36–1.70; p < 0.01). Conclusion Vibrio vulnificus NSTI was associated with higher in-hospital mortality and longer hospital stay which may increase health care costs, suggesting that preventing V. vulnificus infection is essential.

A 59-year-old man with hypertension presented to the emergency department with 2 hours of acute back pain. He had a blood pressure of 79/44 mm Hg, a pulse rate of 76 beats/min, a respiratory rate of 28 breaths/min, and an oxygen saturation level of 87% on ambient air. Physical examination was notable for decreased breath sounds on the left side. Bedside ultrasonography of the left side of his chest showed a hematocrit sign (Figure 1), and color Doppler showed an aneurysmal lesion with a feeding artery (Figure 2). Computed tomography of the chest confirmed the diagnosis of left pulmonary arteriovenous malformation with massive left hemothorax (Figure 3). Surgeons performed an emergency video-assisted wedge resection (Figure 4), and the pathology report confirmed pulmonary arteriovenous malformation.Figure 2Color Doppler ultrasonography showed an aneurysmal lesion (arrowhead) with a feeding artery (arrow) in the left side of the chest cavity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Computed tomography revealed a left pulmonary arteriovenous malformation (arrowhead) with a feeding artery (arrow) and massive left hemothorax (star).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Video-assisted thoracic surgery demonstrated a bleeding aneurysm.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Ruptured pulmonary arteriovenous malformation. Clinical manifestations of pulmonary arteriovenous malformation range from an absence of symptoms to cough, chest pain, dyspnea, and hemoptysis and cyanosis.1Santhirapala V. Chamali B. McKernan H. et al.Orthodeoxia and postural orthostatic tachycardia in patients with pulmonary arteriovenous malformations: a prospective 8-year series.Thorax. 2014; 69: 1046-1047Crossref PubMed Scopus (28) Google Scholar Hemothorax is a rare but life-threatening complication of pulmonary arteriovenous malformation and generally results from vascular lesions, neoplastic lesions, or coagulopathy.2Berg A.M. Amirbekian S. Mojibian H. et al.Hemothorax due to rupture of pulmonary arteriovenous malformation: an interventional emergency.Chest. 2010; 137: 705-707Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,3Zeiler J. Idell S. Norwood S. et al.Hemothorax: a review of the literature.Clin Pulm Med. 2020; 27: 1-12Crossref PubMed Scopus (12) Google Scholar Stable pulmonary arteriovenous malformation can be embolized, whereas hemorrhage is managed surgically.4Saboo S.S. Chamarthy M. Bhalla S. et al.Pulmonary arteriovenous malformations: diagnosis.Cardiovascular Diagnosis and Therapy. 2018; 8: 325-337Crossref PubMed Scopus (43) Google Scholar

An 80-year-old woman with a history of choledocholithiasis with common bile duct obstruction status post endoscopic retrograde biliary drainage presented to the emergency department with acute right upper abdominal pain for 3 days. In the ED, he was febrile and hemodynamically stable. Physical examination revealed right upper abdominal tenderness without signs of peritonitis. Laboratory test results showed a WBC count of 17, 600/μL, C-reactive protein level of 176 mg/L, and total bilirubin of 4.4 mg/dL. A point-of-care ultrasonography was performed (Figure 1), and an abdominal computed tomography (CT) confirmed the diagnosis (Figures 2 and 3, and Video E1 [available online at http://www.annemergmed.com]).Figure 2Axial CT showed that the migrated biliary stent (long arrow) perforated the duodenum (arrowhead). A pancreatic stent (short arrow) can be seen in the appropriate location.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Coronal CT showed that the tip of the migrated biliary stent (arrow) penetrated the right renal parenchyma.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Duodenal perforation and penetrated renal parenchyma secondary to a migrated plastic biliary stent. The patient received successful endoscopic treatment for the removal of the migrated stent and wound closure (Figure 4). Endoscopic retrograde biliary drainage is a therapeutic procedure used to treat biliary tract obstruction, and its complications include pancreatitis, cholangitis, hemorrhage, perforation, and stent migration.1Wang X. Qu J. Li K. Duodenal perforations secondary to a migrated biliary plastic stent successfully treated by endoscope: case-report and review of the literature.BMC Gastroenterol. 2020; 20: 149Crossref PubMed Scopus (5) Google Scholar Biliary stent migration rates were reported to be from 3.1% to 4.9%.2Kim H.S. Moon H.J. Lee N.Y. et al.Endoscopic management of duodenal perforations caused by migrated biliary plastic stents.Endosc Int Open. 2019; 7: E792-E795Crossref PubMed Google Scholar However, the rate of bowel perforation as a result of biliary stent migration is rare.1Wang X. Qu J. Li K. Duodenal perforations secondary to a migrated biliary plastic stent successfully treated by endoscope: case-report and review of the literature.BMC Gastroenterol. 2020; 20: 149Crossref PubMed Scopus (5) Google Scholar,2Kim H.S. Moon H.J. Lee N.Y. et al.Endoscopic management of duodenal perforations caused by migrated biliary plastic stents.Endosc Int Open. 2019; 7: E792-E795Crossref PubMed Google Scholar Furthermore, to our knowledge, this is the first report of penetrating kidney injury caused by a migrated biliary stent. Management of intraperitoneal perforation usually requires surgical intervention, while small retroperitoneal perforation can be managed with medical treatment.3Szary N.M. Al-Kawas F.H. Complications of endoscopic retrograde cholangiopancreatography: how to avoid and manage them.Gastroenterol Hepatol (N Y). 2013; 9: 496-504PubMed Google Scholar In addition, many cases have reported successful endoscopic treatment for duodenal perforation.2Kim H.S. Moon H.J. Lee N.Y. et al.Endoscopic management of duodenal perforations caused by migrated biliary plastic stents.Endosc Int Open. 2019; 7: E792-E795Crossref PubMed Google Scholar https://www.annemergmed.com/cms/asset/332259e8-2221-41e5-90cf-8de956255417/mmc1.mp4Loading ... Download .mp4 (9.06 MB) Help with .mp4 files Video E1(a) Axial CT and (b) Coronary CT. CT of the abdomen showed that the migrated biliary stent perforated through the second portion of the duodenum and penetrated the right renal parenchyma.https://www.annemergmed.com/cms/asset/996c172d-1db7-4a92-84d1-0d1b7f9b88ed/mmc2.mp4Loading ... Download .mp4 (10.49 MB) Help with .mp4 files Video E1(a) Axial CT and (b) Coronary CT. CT of the abdomen showed that the migrated biliary stent perforated through the second portion of the duodenum and penetrated the right renal parenchyma.

BACKGROUND:Current American Heart Association Pediatric Life Support (PLS) guidelines do not recommend the routine use of sodium bicarbonate (SB) during cardiac arrest in pediatric patients. However, SB administration during pediatric resuscitation is still common in clinical practice. The objective of this study was to assess the impact of SB on mortality and neurological outcomes in pediatric patients with in-hospital cardiac arrest. METHODS:We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to January 2021. We included studies of pediatric patients that had two treatment arms (treated with SB or not treated with SB) during in-hospital cardiac arrest (IHCA). Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was assessed using GRADE system. RESULTS:We included 7 observational studies with a total of 4877 pediatric in-hospital cardiac arrest patients. Meta-analysis showed that SB administration during pediatric cardiac resuscitation was associated with a significantly decreased rate of survival to hospital discharge (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.25-0.63, p value = 0.0003). There were insufficient studies for 24-h survival and neurologic outcomes analysis. The subgroup analysis showed a significantly decreased rate of survival to hospital discharge in both the "before 2010" subgroup (OR 0.47; 95% CI 0.30-0.73; p value = 0.006) and the "after 2010" subgroup (OR 0.46; 95% CI 0.25-0.87; p value = 0.02). The certainty of evidence ranged from very low to low. CONCLUSIONS:This meta-analysis of non-randomized studies supported current PLS guideline that routine administration of SB is not recommended in pediatric cardiac arrest except in special resuscitation situations. TRIAL REGISTRATION:The protocol was registered with PROSPERO on 8 August 2020 (registration number: CRD42020197837).

Background Necrotizing soft tissue infection (NSTI) of the lower extremity (LE) is a rapidly progressing infection that requires early diagnosis and prompt treatment to decrease risks of loss of limb or life. Clinical presentation, particularly of early NSTI, can appear similar to severe cellulitis. The purpose of this study is to identify factors that are associated with NSTI rather than severe cellulitis to differentiate patients with similar clinical presentation. Methods This retrospective cohort design study compares patients finally diagnosed with LE NSTI versus those diagnosed with severe cellulitis. Cohorts were matched using the modified Laboratory Risk Indicator for Necrotizing Fasciitis (m-LRINEC) score in the setting of LE soft tissue infection. Laboratory values, vital signs, subjective symptoms, and social factors including substance abuse were recorded. Univariate and multivariate analyses were performed. Results Multivariate statistical analysis and clinical interpretation of data identified four factors more associated with a diagnosis of NSTI than severe cellulitis: elevated lactate, a patient-reported history of fever, male gender, and intravenous substance user. Conclusion In patients with lower extremity infections, the clinical presentation of NSTI and severe cellulitis may appear similar. In this retrospective cohort of patients matched with m-LRINEC scores, elevated lactate, subjective fever, male gender, and intravenous substance abuser were significantly associated with NSTI rather than severe cellulitis. Further studies of these factors in the clinical setting can help tailor the differential diagnosis in the care of patients with severe lower extremity infections. Matched with m-LRINEC scores, elevated lactate, subjective fever, male gender, and intravenous substance abuser were significantly associated with NSTI rather than severe cellulitis. Further studies of these factors in the clinical setting can help tailor the differential diagnosis in the care of patients with severe lower extremity infections.

Background We conducted this study to promote a modified Laboratory Risk Indicator for Necrotizing Fasciitis (MLRINEC) score and evaluate the utility in distinguishing necrotizing fasciitis (NF) from other soft-tissue infections. Method A retrospective cohort study of hospitalized patients with NF diagnosed by surgical finding was conducted in two tertiary hospital in southern Taiwan between January 2015 and January 2020. Another group was matched by controls with non-necrotizing soft tissue infections based on time, demographics, and immune status. Data such as infectious location, comorbidities, and laboratory findings were recorded and compared. Logistics regression were used to determine the association with NF after adjustment for confounders and MLRINEC score was developed by then. Receiver operating curve (ROC) and the area under the curve (AUC) were used to evaluate its discriminating ability. Result A total of 303 patients were included; 101 in NF group and 202 in non-NF group. We added serum lactate and comorbid liver disease to the original LRINEC score and re-defined the cut-off values for 3 variables to develop the MLRINEC score. The cut-off value for MLRINEC score was 12 points with corresponding sensitivity of 91.8% and a specificity of 88.4%, and the area under ROC (AUC) was 0.893 (95% CI, 0.723 to 0.948; p < 0.01). Conclusion MLRINEC score shows a high sensitivity and specificity in distinguishing NF from non-necrotizing soft-tissue infections. Patients with a MLRINEC score > 12 points should be highly suspected of presence of necrotizing fasciitis.

Background: Detecting acute ST-segment elevation myocardial infarction (STEMI) in the setting of left bundle branch block (LBBB) remains a challenge to clinicians. Several diagnostic and triage algorithms have been proposed to accurately identify LBBB patients with an acute culprit vessel. We aimed to validate the algorithm proposed by Cai et al., which uses patients' hemodynamic status and the modified Sgarbossa electrocardiography criteria to guide reperfusion therapy. Methods: This retrospective study was performed with a chart review in emergency departments (EDs) of 2 medical centers, 2 regional hospitals, and 1 local hospital. From January 2010 to December 2014, 2432 consecutive patients were diagnosed as having STEMI in the ED, including 65 patients with LBBB (2.6%). Results: The patients with LBBB were older and more frequently presented with acute pulmonary edema (58.5% vs 22.1%, p < 0.001), cardiogenic shock (16.9% vs 6.3% p = 0.006), and VT/VF episodes (7.7% vs 2.2%, p = 0.034) and had a higher 30-day mortality rate (20.0% vs 10.4% p = 0.032) than those without LBBB. We then tested the algorithm proposed by Cai et al. and noted a sensitivity of 93.8% in identifying a culprit lesion. Conclusions: The inconsistency of the guideline recommendations reflects the uncertainty of diagnostic and therapeutic strategies and the pressing need for tools to accurately identify the true acute myocardial infarction in patients presenting with chest pain and LBBB. The algorithm proposed by Cai et al. had good sensitivity and would allow emergency physicians to implement the timely treatment protocol for this high-risk population. (C) 2020 Elsevier Inc. All rights reserved.

Objectives. Frequent attendance for nonemergency problems to emergency departments (EDs) contributes to ED overcrowding, resulting in medical care delays, increased medical errors, and social and economic burdens. Most studies regarding frequent attenders of EDs examine general patients without classifying certain subgroups. This study aimed to investigate patients with liver cirrhosis who present repeatedly to the ED. Methods. This was a retrospective, observational cohort study of adult patients with a history of liver cirrhosis presenting to the ED from January 2011 to December 2015. We included patients with cirrhosis whose first ED visit occurred during the study period. We went far back for 20 years and excluded patients with any ED visits (including both cirrhosis and noncirrhosis-related ones) before the study period. We categorized frequent attenders as patients with more than 4 ED visits within 12 months after the first ED visit; infrequent attenders were those who did not meet this criterion. Results. A total of 3513 patients with cirrhosis were included in this retrospective cohort study. Compared with the infrequent attenders, frequent attenders had a higher rate of presentations due to hepatic encephalopathy (15.2% vs 13.7%, P<0.001) and ascites (10% vs 4%, P<0.001). A Kaplan–Meir survival analysis revealed that frequent attendance was not associated with increased mortality during the study period (hazard ratio 1.02, 95% confidence interval 0.92–1.14; P=0.68). Conclusions. Hepatic encephalopathy and ascites account for more ED visits in frequent than in infrequent attenders. Our findings provide information for those planning outpatient support for patients with cirrhosis. Further research is warranted.

Background: The 2010 Advanced Cardiac Life Support guidelines stated that routine sodium bicarbonate (SB) use for cardiac arrest patients was not recommended. However, SB administration during resuscitation is still common. Objectives: To evaluate the effect of SB on return of spontaneous circulation (ROSC) and survival-to-discharge rates in adult cardiac arrest patients. Methods: We searched Medline, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to December 2019. We included trials on nontraumatic adult patients after cardiac resuscitation and SB treatment vs. controls. Results: A meta-analysis was performed with six observational studies, including 18,406 adult cardiac arrest patients. There were no significant differences in the ROSC rate (odds ratio [OR] 1.185; 95% confidence interval [CI] 0.680-2.065) and survival-to-discharge rate (OR 0.296; 95% CI 0.066-1.323) between the SB and no-SB groups. In the subgroup analysis based on the year factor, there were no significant differences in the mortality rate in the After-2010 group. In the subgroup analysis based on the continent, the ROSC rate (OR 0.521; 95% CI 0.432-0.628) and survival-to-discharge rate (OR 0.102; 95% CI 0.066-0.156) were significantly lower in the North American group. Conclusions: SB use was not associated with improvement in ROSC or survival-to-discharge rates in cardiac resuscitation. In addition, mortality was significantly increased in the North American group with SB administration. (C) 2020 Elsevier Inc. All rights reserved.

Background and study aims: Azotaemia is commonly identified among patients with upper gastrointestinal bleeding (UGIB) due to absorption of blood products in the small bowel. Previous studies have found blood urea nitrogen-to-creatinine (BUN/Cr) ratio to be significantly elevated among patients UGIB bleeding compared to patients with lower GI bleeding. However, no studies have explored the relationship between BUN/Cr ratio and mortality. This study is aimed at investigating how BUN/Cr ratio relates to outcomes for UGIB patients. Patients and methods: This study was conducted prospectively at a university-affiliated teaching hospital with approximate 70,000 annual emergency department (ED) visits. Data from a total of 258 adult UGIB patients were collected between March 1, 2011 and March 1, 2012. Cox regression analysis was used to identify risk factors for 30-day mortality. Results: Malignancy and Rockall score were associated with increased risk of 30-day mortality (Unadjusted hazard ratio (HR): 3.87, 95% CI: 1.59-9.41, p = 0.0029; HR: 1.31, 95% CI: 1.02-1.71, p = 0.0476, respectively). However, BUN/Cr > 30 was associated with lower risk of 30-day mortality (HR: 0.32, 95% CI: 0.11-0.97, p = 0.0441). Conclusions: A BUN/Cr ratio of >30 was found to be an independent risk factor for mortality and may be useful for pre-endoscopic assessment. Development of future risk scoring systems might warrant consideration of including BUN/Cr ratio as a parameter for estimating risk. (C) 2018 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.

Background: Prognostic factors for the outcomes in traumatic cardiac arrest (TCA) patients transported to hospitals without prehospital return of spontaneous circulation (ROSC) remain uncertain. The aim of this study is to investigate factors associated with outcomes in TCA patients without prehospital ROSC. Methods: We conducted a retrospective cohort study using a multi-institutional, 5-year database. Only TCA patients without prehospital ROSC were included. The primary outcome was ROSC in the emergency department (ED), and the secondary outcome was 30-day survival. Logistic regression analysis was performed to determine the factors associated with primary and secondary outcomes. Results: Among 463 TCA patients, 73 (16%) had ROSC during ED resuscitation, and among those with sustained ROSC, 10 (14%) survived for at least 30 days. Injury severity score >= 16 (OR, 0.06; 95% CI: 0.02-0.20), trauma center admission (OR, 2.69; 95% CI: 1.03-7.03), length of ED resuscitation (OR, 0.98; 95% CI: 0.96-0.99), and total resuscitation length > 20 min (OR, 0.21; 95% CI: 0.08-0.54) were associated with ROSC. Conclusions: In TCA patients transported to hospitals without prehospital ROSC, resuscitation attempts could be beneficial. We should aim to resuscitate patients as soon as possible with appropriate treatments for trauma patients, early activation of trauma team, and then, as a result, shorter resuscitation time will be achieved. (C) 2018 The Author(s). Published by Elsevier Ltd.