Acute myocardial infarction diagnosed early by multidetector computed tomography.
Explore the source record for details and available documents.
Angioplasty↗
Biomedical subjects
Lee-Min Wang
Publications and source records attributed to Lee-Min Wang.
A pilot study of a new thrombolytic agent for acute ischemic stroke in Taiwan within a five-hour window.
BACKGROUND AND PURPOSE: This study was the first clinical trial in Taiwan of a new thrombolytic agent human tissue urokinase type plasminogen activator (HTUPA) in patients with acute ischemic stroke. METHODS: Patients were treated with a single bolus intravenous HTUPA under an open-label dose escalation design within 5 hours after symptom onset. Safety outcomes were assessed by symptomatic and asymptomatic intracerebral hemorrhage (ICH) as well as other bleeding episodes. Preliminary efficacy was measured by National Institutes of Health Stroke Scale (NIHSS). RESULTS: Three doses of HTUPA (0.3 mg/kg, 0.35 mg/kg, and 0.4 mg/kg) were administered to 33 patients, with the majority of patients (n=29) receiving 0.3 mg/kg. Two cases of fatal ICH occurred: 1 in the patient who received 0.4 mg/kg and the other in the 0.3 mg/kg group. Asymptomatic ICH occurred in 6 patients. Other treatment-related serious adverse events were ecchymosis, hematuria, and upper gastrointestinal bleeding, which were completely recovered. At day 90, in patients treated with 0.3 mg/kg within a 0- to 5-hour window, 34% reached NIHSS scores 0 to 1, whereas of those treated within 0 to 3 hours, 86% reached this score. CONCLUSIONS: Intravenous HTUPA, given at 0.3 mg/kg as a bolus injection within 5 hours after symptom onset, had an acceptable safety and efficacious profile in patients with acute ischemic stroke.
Aged↗
Serious pancytopenia from methotrexate treatment of psoriatic arthritis.
Explore the source record for details and available documents.
Aged↗
Declining emergency department visits and costs during the severe acute respiratory syndrome (SARS) outbreak.
BACKGROUND: The immediate and long-term impact of severe acute respiratory syndrome (SARS) outbreak on emergency department (ED) visits and hospital expenditures for these visits has not been thoroughly investigated. The objectives of this retrospective observational study investigated the impact of SARS outbreak on ED visits and the cost of these visits in a designated SARS medical center. METHODS: Data related to the total number of ED visits and their costs were collected for the SARS epidemic period in 2003 and the same period in the preceding year in 2002. Data collected included total number of ED visits, services provided, triage categories, and total expenditures for all patients. Data for before and during the outbreak were retrieved and compared. RESULTS: At the peak of the SARS epidemic, the reduction in daily ED visits reached 51.6% of pre-epidemic numbers (p < 0.01). In pediatric, trauma and non-trauma patients, the maximum mean decreases in number of visits were 80.0% (p < 0.01), 57.6% (p < 0.01) and 40.8% (p < 0.01), respectively. In triage 1, 2 and 3 patients, the maximum mean decreases were 18.1% (p < 0.01), 55.9% (p < 0.01) and 53.7% (p < 0.01), respectively. The maximum decrease in total costs was 37.7% (p < 0.01). The maximum mean costs per patient increased 35.9% (p < 0.01). The proportions of increases in mean costs for each patient were attributed to laboratory investigations (31.4%), radiography (21.9%) and medications (29.5%). CONCLUSION: The SARS outbreak resulted in a marked reduction in the number of ED visits which persisted for 3 months after the end of the epidemic. Total cost of treating individual patients showed a simultaneous marked increase, while overall operational costs in the ED showed a marked decrease. The increased total cost for each patient was attributed to the increased number of diagnostic procedures to screen for possible SARS in the ED.
Emergency Service, Hospital↗
Different clinical presentations in chinese people with acute myocardial infarction in the emergency department.
BACKGROUND: The purpose of this study was to investigate the clinical characteristics of younger- ( 45 years) Chinese patients presenting to the emergency department (ED) with an initial acute myocardial infarction (AMI). METHODS: A retrospective review of 372 patients who had suffered an AMI (134 younger-aged, 238 older-aged), from 2,858 suspected AMI or ischemia patients during the period January 1996 to June 2003 inclusive, was conducted. Only patients who were diagnosed with AMI and who had been admitted to our institution's ED were enrolled into this study. RESULTS: The incidence of AMI for individuals who were < or = 45 years old was approximately 12.3% of those admitted to hospital under the impression of AMI. The percentage of males was more predominant in the younger-aged group (p < 0.01). Regarding major risk factors for coronary artery disease (CAD), younger patients were more likely to have a family history of cardiac disease (p < 0.01), obesity with an elevated body mass index (26.2 +/- 4.1 vs. 24.2 +/- 3.7, p < 0.01),and hyperlipidemia (p < 0.01) when compared to the older-aged patients, who were more likely to suffer from hypertension (p < 0.01) and/or diabetes mellitus than their younger-aged counterparts (p < 0.01). Younger patients also featured a higher incidence of single-vessel CAD (p = 0.05), an insignificant rate of CAD (p = 0.02), and a lower rate of triple-vessel CAD (p = 0.03). CONCLUSION: For Chinese, male gender and incidences of chest pain, positive family history of heart disease, obesity and hyperlipidemia were significantly greater in the younger-aged AMI patient group than in the older-aged AMI patient group. Younger-aged patients also had a greater rate of single-vessel CAD but a lower rate of triple-vessel CAD than older-aged patients.
Adult↗
Press through package mis-swallowing.
A press through package (PTP) is commonly used as a package for drugs and also being seen increasingly in cases of foreign body in the digestive tract. We presented three cases of inadvertent PTP ingestion with a variety of clinical presentations. Although commonly considered to be small and soft to cause bowel damage, a PTP tends to be caught and poses potential risk for perforation of the bowel because of its sharp edges. The PTP material is thought to be difficult to detect on plain abdominal roentgenography due to its radiolucency. However, air trapped in the PTP makes the drug tablet possibly visible on the radiograph. All of the three cases were diagnosed with correct interpretation of these special radiographic findings, even without the recall of accidental swallowing of the tablet. A PTP in the oesophagus and stomach should be tried to be removed, while computerised tomography and early laparotomy should be considered when it passes through the pyloric ring and the patient develops symptoms. An effort to prevent the PTP swallowing should be an essential part in our everyday practice, especially for the elderly patients.
Aged↗
Effect of lung resection on exercise capacity and on carbon monoxide diffusing capacity during exercise.
OBJECTIVE: To evaluate the effect of lung resection on lung function and exercise capacity values, including diffusion capacity of the lung for carbon monoxide (Dlco), during exercise, and to determine whether postoperative lung function, including exercise capacity and Dlco during exercise, could be predicted from preoperative lung function and the number of functional segments resected. DESIGN: Prospective study. SETTING: Clinical pulmonary function laboratory in a university teaching hospital. PATIENTS: Twenty-eight patients undergoing lung resection at Vancouver General Hospital from October 1998 to May 1999, were studied preoperatively and 1-year postoperatively. INTERVENTIONS: We determined FEV(1) and FVC, and maximal oxygen uptake (Vo(2)max) and maximal workload (Wmax) achieved during incremental exercise testing. We used the three-equation modification of the single-breath Dlco technique to determine Dlco at rest (RDlco) and during steady-state exercise at 70% of Wmax, and the increase in Dlco from rest to exercise (ie, the mean increase in Dlco percent predicted at 70% of Wmax from resting Dlco percent predicted [(70%-R)Dlco]). We calculated the predicted postoperative (PPO) values for all the above parameters using the preoperative test data and the extent of functioning bronchopulmonary segments resected, and compared the results with the actual 1-year postoperative results. RESULTS: Following lung resection, there was a significant reduction in FEV(1), FVC, and Dlco with decreases of 12%, 13%, and 22% predicted, respectively. There were also significant decreases in Vo(2)max per kilogram of 2.1 mL/min/kg (8% of predicted Vo(2)max) and in Wmax of 12 W (7% of predicted Wmax). However, (70%-R)Dlco did not significantly decrease after lobectomy but decreased after pneumonectomy. The calculated PPO values significantly underestimated postoperative values after pneumonectomy but were acceptable for lobectomy. CONCLUSIONS: Exercise tests may be better indicators of functional capacity after lung resection than measurements of FEV(1) and FVC or RDlco. PPO results calculated by estimating the functional contribution of the resected segments, are comparable with those obtained using ventilation-perfusion lung scanning and significantly underestimate postoperative lung function after pneumonectomy, but are acceptable for lobectomy.
Aged↗
Epigastraglia with tarry stools in a middle-aged female caused by jejunal intussusception due to a hamartoma.
Upper gastrointestinal (GI) hemorrhage is a common presentation to an emergency department. Often, the diagnosis is peptic ulcer disease in which vague or sharp abdominal pain is associated with bleeding. In contrast, intussusception is a rare cause of abdominal pain and coincident GI bleeding. In this case, we report a 41-year-old woman who had an intussuscepting jejunal obstruction due to a hamartoma of the small bowel. The diagnosis was established by ultrasonography. In review of the literature, abdominal pain and bleeding are two common manifestations of intussusception when the lesion originates in the small bowel. Intussusception is frequently included in the differential diagnosis of pediatric patients with coincident abdominal pain and bleeding. However, it is rarely mentioned as an adult cause of these two findings. Because of the delayed and nonspecific presentations of abdominal discomfort in adult patients with intussusception, the diagnosis is often delayed. This case points out the need for considering intussusception even in middle-aged patients whose initial presentation is concomitant bleeding and pain.
Abdominal Pain↗
Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes.
STUDY OBJECTIVE: We evaluate the effect on adverse events of a telephone follow-up quality improvement program. METHODS: This was a before-and-after intervention comparison based on prospectively collected data in a tertiary care hospital emergency department (ED) (82,000 visits per year). The first half (April 15 to July 31, 2001) served as control, and the second half (August 1 to November 15, 2001) served as intervention with feedback to physicians on telephone follow-up outcomes of discharged patients and resident training about the uncertain presentations of serious diseases and the need to use additional evaluation on selected patients (observation unit, hospital admission). Telephone follow-up of the high-risk patients and retrospective review of 3-day return visits were used to quantify outcome measures: return visits to EDs and clinically significant adverse events (return visits with serious misdiagnoses or an erroneous management plan). The differences in proportions of outcomes were measured with 95% confidence intervals (CIs). RESULTS: High-risk patients were enrolled: 566 (13.7%) of 4,139 discharged patients in the before-intervention period and 397 (11.3%) of 3,507 in the after-intervention period. The quality improvement initiative decreased return visits on enrolled patients from 10.1% (57/566) to 4.9% (19/397) (5.2% difference with 95% CI 1.8% to 8.8%) and decreased clinically significant adverse events from 4.1% (23/566) to 1.5% (6/397) (2.6% difference with 95% CI 0.3% to 4.8%). For all ED discharged patients, clinically significant adverse events decreased from 0.9% (39/4,139) to 0.4% (15/3,507) (0.5% difference with 95% CI 0.1% to 0.9%). During the study, the observation rate increased 4.3% (95% CI 2.8% to 5.7%), and the admission rate increased 3.4% (95% CI 2.1% to 4.8%). CONCLUSION: A quality improvement program with feedback to physicians of telephone follow-up and resident education can decrease clinically significant adverse events in ED discharged patients.
Diagnostic Errors↗
A rare case of massive pericardial effusion secondary to hypothyroidism.
Massive pericardial effusions secondary to hypothyroidism are rarely seen in the emergency department (ED). The case of a patient presenting with a relatively asymptomatic massive pericardial effusion due to hypothyroidism is described. The patient had a history of laryngeal carcinoma post-total laryngectomy and adjuvant radiotherapy 12 years previous. Although underlying malignancy was in the differential diagnosis, hypothyroidism was diagnosed through a detailed history and physical examination, thereby avoiding the need for pericardiocentesis. Thyroid replacement alone is sufficient for resolution of these effusions, although it may take many months. Pericardiocentesis is indicated only if cardiac tamponade develops. This rare but significant condition should be considered, especially when it occurs after acute cold exposure.
Aged↗
Diagnosis of appendicitis with left lower quadrant pain.
Abdominal pain is one of the most common chief complaints of patients presenting to the emergency department and, among the diagnoses of abdominal pain, appendicitis is the most common surgical disorder. Traditionally, the diagnosis of appendicitis is based on well-established clinical criteria combined with physician experience. However, appendicitis presenting with rare and misleading left lower quadrant (LLQ) pain may result in an initial false-negative diagnosis by the physician and even result in failure to order the subsidiary examination of computed tomography (CT) or ultrasound, so increasing the risk of perforation/abscess formation and prolonged hospital stay. In this report, we present 2 cases of atypical appendicitis with LLQ pain where the correct diagnosis was not initially considered. One patient had right-sided appendicitis; the inflamed appendix was 12 cm in length and projected into the LLQ. Local peritonitis developed during observation. With the aid of CT, the diagnosis was established in time. The other patient had left-sided appendicitis with situs inversus totalis. Adverse outcomes with appendiceal rupture and abscess formation occurred due to inadvertent physical examinations and inadequate observation. Early clinical suspicion and adequate observation are indicated in patients with uncertain clinical features. However, in patients with unresolved clinical symptoms and/or local peritonitis that develop during observation, imaging studies play a significant role in preoperative diagnosis and determination of proper treatment.
Abdominal Pain↗
Clinical features and outcomes of severe acute respiratory syndrome and predictive factors for acute respiratory distress syndrome.
BACKGROUND: Severe acute respiratory syndrome (SARS) is an emerging infectious disease, and indeed, the SARS epidemic in Taiwan from March to July 2003 had a great impact. This study depicts the clinical characteristics and short-term outcomes of patients with SARS treated at Taipei Veterans General Hospital; potential predictive factors for acute respiratory distress syndrome (ARDS) are also analyzed. METHODS: This study retrospectively analyzed data for 67 SARS patients, who were grouped according to whether or not ARDS developed during the clinical course of SARS. RESULTS: There were 32 males (mean age, 50.3 years; range, 20-75 years) and 35 females (mean age, 51.1 years; range, 23-86 years). Twenty-five patients (37.3%) were health care workers. At admission, 50 patients (74.6%) had abnormal chest radiographs, and all patients developed pulmonary infiltrates during the following week. During hospitalization, lymphopenia was found in 57 patients (85.1%); and elevated levels of lactate dehydrogenase (LDH; n = 55; 83.3%), C-reactive protein (n = 55; 83.3%), aminotransferases (n = 44; 65.7%), and creatine kinase (n = 14; 20.9%) were also noted. ARDS developed in 33 patients (49.3%), who were generally older than the patients in whom ARDS did not develop, male, non-health care workers, and who generally had dyspnea at the time of diagnosis, and a history of diabetes mellitus, hypertension or cerebrovascular accident. Patients with, versus those without, ARDS also tended to present with more severe lymphopenia and leukocytosis, and with higher levels of LDH and aspartate aminotransferase. The overall mortality rate was 31.3% (21/67), whereas the rate for patients who developed ARDS was 63.6% (21/33). Multivariate analyses showed that age greater than 65 years (odds ratio, OR, 10.6; 95% confidence interval, CI, 2.1-54.1), pre-existing diabetes mellitus (OR, 13.7; 95% CI, 1.3-146.9), and elevated levels of LDH (OR, 8.4; 95% CI, 1.9-36.9) at admission, were independent predictors of ARDS. CONCLUSION: The clinical manifestations of SARS showed high variability, and were related to the underlying health status of individual patients. Importantly, the development of ARDS was associated with significant mortality, despite aggressive therapy.
Adult↗
Impact of severe acute respiratory syndrome (SARS) outbreaks on the use of emergency department medical resources.
BACKGROUND: The impact of the severe acute respiratory syndrome (SARS) outbreak in 2003 on the emergency department (ED) medical needs of adult patients has not been elucidated. The purpose of this study was to investigate the demographic and clinical characteristics of ED adult patients before, during and after the SARS epidemic in a SARS-dedicated hospital. METHODS: A retrospective, ED chart review was conducted, and demographic data were obtained from a computer database, for a total of 17,586 patients. Patient information, including age, gender, mode of arrival, triage category, time of visit, main diagnosis, use of ED services, and status after the ED visit, were collected and compared for pre-, early-, peak-, late-, and post-SARS epidemic stages. RESULTS: Demographic data demonstrated a significant decrease in patient attendances per day, with a mean reduction of 92.5 +/- 8.3 patients (43.7 +/- 3.9% reduction in rate; p < 0.01) during peak- versus pre-epidemic stages, but revealed no differences in patient age and gender. The numbers of patients with ambulance transport, inter-hospital referral, and critical illnesses, including DOA, categorized as triage 1, or admitted to a ward or intensive care unit after the ED visit, were not influenced by the SARS epidemic. The number of patients with upper airway infections and suicide attempts from drug overdoses increased, but not statistically significantly. The number of patients with other diagnoses decreased progressively from early- to peak-epidemic stages, but returned to their earlier levels at the post-epidemic stage. Statistically significant decreases (p < 0.05) were noted in mean attendance at peak-versus pre- and early-epidemic stages for patients with cardiovascular disease, inflammatory or functional bowel disease, endocrine disease, dizziness or vertigo, or trauma. CONCLUSION: The SARS outbreak did not eliminate the need of critically ill patients for advanced medical support. However, besides an overall decrease in patient numbers, the SARS epidemic markedly altered demographic information, clinical characteristics, and the use of medical services by adult patients in the ED of a SARS-dedicated hospital.
Adult↗
Clinical factors and outcomes in patients with acute mesenteric ischemia in the emergency department.
BACKGROUND: The purpose of this study was to determine the initial clinical characteristics of acute mesenteric ischemia and identify variables associated with adverse outcomes in the emergency department (ED). METHODS: The charts of 124 consecutive patients with surgically and pathologically identified acute mesenteric ischemia from September 1990 to September 2000 were reviewed retrospectively to obtain data about demographics, initial clinical presentations, predisposing diseases, previous medications, laboratory tests, and common findings on computed tomography scans with contrast. Only patients admitted through the ED and treated on medical or surgical wards were enrolled. RESULTS: Mean patient age was 71.1 years (range, 25-100 years). The overall mortality rate was 50%. There were no significant differences in gender, underlying disease, previous medication, initial signs and symptoms, and causes of mesenteric infarction, between survivors and non-survivors. Univariate analysis demonstrated that older age, bandemia, hepatic and renal impairment, hyperamylasemia, metabolic acidosis, hypoxia, intramural pneumatosis, and septic syndrome, were more frequent in patients who died than in those who survived (p < 0.05). Logistic regression identified the following variables as independent predictors of death: old age (odds ratio, OR, 1.077; 95% confidence interval, Cl, 1.013, 1.146; p = 0.02); bandemia (OR, 3.894; 95% Cl, 1.160, 13.074; p = 0.03); elevated serum aspartate aminotransferase (AST; OR, 4.532; 95% Cl, 1.274, 16.122; p = 0.02); increased blood urea nitrogen (BUN; OR, 7.219; 95% Cl, 1.166, 44.696; p = 0.03); and metabolic acidosis (OR, 6.604; 95% Cl, 1.804, 24.171; p < 0.01). CONCLUSION: A high index of suspicion and aggressive diagnostic imaging can facilitate early diagnosis and improve outcomes for patients with acute mesenteric ischemia. Risk stratification showed that elderly patients with metabolic acidosis, bandemia, or elevated AST and BUN had a poor prognosis. Greater therapeutic intervention is advocated to reduce mortality in high-risk patients with acute mesenteric ischemia.
Acute Disease↗
ED presentation of neutropenic enterocolitis in adult patients with acute leukemia.
The purpose of this study was to investigate the initial clinical features and subsequent outcomes in patients with adult leukemia with typhlitis or neutropenic enterocolitis. A retrospective review of 10 episodes of neutropenic enterocolitis in nine patients (age range, 21-71 years) with acute leukemia from March 1, 1990, through February 28, 2002, was conducted. In clinical presentations, fever appears in all patients, followed by abdominal pain or tenderness (90%) and diarrhea (60%), respectively. In particular, three cases were coincidentally diagnosed as leukemia before any chemotherapy. The most common diagnostic modality used for the diagnosis of neutropenic enterocolitis was computed tomography (CT) scan (seven episodes). Medical treatments, including broad-spectrum antibiotics, bowel rest, and total parenteral nutrition, were applied to seven patients. Laparotomy with bowel resection was performed on two patients with bowel necrosis and severe peritonitis. Of all nine cases, six were fatal as a result of sepsis, a common complication of neutropenic enterocolitis. As the incidence of neutropenic enterocolitis increases in patients with acute leukemia, EPs should be alert and make an early diagnosis of this rapidly deteriorated and life-threatening disease.
Adult↗
Hepatic portal venous gas: clinical significance of computed tomography findings.
Hepatic portal venous gas (HPVG) is a rare radiographic finding of significance. Most cases with HPVG are related to mesenteric ischemia that have been associated with extended bowel necrosis and fatal outcome. With the help of computed tomography (CT) in early diagnosis of HPVG, the clinical outcome of patients with mesenteric ischemia has improved. There has been also an increasing rate of detection of HPVG with certain nonischemic conditions. In this report, we present two cases demonstrating HPVG unrelated to mesenteric ischemia. One patient with cholangitis presented abdominal pain with local peritonitis and survived after appropriate antibiotic treatment. Laparotomy was avoided as a result of lack of CT evidence of ischemic bowel disease besides the presence of HPVG. The other case had severe enteritis. Although his CT finding preluded ischemic bowel disease, conservative treatment was implemented because of the absence of peritoneal signs or clinical toxic symptoms. Therefore, whenever HPVG is detected on CT, urgent exploratory laparotomy is only mandatory in a patient with whom intestinal ischemia or infarction is suspected on the basis of radiologic and clinical findings. On the other hand, unnecessary exploratory laparotomy should be avoided in nonischemic conditions that are usually associated with a better clinical outcome if appropriate therapy is prompted for the underlying diseases. Patients with radiographic diagnosis of HPVG should receive a detailed history review and physical examination. The patient's underlying condition should be determined to provide a solid ground for exploratory laparotomy. A flow chart is presented for facilitating the management of patients with HPVG in the ED.
Aged↗
Tetrodotoxin poisoning.
Tetrodotoxin (TTX) poisoning, although uncommon, is frequently seen in Taiwan, Japan, and Southeast Asia. It is rare but significant in the United States as well. Only three cases have been reported in the EM literature. We report an outbreak of six cases of TTX poisoning from eating puffer fish. On April 17, 2001, an outbreak of TTX poisoning occurred among Mainland Chinese fishermen who shared puffer fish on their boat in the Taiwan Strait. All six cases were middle-aged men (aged 32-49 yr). Onset of symptoms began approximately 2 to 3 hours after ingestion; symptoms included orolingual numbness, acroparesthesia, and breathlessness. As a result of delayed transportation and initial resuscitation, one patient presented in full cardiac arrest, with recovery of spontaneous circulation after successful cardiopulmonary resuscitation. With the exception of this patient, the initial acid-base abnormalities were inconsistent with severity of illness and mild hypercapnia was common (4 out of 5). The patient who presented in full arrest died 1 day after admission as a result of intractable bradycardia (complete atrioventricular block), a finding rarely mentioned in the literature, despite intravenous atropine and dopamine infusion. The remaining patients survived without significant sequelae and were discharged after short-term observation and supportive care, although some had neurologic and cardiopulmonary manifestations (muscle weakness, hypotension, hypoxemia, and hypercapnia). Some mildly hypoventilated patients recovered well without endotracheal intubation and ventilatory support. Favorable outcomes in most patients can be obtained if aggressive supportive treatment is provided in time. Thus, appropriate prehospital and ED ventilatory support (the implementation of a bag-valve mask or endotracheal intubation with good ventilatory support) is mandatory for those patients with respiratory failure. Most patients experience onset of symptoms within 6 hours of ingestion, but a few have a delayed onset up to 20 hours. Therefore, for those TTX-intoxicated patients without immediate prominent respiratory insufficiency, at least 24 hours of intensive monitoring of their respiratory state is necessary because of the different susceptibility and unpredictability of an individual course.
Adult↗