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1.  Management of patients with implantable cardioverter defibrillators at emergency departments 
Emergency Medicine Journal : EMJ  2007;24(2):106-109.
With rapid improvements in technology and accumulation of clinical evidence, the implantable cardioverter defibrillator (ICD) has become a standard treatment for either primary or secondary prevention of sudden cardiac death. However, no analysis based on the perspective of emergency department has been reported, and managing patients with ICD remains a challenge to the emergency department doctors.
This study reviewed the emergency department visits of patients who received ICD implantation in a single university hospital from 1995 to 2004. The baseline demographic and laboratory data were compared between groups with the non‐parametric method of the Mann–Whitney U test for continuous data and the χ2 test for categorical data; p<0.05 was considered significant.
81 patients (56 men and 25 women) were included in this study. 43% of patients had at least one emergency department visit during the follow‐up period, and a total of 86 emergency department visits were recorded. The most frequent aetiology of emergency department visits was ICD discharge (37 episodes; 43.1%) and the most frequent presenting symptom was electric shock sensation (25 episodes; 29.1%). Only 11 (12.8%) emergency department visits were because of non‐cardiac aetiologies. Patients with emergency department visits had significant lower left ventricular ejection fraction (mean (SD) 41.5 (19.8) v 55.2 (18.4) ejection fraction units; p = 0.005) and more use of warfarin (8.6% v 0%; p<0.05). Although most emergency department visits were device or arrhythmia related, the acute coronary syndrome and congestive heart failure still accounted for 27.9% of hospital returns in combination.
Defibrillator discharge, acute coronary syndrome and heart failure constitute most aetiologies of emergency department visits of patients with ICD. The risk factors include lower left ventricular ejection fraction and use of warfarin.
PMCID: PMC2658183  PMID: 17251615
2.  Disease-Targeted Sequencing of Ion Channel Genes identifies de novo mutations in Patients with Non-Familial Brugada Syndrome 
Scientific Reports  2014;4:6733.
Brugada syndrome (BrS) is one of the ion channelopathies associated with sudden cardiac death (SCD). The most common BrS-associated gene (SCN5A) only accounts for approximately 20–25% of BrS patients. This study aims to identify novel mutations across human ion channels in non-familial BrS patients without SCN5A variants through disease-targeted sequencing. We performed disease-targeted multi-gene sequencing across 133 human ion channel genes and 12 reported BrS-associated genes in 15 unrelated, non-familial BrS patients without SCN5A variants. Candidate variants were validated by mass spectrometry and Sanger sequencing. Five de novo mutations were identified in four genes (SCNN1A, KCNJ16, KCNB2, and KCNT1) in three BrS patients (20%). Two of the three patients presented SCD and one had syncope. Interestingly, the two patients presented with SCD had compound mutations (SCNN1A:Arg350Gln and KCNB2:Glu522Lys; SCNN1A:Arg597* and KCNJ16:Ser261Gly). Importantly, two SCNN1A mutations were identified from different families. The KCNT1:Arg1106Gln mutation was identified in a patient with syncope. Bioinformatics algorithms predicted severe functional interruptions in these four mutation loci, suggesting their pivotal roles in BrS. This study identified four novel BrS-associated genes and indicated the effectiveness of this disease-targeted sequencing across ion channel genes for non-familial BrS patients without SCN5A variants.
PMCID: PMC4206841  PMID: 25339316
3.  Nonsurgical management of partial adhesive small-bowel obstruction with oral therapy: a randomized controlled trial 
Patients with partial adhesive small-bowel obstruction are usually managed conservatively, receiving intravenous hydration and nothing by mouth. Previous studies have suggested that this approach is associated with longer hospital stays and an increased risk of delayed surgery. We conducted a randomized controlled trial to see if combining standard conservative treatment with oral administration of a laxative, a digestant and a defoaming agent would reduce the frequency of subsequent surgical intervention and reduce the length of hospital stay.
We identified 144 consecutive patients admitted between February 2000 and July 2001 with adhesive partial small-bowel obstruction and randomly assigned 128 who met the inclusion criteria to either the control group (intravenous hydration, nasogastric-tube decompression and nothing by mouth) or the intervention group (intravenous hydration, nasogastric-tube decompression and oral therapy with magnesium oxide, Lactobacillus acidophilus and simethicone). The primary outcome measures were the number of patients whose obstruction was successfully treated without surgery and the length of hospital stay. We also monitored rates of complications and recurring obstructions.
Of the 128 patients, 63 were in the control group and 65 in the intervention group; the mean ages were 54.4 (standard deviation [SD] 15.9) years and 53.9 (SD 16.3) years respectively. Most of the patients were male. More patients in the intervention group than in the control group had successful treatment without surgery (59 [91%] v. 48 [76%], p = 0.03; relative risk 1.19, 95% confidence interval 1.03–1.40). The mean hospital stay was significantly longer among patients in the control group than among those in the intervention group (4.2 [SD 2.7] v. 1.0 [SD 0.7] days, p < 0.001). The complication and recurrence rates did not differ significantly between the 2 groups.
Oral therapy with magnesium oxide, L. acidophilus and simethicone was effective in hastening the resolution of conservatively treated partial adhesive small-bowel obstruction and shortening the hospital stay.
PMCID: PMC1277043  PMID: 16275967
4.  SARS Exposure and Emergency Department Workers 
Emerging Infectious Diseases  2004;10(6):1117-1119.
Of 193 emergency department workers exposed to severe acute respiratory syndrome (SARS), 9 (4.7%) were infected. Pneumonia developed in six workers, and assays showed anti-SARS immunoglobulin (Ig) M and IgG. The other three workers were IgM-positive and had lower IgG titers; in two, mild illness developed, and one remained asymptomatic.
PMCID: PMC3323160  PMID: 15207066
SARS; serologic responses; emergency department workers
5.  Association of Lower Extremity Arterial Calcification with Amputation and Mortality in Patients with Symptomatic Peripheral Artery Disease 
PLoS ONE  2014;9(2):e90201.
The clinical implication of the coronary artery calcium score (CS) is well demonstrated. However, little is known about the association between lower extremity arterial calcification and clinical outcomes.
Methods and Results
Eighty-two patients with symptomatic peripheral artery disease (age 61.0±12.4 years) were followed for 21±11 months. CSs, ranging from the common iliac artery bifurcation to the ankle area, were analyzed through noncontrast multidetector computed tomography images retrospectively. The primary endpoints of this study were amputation and mortality. Old age, diabetes, hyperlipidemia, and end-stage renal disease were associated with higher CSs. Patients with more advanced Fontaine stages also tended to have significantly higher CSs (p = 0.03). During the follow-up period (21±11 months), 29 (35%) patients underwent amputation, and 24 (29%) patients died. Among the patients who underwent amputation, there were no significant differences in CSs between the amputated legs and the non-amputated legs. In the Cox proportional hazard model with CS divided into quartiles, patients with CS in the highest quartile had a 2.88-fold (95% confidence interval [CI] 1.18–12.72, p = 0.03) and a 5.16-fold (95% CI 1.13–21.61, p = 0.04) higher risk for amputation and all-cause mortality, respectively, than those with CS in the lowest quartile. These predictive effects remained after conventional risk factor adjustment.
Lower extremity arterial CSs are associated with disease severity and outcomes, including amputation and all-cause mortality, in patients with symptomatic peripheral artery disease. However, the independent predictive value needs further investigation in large scale, prospective studies.
PMCID: PMC3936008  PMID: 24587279
6.  Serum adipocyte fatty acid-binding protein levels in patients with critical illness are associated with insulin resistance and predict mortality 
Critical Care  2013;17(1):R22.
Hyperglycemia and insulin resistance are commonplace in critical illness, especially in patients with sepsis. Recently, several hormones secreted by adipose tissue have been determined to be involved in overall insulin sensitivity in metabolic syndrome-related conditions, including adipocyte fatty-acid binding protein (A-FABP). However, little is known about their roles in critical illness. On the other hand, there is evidence that several adipose tissue gene expressions change in critically ill patients.
A total of 120 patients (72 with sepsis, 48 without sepsis) were studied prospectively on admission to a medical ICU and compared with 45 healthy volunteers as controls. Various laboratory parameters and metabolic and inflammatory profiles were assessed within 48 hours after admission. Clinical data were collected from medical records.
Compared with healthy controls, serum A-FABP concentrations were higher in all critically ill patients, and there was a trend of higher A-FABP in patients with sepsis. In multivariate correlation analysis in all critically ill patients, the serum A-FABP concentrations were independently related to serum creatinine, fasting plasma glucose, total cholesterol, TNF-alpha, albumin, and the Acute Physiology and Chronic Health Evaluation II scores. In survival analysis, higher A-FABP levels (> 40 ng/ml) were associated with an unfavorable overall survival outcome, especially in sepsis patients.
Critically ill patients have higher serum A-FABP concentrations. Moreover, A-FABP may potentially serve as a prognostic biomarker in critically ill patients with sepsis.
PMCID: PMC4056759  PMID: 23375099
7.  Comparative effects of flavonoids on oxidant scavenging and ischemia-reperfusion injury in cardiomyocytes 
European journal of pharmacology  2007;566(1-3):58-66.
Since flavonoids scavenge reactive oxygen species, they may potentially protect against ischemia/reperfusion injury. This study compared the scavenging capacity of specific flavonoids towards different reactive oxygen species. Whether the differential oxidant scavenging capacity correlated with their protective efficacy in ischemia/reperfusion injury of cardiomyocytes was determined. The free radical scavenging capacity of five flavonoids (wogonin, baicalin, baicalein, catechin and procyanidin B2) was analyzed using electron spin resonance spectrometry for 3 radicals: 1,1-diphenyl-2picrylhydrazyl (DPPH), superoxide and hydroxyl radical. A well-established chick cardiomyocyte model of ischemia (1 h)/reperfusion (3 h) was used to evaluate flavonoid-induced protection against ischemia/reperfusion injury in chronic treatment (pretreated 72 h and treated through ischemia/reperfusion) and acute treatment protocols (during ischemia/reperfusion or only at reperfusion). The cell viability was assessed by propidium iodide. The DPPH scavenging was most significant with catechin, followed by procyanidin B2, baicalein, baicalin, and wogonin. The superoxide scavenging was, similarly, most significant with catechin, followed by baicalein, procyanidin B2, and baicalin. For hydroxyl radical, only baicalein showed a significant scavenging capacity (> 50% reduction in ESR signal). For the cardiomyocyte studies, all flavonoids but wogonin showed protection against ischemia/reperfusion injury in the chronic treatment protocol. When flavonoids were administered only during ischemia/reperfusion, baicalein, procyanidin B2, and catechin significantly reduced cell death. If flavonoids were administered just at reperfusion, only baicalein and procyanidin B2 had protective effects, and the efficacy was less. Flavonoids possess specific but differential radical scavenging capacity, which, in conjunction with the timing of treatment, affects their protective efficacy in cardiomyocytes exposed to ischemia/reperfusion.
PMCID: PMC2657475  PMID: 17475241
Flavonoids; Reperfusion injury; Scavenging capacity; Superoxide; Hydroxyl radical
8.  Utilization of and Direct Expenditure for Emergency Medical 
Care in Taiwan: A Population-based Descriptive Study 
Journal of Epidemiology  2009;19(1):41-48.
We surveyed the emergency medical system (EMS) in Taiwan to provide information to policymakers responsible for decisions regarding the redistribution of national medical resources.
A systematic sampling method was used to randomly sample a representative database from the National Health Insurance (NHI) database in Taiwan, during the period from 2000 to 2004.
We identified 10,124, 10,408, 11,209, 10,686, and 11,914 emergency room visits in 2000, 2001, 2002, 2003, and 2004, respectively. There were more males than females, and the majority of adults were younger than 50 years. Diagnose of injury/poisoning was the most frequently noted diagnostic category in emergency departments (EDs) in Taiwan. There were 13,196 (24.3%) and 2,952 (5.4%) patients with 2 and 3 concomitant diagnoses, respectively. There was a significant association between advanced age and the existence of multiple diagnoses (P < 0.001). With the exception of the ill-defined symptoms/signs/conditions, the two most frequent diagnoses were diseases of the circulatory system and diseases of the respiratory system in patients aged 65 years or older. On average, treatment-associated expenditure and drug-associated expenditure in Taiwan EDs averaged NT$1,155 ($35.0) and NT$190 ($5.8), respectively, which was equal to 64.5% and 10.6% of the total ED-associated cost. General ED medical expenditure increased with patient age; the increased cost ratio due to age was estimated at 8% per year (P < 0.001).
The frequency of major health problems diagnosed at ED visits varied by age: more complicated complaints and multiple diagnoses were more frequent in older patients. In Taiwan, the ED system remains overloaded, possibly because of the low cost of an ED visit.
PMCID: PMC3924095  PMID: 19164870
emergency; utilization; expenditure; Taiwan
9.  SARS in Hospital Emergency Room 
Emerging Infectious Diseases  2004;10(5):782-788.
Thirty-one cases of severe acute respiratory syndrome (SARS) occurred after exposure in the emergency room at the National Taiwan University Hospital. The index patient was linked to an outbreak at a nearby municipal hospital. Three clusters were identified over a 3-week period. The first cluster (5 patients) and the second cluster (14 patients) occurred among patients, family members, and nursing aids. The third cluster (12 patients) occurred exclusively among healthcare workers. Six healthcare workers had close contact with SARS patients. Six others, with different working patterns, indicated that they did not have contact with a SARS patient. Environmental surveys found 9 of 119 samples of inanimate objects to be positive for SARS coronavirus RNA. These observations indicate that although transmission by direct contact with known SARS patients was responsible for most cases, environmental contamination with the SARS coronavirus may have lead to infection among healthcare workers without documented contact with known hospitalized SARS patients.
PMCID: PMC3323223  PMID: 15200809
Severe acute respiratory syndrome; healthcare workers; environmental contamination; real-time reverse transcriptase–polymerase chain reaction

Results 1-9 (9)