GB virus-C/hepatitis G virus infection in a hepatitis C virus endemic village: prevalence in residents with low educational attainment and frequent recovery in females

AIMS/BACKGROUND

GB virus-C/hepatitis G virus (HGV) is a newly identified flavivirus, which may share the same mode of transmission as hepatitis C virus (HCV). The aim of this study was to investigate associated factors of HGV infection and clearance in a HCV endemic village in southern Taiwan.

METHODS

Five hundred and ninety-four residents of a village in southern Taiwan were enrolled for hepatitis virus screening. Clinical features were recorded and a questionnaire addressing the possible routes of transmission was filled in by the participating residents.

RESULTS

The prevalence of antibody to hepatitis C virus and hepatitis B surface antigen in the 594 residents was 70.7% and 19.5% respectively. Of the 399 residents tested for HGV RNA, GB virus-C/Hepatitis G virus envelop 2 protein (HGV-E2) antibody, and HCV RNA, the prevalence was 13.5%, 25.3%, 53.1% respectively. Multivariate logistic regression analysis showed that low educational attainment was associated with HGV infection, old age and low educational attainment were associated with HCV infection, and female gender was associated with HGV clearance. Alanine aminotransferase (ALT) values were significantly higher for residents with HCV infection alone, HBV infection alone, and co-infection of HCV and HBV than for those without HBV, HCV, and HGV infection. There were no differences in ALT values between subjects with HGV infection alone and those without HBV, HCV, and HGV infections. Residents with co-infection of HGV and HBV, or HGV and HCV had ALT values similar to those with HBV or HCV infection alone.

CONCLUSION

HGV infection is common in the HCV endemic village. The transmission of HGV is closely related to low educational attainment. HGV clearance is frequently encountered in females. Co-infection of HGV does not compound hepatocellular inflammation.

An autoradiographic assessment of epithelial cell proliferation and post-natal maturation of the tracheal epithelium in infant ferrets

The tracheal epithelium of infant ferrets undergoes rapid postnatal maturation over the first month of life to achieve the pseudostratified columnar configuration characteristic of the large airways of other mammals. We have used in vivo pulsing with tritiated thymidine ((3)HT) to elicit autoradiographic labeling of cells synthesizing nucleic acids in order to characterize more fully the contribution to development of different cell types comprising the nascent epithelial layer during this period of rapid growth. These studies indicate that two distinct populations of epithelial cells possess proliferative potential and contribute to the establishment of the mature adult epithelial layer. These investigations further confirm the mitotic potential of basal cells during a period of rapid postnatal growth and development of the tracheal epithelial layer. These studies also document the contribution to early airway development by non-ciliated cells, which predominate on the luminal border of the ferret trachea at birth. The temporal and histologic patterns of airway epithelial maturation during post-natal life in the ferret as contained in this study exhibit similarities to those which occur with recovery from injury by infection and irritant exposure in mature airways. Thus, the characterization of epithelial cell compartments having proliferative potential may provide insights into the mechanisms whereby normal airway epithelial organization is established and maintained during development as well as the possible recapitulation of these mechanisms during times of epithelial regeneration following injury.

Regulation of CBP-mediated transcription by neuronal calcium signaling

The transcription factor CREB is involved in mediating many of the long-term effects of activity-dependent plasticity at glutamatergic synapses. Here, we show that activation of NMDA receptors and voltage-sensitive calcium channels leads to CREB-mediated transcription in cortical neurons via a mechanism regulated by CREB-binding protein (CBP). Recruitment of CBP to the promoter is not sufficient for transactivation, but calcium influx can induce CBP-mediated transcription via two distinct transactivation domains. CBP-mediated transcription is stimulus strength-dependent and can be induced by activation of CaM kinase II, CaM kinase IV, and protein kinase A, but not by activation of the Ras-MAP kinase pathway. These observations indicate that CBP can function as a calcium-sensitive transcriptional coactivator that may act as a regulatory switch for glutamate-induced CREB-mediated transcription.

Renal abscess: early diagnosis and treatment

The purpose of this study was to identify initial clinical characteristics that can lead to early diagnosis of renal abscess in the emergency department and predict poor prognosis. A retrospective review of 88 renal abscess patients, from April 1979 through January 1996, was conducted. Patients were categorized into two groups. In group 1, renal abscess was diagnosed by an emergency physician, whereas in group 2 renal abscess was not diagnosed by an emergency physician. Clinical characteristics included demographic data, predisposing medical problems, duration of illness before diagnosis, time spent in hospital diagnosis, initial signs and symptoms, laboratory tests, and radiology studies that may have been useful in the early diagnostic regimes. Clinical factors were also analyzed for their value in predicting poor prognosis. The mean age of 88 patients with renal abscess was 59.8 years. The most common predisposing disorder was diabetes mellitus, followed by renal calculi and ureteral obstruction. The duration of diagnosis by emergency physicians was shorter for group 1 patients (1.2 +/- .4 v group 2, 2.8 +/- 2.9 days; P < .01) and the blood urea nitrogen level was higher in group 1 (55.7 +/- 42.2 mg/dL, v group 2, 33.5 +/- 33.5 mg/dL; P = .02). In the early diagnosis of renal abscess, emergency physicians should focus on patients who have predisposing disorders, ie, diabetes mellitus, renal stones, immunosuppression, longer duration of symptoms of urinary tract infection, and renal failure, who should promptly be investigated with ultrasound in the emergency department. The cure rate after treatment with routine antibiotics plus percutaneous drainage was 64%. This therapy is recommended for initial treatment. Poor prognosis is associated with elderly patients with lethargy and with elevation of the serum blood urea nitrogen level.

Elderly use of the ED in an Asian metropolis

To compare emergency department (ED) use by elderly patients (age 65 yrs or older) with that by younger adult patients (age 15-64 yrs), a prospective consecutive chart review study was conducted from August 1, 1995 through May 31, 1996 in eight designated hospitals in Taipei city (which has 2.6 million residents, 8.4% of whom are 65 yrs or older). Patient age, sex, mode of arrival, living status, triage category, advanced life support (ALS) eligibility, referral, confinement to bed, intensive care unit (ICU) admission, impression, trauma mechanism, and disposition were recorded and compared between the two groups. Of 27,765 adult emergency patients studied during the 10 months, 24% were elderly. The elderly were more likely to be ambulance cases, of high acuity and ALS eligibility, living alone, bed-ridden, and ICU cases (19.4% v 10.5%, 14.8% v 5.5%, 14.7% v 4.3%, 9.7% v 4.1%, 16% v 1.1%, and 4.0 v 1.1%, respectively). The three leading illnesses in the elderly were cerebral vascular accident (6.6%), cancer (5.6%), and cardiovascular disease (5.6%), and the two most common trauma mechanisms were trip (fall from the same level surface) (57.2%) and traffic accident (20.7%). Twenty-seven percent and 22.7% of elderly were disposed to admission and observation, respectively, compared with the 10.9% and 11.4% of the younger patients. Elderly patients have significantly different and more severe presentations to the ED compared with younger adults.

Establishing the norm of Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) in Chinese infants

The Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) has been recommended as a useful diagnostic tool for cognitive delay. To provide wider application of this instrument as a general screening tool for pediatricians, a normative percentile graph from a large convenience sample of Chinese infants has been established. The effects of environmental factors on early language and adaptive development were also analyzed. A total of 402 normal infants aged 4 to 36 months attending well-child clinics were recruited. These infants were from all socioeconomic strata, and half were bilingual with Mandarin and Taiwanese. Grandmothers were the chief caretakers or co-caretakers in 28% of this population. The milestones were attained in a sequential and orderly fashion. In contrast to the adaptive ability, there was a wide variation in language acquisition between age 12 and 24 months. Multiple stepwise regression of demographic and environmental factors revealed that age was the main variance in CAT score (P = 0.0001). In CLAMS score, however, age and caretakers were the significant predictors (P = 0.0001). Infants cared for by both mothers and grandmothers had higher CLAMS score by two months over those cared by mothers only (P = 0.001). Those cared for by grandmothers only had lower language score than those by mothers only, though without statistical significance (P = 0.05). Bilingualism, birth order, numbers of siblings, familial structures, and parental socioeconomic status had no effect on early development.

Emergency medical resource use in Taipei city

BACKGROUND

It is a worldwide trend to serve emergency patients at emergency department (EDs) staffed by board-certified emergency physicians (EPs). The question arises as to how many EPs are cost effective? This cannot be answered until utilization of emergency resources in the community is explored, so that appropriate plans for efficient ED use, staffing and training of EPs can be made.

METHODS

A prospective randomized chart-review study was conducted from August 1, 1995, until May 31, 1996, in the EDs of eight large hospitals in Taipei City. These included Chung-Hsin Municipal Hospital (CHH), Chung-Shiaw Municipal Hospital (CSH), Ho-Ping Municipal Hospital (HPH), Jen-Ai Municipal (JAH), Mackay Memorial Hospital (MMH), Tri-Service General Hospital (TSGH), Veterans General Hospital-Taipei (VGH-T) and the Yang-Ming Municipal Hospital (YMH).

RESULTS

Of 37,889 cases reviewed, the average daily ED census at each hospital was: VGH-T 198; TSGH 148; MMH 224; HPH 62; YMH 84; CHH 41; JAH 102; and CSH 139. At MMH, pediatric patients comprised 38.8% of emergency patients and the elderly comprised 49% of patients of VGH-T. The average age of patients was 56 years in VGH-T and 40 years in other hospitals. There were 71 (11.1%) pediatric patients and 3,087 (1.8%) adult patients taken to hospital by an emergency medical services (EMS) ambulance. A total of 176 pediatric and 2,230 (8.1%) adult patients belonged to triage categories 1 and 2. VGH-T had a much higher percentage of triage 1 and 2 patients (769, 13%) than the other hospitals. A total of 30.7% of pediatric and 17.4% of adult patients were classified as triage 4 (pseudoemergency). Patients requiring advanced life support, referral cases and patients requiring an intensive care unit (ICU) bed accounted for 1.1%, 0.9% and 0.6% of pediatric patients, and 6.8%, 3.4% and 1.8% of adult patients, respectively. These figures increased to 11.1%, 7.7% and 3.5%, respectively, in VGH-T. Among patients requiring ICU admission, 30% of pediatric and 53% of adult patients were not admitted on presentation to the ED. Of 10,099 children and 27,555 adults who were evaluated for case disposition, 651 (6.5%) and 4,061 (14.7%), respectively, were considered for admission. Among these 542 (83.3%) and 2,894 (71.3%), respectively, were admitted.

CONCLUSIONS

VGH-T is a favorable training ground for EPs due to its high volume of adult and elderly, advanced life support eligible, ICU and high acuity patients. MMH is an ideal place for training in pediatric emergency medicine. Utilization of the 119 emergency response system is low. The number of patients with high acuity triage in Taipei City is low. However, Taipei City faces a shortage of acute care beds, especially ICU beds.

Regional deposition of inhaled particles in human lungs: comparison between men and women

We measured detailed regional deposition patterns of inhaled particles in healthy adult male (n = 11; 25 +/- 4 yr of age) and female (n = 11; 25 +/- 3 yr of age) subjects by means of a serial bolus aerosol delivery technique for monodisperse fine [particle diameter (Dp) = 1 micron] and coarse aerosols (Dp = 3 and 5 micron). The bolus aerosol (40 ml half-width) was delivered to a specific volumetric depth (Vp) of the lung ranging from 100 to 500 ml with a 50-ml increment, and local deposition fraction (LDF) was assessed for each of the 10 local volumetric regions. In all subjects, the deposition distribution pattern was very uneven with respect to Vp, showing characteristic unimodal curves with respect to particle size and flow rate. However, the unevenness was more pronounced in women. LDF tended to be greater in all regions of the lung in women than in men for Dp = 1 micron. For Dp = 3 and 5 micron, LDF showed a marked enhancement in the shallow region of Vp </= 200 ml in women compared with men (P < 0.05). LDF in women was comparable to or smaller than those of men in deep lung regions of Vp > 200 ml. Total lung deposition was comparable between men and women for fine particles but was consistently greater in women than men for coarse particles regardless of flow rates used: the difference ranged from 9 to 31% and was greater with higher flow rates (P < 0.05). The results indicate that 1) particle deposition characteristics differ between healthy men and women under controlled breathing conditions and 2) deposition in women is greater than that in men.

Continuous flumazenil infusion in preventing complications arising from severe benzodiazepine intoxication

A prospective, randomly controlled study was conducted to test the effect of continuous flumazenil infusion in preventing complications arising from severe benzodiazepine (BZ) intoxication. Patients who were believed to be suffering benzodiazepine intoxication and whose Glasgow Coma Scale (GCS) score was below 10 were enrolled after showing a clear-cut response to flumazenil 0.5 or 1 mg (an improvement by 4 or more on the GCS). The patients were consecutively enrolled and randomized into two groups: a continuous infusion group (CI, n = 50) who were immediately given flumazenil 0.5 mg/h for 5 hours, and a control group (CIN, n = 50). Age, sex, incidence of underlying disease, GCS score at several time points, and complication rate were compared in the two groups. Although the CI group had a higher GCS score at most time points, the complication rate did not significantly differ between the two groups (14 of 36 in the CI group v 12 of 38 in the CIN group, P = .684). A greater incidence of underlying disease and an older age seemed to contribute to the higher complication rates in both groups. Several patients (in both groups) resedated into deeper coma after showing an initial response to flumazenil or after the cessation of flumazenil infusion. For severe BZ intoxication, treatment with flumazenil infusion should still be considered skeptically and should not be recommended as routine management BZ-intoxicated patients with an underlying disease, an older age, and resedation into a deep comatose state after showing an initial response to flumazenil should be treated in an intensive care unit.

Identification of a signaling pathway involved in calcium regulation of BDNF expression

A signaling pathway by which calcium influx regulates the expression of the major activity-dependent transcript of BDNF in cortical neurons has been elucidated. Deletion and mutational analysis of the promoter upstream of exon III reveals that transactivation of the BDNF gene involves two elements 5' to the mRNA start site. The first element, located between 72 and 47 bp upstream of the mRNA start site, is a novel calcium response element and is required for calcium-dependent BDNF expression in both embryonic and postnatal cortical neurons. The second element, located between 40 and 30 bp upstream of the mRNA start site, matches the consensus sequence of a cAMP response element (CRE) and is required for transactivation of the promoter in postnatal but not embryonic neurons. The CRE-dependent component of the response appears to be mediated by CREB since it is part of the complex that binds to this CRE, and since dominant negative mutants of CREB attenuate transactivation of the promoter. A constitutively active mutant of CaM kinase IV, but not of CaM kinase II, leads to activation of the promoter in the absence of extracellular stimuli, and partially occludes calcium-dependent transactivation. The effects of CaM kinase IV on the promoter require an intact CRE. These mechanisms, which implicate CaM kinase IV and CREB in the control of BDNF expression, are likely to be centrally involved in activity-dependent plasticity during development.

The applicability of the theory of planned behavior to the intention to quit smoking across workplaces in southern Taiwan

An examination of the applicability of the theory of planned behavior (TPB) to the intention to quit smoking across workplaces was conducted. Subjects were randomly selected from three workplaces in southern Taiwan. Those from a large public steel-manufacturing company were used for model building, and those from two private auto-parts-manufacturing companies served to cross-validate the model. Eligible subjects were divided into three study samples: a learning sample and two test samples. Three predictors--priority of quitting, past behavior (measured as previous quit attempt), and habit (measured as nicotine dependence)--were added to the TPB model. The results of this study show that TPB based on the learning sample fit well in another sample from the same workplace but poorly in other workplaces. When priority of quitting and past behavior were added to the TPB model, prediction to other workplaces significantly improved. Habit had no significant contribution to the intention to quit in the TPB model. Detailed discussions of the results are provided.

Employers' awareness and compliance with occupational health and safety regulations in Taiwan

An investigation of employers' awareness and compliance with occupational health and safety (OHS) regulations was conducted in a representative group of employers randomly selected from the manufacturing industry in Taiwan. A total of 1,003 employers were interviewed by trained public health personnel. Ten questions related to perceptions of general OHS and five practices on OHS regulations were measured. The results of this study show that the employers were better aware of their responsibility for posting safety warnings, personal protection and providing safety and health equipment. They were less aware of their responsibility in minimizing injuries and accidents in the workplace and in not hiring someone who was found unfit for a certain job from pre-employment physical examination. Less than half of employers knew about regulations of environmental monitoring and even fewer had heard of Material Safety Data Sheets. Level of education and size of the plant were highly associated with employers' awareness of OHS and the awareness was the most significant predictor in the five practices of OHS regulations in this study. Promotion of employers' awareness of OHS in small sized industries in particular, is warranted to enhance better compliance, and a focus for these efforts is identified by this investigation.

Connexin 26 expression in human and ferret airways and lung during development

Coordinated microscopic and molecular biological studies were used to document gap junction expression during postnatal development in ferret tracheal epithelium and lung and in fetal and adult human airway and lung. Expression of connexin 26 (Cx26) in the ferret airways was limited to the epithelial layer and was observed only during the newborn interval. In contrast, we found Cx26 expressed in the alveolar epithelium of the ferret lung by in situ hybridization, Northern blotting, RT-PCR amplification, and immunocytochemical labeling at all ages examined. This finding was further confirmed by documentation of gap junctional plaques upon ultrastructural examination of freeze-fracture replicas of adult ferret lung tissue. Parallel studies of developing human fetal lung and airway suggested connexin expression in the airways only in the first trimester but, as in the ferret, persistent expression was observed in both fetal and adult lung. These studies suggest that the transient expression of Cx26 is a reliable early indicator of airway epithelial development and differentiation in the airways. In contrast, Cx26 expression persists throughout life in the lung, suggesting that gap junctions serve more perennial intercellular communication functions in the peripheral lung.

Arterial oxygen desaturation during emergent nonsedated upper gastrointestinal endoscopy in the emergency department

A prospective study was conducted to see whether emergent esophagogastroduodenoscopy (EGD) in patients with active upper gastrointestinal (GI) bleeding is associated with more oxygen desaturation than nonemergent EGD. Emergent EGD was performed in the study patients with active upper GI bleeding. Nonemergent EGD was performed in the control patients. Determination of oxygen saturation (Sao2) was measured by pulse oximeter. A decrease in Sao2 of > 4% was more frequent in the study patients (26%, 13 of 50) than in controls (6%, 3 of 50) (P < .01). During EGD, mean oxygen saturation decreased significantly in both groups of patients. After EGD, mean oxygen saturation did not recover toward the pre-endoscopy insertion level in the study group (P < .01). A linear association was found that oxygen desaturation = 5.46 + 0.15 (status) -0.06 (baseline oxygen saturation). Emergent EGD for active upper GI bleeding in the emergency department tends to be associated with more frequent significant oxygen desaturation than nonemergent EGD. Continuous oxygen supplementation and oxygen saturation monitoring may be used during emergent nonsedated EGD in the emergency department.

Direct surgery of carotid cavernous fistulae and dural arteriovenous malformations of the cavernous sinus

OBJECTIVE

To save the patency of the internal carotid artery (ICA) during the treatment of carotid cavernous fistulae or cavernous sinus dural arteriovenous malformations, direct surgery of the cavernous sinus after failure of endovascular treatment was attempted in this study.

METHODS

A total of 78 patients with carotid cavernous fistulae or cavernous sinus dural arteriovenous malformations were treated. Obliteration of the fistulous rent and preservation of the ICA were the therapeutic goals. All patients, except one in whom acute bleeding occurred, received endovascular treatment as the first treatment. In 18 (23.4%) of these 77 patients, it was not possible to obliterate the fistulous rents without sacrificing the ICAs. The 18 patients and the 1 patient with acute bleeding underwent direct surgery to open the cavernous sinus.

RESULTS

Various methods, including suturing or clipping the fistulae, sealing the fistulae with fascia and acrylate glue, and packing the cavernous sinus were applied. In each of three complicated cases, the cavernous segment of the ICA was trapped and an intracranial bypass from the petrous segment to the supraclinoid segment was performed. There was nor mortality, and the most common morbidity was transient oculomotor palsy, which occurred in eight patients. Follow-up angiography revealed that the ICAs or bypass grafts were thrombosed in 5 of the 19 patients who had undergone surgery.

CONCLUSION

In this series, the overall ICA patency rate of patients who underwent embolization and surgery was 94%, and the obliteration rate of the fistulae was 100%. Direct surgery of the cavernous sinus as a complimentary treatment of embolization can increase the preservation rate of the ICA.

Psoas abscess: making an early diagnosis in the ED

The variable and nonspecific presentations of psoas abscess, as well as its infrequent incidence in the emergency department (ED), can result in delayed diagnosis or misdiagnosis. Previous reports have not discussed the diagnostic difficulties of psoas abscess from the viewpoint of emergency physicians (EPs), especially in light of the widespread use of ED ultrasonography. This report describes a 1-year experience between November 1993 and October 1994, during which 10 ED patients were diagnosed to have psoas abscess; in 7 cases, diagnoses were established in the ED. Patients' mean age was 64.6 years (range, 46 to 76). Pain was the most frequently encountered symptom (80%), with 5 patients (50%) complaining of flank pain. The triad of fever, flank pain, and limitation of hip movement, which is specific for psoas abscess, was present only in 3 patients (30%). The mean duration of symptoms was 10.6 days (range, 1 to 30 days). The mean time spent to establish the diagnosis was 1.7 days (range, 0 to 7 days). The diagnosis of psoas abscess was established by ultrasound in 6 patients, by computed tomography (CT) in 3 patients, and by surgery in 1 patient. Four patients who presented with either sepsis and nonspecific abdominal/flank pain or sepsis and thigh swelling were diagnosed to have psoas abscess by ultrasound performed by EPs. Only 3 patients were admitted to the ED with an initial diagnosis of psoas abscess. The remaining 7 had the following initial ED diagnoses: 2, fever of unknown origin; 2, septic shock; 1, shock; 1, sepsis; and 1, peritonitis. All but one had manifestations of sepsis. Two patients died of septic shock; these two patients had failed to be drained well. This report also includes a discussion of the role of EPs and ultrasonography in the diagnosis of psoas abscess. With their alertness and their expertise in ultrasonographic techniques, EPs can make an immediate diagnosis and arrange an early drainage procedure. For patients with sepsis of unknown origin, prolonged fever of unknown origin, and some specific manifestations suggestive of psoas abscess, the screening ultrasound should scan not only abdominal solid organs but also peritoneal cavity and retroperitoneal space. In addition, a flow chart is presented for facilitating the diagnosis of psoas abscess in the ED.

Assessment of regional deposition of inhaled particles in human lungs by serial bolus delivery method

Detailed regional deposition of inhaled particles was investigated in young adults (n = 11) by use of a serial bolus aerosol delivery technique. A small bolus (45 ml half-width) of monodisperse aerosols [1-, 3-, and 5-microns particle diameter (Dp)] was delivered sequentially to a specific volumetric depth of the lung (100-500 ml in 50-ml increments), while the subject inhaled clean air via a laser aerosol photometer (25-ml dead volume) with a constant flow rate (Q = 150, 250, and 500 ml/s) and exhaled with the same Q without a pause to the residual volume. Deposition efficiency (LDE) and deposition fraction in 10 local volumetric regions and total deposition fraction of the lung were obtained. LDE increased monotonically with increasing lung depth for all three Dp. LDE was greater with smaller Q values in all lung regions. Deposition was distributed fairly evenly throughout the lung regions with a tendency for an enhancement in the distal lung regions for Dp = 1 micron. Deposition distribution was highly uneven for Dp = 3 and 5 microns, and the region of the peak deposition shifted toward the proximal regions with increasing Dp. Surface dose was 1-5 times greater in the small airway regions and 2-17 times greater in the large airway regions than in the alveolar regions. The results suggest that local or regional enhancement of deposition occurs in healthy subjects and that the local enhancement can be an important factor in health risk assessment of inhaled particles.

Longitudinal distribution of ozone absorption in the lung: simulation with a single-path model

A one-dimensional unsteady state diffusion model was used as a basis for simulating the absorption (lambda), breakthrough (V(B)), and dispersion (sigma2) of inhaled ozone boluses as a function of penetration (V(P)) into intact human lungs. The model idealized the respiratory system as a single equivalent tube with cross-sectional and surface areas that varied as a function of longitudinal position. Longitudinal gas transport in the lumen of the equivalent tube occurred by the joint action of bulk flow and a dispersion coefficient, D. Lateral absorption between respired gas and the tube wall was characterized by an overall mass transfer coefficient, K. By inputting published values of anatomic dimensions scaled to a 160-ml conducting airway volume, D values previously reported for inert insoluble gases, and K values equal to gas-phase transfer coefficients determined in physical lung models, a reasonable simulation of the lambda-V(P) distribution measured at a 250 ml/sec respiratory flow was obtained. Simulations of the corresponding V(B)-V(P) and sigma2-V(P) distributions both exhibited the correct shapes but underestimated the actual values. Although the addition of an estimated tissue resistance to K resulted in a poorer simulation of the data, an increase in conducting airway volume from a value of 160 ml estimated by the subjects' CO2 dead space to a value of 200 ml substantially improved the V(B)-V(P) and sigma2-V(P) simulations without sacrificing the quality of the lambda-V(P) simulation. We conclude that the inclusion of a tissue diffusion resistance is not necessary to properly simulate bolus inhalation data during quiet breathing, but a reliable measurement of conducting airway volume is crucial.

Analysis of prehospital ALS cases in a rural community

BACKGROUND

An Emergency Medical Services (EMS) system containing the advanced life support (ALS) and manned with paramedics, is developing in many countries in view of the importance of prehospital ALS skills on ALS eligible patients, although previous studies have only revealed that a meager need for ALS in urban community. The purpose of this study is to understand the real demand of ALS in a rural community, so that a well organized and cost-effective EMS system can be developed in this country.

METHODS

An EMS system with a single tiered response configuration, using firefighters to give basic prehospital care, stored in computer with some necessary informations was established in Ilan County. Cases with ALS from January 1993 through December 1994 were retrieved from the computer. The ones truely eligible for ALS were reconfirmed and analized in terms of neurological outcome while discharging from hospital, sex, age, response time, time spent on scene, transportation time, as well as whether the cases were trauma or medically induced.

RESULTS

Of 11352 cases collected during 731 study days, 594(5.28%) ALS eligible cases (including 211 DOA and 383 nonDOA) were studied. Of 211 DOA, 103(48%) were caused by trauma. The response time, time spent on scene and transportation time in ALS and DOA cases were 5.5min., 4.7min., 13.6min., and 5.6min., 5.6min., and 15.7min., respectively. Of 211 cases of trauma (55% of total ALS cases), traffic accident accounted for 46%. Altered mental status and chest pain or tightness made of 90% of medical induced ALS cases. Five percent of patients felt worsening of condition during transit. One third of patients seemed to experience a bad outcome.

CONCLUSIONS

Based on the characteristics of low demand for ALS services, more than half trauma-induced ALS cases, acceptable response time, short transportation time, extremely few medically-induced DOA cases, and quite a poor outcome in the setting of limited prehospital care, a unique EMS system different from that in the United States or in the urban area is needed in the rural area.

Outcomes in severely ill patients transported without prehospital ALS

Because of the debate regarding the impact of advanced life support (ALS) care on the outcome of prehospital patients, we monitored the influence of lack of sophisticated prehospital treatment in cases of severe illness arriving by ambulance to the emergency department (ED). A prospective cohort study to examine and compare the outcome of trauma- and nontrauma-induced "ALS-eligible" cases in the setting of no prehospital care was carried out from August 1, 1993 through May 31, 1994. On arriving at the ED, patients meeting the criteria for ALS cases and sent by EMS public prehospital personnel were assessed for subjective and objective status and change in severity by triage nurses as well as being followed up for neurological status until discharged from the hospital. Chi-Square method was used to compare the data between two groups and P < .05 was considered statistically significant. Of 667 studied ALS cases (155 trauma and 512 nontrauma), < 20% had their condition change subjectively and < 10% had their condition change objectively; 68% of medical patients and 60% of trauma cases were discharged from the hospital (neurologically intact). However, subgroup analysis showed that objective measures worsened in transit in nearly 18% of trauma victims, a rate nearly 3 times greater than that of medical cases. Moreover, neurological outcome was particularly poor in trauma cases. These results suggest that ALS care may be valuable for severely ill trauma victims.

EMS characteristics in an Asian Metropolis

A prospective citywide cohort study was conducted from August 1, 1993, through May 31, 1994 to analyze the epidemiological characteristics of emergency medical services (EMS) in an Asian city. Of 5,459 studied cases, the leading 3 causes were trauma (49.7%), alcohol intoxication (8.6%), and altered mental status (AMS) (6.9%). Half of the studied cases needed no prehospital care and 16.4% needed advanced life support (ALS) care. Traffic accidents accounted for 68% of trauma cases. Of 897 cases requiring ALS care, the two most common causes were AMS and dead on arrival (DOA) (32.1% and 21.2% in medical group, 10.1% and 4.5% in trauma group, respectively). The response time, time on scene, and transportation time were 4.6, 4.3, and 9.4 minutes, respectively. This Oriental EMS system experienced very short prehospital times, many traffic accidents, and extremely few DOA cases. Because few patients required ALS care, an emergency medical technician-based EMS system would probably be able to handle the majority of prehospital patients.

Seasonal variation in the incidence of peptic ulcer and esophageal variceal bleeding in Taiwan

BACKGROUND

Seasonal variation of peptic ulcer and peptic ulcer bleeding has been reported in many western countries. To investigate the seasonal variation of peptic ulcer (PU) and esophageal variceal (EV) bleeding in Taiwan, this retrospective study was conducted.

METHODS

Seven hundred and forty-six cases of gastric ulcer (GU) bleeding, 777 cases of duodenal ulcer (DU) bleeding and 264 cases of EV bleeding were recruited from January 1, 1991 to December 31, 1992. Patients were sent to the Medical Emergency Room (MER) for hematemesis and/or melena. Upper gastrointestinal (UGI) endoscopic examinations were completed within 24 hours for all patients.

RESULTS

Significant seasonal variation was found in the incidence of PU and EV bleeding. PU bleeding was most often seen in March and EV bleeding was most often seen in February.

CONCLUSIONS

The possible mechanism for the cyclic change of PU and EV bleeding is unclear, but clearly more manpower is needed during the months of February and March for better management of the increasing number of cases of PU and EV bleeding.

[Three years' experience of emergency medical services in Ilan County]

The Emergency Medical Services (EMS) aims to improve the survival rate of patients who are dead on arrival (DOA) at hospital, particularly those whose coronary artery disease (CAD) has induced sudden death. Based on the low prevalence of CAD-induced sudden death in Taipei city, as well as the differences between urban and rural communities in Taiwan, an understanding of the characteristics of rural areas is necessary in order to establish a well-organized and cost-effective EMS policy in this country. The data were drawn from a computer database which stored prehospitalization information from Ilan County from 1992 through 1994, including age, sex, response time, time spent on the scene, transportation time, service unit, reasons for emergency call and trauma mechanism. In 1096 study days, 20058 cases (18/day) were collected, of which 16560 (15/day; 83.6%) were transported to hospital. Trauma was responsible for the majority (77%) of these cases, followed by chronic diseases (4.0%), trivial matters (2.6%), drunkenness (2.3%), altered mental status (2.3%), suicide attempt (2.2%), and cardiac arrest (1.8%). Among the trauma cases, traffic accidents were the most common cause (84%); motorcycle accidents comprised 65% of trauma cases. The average response time was 6.6 minutes, time spent on the scene was 3.6 minutes, and transportation time was 17.7 minutes. Trauma and non-trauma accounted for half of the DOA cases, with each making up 0.9% of the total cases transported. In conclusion, it is important that the EMS needs of each community are known for a proper system appropriate to that particular area to be developed.

The clinical experience of acute cyanide poisoning

The authors reviewed the clinical manifestations, complications, and the prognosis affected by Lilly Cyanide Antidote in 21 victims of acute cyanide poisoning over a 10-year period. The clinical signs and symptoms in cyanide poisoning are variable. Among 21 cases, loss of consciousness (15), metabolic acidosis (14), and cardiopulmonary failure (9) were the three leading manifestations of cyanide intoxication. Anoxic encephalopathy (6) was not uncommon in the severely intoxicated victims. Diabetes insipidus (1) or clinical signs and symptoms mimicking diabetes insipidus (3) may be an ominous sign to encephalopathy victims. The major cause of fatal cyanide poisoning is the intentional ingestion of cyanide compounds as part of a suicide attempt. Decrease of arteriovenous difference of O2 partial pressure may be a clue for the suspicion of cyanide intoxication. Although the authors cannot show a statistically significant difference (P = .47) for the Lilly cyanide antidote kit in terms of improving the survival rate for victims of cyanide poisoning, the antidote kit was always mandatory in our study in the cases of severely intoxicated victims who survived. Early diagnosis, prompt, intensive therapy with antidote, and supportive care are still the golden rules for the treatment of acute cyanide poisoning, whether in the ED or on the scene.