The synthesis of cerium-doped yttrium aluminum garnet (YAG:Ce) phosphor of different sizes with uniform size distribution was carried out using solid-state reaction followed by grinding and sieving method. The effect of particle size distribution of YAG:Ce phosphors on the photoluminescence (PL) properties was investigated. The results demonstrate that the uniform size distribution and particle size affects the packaging performance in white light emitting diode (LED) applications. The YAG:Ce phosphors with different particle sizes were packaged in white LEDs using different amounts of each phosphors in order to get similar efficiency as that of commercially available YAG:Ce phosphors. It was observed that minimum amount of phosphor material is required for smaller particle size for getting the similar efficiency as that exhibited by commercially available YAG:Ce phosphors. The results are particularly interesting in view of reducing the cost of current LEDs by lowering the amount of phosphors without compromising the efficiencies of final LED package. A systematic study of YAG:Ce phosphors on the packing performance in white LEDs is reported.

Objectives:To investigate the clinical predictors and the aetiologies for surgery in patients with Naja atra (Taiwan or Chinese cobra) envenomation.Methods: This case series was conducted in the only tertiary care centre in eastern Taiwan. Patients who presented to the emergency department with Naja atra bite between January 2008 and September 2014 were included. Clinical information was collected and compared between surgical and non-surgical patients.Results: A total of 28 patients with Naja atra envenomation presented to the emergency department during the study period. Of these, 60.7% (n=17) required surgery. Necrotising fasciitis (76.5%) was the main finding in surgery. Comparisons between surgical and non-surgical patients showed skin ecchymosis (odds ratio=34.36; 95% confidence interval, 2.20-536.08; P=0.012) and a high total dose of antivenin (≥6 vials; odds ratio=14.59; 95% confidence interval, 1.10-192.72; P=0.042) to be the most significant predictors of surgery. The rate of bacterial isolation from the surgical wound was 88.2%. Morganella morganii (76.5%), Enterococcus faecalis (58.8%), and Bacteroides fragilis (29.4%) were the most common pathogens involved. Bacterial susceptibility testing indicated that combined broadspectrum antibiotics were needed to cover mixed aerobic and anaerobic bacterial infection.

Campaign, a care bundle of sepsis treatmentincluding fluid resuscitation, antimicrobial therapy, and source control-is recommended as life-saving treatment for patients with sepsis. 2 Computed tomography (CT) scanning is a popular method for ORIGINAL ARTICLE (20 vs 19 days, P=0.742). Conclusions: Intravenous contrast administration during CT scanning was not associated with prolonged length of hospital stay in patients with sepsis in an emergency setting. Moreover, the use of contrast-enhanced CT was not associated with increased risks of acute kidney injury, emergent dialysis, or short-term mortality.

BackgroundThere are 6 species of venomous snakes in Taiwan. Two of them, Deinagkistrodon acutus (D. acutus) and Daboia siamensis (D. siamensis), can cause significant coagulopathy. However, a significant proportion of patients with snakebites cannot identify the correct snake species after envenomation, which hampers the application of antivenom. Hence, the differential diagnosis between the two snakebites by clinical presentations is important. This study aims to compare their clinical and laboratory features for the purpose of differential diagnosis between the two snakebites.MethodsWe retrospectively reviewed the medical records of patients who arrived at the emergency department due to D. acutus or D. siamensis envenomation, between 2003 and 2016, in one medical center in eastern Taiwan. Since these snakebites are rare, we also included 3 cases reported from another hospital in central Taiwan.ResultsIn total, 15 patients bitten by D. acutus and 12 patients by D. siamensis were analyzed. Hemorrhagic bulla formation and the need for surgical intervention only presented for D. acutus envenomation cases (Both 53.3% vs. 0.0%, P = 0.003). As to laboratory features, lower platelet counts (20.0 ×  103/μL [interquartile range, 14–66 × 103/μL] vs. 149.0 × 103/μL [102.3–274.3 × 103/μL], P = 0.001), lower D-dimer level (1423.4 μg/L [713.4–4212.3 μg/L] vs. 12,500.0 μg/L [2351.4–200,000 μg/L], P = 0.008), higher proportion of patients with moderate-to-severe thrombocytopenia (platelet count < 100 × 103/μL) (80% vs. 16.7%, odds ratio (OR) = 20.0, 95% CI, 2.77–144.31; P = 0.002), and lower proportion of patients with extremely high D-dimer (> 5000 ng/mL) (16.7% vs. 66.7%, adjusted OR = 0.1 (95% CI, 0.01–0.69; P = 0.036) were found among cases of D. acutus envenomation compared to D. siamensis envenomation. The combination of hemorrhagic bulla, thrombocytopenia, and a lack of extremely high D-dimer had good discriminatory power (area under the curve (AUC) = 0.965; 95% CI, 0.904–1.00) for distinguishing D. acutus from D. siamensis envenomation.ConclusionsThe presentation of moderate to severe thrombocytopenia (platelet count < 100 × 103/μL) and hemorrhagic bulla formation may indicate D. acutus envenomation. However, the envenomed patient with extremely high D-dimer levels may indicate a D. siamensis envenomation. These findings may help diagnose and select the right antivenom in patients with unknown snakebites who present significant coagulopathy.

Timely performing electrocardiography (ECG) is crucial for early detection of ST-elevation myocardial infarction (STEMI). For shortening door-to-ECG time, a chief complaint-based “cardiac triage” protocol comprising (1) raising alert among medical staff with bedside triage tags, and (2) immediate bedside ECG after focused history-taking was implemented at the emergency department (ED) in a single tertiary referral center. All patients diagnosed with STEMI visiting the ED between November 2017 and January 2020 were retrospectively reviewed to investigate the effectiveness of strategy before and after implantation. Analysis of a total of 117 ED patients with STEMI (pre-intervention group, n = 57; post-intervention group, n = 60) showed significant overall improvements in median door-to-ECG time from 5 to 4 min (p = 0.02), achievement rate of door-to-ECG time < 10 min from 45 to 57% (p = 0.01), median door-to-balloon time from 81 to 70 min (p < 0.01). Significant trends of increase in achievement rates for door-to-ECG and door-to-balloon times (p = 0.032 and p = 0.002, respectively) was noted after strategy implementation. The incidences of door-to-ECG time > 10 min for those with initially underestimated disease severity (from 90 to 10%, p < 0.01) and walk-in (from 29.2 to 8.8%, p = 0.04) were both reduced. In conclusion, a chief complaint-based “cardiac triage” strategy successfully improved the quality of emergency care for STEMI patients through reducing delays in diagnosis and treatment.

investigation of physician-related causes of unscheduled revisits to the emergency department (eD) within 72 h with subsequent admission to the intensive care unit (ICU) is an important parameter of emergency care quality. Between 2012 and 2017, medical records of all adult patients who visited the ED and returned within 72 h with subsequent ICU admission were retrospectively reviewed by three experienced emergency physicians. Study parameters were categorized into "input" (Patient characteristics), "throughput" (Time spent on first ED visit and seniority of emergency physicians, and "output" (Charlson Comorbidity Index). Of the 147 patients reviewed for the causes of ICU admission, 35 were physician-related (23.8%). Eight belonged to more urgent categories, whereas the majority (n = 27) were less urgent. Patients who spent less time on their first ED visits before discharge (< 2 h) were significantly associated with physician-related causes of ICU admission, whereas there was no significant difference in other "input," "throughput," and "output" parameters between the "physician-related" and "non-physician-related" groups. Short initial management time was associated with physician-related causes of ICU admission in patients with initial less urgent presentations, highlighting failure of the conventional triage system to identify potentially lifethreatening conditions and possibility of misjudgement because of the patients' apparently minor initial presentations. An unscheduled revisit to the emergency department (ED) within 72 h is an important parameter for the assessment of emergency medical care quality 1,2. There are myriad factors affecting the rate of 72-h ED revisit, including patient demography, ethnical and cultural differences, epidemiology of diseases, and the accessibility to medical care 3. For instance, children and the elderly have been reported to have higher rates of ED revisits compared with those of other demographic groups 1,4. From the perspective of emergency healthcare quality improvement, a number of studies have focused on preventable medical errors 5-7. A previous study has reported a rate of medical error-related 72-h ED revisit between 5 and 45% 8. In addition to the lack of physician experience and absence of standard operation guidelines for diagnosis, other reasons include ineffective communication, staff shortage,

The outbreak of coronavirus disease-2019 (COVID-19) has resulted in a global public health emergency. Patients with cirrhosis were deemed more susceptible to viral infection because of their dysregulated immune response. Similar to the general population, cirrhotic patients exhibit various degrees of COVID-19-related liver injury, which could be attributed to direct virus cytotoxicity, systemic immune system activation, drug-related liver injury, reactivation of pre-existing liver disease, and hypoxic hepatitis. The clinical symptoms in patients with cirrhosis and COVID-19 were similar to those in the general population with COVID-19, with a lower proportion of patients with gastrointestinal symptoms. Although respiratory failure is the predominant cause of mortality in cirrhotic patients with COVID-19, a significant proportion of them lack initial respiratory symptoms. Most evidence has shown that cirrhotic patients have relatively higher rates of morbidity and mortality associated with COVID-19. Advanced cirrhosis was also proposed as an independent factor affecting a poor prognosis and the need to consider COVID-19 palliative care. General measures implemented to prevent the transmission of the virus are also essential for cirrhotic patients, and they should also receive standard cirrhosis care with minimal interruptions. The efficacy of the available COVID-19 vaccines in cirrhotic patients still needs investigation.

Objective Protobothrops mucrosquamatus, a Crotalinae snake with haemorrhagic venom, is responsible for the most common poisoning snakebites in Taiwan. Although a specific antivenin has been developed to treat this snakebite, surgical intervention is still needed in some patients because of the progression of tissue injury. Early risk stratification is important to identify the early signs of need for surgery. The purpose of this study was to investigate the early predictors for surgery in patients with P. mucrosquamatus envenomation. Methods The medical records of inpatients with P. mucrosquamatus envenomation between 2008 and 2013 were retrospectively reviewed. Clinical information was collected and analysed between surgical and nonsurgical patients. Results A total of 60 patients with P. mucrosquamatus envenomation, including 8 surgical patients (13.3%) and 52 non-surgical patients (86.7%), presented to the emergency department during the study period. Compartment syndrome (62.5%) and tissue necrosis (37.5%) were the main reasons for surgery. Comparison between surgical and non-surgical patients showed significantly higher white blood cell count (17.1 × 103/μL vs. 8.5 × 103/μL; p=0.002) and peak D-dimer level (1924.8 ng/mL vs. 730.0 ng/mL; p=0.006) in the surgical group. Ecchymosis (p=0.009), haemorrhagic bulla formation (p=0.002), leukocytosis (p=0.002), elevated peak D-dimer level (>1000 ng/mL) (p=0.005), and rhabdomyolysis (creatine kinase level >1000 IU/L) (p=0.007) were the significant signs relevant to surgery. On multivariate analysis, leukocytosis and ecchymosis were the most significant predictors of surgery in patients with P. mucrosquamatus envenomation. Conclusions Patients with P. mucrosquamatus envenomation presenting with leukocytosis and wound ecchymosis will have a high probability of requiring surgical therapy. (Hong Kong j.emerg.med. 2016;23:210-219)