Pneumonia is an inflammatory condition of the lungs caused by infection, which may be triggered and exacerbated by particulate matter (PM) exposure. We aimed to estimate the effect of PM on emergency department (ED) visits in pneumonia patients with septicemia after controlling for gaseous pollutants. Measurements on PM 2.5 , PM 10 , and other air pollutants at each of the 11 air-quality monitoring stations in Kaohsiung City, Taiwan, were collected between 2007 and 2013. The medical records of non-trauma patients who were over 17 years old and had visited the ED with a principal diagnosis of pneumonia were extracted. Poisson models were used to examine the relationship between air pollutants and daily ED visits for pneumonia with septicemia. Interquartile increments in the levels of PM 2.5 , PM 10 , and NO 2 at lag 0 were associated with increments of 25.5%, 21.61%, and 21.97%, respectively, in the number of ED visits for pneumonia with septicemia during the warm season. The effect estimates of PM 2.5 were robust after adjusting for PM 10 and NO 2 in the twopollutant model. PM 2.5 had stronger associations with ED visits in the cases of pneumonia with septicemia in relatively healthy patients, such as those without comorbid hypertension, diabetes, stroke, liver cirrhosis, respiratory disease, or malignancy. In conclusion, although the existing evidence already supports a causal relationship between PM 2.5 and pulmonary dysfunction, we propose that PM 2.5 may also play an important role in emergency visits for pneumonia with septicemia during the warm season in southern Taiwan after adjusting for PM 10 and NO 2 , especially among relatively healthy residents.

Objective:This study aimed to investigate the characteristics and outcomes of patients with emergency department (ED) revisits within 72 hours and subsequent admission to the intensive care unit (ICU).Materials and Methods:The medical records of all adult patients revisiting the ED of a single tertiary referral medical center with ICU admissions between January 2012 and September 2014 were reviewed in terms of patient characteristics, clinical manifestations, diagnoses, triage according to the Taiwan Triage and Acuity Scale, causes of revisits, and mortality.Results:The majority of the 51 patients reviewed were male (64.7%). Their mean age was 62.9 ± 14.9 years. Most patients visited the ED during the evening shift (51%) and were categorized into triage Level III (76.5%) during their first ED visit. The causes of revisits were doctor-related (21/51, 41.1%), illness-related (18/51, 35.3%), and patient-related (12/51, 23.5%). Disease categories included the neurological (23.5%), digestive (23.5%), and cardiovascular systems (21.6%). Abdominal pain and vertigo/dizziness were the two most common initial manifestations. The mortality rate was 27.5%. Malignancy and hepatic diseases were the two most common underlying medical conditions for nonsurvivors. In addition, patients initially presenting to the ED with lower triage scores (III & IV) had a higher mortality rate than those with higher scores (I & II).Conclusion:Most of the patients who revisited the ED within 72 hours and were subsequently admitted to the ICU visited the ED during the evening shift and were categorized into triage Level III on their first visit. The most common chief complaint at the first visit was abdominal pain. The most common cause of revisits with ICU admission was doctor-related, while the most common underlying disease was hypertension. Significantly higher mortality was observed after ED revisits in patients with lower triage scores with underlying malignancy and liver cirrhosis.

Background The prognosis of out-of-hospital cardiac arrest (OHCA) is very poor. While several prehospital factors are known to be associated with improved survival, the impact of prehospital factors on different age groups is unclear. The objective of the study was to access the impact of prehospital factors and pre-existing comorbidities on OHCA outcomes in different age groups. Methods A retrospective observational analysis was conducted using the emergency medical service (EMS) database from January 2015 to December 2019. We collected information on prehospital factors, underlying diseases, and outcome of OHCAs in different age groups. Kaplan-Meier type survival curves and multivariable logistic regression were used to analyze the association between modifiable pre-hospital factors and outcomes. Results A total of 4188 witnessed adult OHCAs were analyzed. For the age group 1 (age ≦75 years old), after adjustment for confounding factors, EMS response time (odds ratio [OR] = 0.860, 95% confidence interval [CI]: 0.811–0.909, p < 0.001), public location (OR = 1.843, 95% CI: 1.179–1.761, p < 0.001), bystander CPR (OR = 1.329, 95% CI: 1.007–1.750, p = 0.045), attendance by an EMT-Paramedic (OR = 1.666, 95% CI: 1.277–2.168, p < 0.001), and prehospital defibrillation by automated external defibrillator (AED)(OR = 1.666, 95% CI: 1.277–2.168, p < 0.001) were prognostic factors for survival to hospital discharge in OHCA patients. For the age group 2 (age > 75 years old), age (OR = 0.924, CI:0.880–0.966, p = 0.001), EMS response time (OR = 0.833, 95% CI: 0.742–0.928, p = 0.001), public location (OR = 4.290, 95% CI: 2.450–7.343, p < 0.001), and attendance by an EMT-Paramedic (OR = 2.702, 95% CI: 1.704–4.279, p < 0.001) were independent prognostic factors for survival to hospital discharge in OHCA patients. Conclusions There were variations between younger and older OHCA patients. We found that bystander CPR and prehospital defibrillation by AED were independent prognostic factors for younger OHCA patients but not for the older group.

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Background: Several instruments are currently used to assess Coronavirus Disease 2019 (COVID-19) -induced psychological distress, including the 22-item Impact of Event Scale-Revised (IES-R). The IES-R is a self-administered scale used to assess post-traumatic stress disorder (PTSD). The current study aimed to examine the construct validity of the IES-R, based on the Rasch model, with COVID-19-related data, as well as to test the multilevel construct validity of the IES-R within and among countries during the pandemic crisis. Methods: A multi-country web-based cross-sectional survey was conducted utilizing the 22-item IES-R. A total of 1020 participants enrolled in our survey, of whom 999 were included in the analyses. Data were analyzed using Rasch modeling and multilevel confirmatory factor analysis (MCFA). Results: The Rasch modeling results of the IES-R demonstrated that the IES-R is a satisfactory instrument with the five-point Likert scale, asserting that its 22 items are significant contributors to assessing PTSD as a unidimensional construct covered by the items of the IES-R. The MCFA confirmed that the 22-item IES-R, with its three factors, including intrusion, avoidance, and hyperarousal, demonstrates adequate construct validity at the within- and among-country levels. However, the results of the Akaike information criterion (AIC) model determined that the 16-item IES-R is better than the 22-item IES-R. Conclusion: The results suggested that the 22-item IES-R is a reliable screening instrument for measuring PTSD related to the COVID-19 pandemic, and can be utilized to provide timely psychological health support, when needed, based on the screening results.

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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.

Di(2-ethylhexyl) phthalate (DEHP) is widely used as a plasticizer in the manufacture of polyvinylchloride plastics and has been associated with concerns regarding male reproductive toxicity. In this study, we hypothesized that maternal exposure to DEHP induces transgenerational inheritance of adult-onset adverse reproductive outcomes through the male germline in the F1, F2, and F3 generations of male offspring. Pregnant rats were treated with 5 or 500 mg of DEHP/kg/day through gavage from gestation day 0 to birth. The offspring body weight, anogenital distance (AGD), anogenital index (AGI), sperm count, motility, and DNA fragmentation index (DFI) were measured for all generations. Methyl-CpG binding domain sequencing was performed to analyze sperm DNA methylation status in the F3. DEHP exposure at 500 mg/kg affected AGD, AGI, sperm count, mean DFI, and %DFI in the F1; AGD, sperm count, and mean DFI in the F2; and AGD, AGI, mean DFI, and %DFI in the F3. DEHP exposure at 5 mg/kg affected AGD, AGI, sperm count, and %DFI in the F1; sperm count in the F2; and AGD and AGI in F3. Compared with the control group, 15 and 45 differentially hypermethylated genes were identified in the groups administered 5 mg/kg and 500 mg/kg DEHP, respectively. Moreover, 130 and 6 differentially hypomethylated genes were observed in the groups administered 5 mg/kg and 500 mg/kg DEHP. Overall, these results demonstrated that prenatal exposure to DEHP caused transgenerational epigenetic effects, which may explain the observed phenotypic changes in the male reproductive system.