BackgroundPrimary aortoduodenal fistula (ADF) is a rare cause of gastrointestinal (GI) bleeding and is difficult to diagnose as the clinical presentation is subtle. Clinicians should keep a high level of suspicion for an unknown etiology of GI bleeding, especially in older patients with or without abdominal aortic aneurysm (AAA). Computed tomographic angiography (CTA) can be used to detect primary ADF. Open surgery or endovascular aortic repair (EVAR) for ADF with bleeding will improve the survival rate.Case presentationWe report a rare case of AAA complicating ADF with massive GI bleeding in a 73-year-old Taiwanese man. He presented with abdominal pain and tarry stool for 5 days and an initial upper GI endoscopy at a rural hospital showed gastric ulcer only, but hypotension with tachycardia and a drop in hemoglobin of 9 g/dl from 12 g/dl occurred the next day. He was referred to our hospital for EVAR and primary closure of fistula defect due to massive GI bleeding with shock from ADF caused by AAA. Diagnosis was made by CTA of aorta.ConclusionsA timely and accurate diagnosis of primary ADF may be challenging due to insidious episodes of GI bleeding, which are frequently under-diagnosed until the occurrence of massive hemorrhage. Clinical physicians should keep a high index of awareness for primary ADF, especially in elderly patients with unknown etiology of upper GI bleeding with or without a known AAA.

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Patients with LOS of >32 h were reevaluated first. After QIP, the proportion of LOSs of >48 h dropped significantly. Changing the choice architecture may require further systemic effort and a longer observation duration. Higher-level administrators will need to formulate a more comprehensive bed management plan to speed up the turnover rate of free inpatient beds.

Research on relationships between physical fitness and sleep duration among older adults is scarce, especially in Taiwanese representative samples of elderly people who undergo physical fitness measurements. This study aimed to determine the associations between physical fitness and short and long sleep durations among older adults in Taiwan. We conducted a cross-sectional study and reviewed data derived from the National Physical Fitness Survey in Taiwan. A total of 24,125 Taiwanese adults aged 65 years and older participated in this study between October 2014 and March 2015. Each individual’s sleep duration was recorded with a standard questionnaire method. Sleep duration data were stratified into short (≤5 h), normal (6–7 h), and long (≥8 h) sleep duration groups. Physical fitness was assessed by five components: aerobic endurance (2 min step test), muscle strength and endurance (30 s arm curl and 30 s chair stand tests), flexibility (back scratch and chair sit-and-reach tests), body composition (body mass index (BMI) and waist-to-hip ratio (WHR)), and balance (one-leg stance with eye open and 8-foot up-and-go tests). To understand whether a dose–response relationship exists between physical fitness and short or long sleep duration, we analyzed four levels of performance on the basis of quartiles of physical fitness measurements by using logistic regression. The first quartile of physical fitness performance was the baseline level. The odds ratio (OR) for short sleep duration for the third quartile of BMI was 0.8031 times (95% CI, 0.7119–0.9061) lower than the baseline. For the fourth quartile of BMI, the OR was 0.8660 times (95% CI, 0.7653–0.9800) lower than the baseline. The adjusted OR for long sleep duration significantly decreased in the second, third, and fourth quartiles of the 30 s chair stand, back scratch, chair sit-and-reach test, one-leg stance with one eye open, and BMI. The adjusted OR was increased in the third and fourth quartiles of the 8-foot up-and-go and WHR. The results of the current study suggest that physical fitness performance may influence sleep duration as an associated factor, and the relationship is much stronger for long sleep duration than for short sleep duration.

Our data suggest that OSCC cells express functional AR proteins which are critical for promoting cell growth and causing malignant disease.

The present study aimed to construct a prognostic nomogram incorporating pre-treatment and post-treatment factors to predict progression-free survival (PFS) after use of sunitinib in patients with metastatic gastrointestinal stromal tumors (GISTs) following imatinib intolerance or failure. From 2007 to 2018, 109 metastatic GIST patients receiving sunitinib at Chang Gung Memorial Hospital, Taiwan, were enrolled. A prognostic nomogram to predict PFS was developed. Sixty-three male and forty-six female metastatic GIST patients, with a median age of 61 years (range: 15–91 years), received sunitinib. The median PFS for 109 patients is 9.93 months. For pre-treatment factors, male gender, body mass index more than 18.5 kg/m2, no sarcopenia status, higher lymphocyte count, lower platelet/lymphocyte ratio, good performance status, higher sunitinib dose, and non-liver metastasis were significantly associated with favorable PFS. For post-treatment factors, adverse events with hypertension, hand–foot skin reaction, and diarrhea were significantly associated with favorable PFS. However, only eight clinicopathological independent factors for PFS prediction were selected for prognostic nomogram establishment. The calibration curve for probability of PFS revealed good agreement between the nomogram prediction and actual observation. High risk patients will experience the lowest PFS. A prognostic nomogram integrating eight clinicopathological factors was constructed to assist prognostic prediction for individual patients with advanced GIST after sunitinib use.

BackgroundIliopsoas abscess (IPA) is a rare clinical entity and is difficult to diagnose due to its insidious onset and nonspecific symptoms. The association between IPA and cardiovascular disorders (CVD) has been rarely reported. Computed tomographic (CT) scan can provide a definitive diagnosis of IPA and associated foci of adjacent structures. IPA is a life-threatening condition, especially when associated with CVD.Materials and methodsWe conducted a hospital-based observational study of IPA associated with CVD. Data were collected from the electronic clinical database of Taichung Veterans General Hospital (1520-bed tertiary referral hospital in central Taiwan) between July 2007 and December 2017. The diagnosis of IPA associated with CVD was confirmed by classical findings on CT and transesophageal echocardiography with compatible clinical presentation and cultures from pus/tissue and blood.ResultsFifteen patients of IPA associated with CVD were studied. They included 12 males (80%) and 3 females (20%), with a mean age 63.2 ± 16.9 years (31–85 years). CVD included stent-graft/endograft infection of abdominal aortic aneurysm (AAA) (40%), primary mycotic AAA (33.3%), and infective endocarditis (26.7%). Staphylococcus aureus is the most common microorganism in pus/tissue cultures (n = 3, 37.5%) and in blood cultures (n = 6, 40%). The average length of hospital stay was 33.1 ± 20.5 days (range, 3–81 days; median, 33 days). Hospital stay lasted 42.6 ± 19.2 days in the survival group and 19.0 ± 14.1 days (P = 0.018) in the non-survival group. Incidence of patients staying in the intensive care unit (ICU) with intubation > 3 days was 33% in the survival group and 100% (P = 0.028) in the non-survival group. Intra-hospital mortality rate was 40%. Poor prognostic factors in the non-survival group were hypoalbuminemia, hyponatremia, involved disc/vertebral body and/or epidural abscess, and ICU stay with intubation > 3 days. Cumulative survival rate was 25% under conservative treatments and 66.3% under aggressive treatments (P = 0.038).ConclusionDue to high mortality rates, clinicians should keep a high suspicion index for IPA associated with CVD through clinical presentation, physical examination, and imaging study. Timely empiric antibiotics for common bacteria, drainage for IPA, endovascular repair, or vascular reconstruction by graft replacement or bypass with intensive care should be mandatory to shorten the hospital stay, reduce medical costs, and lower mortality rate.

Fatal haemoptysis caused by a ruptured Rasmussen's aneurysmA 47-year-old woman with a past history of pulmonary tuberculosis presented to our institution with out-of-hospital cardiac arrest because of massive haemoptysis after severe coughing. On arrival, immediate cardiopulmonary resuscitation with chest compression, endotracheal intubation and intravenous epinephrine 1 mg with an interval of 3 min for asystole was performed. Twelve minutes later she was defibrillated twice with 150 joules and intravenous epinephrine of 1 mg with an interval of 3 min for ventricular fibrillation was given. Return of spontaneous circulation with a blood pressure of 181/98 mm Hg and a pulse rate of 80 beats/min was achieved 4 min later. Fluid replacement, blood transfusion, tranexamic acid and pitressin were given for persistent gushing of fresh blood from the endotracheal tube. It was suspected that the bleeding originated from the pulmonary or bronchial vessels. Laboratory evaluation revealed a white blood cell count of 13 100/mm 3 with 43.2% segmented neutrophils and 50.4% lymphocytes, haemoglobin 8.5 g/dl and platelet counts of 134310 3 /mm 3 . Thoracic contrastenhanced 64-slice multidetector computed tomographic angiography (MDCTA) demonstrated a vascular lesion 29 mm in diameter originating from a branch of the pulmonary artery (PA) with contrast media extravasations indicating a ruptured Rasmussen's aneurysm (figures 1 and 2). Pulmonary angiography with embolisation was attempted and a thoracic surgeon was consulted. However, cardiopulmonary resuscitation, defibrillation, fluid replacement, epinephrine and pitressin were prescribed for pulseless electrical activity and recurrent ventricular fibrillation. Four hours later the patient died after return of spontaneous circulation. Sputum culture 1 month later confirmed tuberculosis.Massive haemoptysis has a mortality rate of >50%. The prevalence of haemoptysis originating from the PA is <10%. Rasmussen's aneurysm has a prevalence of 5%.1 MDCTA can demonstrate the PA and pseudoaneurysm of PA in the adjacent cavity.1 2 The mortality rate for emergency surgery in unstable haemodynamic patients is high, so radiological endovascular embolisation of endovascular embolisation with coils is recommended first in these patients. Learning points< Massive haemoptysis is a life-threatening condition associated with a mortality rate of >50% and ruptured Rasmussen's aneurysm should be considered in patients with massive haemoptysis, especially if there is a history of pulmonary tuberculosis.1 < Rasmussen's aneurysm is a rare phenomenon caused by weakening of the pulmonary artery wall from adjacent cavitary tuberculosis, with a prevalence of 5%.1 < Mandatory radiological studies should include thoracic MDCTA and digital substrate angiography to differentiate between bleeding from pulmonary or bronchial origins. 1 2 < Surgical or angiographic interventions with endovascular embolisation is recommended in this life-threatening condition.