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.