The Eschar Size and Early Inoculation Lesion of Tsutsugamushi Disease on Jeju Island, Korea / 감염과화학요법

BACKGROUND@#Tsutsugamushi disease, or scrub typhus, is an acute febrile illness caused by Orientia tsutsugamushi, which is followed by chronic latent infection. People who reside in areas endemic of tsutsugamushi disease may be frequently reinfected with this organism. Volunteers who are experimentally reinfected with O. tsutsugamushi manifest various systemic and local reactions, including the presence of small-sized eschar. The present study recorded the morphology and size of eschars in patients with tsutsugamushi disease on Jeju Island, Korea.@*MATERIALS AND METHODS@#From March 2018 to February 2019, 23 patients manifesting clinical characteristics and epidemiologic features of tsutsugamushi disease on Jeju Island were investigated. For comparison of eschar sizes between the two regions, 12 patients with tsutsugamushi disease in Incheon were similarly examined.@*RESULTS@#Three patients, two on the first day and one on the fourth day of fever, presented with papules of 2 – 5 mm in diameter. Another three patients, one on the second day and two on the fourth day, presented with ruptured vesicles of 5 – 8 mm in diameter. Thirteen patients presented with eschars covered with dark scabs, with a median diameter of 5 (95% confidence interval [CI], 5 – 7.5) × 4 (95% CI, 3 – 5) mm. The medians of the eschar sizes did not differ between the two cities (P = 0.46 by Mann-Whitney U test), but eschars ≥10 mm in diameter were more frequent in Incheon than in Seogwipo-si (4 of 12 vs. 0 of 13 patients, P = 0.04 by Fisher's exact test). One patient presented with multiple eschars, and no eschar was detected in the remaining three patients. Among 11 Jeju Island patients with positive IgG and IgM antibodies, seven patients revealed higher IgG than IgM antibody titers during the acute phase of the illness, i.e., the IgG antibody response, two patients had equal IgG and IgM titers, and two patients presented the IgM antibody response. Life-threatening complications and death were not observed in this study.@*CONCLUSION@#The patients in Seogwipo-si had small-sized eschars and occasionally exhibited non-necrotic lesions. Many patients had serologically reinfected tsutsugamushi disease. Further studies are needed to investigate the association between these findings.

A Case of Myocardial Infarction Occurred after Endoscopic Submucosal Dissection under Bridging Therapy with Low Molecular Weight Heparin

Myocardial infarction (MI) is a complication that can occur after endoscopic submucosal dissection (ESD). However, very few reports are available about this complication. A 71-year-old male, who had two drug eluting stents inserted due to ischemic heart disease, was referred to the Division of Gastroenterology for ESD of a lesion suspicious of early gastric cancer. ESD was performed after dual antiplatelet agents were discontinued and bridging therapy with low molecular weight heparin (LMWH) was initiated. However, MI occurred immediately after the ESD procedure. A coronary angiogram did not show any significant stent thrombosis or restenosis. The patient recovered spontaneously. Here, we report a case of MI that occurred after ESD under bridging therapy with LMWH.

Does the Incidence of Rhabdomyolysis Induced by Doxylamine Overdose Increase in the Elderly?

BACKGROUND: Doxylamine is an over-the-counter drug that is popular in the treatment of insomnia. Doxylamine is relatively safe but can cause rhabdomyolysis. The aim of this study was to evaluate whether the incidence of rhabomyolysis increased in elderly patients (age> or =65 years) with doxylamine overdose. METHODS: This study included 108 patients admitted to an Emergency Department after doxylamine overdose between January 1, 2000, and March 31, 2013. Age, sex, time ingested before admission, amount of drug ingested, gastric lavage, tachycardia, vomiting, hematuria, blood urea nitrogen, blood creatinine, urine pH, and alcohol ingestion were investigated for the risk factors of rhabdomyolysis. RESULTS: Forty-three patients (47.6%) developed rhabdomyolysis. Of 16 elderly patients, 11 developed rhabdomyolysis. Of the 92 patients <65 years-of-age, 34 developed rhabdomyolysis. Advanced age, alcohol ingestion, and increased blood creatinine level were significantly associated with the development of rhabdomyolysis. CONCLUSION: In elderly patients with doxylamine overdose, the incidence rate of rhabdomyolysis may be increased. A high index of suspicion and evaluation of rhabdomyolysis is warranted in elderly patients with doxylamine overdose.

The Relationship between Rhabdomyolysis and Alcohol Ingestion in Doxylamine Intoxicated Patients

PURPOSE: Doxylamine is commonly used for relief of insomnia; in addition, it is also a drug that is freguently used for intoxication in Korea. This drug is relatively safe; however, it is known to occasionally induce rhabdomyolysis. We have seen many cases of alcohol ingestion in doxylamine intoxications; however, few previous studies have documented the effects of alcohol on rhabdomyolysis. Therefore, the purpose of this study is to determine the effect of alcohol on rhabdomyolysis in doxylamine intoxicated patients. METHODS: This study was conducted on 91 patients admitted to an emergency department after doxylamine intoxication during the period from January 2001 to March 2012. Using the protocol developed beforehand, the amount of drug ingestion, past history, laboratory results, and whether or not alcohol was ingested were recorded. Rhabdomyolysis was defined as serum creatine kinase (CK) over 1,000 U/L. The SPSS package with logistic regression, t-test, and Fisher's test was used for analysis of data. RESULTS: Alcohol ingestion was detected in 52% of the study patients. The presence of hematuria and alcohol ingestion showed a significant association with development of rhabdomyolysis. CONCLUSION: Doxylamine intoxicated patients with alcohol ingestion may have a high rate of incidence of rhabdomyolysis. Therefore, doxylamine intoxicated patients who drink alcohol at the same time should be aware of rhabdomyolysis.

Effect of Gender on Moderate to Severe Traumatic Brain Injury: A Meta-Analysis and Systematic Review

PURPOSE: Case-control and cohort studies have reported inconsistent findings for the association between gender and mortality from a traumatic brain injury. We investigated the effect and association of gender on moderate to severe traumatic brain injury using meta-analysis. METHODS: We searched electronic health care databases including MEDLINE (Pubmed), the Cochrane Library, CINAHL, and Koreamed (January 2001 to December 2009) in August 2010. The keywords searched included traumatic brain injury or traumatic head injury, gender, and mortality. Two independent investigators selected and reviewed articles according to predefined inclusion and exclusion criteria. The quality of selected articles was evaluated by applying the Newcastle Ottawa scale. Data were abstracted by predetermined criteria. Odds ratios were calculated and combined using fixed and random effect models. RESULTS: Of 130 articles, four case-control studies and three cohort studies were included in the final analysis. In total, 89,335 patients were included(26,287 females and 63,048 males). Compared with the mortality of male patients, the combined odds ratio for the mortality of female patients was 1.074(95% confidence interval [CI], 1.027~1.124) in a fixed effect model, and 1.319(95% CI, 1.104~1.576) in a random effects model, respectively. The heterogeneity of all participants was severe, so the results were discarded and a subgroup analysis was conducted. The total number of participants was divided into premenopausal and postmenopausal groups by the menopausal age defined in each article. The pooled odds ratio of the premenopausal group was 1.014(95% CI, 0.949~1.083) in the fixed effect model and that of the postmenopausal group was 1.237(95% CI, 0.895~1.712) in the random effects model. The pooled estimate of the random effect model was adopted because of the severe heterogeneity of the postmenopausal group. CONCLUSION: We found no distinct effect of gender on moderate to severe traumatic brain injury. Large-scaled prospective studies based on female hormone levels are needed.

Is a Psychiatric Consultation Necessary for the Non-Suicidal Intentional Drug Ingestion Patient in an Emergency Department?

PURPOSE: The purpose of this study was to investigate the relationship between suicide risk factors and psychiatric disorders, and between suicide risk factors and suicide attempts after discharge, and to analyze the necessity of a psychiatrist referral in patients who intentionally ingested drug but did not make a suicide attempt. METHODS: Between January 1, 2004 and December 31, 2008, we investigated cases of intentional drug ingestion in patients greater than 15 years of age who visited Kyung Hee University emergency medical center. We divided the patients into two groups - a suicide attempt group and a non-suicide attempt group. The difference between suicide risk factors of the two groups was investigated prospectively. Among the risk factors for suicide, we determined whether psychiatric diagnosis was highly associated with suicide and whether it was an influential factor in suicide attempts after discharge. SPSS version 13.0 was used for statistical analysis. Chi-square, paired sample t-test, and Fisher's exact test were performed, and a p0.05). Patients who did not attempt suicide who had a psychiatric history associated with suicide attempts, who had previous suicide attempts, who had a family history of suicide, and who lived alone, may have psychiatric disorders associated with suicide or suicide attempt after discharge (p<0.05). CONCLUSION: All patients who intentionally ingested drugs should be given a psychiatrist referral, even if the patients did not attempt suicide. In particular, the psychiatric referral should be made when the patient has risk factors such as a psychiatric history associated with suicide attempts, previous suicide attempts, a family history of suicide, and living alone.

Medical Malpractice Claims on Emergency Medical Facilities: Medicolegal Consideration Based on Judicial Precedents

PURPOSE: To investigate which factors are associated with the causes and results of medical malpractice claims on emergency medical facilities. The study analyzed the alteration of judicial precedents between before and after 1995 when the court ruled that the burden of proof was to be placed upon the accused as well as the plaintiff. METHODS: We collect 213 medical malpractice claims covering from 1953 to 2008, using a database of closed claims maintained by the Supreme Court of Korea. Of the 213 claims, 31 involved emergency medical facilities. The cases were divided into 4 groups according to the physician's specialty and the causes and results of the claims were compared among each group. The causes and results were also compared between before and after 1995. RESULTS: In the medical department, the physicians were mainly accused in connection with mis- or delayed diagnosis. In the surgical and emergency departments, the plaintiff denounced the physician generally for neglect of duty in the emergency medical service system. The tendency of the court's ruling related to the distribution of the burden of proof has been changed after 1995 and the rate of physician legal victory in the judicial precedents has declined since then. CONCLUSION: Medical malpractice claims on emergency medical facilities were mostly related to misdiagnosis or emergency medical service system. Due to the change in the court's ruling regarding the distribution of the burden of proof, emergency physicians with medical malpractice claims need to change their attitude with regards to the activeness in the claims.

The Educational Benefits at Each Steps by Expository Cardiopulmonary Resuscitation Teaching and Immediate Remediation for Non-Healthcare Providers in Hospital

PURPOSE: We undertook this study to evaluate the educational benefits at each steps of expository cardiopulmonary resuscitation (CPR) training by immediate remediation for non-healthcare providers in our hospital. METHODS: The 150 office staffs who worked in our hospital participated in this study. Following an educational session consisting of a one-hour video tape and slides, we tested single-rescuer BLS performance (15 checklists) with Fullbody SkillReporter(TM) Resusci(R) Anne and Skillmeter Resusci(R) Anne according to 2005 AHA guidelines for CPR. Three tests and two remediations were given to each person, and data were collected after each trial. A statistical analysis was done using the SPSS statistical software package. A pvalue<0.05 was considered to be statistically significant. RESULTS: Staff pass rates were improved in 13 checklists after remediation of CPR training. In the initial testing, the highest rate of pass was in assessment of responsiveness (0.89+/-0.31) and the lowest rate of pass was in the looking of in the checking-breathing test items (0.23+/-0.42). The highest rate of pass after two remediations was in the checking-breathing within 10 seconds (0.94+/-0.23) and the lowest rate of pass was in the rate of chest compression (0.52+/-0.50). The difference between males and females was in the rate of chest compression (p=0.001), but there is no difference of the educational benefits after two remediations by age-group. CONCLUSION: We found that the rate of passing in each steps of CPR training was improved by two remediations. Therefore, many iterations of remediation of CPR training for non-healthcare providers are necessary.

Maintenance of Insulin Therapy by Desensitization in Insulin Allergy Patient / 당뇨병

Allergic reaction to human insulin is uncommon. But they can cause mild to severe symptoms such as dyspnea, hypotensive shock, etc. Here we report the case of a patient with type 2 diabetes and insulin allergy successfully managed with desensitization. A 60-year-old man with insulin allergy was transferred. He had poorly controlled type 2 diabetes (fasting blood glucose 230 mg/dL). He developed itching sense and erythema at the injection sites of human insulin in a few minutes. And serum IgE level was elevated to 1618.0 IU/mL. The insulin was changed to other preparations, including short and long-acting insulin analogues, with similar responses. He was commenced on twice a day injection protocol in addition to his oral hypoglycemic agents, and achieved fair control (fasting blood glucose 100 mg/dL) on 24 units of Novomix Flex Pen per day, with little or no skin or systemic reaction. This is the case report of insulin allergy in type 2 diabetes being successfully managed by desensitization.

The Diagnostic Accuracy of Abdominal Ultrasonography for Acute Appendicitis and Acute Cholecystitis Performed by Emergency Physicians after Systematic Training for the Abdominal Ultrasonography

PURPOSE: The purpose of this study was to evaluate the diagnostic accuracy of abdominal ultrasonography (USG) as performed by emergency physicians (EP) after systematic training and to compare it with the performance of a radiologist. METHODS: From 4 March, to 3 October, 2006, we enrolled 368 patients with suspected acute appendicitis and 177 patients with suspected acute cholecystitis. During night hours, abdominal USG was performed by EPs who had been trained for more than 2 years (Group I), and during day, it was performed by a radiologist (Group II). In group I, 201 patients were suspected to have acute appendicitis and 103 patients were suspected to have acute cholecystitis. In group II, 167 patients were suspected to have acute appendicitis and 74 patients were suspected to have acute cholecystitis. We reviewed pathology reports and the final diagnoses of all patients after one month. We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for each group and then compared the diagnostic accuracy for group I with that of group II using the chisquare test. RESULTS: With suspected acute appendicitis patients, the sensitivity, specificity, PPV, NPV and accuracy of USG were 92.0%, 85.2%, 88.9%, 89.3%, and 89.1% for group I and 94.2%, 85.7%, 91.6%, 90.0%, and 91.0% for group II. With suspected acute cholecystitis patients, the sensitivity, specificity, PPV, NPV and accuracy of USG were 87.2%, 93.8%, 89.5%, 92.3%, and 91.3% for group I and 92.0%, 93.9%, 88.5%, 95.8%, and 93.2% for group II. There was no significant difference in the diagnostic accuracy between the two groups. (p=0.533, p=0.630) CONCLUSION: In this study, there was no significant difference between EPs and a radiologist in diagnostic accuracy of abdominal USG. This result suggests that diagnostic abdominal USG for acute abdominal diseases, such as acute appendicitis and acute cholecystitis can be appropriately used as a diagnostic modality by emergency physicians who are properly trained in a systematic educational program.

The Relationship of Self-reported Pain Scores with Vital Signs in Ureter Stone Patients

PURPOSE: Some studies indicate that vital signs such as blood pressure, heart rate, respiration rate, body temperature correlate with each other. However, no study has rigorously confirmed the correlations between vital signs due to study limitations. The aim of this study is to determine the relationship of pain to vital sings and to assess its clinical utility in ureter stone patients. METHODS: All 371 patients with ureter stone admitted to the Emergency Department (ED) at Kyung Hee University Hospital from September 1, 2005 to August 31, 2006 were prospectively involved in our study. We recorded vital signs of all patients 3 times every 10 minutes before analgesic injection and determined mean values. We analyzed the data by using the SPSS 13.0 statistics program. RESULTS: The means for systolic and diastolic blood pressure, heart rate and respiration rate were significantly different in pain score (p<0.05), but were not different by body temperature. Correlations of pain grade to vital signs were calculated, and blood pressure, heart rate and respiration rate showed positive correlation with pain grade (p<0.05). In multivariate analysis by general linear analysis, only systolic blood pressure and respiration rate were significantly associated with pain scores (p<0.05). CONCLUSION: In general, we have a tendency to underestimate the importance of the respiration rate relative to blood pressure, heart rate, and body temperature except in special circumstances, such as COPD or asthma exacerbation. Self-reported pain scores of patients correlate with vital signs, especially blood pressure and respiration rate.

Is There Any Relationship Between Hematuria in Rhabdomyolysis and Renal Injury?

PURPOSE: In previous literature, urinalysis in rhabdomyolysis has been known to be positive for occult blood, but without overt hematuria. Recently, however, we have reported hematuria in patients with doxylamine overdose in association with rhabdomyolysis. We wanted to determine whether the hematuria resulted from the toxicity of doxylamine itself or from rhabdomyolysis, and further to investigate the relationship between hematuria, acute renal failure (ARF), and the presence of urine alkalinization. METHODS: The medical records of 167 patients diagnosed with rhabdomyolysis who were admitted to Kyung Hee Medical Center between 2000 and 2004 were retrospectively examined. Patients without laboratory results 3 times a day, patients with inaccurate records, and patients with diseases that could cause hematuria were excluded, leaving 79 patients for evaluation. The relationship between laboratory results, occurrences of ARF and urine alkalinization were compared and assessed. RESULTS: Hematuria was observed in 76 of 79 patients with rhabdomyolysis, irrespective to the cause of rhabdomyolysis. The percentage of dysmorphic RBC was 58% and MCV (mean corpuscular volume) was 76+/-15 fL found in hematuria. Urine alkalinization was not associated with the presence of hematuria. The laboratory results of ARF patients compared to those of non-ARF patients showed a significant difference in the average urine pH, and ARF with rhabdomyolysis was not associated with muscle enzyme levels but rather was associated with the duration of hematuria. CONCLUSION: Hematuria was found in patients with rhabdomyolysis irrespective of the cause of rhabdomyolysis. Therefore, hematuria is associated with rhabdomyolysis rather than doxylamine intoxication. The occurrence of hematuria in rhabdomyolysis is unrelated to urine alkalinization. The duration of hematuria in ARF group was significantly longer than in non-ARF group. It is therefore important to bear in mind the possibility that ARF will develop when hematuria lasts for a long time. Furthermore, we feel that additional prospective studies and investigations into the mechanism of hematuria in rhabdomyolysis should be done.

Validity of Diagnostic Categories Based on Computed Tomography Findings for Acute Lobar Cerebral Hematoma in Patients with a Ruptured Cerebral Aneurysm Compared with That of Patients with Hypertensive Lobar Cerebral Hematoma

PURPOSE: The rupture of a cerebral aneurysm generally presents as a subarachnoid hemorrhage (SAH) and less often involves a lobar cerebral hematoma (LCH). Also, compared with a hypertensive LCH, an aneurysmal LCH is an unfavorable factor for a favorable outcome. Thus, the earlier we detect an aneurysmal LCH, the more favorable the outcome we can expect. We designed this study to use diagnostic categories to compare aneurysmal LCHs with hypertensive LCHs based on computed tomography (CT) findings. METHODS: From Mar. 2003 to Feb. 2004, patients with LCH who visited the emergency department of Kyung Hee University Hospital were divided into two groups. One was the aneurysmal LCH group (29 patients), and the other was the hypertensive LCH group (155 patients). Based on CT findings, we retrospectively compared the two groups by using the following six diagnostic categories: 1) location of hematoma, 2) presence of an aneurysm on enhanced CT findings, 3) disruption of the cerebral cortex, 4) connection of the hematoma to the main cerebral artery, 5) a hematoma involved with a SAH or an intraventricular hemorrhage (IVH), and 6) heterogeneity of a hematoma in Hounsfield unit. RESULTS: The patterns of aneurysmal LCHs and hypertensive LCHs were specific. Statistically, frontal, corpus callosal, and temporal hematomas may result from ruptured aneurysms, but systemic hypertension may cause thalamic, pontine, cerebellar, and subcortical hematomas. The other diagnostic categories, except for heterogeneity of the hematoma, were statistically more specific for the aneurysmal LCH group than they were for the hypertensive LCH group. CONCLUSION: Based on CT findings, we can make a diagnosis of whether the hematoma in a cerebral parenchyma is due to a ruptured aneurysm or not. Moreover, enhanced CT gives more valuable information for a differential diagnosis. Thus, we propose that enhanced CT be carried out for all non-traumatic LCH patients.

Cerebral Infarction Following Snakebite

There are only three species of poisonous snakes in Korea. Deaths from poisonous snakebites are rare in Korea, but the World Health Organization estimates that as many as 30,000 to 40,000 death occur following venomous snakebites. The most important factor for determining a prognosis for a victim of a venomous snakebite is the grade of envenomation, because the grade of envenomation is highly correlated with severe complications such as disseminated intravascular coagulopathy, a bleeding tendency, acute renal failure, pulmonary edema, and sepsis. Also, bleeding complications with the central nervous system are well known to occur following a snakebite. However, non hemorrhagic manifestations, such as ischemic stroke, are extremely rare. We report the case of 72-year-old male who suffered a cerebral infarction following a snakebite. We also present a review of the literature of possible mechanisms for the cerebral infarction.

Traumatic Tricuspid Regurgitation and Acute Hearth Failure after Blunt Chest Trauma: 1 Case

Blunt chest trauma to the heart may produce instantaneous death or, more frequently, congestive heart failure due to myocardial injury or disruption of intracardiac structures. Cardiac injury following by blunt chest trauma is often unsuspected and can range from cardiac contusion to chamber rupture, or to valvular dysfunction. The rate of occurrence of acute traumatic valvular insufficiency is extremely rare. Especially, the tricuspid valve is very rarely injured. Although clinical diagnosis of acute traumatic valvular insufficiency can be difficult to make for trauma patients with multiple injuries, echocardiography can establish diagnosis quickly and accurately. This report describes a patient who developed tricuspid regurgitation and acute heart failure following by an MCV.

A Case Report and Review of Tetanus

Tetanus is a rare disease in the developed countries, including Korea, as a result of nearly universal active immunization. Because many physicians have little experience with its diagnosis and management, misdiagnosis and therapeutic delay may result in catastrophic consequences. We report one case of generalized tetanus. A previously healthy 35-year-old man was admitted to the emergency department because of stiffness on jaw and neck. board-like abdomen, extended and rigid both legs, chest tightness, and dyspnea. Seven days before admission, he was injured on the right thing at work. In the emergency department, he was given 5,000 units of human tetanus immunoglobulin intramuscularly, as well as diazepam 2 mg/hr intravenously. On the second hospital day, tracheostomy was performed. Ten days later, his condition was improved. Twenty eight days after admission, he was discharged without any complication.