Severe Systemic Reactions Following Bee Sting Injuries in Korea

Purpose@#Most bee sting injuries are benign, although sometimes they can result in life threatening outcomes, such as anaphylaxis and death. The purpose of this study was to investigate the epidemiologic status of bee sting injuries in Korea and to identify risk factors associated with severe systemic reactions (SSRs). @*Materials and Methods@#Cases were extracted from a multicenter retrospective registry for patients who had visited emergency departments (EDs) for bee sting injuries. SSRs were defined as hypotension or altered mental status upon ED arrival, hospitalization, or death. Patient demographics and injury characteristics were compared between SSR and non-SSR groups. Logistic regression was performed to identify risk factors for bee sting-associated SSRs, and the characteristics of fatality cases were summarized. @*Results@#Among the 9673 patients with bee sting injuries, 537 had an SSR and 38 died. The most frequent injury sites included the hands and head/face. Logistic regression analysis revealed that the occurrence of SSRs was associated with male sex [odds ratio (95% confidence interval); 1.634 (1.133–2.357)] and age [1.030 (1.020–1.041)]. Additionally, the risk of SSRs from trunk and head/ face stings was high [2.858 (1.405–5.815) and 2.123 (1.333–3.382), respectively]. Bee venom acupuncture [3.685 (1.408–9.641)] and stings in the winter [4.573 (1.420–14.723)] were factors that increased the risk of SSRs. @*Conclusion@#Our findings emphasize the need for implementing safety policies and education on bee sting-related incidents to protect high-risk groups.

Effect of a Boarding Restriction Protocol on Emergency Department Crowding

Purpose@#Access block due to the lack of hospital beds causes crowding of emergency departments (ED). We initiated the “boarding restriction protocol” that limits the time of stay in the ED for patients awaiting hospitalization to 24 hours from arrival. The purpose of this study was to determine the effect of the boarding restriction protocol on ED crowding. @*Materials and Methods@#The primary outcome was ED occupancy rate, which was calculated as the ratio of the number of occupying patients to the total number of ED beds. Time factors, such as length of stay (LOS), treatment time, and boarding time, were investigated. @*Results@#The mean of the ED occupancy rate decreased from 1.532±0.432 prior to implementation of the protocol to 1.273±0.353 after (p<0.001). According to time series analysis, the absolute effect caused by the protocol was -0.189 (-0.277 to -0.110) (p=0.001). The proportion of patients with LOS exceeding 24 hours decreased from 7.6% to 4.0% (p<0.001). Among admitted patients, ED LOS decreased from 770.7 (421.4–1587.1) minutes to 630.2 (398.0–1156.8) minutes (p<0.001); treatment time increased from 319.6 (198.5–482.8) minutes to 344.7 (213.4–519.5) minutes (p<0.001); and boarding time decreased from 298.9 (109.5–1149.0) minutes to 204.1 (98.7–545.7) minutes (p<0.001). In pre-protocol period, boarding patients accumulated in the ED during the weekdays and resolved on Friday, but this pattern was alleviated in post-period. @*Conclusion@#The boarding restriction protocol was effective in alleviating ED crowding by reducing the accumulation of boarding patients in the ED during the weekdays

Therapeutic Efficacy of Spironolactone for Central Serous Chorioretinopathy

Purpose@#To evaluate the therapeutic effects and safety of oral spironolactone (SPRL) in patients with central serous chorioretinopathy (CSC). @*Materials and Methods@#The medical records and imaging data of patients diagnosed with CSC and treated with SPRL were retrospectively reviewed. Central macular thickness (CMT), subretinal fluid (SRF) height, subfoveal choroidal thickness (SFCT), and best-corrected visual acuity (BCVA) at baseline, at 1, 3, and 6 months, and at the last visit after the treatment were analyzed. @*Results@#In total, 103 patients with 107 eyes were included. The mean age of the patients was 51.5±9.3 years, and 77 (72.0%) were male. The mean follow-up duration was 48.6±40.2 weeks. The mean duration of oral SPRL therapy was 15.5±13.4 weeks. CMT, SRF height, and SFCT improved significantly at 1, 3, and 6 months after SPRL therapy and at the last follow-up. BCVA, however, showed no significant change at any time point. The rate of complete resolution of SRF at 1 month was higher in those with chronic CSC than in those with acute CSC (21.1% vs. 6.0%, respectively). Recurrence occurred in 14 (13.1%) eyes after the complete resolution of SRF. Older age (p=0.001), a greater number of previous intravitreal bevacizumab injections (p=0.006), and poor initial visual acuity (p=0.048) were associated with recurrence. No permanent adverse effects were observed. @*Conclusion@#Oral SPRL showed therapeutic benefits in patients with CSC in terms of SRF resolution, but relatively frequent recurrence was observed, especially in older patients.

Scleral Fixation of a Hydrophobic Acrylic Intraocular Lens with Eyelets Using 8-0 Polypropylene Suture

Purpose@#To report clinical outcomes of a scleral fixation technique of a hydrophobic acrylic intraocular lens with eyelets using 8-0 polypropylene suture. @*Methods@#Nine eyes of nine patients who underwent combined pars plana vitrectomy and sclera fixation of an intraocular lens using this technique were analyzed. @*Results@#The mean follow-up period was 7.11 months (range, 6–12 months), and there was a significant visual improvement at 6 months after surgery. The mean logarithm of the minimum angle of the resolution changed from 0.54 at baseline to 0.29 at postoperative 6 months (p = 0.016). The mean postoperative spherical equivalent at 6 months was -0.90 ± 0.90 diopters, and the mean predictive error was -0.49 ± 0.62 diopters. @*Conclusions@#Postoperative visual and refractive outcomes were favorable, and the positions of intraocular lenses were well centered in all cases. This technique could be a useful alternative for surgeons without easy access to Gore-Tex suture.

Effect of the Computerized Emergency Consultation System on Communication Between Medical Staff for Emergency Care / 의료커뮤니케이션

Purpose@#: In emergency department(ED), emergency consultation is often omitted or delayed, resulting in an increase of the length of stay for patients. The present study investigated the emergency consultation computerized system designed for prompt and accurate communication can shorten the time for consultation care. In addition, we tried to confirm how users’ satisfaction with communication for emergency consultation changed before and after using the system. @*Methods@#: We divided the period from arrival to exit of the emergency department into 4 stages, and the time taken for each stage was measured. In addition, the present study conducted a satisfaction survey on the convenience and accuracy of communication among users. @*Results@#: After using the computerized system, the median value of time for emergency consultation treatment decreased significantly from 78 minutes to 39 minutes (p<0.001). In terms of communication convenience, more than two-thirds of the users responded positively. @*Conclusion@#: The system that computerized the initial communication shortened the time required for emergency consultation and increased satisfaction in terms of convenience of communication between medical staff.

Comparison among frailty screening tools in the emergency department: a systematic review

Objective@#It is important to identify high-risk elderly patients in the emergency department (ED), and various screening tools should be used. This study aimed to find the most appropriate tool by comparing frailty screening tools used in the ED. @*Methods@#The authors searched PubMed, EMBASE, Cochrane library, and KoreaMed databases for medical literature. Two or more frailty screening tools were studied. Sensitivities and values of the area under the receiver operating characteristic curve of each tool used in individual studies were compared. @*Results@#After the screening process, six studies using 12 tools were selected. Most of the tools had low sensitivities. The sensitivities were 90% or more in case of the Clinical Frailty Scale (CFS) and Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA-7). Seniors at Risk (ISAR) tools for frailty screening, Vulnerable Elders Survey (VES-13) and Geriatric (G8) tools were identified for predicting postoperative mortality, and CFS, Fried and Stable, Unstable, Help to walk, Bedbound (SUHB) tools were used for determining bad composite outcomes. The areas under the curve values predicting outcome were as follows: 0.63-0.67 for death, 0.52-0.64 for postoperative death, 0.52-0.68 for postoperative adverse outcome, 0.55-0.64 for poor prognosis, 0.65-0.69 for activity daily living disability, 0.66-0.78 for functional decline, 0.58-0.61 for hospitalization, 0.57-0.59 for fall, and 0.77-0.91 for frailty screening. @*Conclusion@#It was difficult to select the most appropriate tool among the 12 frailty tools included in this review. However, Fatigue, Resistance, Ambulation, Illnesses, Loss of weight (FRAIL), Study of Osteoporotic Fracture (SOF), CFS, VES-13, and PRISMA-7 were relatively useful in the ED.

Induced Pluripotent Stem Cell Modeling of Best Disease and Autosomal Recessive estrophinopathy

Purpose@#To understand the pathophysiology of Best disease (BD) and autosomal recessive bestrophinopathy (ARB) by establishing an in vitro model using human induced pluripotent stem cell (iPSC). @*Materials and Methods@#Human iPSC lines were generated from mononuclear cells in peripheral blood of one ARB patient, one autosomal dominant BD patient, and two normal controls. Immunocytochemistry and reverse transcriptase polymerase chain reactionin iPSC lines were conducted to demonstrate the pluripotent markers. After the differentiation of iPSC into functional retinal pigment epithelium (RPE), morphological characteristics of the RPE were evaluated using confocal microscopy and immunocytochemistry.The rates of fluid flow across iPSC-RPE monolayer were measured to compare apical to basal fluid transports by RPE. RNA sequencing was performed on iPSC-RPE to identify the differences in gene expression profiles, and specific gene sets were tested using Gene Set Enrichment Analysis. @*Results@#Morphological characteristics, gene expression, and epithelial integrity of ARB iPSC were comparable to those of BD patient or normal control. Fluid transport from apical to basal was significantly decreased in ARB iPSC-RPE compared with BD iPSCRPE or control iPSC-RPE. Gene Set Enrichment Analysis confirmed that ARB iPSC-RPE exhibited significant enrichments of epithelial-mesenchymal transition gene set and TNF-α signaling via NF-κB gene set compared to control iPSC-RPE or BD iPSC-RPE. @*Conclusion@#A human iPSC model of ARB showed a functional deficiency rather than anatomical defects. ARB may be caused by RPE dysfunction following BEST1 mutation.

Prognostic Factors and Long-term Surgical Outcomes for Exudative Age-related Macular Degeneration with Breakthrough Vitreous Hemorrhage

Purpose@#We sought to evaluate the long-term outcomes for patients with exudative age-related macular degeneration (AMD) undergoing vitrectomy for breakthrough vitreous hemorrhage and to investigate possible prognostic factors. @*Methods@#Consecutive patients treated at two high-volume referral-based tertiary hospitals between July 2006 and Decem-ber 2019 were retrospectively reviewed. Surgery was performed using the standard three-port vitrectomy. The primary out-come was the change in best-corrected visual acuity (BCVA) over long-term follow-up, while secondary outcomes included the assessment of possible prognostic factors. @*Results@#Among 50 eyes from 50 patients included in this study, 23 (46%) were diagnosed with polypoidal choroidal vascu-lopathy (PCV) and 27 (54%) were diagnosed with neovascular AMD. Preoperative vision at the time of vitreous hemorrhage onset was 20 / 3,027 (logarithm of the minimum angle of resolution [logMAR], 2.18 ± 0.34). At 12 months after surgery, the mean BCVA improved to 20 / 873 (logMAR, 1.64 ± 0.76; p < 0.001). At 24 months, the BCVA was 20 / 853 (logMAR, 1.63 ± 0.75; p < 0.001). Univariate analysis revealed that older age (odds ratio [OR], 0.879; p = 0.007] and the presence of submac-ular hemorrhage (OR, 0.081; p= 0.022) were factors associated with a poor 2-year visual outcome. Multivariable regression showed that older age (OR, 0.876; p= 0.026) and neovascular AMD (as compared with PCV) (OR, 0.137; p= 0.014) were significant negative factors influencing the 2-year visual outcome. The mean injection interval prior to vitrectomy was 4.53 months, which extended to 27.64 months after vitrectomy ( p = 0.028). @*Conclusions@#Younger age, the absence of submacular hemorrhage, and PCV type were associated with a favorable 2-year visual outcome after vitrectomy for vitreous hemorrhage in patients with exudative AMD. Overall, vitrectomy resulted in im-proved visual acuity and patients showed a decreased need for anti-vascular endothelial growth factor therapy thereafter.

The impact of emergency department expansion on crowding and patient flow

Objective@#Overcrowding in the emergency department (ED) has been a long-standing global problem, but has yet to be resolved. This study was undertaken to investigate whether expansion of the ED can affect overcrowding. @*Methods@#This was a retrospective study comparing two 10-month periods: before (September 2015 to June 2016) and after (September 2017 to June 2018) the ED expansion in an urban tertiary hospital. The ED expansion included expansion of the ambulatory area and establishment of a 25-bedded emergency ward dedicated to patients admitted through the ED. @*Results@#Comparing the two study periods, we noted an increase in the number of patients visiting the ED, from 77,078 to 87,027. Moreover, the proportion of patients who returned home untreated significantly decreased from 11.5% to 0.9% (P<0.001). The number of adult patients increased from 40,814 to 60,720; in particular, the number of ambulatory patients increased from 18,648 to 42,944. Conversely, waiting time for X-ray and computed tomography increased (10.0 to 17.0 minutes, and 35.0 to 48.0 minutes, respectively). Other areas with increased time duration include median ED length of stay of total patients (193.0 minutes to 205.8 minutes), and time from consultation to admission decision (122.3 to 161.4 minutes). However, the boarding time decreased from 239.2 to 190.9 minutes. @*Conclusion@#The ED expansion allowed more patients to be treated, and the boarding time of admitted patients was reduced through operation of the emergency ward. However, due to increase in the number of visiting patients, the time required for medical treatment increased concurrently.

Implementing Best Practice in Critically Ill Organophosphate Poisoned Patient Through Simulation-Based Learning Program

PURPOSE: Despite the clinical and socio-economic impact of acute poisoned patients, many of the treatments are not standardized in Korea. Moreover, no formal training that is specifically focused on clinical toxicology exists. Rather, training and education are conducted case by case in various institutions. This study was conducted to develop a standardized simulation-based clinical toxicology training curriculum for healthcare providers. This program will focus on specific assessment and treatment of critical toxicology patients, specifically those who have been poisoned with organophosphate. METHODS: The study was performed using a pre- and post-design to determine the effects of implementation of this program. The study was conducted at eight different urban teaching hospitals in a simulated room in the clinical area. The study was targeted to 19 groups composed of emergency residents and nurses. Simulation-based learning was conducted for each group. RESULTS: All 19 groups achieved the minimum passing score of 75%. Implementation of the program led to improved performance rates for overall management and cooperative moods competency (p<0.01). Inter-rater agreement between the two evaluators was excellent. In general, the participants thought the program was realistic and were able to recognize and improve the competencies needed to care for organophosphate poisoned patients. CONCLUSION: Simulation-based learning is an effective educational strategy that can be applied to improving and understanding proper care for rare but critical patients. This program was effective at improving team performance and cooperative moods when managing an organophosphate poisoned patient in the Emergency Department.

The efficacy of combination treatment of gabapentin and electro-acupuncture on paclitaxel-induced neuropathic pain

Paclitaxel, a chemotherapeutic drug, induces severe peripheral neuropathy. Gabapentin (GBT) is a first line agent used to treat neuropathic pain, and its effect is mediated by spinal noradrenergic and muscarinic cholinergic receptors. Electro-acupuncture (EA) is used for treating various types of pain via its action through spinal opioidergic and noradrenergic receptors. Here, we investigated whether combined treatment of these two agents could exert a synergistic effect on paclitaxel-induced cold and mechanical allodynia, which were assessed by the acetone drop test and von Frey filament assay, respectively. Significant signs of allodynia were observed after four paclitaxel injections (a cumulative dose of 8 mg/kg, i.p.). GBT (3, 30, and 100 mg/kg, i.p.) or EA (ST36, Zusanli) alone produced dose-dependent anti-allodynic effects. The medium and highest doses of GBT (30 and 100 mg/kg) provided a strong analgesic effect, but they induced motor dysfunction in Rota-rod tests. On the contrary, the lowest dose of GBT (3 mg/kg) did not induce motor weakness, but it provided a brief analgesic effect. The combination of the lowest dose of GBT and EA resulted in a greater and longer effect, without inducing motor dysfunction. This effect on mechanical allodynia was blocked by spinal opioidergic (naloxone, 20 μg), or noradrenergic (idazoxan, 10 μg) receptor antagonist, whereas on cold allodynia, only opioidergic receptor antagonist blocked the effect. In conclusion, the combination of the lowest dose of GBT and EA has a robust and enduring analgesic action against paclitaxel-induced neuropathic pain, and it should be considered as an alternative treatment method.

Characteristics of Young Korean Metabolically Healthy Obese Patient: Based on Retrospective Analysis of Republic of Korea Navy Soldiers' Medical Examination

OBJECTIVE: The aim of this study was to evaluate the characteristics of the young Korean obese but metabolically healthy subjects and to identify the factors associated with metabolic health status among them. METHODS: We reviewed the medical record of South-Korea Navy soldiers at 1st marine division with routine medical examination. Within this population, we selected obese subjects whose body mass index (BMI) were more than 25 kg/m². The clinical characteristics between obese subjects with metabolically healthy and unhealthy factors were retrospectively compared. RESULTS: Of the 1,522 subjects with medical record, 319 (20.9%) subjects were identified as obese. Among them, 60 subjects (18.8%) were classified as metabolically unhealthy, whereas 259 (81.2%) subjects were metabolically healthy. Multivariate analysis revealed that higher BMI (odds ratio, OR 1.26, 95% confidence interval, CI, 1.07-1.49), higher alanine transaminase (ALT) (OR 1.03, 95% CI 1.01-1.06), and drinking alcohol (OR 3.65, 95% CI 1.02-13.02) were associated with metabolically unhealthy status in obese subjects. Meanwhile, regular physical activity was associated with metabolically healthy status in obese subjects. (OR 0.33, 95% CI 0.17-0.62) CONCLUSION: This study found that higher BMI, higher ALT, and drinking alcohol were related to metabolically unhealthy status in young Korean obese subjects; meanwhile, regular physical activity was related to metabolically healthy status.

Involvement of spinal muscarinic and serotonergic receptors in the anti-allodynic effect of electroacupuncture in rats with oxaliplatin-induced neuropathic pain

This study was performed to investigate whether the spinal cholinergic and serotonergic analgesic systems mediate the relieving effect of electroacupuncture (EA) on oxaliplatin-induced neuropathic cold allodynia in rats. The cold allodynia induced by an oxaliplatin injection (6 mg/kg, i.p.) was evaluated by immersing the rat's tail into cold water (4℃) and measuring the withdrawal latency. EA stimulation (2 Hz, 0.3-ms pulse duration, 0.2~0.3 mA) at the acupoint ST36, GV3, or LI11 all showed a significant anti-allodynic effect, which was stronger at ST36. The analgesic effect of EA at ST36 was blocked by intraperitoneal injection of muscarinic acetylcholine receptor antagonist (atropine, 1 mg/kg), but not by nicotinic (mecamylamine, 2 mg/kg) receptor antagonist. Furthermore, intrathecal administration of M(2) (methoctramine, 10 µg) and M(3) (4-DAMP, 10 µg) receptor antagonist, but not M(1) (pirenzepine, 10 µg) receptor antagonist, blocked the effect. Also, spinal administration of 5-HT(3) (MDL-72222, 12 µg) receptor antagonist, but not 5-HT(1A) (NAN-190, 15 µg) or 5-HT(2A) (ketanserin, 30 µg) receptor antagonist, prevented the anti-allodynic effect of EA. These results suggest that EA may have a signifi cant analgesic action against oxaliplatin-induced neuropathic pain, which is mediated by spinal cholinergic (M(2), M(3)) and serotonergic (5-HT(3)) receptors.

The Effect of Clinical Pathway for Patient with Postpartum Hemorrhage in the Emergency Department

PURPOSE: Postpartum hemorrhage (PPH) is a major cause of maternal death. The aim of this study is to analyze the effect of clinical pathway (CP) and off-hours effects in PPH patients who visit the emergency department. METHODS: A retrospective study of PPH patients who visited the emergency department between December 1, 2005 and February 28, 2014 was conducted. A multidisciplinary team was designed for PPH in August 1, 2009. We compared time to intervention, volume of transfusion, length of stay (LOS), and uterus preservation rate between the before CP group and after CP group. RESULTS: A total of 143 post CP groups were compared with 101 before CP visits. Time to operation was less compared with the pre CP group (77 min (22-140) vs 47.5 min (13-114) p=0.011). Volume of transfusion and admission to intensive care units (ICU) were increased in the post CP group. (2 (0-16) vs 2 (0-25) p=0.045, 20 (19.8%) vs 54 (37.8%) p=0.003) LOS of ICU was lower than in the pre CP group and uterus preservation was higher than in the pre CP group. (0 day (0-43) vs 0 day (0-6) p=0.015, 82 (81.2%) vs 129 (90.2%) p=0.042) Time to angiographic embolization was less in the post-CP group with on-duty visits than in post-CP with off hours visits. (38.50 min (16-112) vs 71.0 min (28-633), p=0.025) CONCLUSION: A clinical pathway for PPH is associated with improvement of uterine preservation rate and reduced LOS of ICU. However this CP could not eliminate off-hour effects from time to intervention.

Inflammatory Cytokine and Osmolarity Changes in the Tears of Dry Eye Patients Treated with Topical 1% Methylprednisolone

PURPOSE: To evaluate changes in clinical outcomes, inflammatory cytokine levels, and tear osmolarity in the tears of patients with moderate to severe dry eye syndrome before and after the application of topical 1% methylprednisolone. MATERIALS AND METHODS: Thirty-two patients with moderate to severe dry eye unresponsive to previous aqueous enhancement therapy were enrolled. Five patients were lost to follow up, and twenty-seven patients were eligible for analysis. Patients were instructed to apply topical 1% methylprednisolone four times per day, as well as to continue applying their current therapy of preservative-free 0.1% sodium hyaluronate four times per day. Corneal and conjunctival staining scores, tear film breakup time (TFBUT), Schirmer test, and tear osmolarity were assessed at baseline, 4 weeks, and 8 weeks. Tear samples were collected at every visit for cytokine analysis. RESULTS: Corneal and conjunctival staining scores and TFBUT showed significant improvement at 4 (p<0.001, <0.001, <0.001 respectively) and 8 (p<0.001, <0.001, <0.001 respectively) weeks. Tear osmolarity decreased significantly at 8 weeks (p=0.008). Interleukin (IL)-1beta, IL-8, and monocyte chemoattractant protein-1 were significantly decreased at 8 weeks compared with those at baseline (p=0.041, 0.001, 0.008 respectively). CONCLUSION: Short-term treatment with topical 1% methylprednisolone not only improved clinical outcomes, but also decreased tear osmolarity and cytokine levels. By measuring the changes in cytokine levels and tear osmolarity, we could objectively evaluate the anti-inflammatory effects of topical methylprednisolone applied in the treatment of patients with moderate to severe dry eye syndrome.

Methylene Blue Dye-Induced Skin Necrosis in Immediate Breast Reconstruction: Evaluation and Management

BACKGROUND: For early breast cancer patients, skin-sparing mastectomy or nipple-sparing mastectomy with sentinel lymph node biopsy has become the mainstream treatment for immediate breast reconstruction in possible cases. However, a few cases of skin necrosis caused by methylene blue dye (MBD) used for sentinel lymph node localization have been reported. METHODS: Immediate breast reconstruction using a silicone implant was performed on 35 breasts of 34 patients after mastectomy. For sentinel lymph node localization, 1% MBD (3 mL) was injected into the subareolar area. The operation site was inspected in the postoperative evaluation. RESULTS: Six cases of immediate breast reconstruction using implants were complicated by methylene blue dye. One case of local infection was improved by conservative treatment. In two cases, partial necrosis and wound dehiscence of the incision areas were observed; thus, debridement and closure were performed. Of the three cases of wide skin necrosis, two cases underwent removal of the dead tissue and implants, followed by primary closure. In the other case, the breast implant was salvaged using latissimus dorsi musculocutaneous flap reconstruction. CONCLUSIONS: The complications were caused by MBD toxicity, which aggravated blood disturbance and skin tension after implant insertion. When planning immediate breast reconstruction using silicone implants, complications of MBD should be discussed in detail prior to surgery, and appropriate management in the event of complications is required.

Dermatofibroma of the Lower Lip: A Case Report

PURPOSE: Dermatofibroma is a common benign dermal tumor characterized by a proliferation of fibroblast-like spindle cells. It is commonly localized on the skin of extremities and presents as a slow growing solitary nodule. To our knowledge, the occurrence of dermatofibroma in the oral cavity is rare. Herein, we report a rare case of dermatofibroma on the lower lip. METHODS: A 60-year-old woman presented with a slow growing mass that measured 1 x 0.8 cm in diameter on the lower lip. The mass was surgically excised with clear margins. RESULTS: Histologically, the mass was characterized by a nodular tumor composed of collagen bundles, fibroblasts, and histiocytes, which were findings consistent with dermatofibroma. The postoperative course was uneventful without any complications. CONCLUSION: When evaluating nodular tumors of the oral area, dermatofibroma should be considered in the differential diagnosis.

Dermatofibroma of the Lower Lip: A Case Report

PURPOSE: Dermatofibroma is a common benign dermal tumor characterized by a proliferation of fibroblast-like spindle cells. It is commonly localized on the skin of extremities and presents as a slow growing solitary nodule. To our knowledge, the occurrence of dermatofibroma in the oral cavity is rare. Herein, we report a rare case of dermatofibroma on the lower lip. METHODS: A 60-year-old woman presented with a slow growing mass that measured 1 x 0.8 cm in diameter on the lower lip. The mass was surgically excised with clear margins. RESULTS: Histologically, the mass was characterized by a nodular tumor composed of collagen bundles, fibroblasts, and histiocytes, which were findings consistent with dermatofibroma. The postoperative course was uneventful without any complications. CONCLUSION: When evaluating nodular tumors of the oral area, dermatofibroma should be considered in the differential diagnosis.

The Effect of Symptom Recognition on Pre-hospital Delay in Patients with Acute Coronary Syndrome

PURPOSE: This study was performed to determine the association of symptom recognition with pre-hospital delay in patients with acute coronary syndrome (ACS), and to determine the factors influencing symptom recognition. METHODS: A prospective study from June 1, 2009 to July 31, 2009 was performed. The pre-hospital delay was calculated by subtraction of the hospital-arrival time from the symptom-onset time. The pre-hospital delay of the patients that recognized the symptoms as cardiovascular in origin was compared to the patients that did not recognize the symptoms as cardiac in origin. In addition, the socioeconomic indexes and risk factors were evaluated. RESULTS: Eighty three subjects were enrolled from a total of 205 patients suspected of having an ACS during the study period. No statistical differences were identified in the comparison of the pre-hospital delay by socioeconomic and risk factors of ischemic heart disease. The median pre-hospital delay of the patients that recognized the symptoms as cardiac was 2.9 hours compared to 11.9 hours among the patients that did not recognize the symptoms as cardiac; this difference was statistically significant (p=0.003). There were statistically significant differences in symptom recognition between the patients that had a history of cardiovascular disease and those that did not (p=0.037), and between the patients that took aspirin and those that did not (p=0.014). In addition, the severity of symptoms differed between the patients that recognized their symptoms and those that did not; this difference was statistically significant (p=0.019). Only the severity of symptoms was statistically significant by the logistic regression analysis (p=0.018). CONCLUSION: The pre-hospital delay was shorter, if patients that recognized the symptoms as cardiac in origin. A history of cardiovascular disease, taking aspirin and severity of symptoms were factors influencing the recognition of symptoms.

Risk Factors Associated with the Severity of Thyroid-Associated Orbitopathy in Korean Patients

PURPOSE: The purpose of this study is to identify risk factors for severe thyroid-associated orbitopathy (TAO) and compressive optic neuropathy in Korean patients. METHODS: This study was a retrospective comparative case series. All TAO patients who were first seen at our institution between 2005 and 2009 and who had follow-up periods of at least 6 months were included. Patients were divided into mild or moderate and severe TAO groups. Cases were also segregated based on the presence or absence of optic neuropathy. Demographics, smoking status, comorbidities, thyroid hormonal status, thyroid autoantibody levels, and clinical presentations were assessed. RESULTS: A total of 99 patients (83 with mild to moderate courses and 16 with severe courses; 90 without optic neuropathy and 9 with optic neuropathy) were included in this study. On multiple logistic regression analysis, smoking status was a predictive risk factor for a severe course of TAO and the development of optic neuropathy (odds ratios = 6.57 and 10.00, respectively). Other factors such as age, gender, free T4 level, thyroid binding-inhibiting immunoglobulin, and a history of diabetes were not predictive of severe TAO or optic neuropathy. CONCLUSIONS: Although various factors may influence the severity of TAO and the development of optic neuropathy, this study showed that smoking was a risk factor for severe TAO and the development of optic neuropathy. Therefore, it is important for patients with Graves' disease to refrain from smoking. Frequent and careful observation should also be performed in current smokers, as TAO patients who smoke are susceptible to a severe course and/or optic neuropathy.