The Correlation between Stool Exams and Abdominal Computed Tomography (CT) Findings in the Patients with Acute Diarrhea Visiting Emergency Department (ED)

PURPOSE: Stool exams are a useful tool for the early presumptive diagnosis of infectious bacterial diarrhea in the Emergency Department (ED). CT scans are often used to increase the physician's level of certainty and to facilitate patient triage by identifying the source of pain in most patients with an acute abdomen in the ED. This study was designed to investigate the correlation between stool exams and abdominal CT in patients with acute diarrhea visiting the ED. METHODS: We conducted a retrospective study in the emergency department of a national university hospital from January 1, 2012 to June 30, 2013. The subjects consisted of 156 patients with acute diarrhea and abdominal pain who had stool exam results and abdominal CT findings. We divided the patients into three groups according to the stool exam results. Simultaneously, we evaluated their CT findings of the bowel and adjacent structures. RESULTS: A total of 156 patients were enrolled. Frequency of abnormal CT findings showed statistically significant correlation with stool exams (p-value <0.001). Abnormal CT findings increased as WBCs and RBCs in stool increased (p-value <0.001). CONCLUSION: The stool exam was a statistically significant predictive variable in indirectly determining the severity of acute diarrhea and it showed correlation with the frequency of abnormal CT findings. It is suggested that stool exams can be used as a susceptible marker for predicting the probability of severe infectious colitis, and for making an early decision regarding close medical attention.

A Comparative Study of Tissue Injury Grades, with Clinical Factors, in Patients with Hydrofluoric Acid Burns who Received Intra-arterial Infusion of Calcium Gluconate

PURPOSE: Hydrofluoric acid (HFA) causes injury via tissue penetration by the free fluoride ion. Methods for treatment of HFA burns include continuous intra-arterial infusion of calcium gluconate, which is especially useful for patients with dermal burns of the digits caused by HFA. However, no comparative study of tissue injury grade with clinical factors among patients with HFA burns treated with continuous intra-arterial infusion of calcium gluconate has been conducted in Korea. METHODS: We conducted a prospective study at the emergency department of a university teaching hospital between January 2011 and June 2013. The subjects enrolled in this study consisted of 33 patients with HFA burns. After completion of treatment, we divided the patients into three groups according to the type of skin lesions. Patients requiring a skin graft or surgical flap were included in the poor outcome group, those who had to undergo incision and drainage in the moderate outcome group, and those who did not require further treatment in the good outcome group. RESULTS: After completion of all treatments, 22 of the 33 patients were included in the good outcome group and seven in the moderate outcome group; the remaining four patients were included in the poor outcome group, as they met the above-mentioned criteria, experienced longer-lasting pain, and were more frequently treated with injection in comparison with the other patients. CONCLUSION: Patients with HFA burns with long-term pain who need frequent arterial injections despite undergoing intra-arterial calcium gluconate treatment are likely to have poor outcome; therefore, they require more proactive interventions.

A Case of Chemical Pneumonitis with Gastrointestinal Disturbance Caused by Nitric Acid Inhalation

Nitric acid is a typical strong acid that is colorless, corrosive, and flammable. It is often used for industrial purposes, such as refining, metal cleaning, and electroplating. In Korea, some cases of chemical pneumonitis from nitric acid poisoning have been reported, but to our knowledge, there have been no reports of diarrhea caused by nitric acid poisoning. A 42-year-old man visited a nearby hospital because of continuous diarrhea, coughing, and dyspnea after inhaling nitric acid fumes at his workplace the previous day. He was transferred to our hospital and admitted to the intensive care unit. He showed tachypnea and hypoxemia in our emergency department. Initial chest radiographs showed diffuse interstitial infiltrates and ground glass opacity in both lungs. The patient showed improvements in clinical symptoms and on chest radiographs after receiving oxygen and mechanical ventilation, antibiotics, and systemic glucocorticoid therapy. After 20 days he was discharged and showed no symptoms and sequelae on his 1-year follow-up.

A Case of Methanol Intoxication from Windshield Washer Fluid Ingestion Misidentified as an Alcoholic Beverage

Almost all cases of acute methanol intoxication result from ingestion. Absorption of methanol following oral administration is rapid and peak concentration occurs within 30-60 min. Foromic acid converted metabolites of methanol are responsible for its toxic effect. Methanol poisoning typically induces nausea, vomiting, abdominal pain, and mild central nervous system depression. Then there is a latent period lasting, followed by an uncompensated metabolic acidosis and visual dysfunction, depending on the dose of methanol ingested. Here we report on three patients who were victims of methanol intoxication due to ingestion of windshield washer fluid, which was misidentified as an alcoholic beverage. One patient had a mild form, which included abdominal discomfort, another patient had a moderate case, which included nausea, vomiting, and acidosis, and the other patient had severe acidosis and altered mentality and visual dysfunction. Except one case of visual dysfunction, all three patients recovered successfully following medical treatment and hemodialysis.

Spinal Schwannoma in a Patient with Chronic Right Flank Pain Presenting at an Emergency Department

Many patients with flank pain present to an emergency department (ED). The differential diagnosis of flank pain is difficult, especially in the case of women. Spinal schwannoma (SS) is one of the most common intraduralextramedullary spinal tumors. SS can present as symmetrical pain in the back or pain that radiates to both the lower extremities, which is commonly observed in clinical practice. We report the case of a 47-year-old woman with pain in her right flank area that began 2 months before she presented to our ED. Abdominal contrast computed tomography was performed to identify an intra-abdominal cause for the pain. Incidentally, we found a schwannoma, a spinal cord tumor, at the 10th thoracic vertebrae level. The pain disappeared after the tumor was surgically resected. On the basis of our findings, we conclude that the pain in her right flank pain area was caused by the SS.

Availability of the Peripheral Perfusion Index for Monitoring of Hemodynamic Stability in the Emergency Department

PURPOSE: In hemodynamically unstable patients, tissue perfusion is decreased and various means of continuous observation are required. However, prior methods for observing hemodynamic instability are invasive and/or difficult for continual observation. The present study evaluated the usefulness of the perfusion index (PI) in monitoring hemodynamically unstable patients in the emergency department. METHODS: From December, 2009 to April, 2010, patients admitted to our hospital emergency department with signs of hemodynamic instability were studied. Vital signs and stroke volume index (SVI) and cardiac index (CI) were measured, and PI was continuously monitored by a Radical-7 pulse oximeter (Masimo, USA). Each variable was measured 1 hour before and after treatment, and treatment methods included fluid therapy and vasoconstrictors, according to the patient condition. Status on changes and correlation between variables following treatment were confirmed through the Wilcoxon rank test and Spearman correlation test, respectively. The standard level of significance was p<0.05. RESULTS: Of the 26 patients, 19 were male (73.1%), with an average age of 68.54+/-14.32 years. Significant changes in each variable 1 hour before and after treatment were mean arterial pressure 53.51+/-8.29mmHg / 74.68+/-12.95 mmHg (p<0.001), SVI 26.70+/-14.04/34.27+/-13.56(p<0.001), CI 2.12+/-1.02/3.12+/-1.53(p<0.001), and PI 1.23+/-1.00/1.77+/-1.32(p<0.001). Variations of heart rate (R=-0.430, p=0.032) and SVI (R=0.432, p=0.031) were correlated to the variation of PI (dPI). CONCLUSION: PI may be useful in monitoring hemodynamically unstable patients in the ER.

Availability of the Peripheral Perfusion Index for Monitoring of Hemodynamic Stability in the Emergency Department

PURPOSE: In hemodynamically unstable patients, tissue perfusion is decreased and various means of continuous observation are required. However, prior methods for observing hemodynamic instability are invasive and/or difficult for continual observation. The present study evaluated the usefulness of the perfusion index (PI) in monitoring hemodynamically unstable patients in the emergency department. METHODS: From December, 2009 to April, 2010, patients admitted to our hospital emergency department with signs of hemodynamic instability were studied. Vital signs and stroke volume index (SVI) and cardiac index (CI) were measured, and PI was continuously monitored by a Radical-7 pulse oximeter (Masimo, USA). Each variable was measured 1 hour before and after treatment, and treatment methods included fluid therapy and vasoconstrictors, according to the patient condition. Status on changes and correlation between variables following treatment were confirmed through the Wilcoxon rank test and Spearman correlation test, respectively. The standard level of significance was p<0.05. RESULTS: Of the 26 patients, 19 were male (73.1%), with an average age of 68.54+/-14.32 years. Significant changes in each variable 1 hour before and after treatment were mean arterial pressure 53.51+/-8.29mmHg / 74.68+/-12.95 mmHg (p<0.001), SVI 26.70+/-14.04/34.27+/-13.56(p<0.001), CI 2.12+/-1.02/3.12+/-1.53(p<0.001), and PI 1.23+/-1.00/1.77+/-1.32(p<0.001). Variations of heart rate (R=-0.430, p=0.032) and SVI (R=0.432, p=0.031) were correlated to the variation of PI (dPI). CONCLUSION: PI may be useful in monitoring hemodynamically unstable patients in the ER.

Socioeconomic Costs of Food-Borne Disease Using the Cost-of-Illness Model: Applying the QALY Method / 예방의학회지

OBJECTIVES: This study estimated the annual socioeconomic costs of food-borne disease in 2008 from a societal perspective and using a cost-of-illness method. METHODS: Our model employed a comprehensive set of diagnostic disease codes to define food-borne diseases with using the Korea National Health Insurance (KNHI) reimbursement data. This study classified the food borne illness as three types of symptoms according to the severity of the illness: mild, moderate, severe. In addition to the traditional method of assessing the cost-of-illness, the study included measures to account for the lost quality of life. We estimated the cost of the lost quality of life using quality-adjusted life years and a visual analog scale. The direct cost included medical and medication costs, and the non-medical costs included transportation costs, caregiver's cost and administration costs. The lost productivity costs included lost workdays due to illness and lost earnings due to premature death. RESULTS: The study found the estimated annual socioeconomic costs of food-borne disease in 2008 were 954.9 billion won (735.3 billion won-996.9 billion won). The medical cost was 73.4 - 76.8% of the cost, the lost productivity cost was 22.6% and the cost of the lost quality of life was 26.0%. CONCLUSIONS: Most of the cost-of-illness studies are known to have underestimated the actual socioeconomic costs of the subjects, and these studies excluded many important social costs, such as the value of pain, suffering and functional disability. The study addressed the uncertainty related to estimating the socioeconomic costs of food-borne disease as well as the updated cost estimates. Our estimates could contribute to develop and evaluate policies for food-borne disease.

Correlation Between Sonographic Inferior Vena Cava/Aorta Diameter Index and Central Venous Pressure

PURPOSE: Body fluid status of patients in an emergency room environment is a very important parameter during clinical evaluation. In this study, we wanted to know the relationship between the diameter of the inferior vena cava and the diameter of the (IVC/Ao index) and central venous pressure (CVP) in hemodynamically unstable patients. METHODS: This study was done prospectively in an emergency medical center of a hospital from January to August, 2009. We compared the diameter of the IVC, the diameter of inferior vena cava/the body surface area index (IVC/BSA index), the IVC/Ao index, and other variables. Before and after hydration of patients with a systolic blood pressure less than 90 mmHg and who had a central venous catheter in place. Then, we calculated the correlation coefficient for DeltaCVP, DeltaIVC/Ao index, and other indexes. RESULTS: Fifty-nine patients were enrolled in the study. The mean IVC diameter before hydration was 14.3+/-2.7 mm; it was 15.6+/-2.7 mm after hydration (p<0.01). The IVC/BSA index before hydration was 8.75+/-1.72 and 9.55+/-1.79 after hydration (p<0.01). The IVC/Ao index before hydration was 1.08+/-0.23; it was 1.16+/-0.25 after hydration (p<0.01). The correlation coefficient for DeltaCVP and DeltaIVC was 0.37 (p<0.01); for DeltaCVP vs. the DeltaIVC/BSA index it was 0.37 (p<0.01); for the DeltaIVC/Ao index it was 0.27 (p=0.04). CONCLUSION: CVP has a higher correlation to IVC diameter and to IVC/BSA index than to the IVC/Ao index. Hence, we should estimate the IVC/Ao index and use that estimate along with other indexes to evaluate body fluid status when dealing with hemodynamically unstable patients.

The Obturator Hernia: A Challenge for Early Diagnosis with Computed Tomography in Emergency Situations

Obturator hernias usually occur in elderly persons. We sometimes miss the correct diagnosis because of vague symptoms and signs in older patients at initial presentation. For good clinical outcomes, we should make the correct diagnosis earlier, especially in aged patients. Here we report cases of obturator hernia in two aged patients without specific medical or surgical histories. Two older women suffered obturator hernias, which were characterized by clinical and radiographic features. They did not have any specific surgical and medical histories. For further evaluation of abdominal symptoms and signs, we did an abdominopelvic computed tomography (CT) scan in the emergency department. The CT scan revealed findings compatible with an obturator hernia in the area of the obturator foramen. They were treated and discharged without complications. When obturator hernia is suspected in a patient with related symptoms and signs, early CT scans should be considered to detect obturator hernia.

A Clinical Study of Acute Appendicitis in Schizophrenia Patients Presenting at an Emergency Center

PURPOSE: To investigate the clinical characteristics and Alvarado scores of schizophrenia with patients acute appendicitis presenting at the emergency department. METHODS: We retrospectively reviewed medical records and identified schizophrenia patients who were diagnosed with acute appendicitis between January 2000 to December 2009 and who presented at the emergency department in 6 University hospitals. Comparisons were made with non-schizophrenic patients with acute appendicitis. Data collected included the patient's age, sex, clinical features, time interval between onset of symptoms and visiting the hospital, Alvarado score, disease complications, and diagnostic imaging modality. RESULTS: We identified 27 schizophrenia patients with acute appendicitis. Mean age was 34.5+/-8.3; 51.9% were women. The median time from onset of symptoms to visiting the emergency department was 3.8+/-1.4 days in the schizophrenic group and 2.3+/-2.1 in the normal control group. The mean Alvarado scores were 5.4+/-1.5 for the schizophrenic group and 6.5+/-2.1 for controls. Perforation of the appendix and formation of abscesses was higher in schizophrenic patients with appendicitis. CONCLUSION: These findings suggest that acute appendicitis is diagnosed late and with difficulty in schizophrenic patients and these patients may be the most vulnerable to failure to obtain timely surgical care. Early and careful access is recommended in suspected cases of appendicitis in schizophrenia patients.

The Accuracy of a Simple Radiologic Study for Diagnosing Intra-articular Fractures of the Distal Radius

PURPOSE: To determine the accuracy of a simple radiologic images as a diagnostic tool for intra-articular fractures of the distal radius (IAF). METHODS: This study proceeded prospectively from April 2008 to December 2009. We let 25 ERs (emergency residents) interpret the radiologic images of 45 patients who had injuries of their wrists and presented to a hospital. We used surgical findings or multidetector computed tomography (MDCT) to confirm the final diagnosis of enrolled patients. Finally, we evaluated the sensitivity, specificity, and accuracy of simple radiologic images of IAF. We also compared test performance characteristics between the four grades of the ERs (1st, 2nd, 3rd, and 4th years) via Mann-Whitney and Kruskal-Wallis tests. We considered differences to be significant, if p<0.05 RESULTS: Of 45 patients, 40 (88.9%) had fractures of the distal radius; of the 40, 25 (62.5%) had IAF. There were no differences in sensitivity, specificity, or accuracy between the four grades of the ERs (p=0.86, 0.76, 0.49). The sensitivity of simple radiologic images for diagnosing IAF was 0.69; specificity was 0.77; accuracy was 0.72. CONCLUSION: In this study, we found that simple radiologic images as the primary diagnostic tool for intra-articular fractures of the distal radius were not completely adequate. Therefore, ERs should carefully consider using MDCT imaging to diagnose patients who suffer from wrist pain.

Acute Hydrofluoric Acid Exposure: Our Clinical Experience at Emergency Centers in Two University Teaching Hospitals

PURPOSE: We investigated the clinical characteristics and demographics of patients who suffered from hydrofluoric acid chemical injury and the mechanism of damage. METHODS: We retrospectively reviewed the medical records of patients who were exposed to hydrofluoric acid from March 2004 to March 2009 and who were seen at the emergency centers in two university teaching hospitals. RESULTS: Forty four patients out of 47 patients suffered from chemical burn, while the injuries of the remaining 3 could not be identified by the medical records. A total of 17 hydrofluoric acid chemical injury patients were enrolled during the study period, and their mean age was 29.6+/-7.0. All the patients were accidentally injured by contact with the material and none of them inhaled or ingested the material. Only 6 patients wore appropriate protective equipments and 5 underwent the water irrigation for more than 10 minutes. The most common exposure area was the hand and forearm (70.5%). Less than 1% of all of the patients had their total body surface (TBS) exposed to hydrofluoric acid (mean=0.35%). The mean time interval from calcium gluconate administration to pain relief was 33.6+/-8.8 hours. CONCLUSION: When exposed to hydrofluoric acid, it is important to wear protective equipment and undergo water irrigation for more than 10 minutes. Pain and skin damage were observed in all the patients. After treatment, we concluded that administration of calcium gluconate and pain killers was successful in relieving pain, and the prognosis was also positive for the admitted and followed up patients when less than 1% of the TBS was exposed.