Usefulness of Delta Neutrophil Index in Prediction of Septic Shock in Patients with Community-acquired Pneumonia

PURPOSE: The delta neutrophil index (DNI) corresponds to the calculated immature granulocyte counts and the severity of sepsis. The aim of this study was to investigate the diagnostic value of DNI as a predictable laboratory marker for septic shock in patients with severe community-acquired pneumonia in emergency department. METHODS: The present study was a retrospective analysis of patients with pathologically confirmed community-acquired pneumonia from December 2011 to February 2012 at a hospital. The DNI was automatically calculated as a subset of routine complete blood count test. The diagnostic performance of DNI for septic shock in patients with community-acquired pneumonia was evaluated. RESULTS: During the study period, 105 patients were enrolled. Among them, 27 patients (25.7%) were confirmed as having septic shock according to predetermined criteria. The initial value of DNI was significantly higher in septic shock group than in non-shock group (8.7% vs 2.3%, p=0.008). The peak value of DNI was also significantly higher in septic shock group (18.6% vs 4%, p<0.001). The sensitivity and specificity of the initial and peak DNI values for predicting septic shock in patients with community-acquired pneumonia were 48.2%, 96.2%, 74.1%, and 87.2%, respectively, at initial and peak cutoff levels of 11.2% and 8.7% with an area under the curve (AUC) of 0.72 and 0.81 on the Receiver Operating Characteristic (ROC) curve. The AUC to predict septic shock was 0.74 for the CURB-65 scale. The AUC was significantly increased when peak DNI was added to CURB-65 scale (p=0.007). CONCLUSION: This study suggested that the DNI is associated with septic shock in patients with community-acquired pneumonia. Clinically, the peak value of DNI added to CURB-65 scale could improve predictable performance of septic shock in patients with community-acquired pneumonia.

Oral vs. Intravenous Administration of N-acetylcysteine in the Acetaminophen Poisoning

PURPOSE: Serious acetaminophen (AAP) poisoning causes hepatotoxicity. N-acetylcysteine (NAC) is the most effective therapy for AAP poisoning and can be administered orally and intravenously (IV). Several studies have compared the efficacy of these two routes of administration and the results have been controversial. The purpose of this study was to compare the efficacy of oral and IV NAC for the prevention of hepatic toxicity in Korean patients whose serum AAP levels were higher than normal. METHODS: A retrospective before/after study was performed, in which the patients presented to the emergency department with an AAP overdose from February 1995 to March 2012. A 3-day oral NAC regimen was used in the beginning, and a 20-hr intravenous regimen was then used from 2007. This study assessed the complications of an AAP overdose, such as hepatotoxicity, hepatic failure and renal failure as well as the side effects of the treatment regimen. RESULTS: A total of 41patients was enrolled in this study. The median ALT and AST were 63 (IU/L) and 57 (IU/L) for the oral NAC treated patients, and 14 (IU/L) and 20 (IU/L) for the IV NAC treated patients (p=0.004 and p=0.001, respectively). The incidence of complications was similar in the treatment groups (p=0.399). Among the patients, 7 patients developed hepatotoxicity and were treated successfully with oral or IV NAC. CONCLUSION: This study suggests that IV NAC and oral NAC can prevent and successfully treat hepatic toxicity in patients whose serum AAP levels are higher than normal.

Management of Split Thickness Skin Graft Donor Sites: Comparison of Four Different Dressing Materials

PURPOSE: Split thickness skin graft is a frequently used reconstructive technique in burn wound, but the ideal dressing material of the donor site is yet to be developed. The donor sites have been managed with various dressing materials. The aim of this study is to compare four different dressing materials for management of the donor site in a prospective trial. METHODS: This study is based on 85 patients who had undergone split thickness skin graft from September 2011 to February 2012. The grafts harvested with a same manner and the donor sites were managed with one of the four dressing materials: Aquacel Ag(R), Mepitel(R), Bactigra(R), Op-Site(R). We compared post-operative pain scale, the time required epithelialization, ease of application, post-operative infection and number of dressings. RESULTS: Aquacel Ag(R) was the more painless dressing materials in post-operative day 1, 4, 7, 10 than Mepitel(R), Bactigra(R), Op-Site(R). Number of dressings was more lower for Aquacel Ag(R) with Mepitel(R). Ease of application was more higher for Aquacel Ag(R) with Mepitel(R). But Aquacel Ag(R) was not earliest epithelialization. The incidence of infection was not low in Aquacel Ag(R). CONCLUSION: Aquacel Ag(R) dressing is better than other dressing materials for split thickness skin graft donor site in the number of dressings, ease of application, post-operative pain.

Assessment of Perforation of Acute Appendicitis using the Delta Neutrophil Index Reflecting Peripheral Immature Granulocyte Count

PURPOSE: The delta neutrophil index corresponds to calculated immature granulocyte counts and severity of sepsis. This study was conducted in order to investigate the diagnostic value of the delta neutrophil index as a preoperative laboratory marker for appendiceal perforation in patients with acute appendicitis. METHODS: This study was conducted as a retrospective analysis of patients confirmed pathologically as appendicitis at two hospitals from November 2009 to September 2010. Delta neutrophil index was automatically calculated as a subset of routine complete blood count testing. The diagnostic performance of the delta neutrophil index for perforated appendicitis was evaluated. RESULTS: During the study period, 308 patients were enrolled. Among them, 32 patients (10.4%) were confirmed as perforated appendicitis. The delta neutrophil index was significantly higher in the perforated group, compared with the non-perforated group (4.8+/-7.1% vs 2.0+/-2.0%, p<0.05). Sensitivity and specificity of the delta neutrophil index for prediction of perforated appendicitis was 25.0% and 96.7%, respectively, at a cutoff level of 5% with an area under the curve of 0.78 on the ROC (receiver operating characteristics) curve. CONCLUSION: Results of this study suggested an association of the delta neutrophil index with perforated appendicitis. However, the sensitivity was not high enough for use as clinical guidance.

Comparative Evaluation of the Harmless Acute Pancreatitis Score and CT Severity Index to Predict Mild Clinical Course of Acute Pancreatitis in the Emergency Department

PURPOSE: Several scoring systems and biochemical markers have been proposed for the early prediction of acute pancreatitis. The Harmless Acute Pancreatitis Score (HAPS) is a novel scoring system to recognize acute pancreatitis patients with a non-severe clinical course. This study was conducted to evaluate the usefulness of HAPS to predict good prognosis of acute pancreatitis in the emergency department (ED). METHODS: We retrospectively reviewed the electronic medical records of patients who presented to the ED with acute pancreatitis from January 2010 to December 2011. The parameters constituting HAPS, including physical signs of peritonitis (rebound abdominal tenderness), hematocrit and serum creatinine levels were abstracted. Severe clinical course was defined as having one of the following: mortality while in hospital, necrosis as assessed by contrast CT, need for artificial ventilation or dialysis. The diagnostic performance of HAPS for predicting harmless course was evaluated by sensitivity, specificity, and predictive values. RESULTS: During the study period, 144 patients with a final diagnosis of acute pancreatitis were included. Among these 144 patients, 79 were predicted to have a non-severe course by HAPS, of whom 4 patients progressed to severe pancreatitis. The sensitivity, specificity, positive and negative predictive values were 61.5%, 81.8%, 94.9% and 27.7%, respectively. CONCLUSION: This study suggests that HAPS is simple and can be assessed within a few hours in the ED. HAPS also showed a high positive predictive value that predicts a non-severe course of acute pancreatitis. Therefore, HAPS may be used as a scoring system to identify non-severe acute pancreatitis in the ED.

Clinical Review of Toxic Alcohol Poisoning Cases in Korea

PURPOSE: Toxic alcohols are responsible for accidental and suicide motivated poisonings, resulting in death or permanent sequelae for the afflicted patients. Major therapeutic modalities in these cases include treatment with alcohol dehydrogenase inhibitors and extracorporeal elimination. There have been a number of case reports of toxic alcohol intoxication in Korea. The purpose of this study was to review the clinical characteristics of patients suffering toxic alcohol intoxication. METHODS: We retrospectively reviewed the medical records of patients who presented with toxic alcohol intoxication at 8 emergency departments (ED) from Jun 2005 to Nov 2011. Patients who ingested methanol, isopropyl alcohol, ethylene glycol, and other alcohols except ethanol, were included in this study. The clinical characteristics of these patients were analyzed to include anion and osmolar gap, and estimated concentration of alcohol in the body. RESULTS: During the study period, 21 patients were identified who had ingested toxic alcohol (methanol; 12 patients, ethylene glycol; 9 patients). At ED arrival, the mean anion gap was 18.7+/-6.9 and the osmolar gap was elevated in 13 patients. Oral and IV ethanol were administrated to 11 patients in order to inhibit alcohol dehydrogenase. Extracorporeal elimination procedures such as hemodialysis were performed in 9 patients. There were no fatalities, but the one patient suffered permanent blindness. CONCLUSION: This study found that ethylene glycol and methanol were the substances ingested which produced toxic alcohol intoxication. The patients presented with high anion gap metabolic acidosis and were typically treated with oral ethanol and hemodialysis.

Comparison of Anatomical and Clinical Characteristics in Emergency Endotracheal Intubation Between Non-Elderly and Elderly Adults

PURPOSE: The aim of the study was to compare the clinical characteristics in emergency endotracheal intubation procedures between non-elderly and elderly patients. METHODS: Data for airway registry, which were collected in two emergency departments (ED) between April 2006 and March 2010, were retrospectively reviewed. The airway registry data included patient's demographic information and variables such as Cormack-Lehane grade, 3-3-2 finger analysis, success rate, the number of attempts at intubation, complications of intubation, and clinical outcomes after intubation. RESULTS: A total of 1,457 patients were enrolled. The mean age of the patients was 62.2+/-15.7 and 62.1%(n=905) were male. A total of 726(49.8%) patients were classified as being in the elderly intubation group(> or =65 years). Cormack-Lehane grade, 3-3-2 finger analysis, the relationship between the number of attempts and success rate, the relationship between Cormack-Lehane classification and success rate, complications, and clinical outcomes after intubation showed no significant difference between elderly and non-elderly groups. CONCLUSION: Anatomical structures related to endotracheal intubation, the process and clinical outcomes of elderly patients are not different than for non-elderly adult patients. However, considering the lower physiologic reservoir and higher comorbidities of elderly patients, a more vigorous approach to emergency airway management in the elderly is needed.