The predictive value of procalcitonin for septic shock in sepsis patients

Objective@#This study examined the difference in procalcitonin between sepsis and septic shock. @*Methods@#The single-center retrospective cohort study was conducted from July 2017 to June 2018 at an emergency department (ED) of a university hospital. The inclusion criteria were patients over 18 years old who visited the ED with an infection. The exclusion criteria were the patients without organ failure by sepsis-3 definition, those with missing serum lactate data, and those discharged without workup. The sepsis patients were divided into those with and without septic shock, and the two groups were compared with biomarkers, including procalcitonin. @*Results@#Of the 406 patients who visited the ED with an infection, 36 were excluded because they did not have sepsis or an unknown infection. Finally, 369 patients were enrolled, and 61.5% fitted the septic shock definition. A comparison of the septic shock and non-shock sepsis groups showed that a history of chronic liver disease, malignancy, pulse rate, prothrombin time, blood urea nitrogen, aspartate and alanine transaminase, troponin-I, Sequential Organ Failure Assessment score and procalcitonin levels were significantly higher in the septic shock group. In multivariate analysis, however, procalcitonin was an independent predictor for septic shock (adjusted odd ratio, 1.05; 95% confidential interval, 1.01-1.09). The area under the receiver operating characteristic curve was 0.729, and the cutoff value was 4.0 ng/mL. @*Conclusion@#The procalcitonin levels were higher in the septic shock group than in the non-shock sepsis group. This could help predict septic shock independently. Further prospective multicenter research is needed to determine if procalcitonin can predict the severity of sepsis.

The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016–2018

Background@#Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. @*Methods@#This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016–2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. @*Results@#We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). @*Conclusion@#The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the firsttransfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.

The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016–2018

Background@#Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. @*Methods@#This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016–2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. @*Results@#We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). @*Conclusion@#The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the firsttransfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.

A Case of Ischemic Duodenal and Jejunal Enteritis in a Patient with Chronic Splanchnic Disease / 대한내과학회지

Gastrointestinal ischemia happens by splanchnic artery stenosis, thrombus, or physiological vasoconstriction during a low-blood-stream state. However, even if arterial stenosis exists in the upper gastrointestinal tract, ischemic injury is very rare due to rich collateral circulation. The authors experienced 92-year-old female patient with vomiting, epigastric pain, and hematemesis. An electrocardiogram showed paroxysmal atrial fibrillation. The patient had diffuse and segmental mucosal edema, erythema, and hemorrhage in the second part of the duodenum on esophagogastroduodenoscopy (EGD). On abdomen computed-tomography angiography, stenosis of the celiac and superior mesenteric arteries was observed, and segmental concentric wall thickness was seen from the proximal second portion of the duodenum to the proximal jejunum. The patient was treated with PPI and fluid therapy for one week. At follow-up EGD, the mucosa had improved compared with the previous EGD examination. In conclusion, ischemic injury rarely affects the duodenum and jejunum; however, it can develop in the presence of inducing factors.

Nasopharyngeal Metastasis from Colon Cancer / 대한내과학회지

Metastatic adenocarcinoma from the gastrointestinal tract to the nasopharynx is rare. The histological morphology of this lesion is indistinguishable from the colonic variant of primary head and neck adenocarcinoma or intestinal-type adenocarcinoma (ITAC) of the nasal cavity. This is a report of metastatic adenocarcinoma of colorectal origin to the nasopharynx in a 58-year-old man who was previously treated for adenocarcinoma of the sigmoid colon. A histopathological study of the specimen from the nasopharynx demonstrated a tumor that was identical to the patient's previous primary tumor from the colon. There was no tumor mass in the nasal cavity or paranasal sinuses. The nasopharyngeal tissue expressed cytokeratin 20 and CDX-2, but not cytokeratin 7. The patient received palliative radiation after the diagnosis. Distinguishing metastatic adenocarcinoma from the gastrointestinal tract from ITAC can be difficult. The clinical manifestation is important in differentiating these conditions. It is important to recognize these as metastatic lesions because treatment is primarily palliative.

Melanosis ilei induced by prolonged charcoal ingestion / 대한외과학회지

Gastrointestinal melanosis is observed most frequently in the colon it also can develop in the ileum, duodenum and esophagus very rarely. Melanosis ilei was thought that causative materials such as aluminum, magnesium, silicate, titanium and other compounds entered the body through the ingestion of agents. We experienced a case of melanosis in the terminal ileum that a 65-year-old female patient ingested 10 g edible charcoal everyday for 3 years to address symptoms of chronic abdominal pain. In Korea, edible charcoal has been considered to be an effective folk remedy for patients with diarrhea or chronic abdominal pain. In our case, a follow up colonoscopy was performed 3.5 years after the termination of the ingestion of edible charcoal, at which point pigmentation was faded color intensity. In conclusion, it is thought that melanosis ilei is a rare disease by ingestion of causative materials and is discontinuous, local and reversible disease.

A Case of Hemophagocytic Syndrome in an Ulcerative Colitis Patient / 대한소화기학회지

A case of hemophagocytic syndrome associated with ulcerative colitis is very rare. A 32-year-old man visited the hospital complaining of fever and severe abdominal pain for 7 days. He was diagnosed to have ulcerative colitis 2 years ago and had been treated with sulfasalazine. Three months ago, he had abdominal pain, weight loss, and hematochezia, so prednisolone and mercaptopurine were added to the treatment. On admission, the physical examination showed splenomegaly. Peripheral blood counts revealed pancytopenia, and bone marrow aspirate smears showed many histiocytes with active hemophagocytosis. There was no evidence of viral and bacterial infections and other neoplasms, which were commonly associated with hemophagocytic syndrome. He was successfully treated with high dose steroid. We report this case along with a review of the related literatures.

Inflammatory Cloacogenic Polyp Mimicking Anorectal Malignancy / 대한소화기내시경학회지

Inflammatory cloacogenic polyp is a polypoid protruding lesion arising from the transitional zone of the anorectal junction. It has a distinctive endoscopic, histological appearance, but it may macroscopically resemble anorectal malignancy. It is important to beware of the possibility of adenoma and malignancy when finding lesions at the anorectal junction. The management of inflammatory cloacogenic polyp is endoscopic or surgical excision. We report here on a 62 year old man who had an anorectal polyp. The initial impression was hemorrhoid or anorectal malignancy. He underwent surgical intervention, and the histology showed inflammatory cloacogenic polyp.

A Case of Cystic Brunner's Gland Hyperplasia with Intracystic Inverted Growth / 대한소화기내시경학회지

Cystic Brunner's gland hyperplasia is a benign lesion of the duodenum that may not be familiar to gastroenterologists because of its rarity. Moreover, cystic Brunner's gland hyperplasia with intacystic inverted growth is more uncommon lesion. Here, we report a case of cystic Brunner's gland hyperplasia in a 34-year-old man. An endoscopy of the upper digestive tract revealed the presence of a 1.2 cm sized polypoid mass of the duodenal second portion. Endoscopic submucosal dissection was performed to remove the mass. Microscopically, a cystic lesion was seen in the submucosa underneath the normal surface duodenal mucosa. Hyperplastic Brunner's glands were seen close by the cyst. The cyst was lined by a layer of columnar epithelium similar to that of Brunner's gland ducts with no cytologic atypia. Also, a part of the cyst lining was inverted into the cyst lumen with fibrovascular core. Therefore, The final diagnosis was a cystic Brunner's gland hyperplasia with intracystic inverted growth.

A Case of Infective Endocarditis associtaed with Microcytic Hypochromic Anemia

We experienced a case of infective endocarditis, which unusual has symptoms and microcytic hypochromic anemia. Anemia associated with infective endocarditis is a common manifestation, but is generally normocytic nor-mochromic. However, microcytic hypochromic anemia is an uncommon manifestation of infective endo-carditis, and has only been noted in a few previous reports. We systematically evaluated anemia, and diagnosed fatal underlying diseases, such as infective endocarditis.

Percutaneous Transluminal Coronary Angioplasty for Coronary Artery Stenosis in a Young Patient with Long Term Kawasaki Disease

Kawasaki Disease (KD) is an acute, febrile, multisystem disease of children. More severe complications in 15~25% of cases include, the development of coronary aneurysms, ischemic heart disease, and sudden cardiac death. The standard treatment for significant coronary artery stenosis has generally been aortocoronary bypass surgery, although percutaneous transluminal coronary angioplasty (PTCA) has been described in a small number of patients. This report describes a 14 year old boy with a history of KD who developed multiple coronary aneurysms and stenosis. We performed PTCA, which was successful in relieving the stenosis of the left circumflex artery.

A Case of Cryptococcal Meningitis Developed after Short-term Therapy of Steroid in a Patient with Autoimmune Hemolytic Anemia / 대한혈액학회지

Cryptococcus neoformans commonly causes opportunistic infection in other immunocompromised patients as well as in AIDS. Among cryptococcosis, cryptococcal meningitis is a relatively frequent manifestation and causes serious morbidity and mortality. It needs urgent diagnosis and effective antifungal therapy. We experienced cryptococcal meningitis in a 25-year-old female patient with autoimmune hemolytic anemia. She was admitted because of autoimmune hemolytic crisis. Her anemic symptoms were controlled by steroid and red cell transfusions. However, she was suddenly readmitted with decreased mentality. Seven days later, she was diagnosed as cryptococcal meningitis and cryptococcemia resulting from culture studies of CSF and blood. Since treated with amphotericin B and flucytosine and maintained with prudent fluconazole therapy, her symptoms and general conditions were improved. We report an unusual case of cryptococcal meningitis developed in a patient with autoimmune hemolytic anemia in spite of short-term steroid therapy.

A case of pheochromocytoma with acute pancreatitis and catecholamine-induced cardiomyopathy / 대한내과학회지

Pheochromocytoma is a catecholamine producing tumor. The features that suggest pheochromocytoma in hypertensive patients are paroxysmal headache, palpitation and excessive sweating. Also, specific catecholamine induced dilated cardiomyopathy and acute pancreatitis have been rarely suggested. We recently experienced a case in which pheochromocytoma manifested as both catecholamine-induced cardiomyopathy and acute pancreatitis. A 64-year-old man presented with acute abdomen and ischemic ST-segment changes on EKG. While abdominal pain and elevated P-type amylase on laboratory data suggested acute pancreatitis, rapid recovery of severely depressed left ventricular systolic function suggested a reversible type of cardiomyopathy. Subsequent abdominal CT scan and hormone assays revealed a pheochromocytoma in the left suprarenal area. To the best of our knowledge, the concurrent occurrence of acute pancreatitis and catecholamine-induced cardiomyopathy in a patient with pheochromocytoma has not been previously reported.

All-trans Retinoic Acid induced Myositis in a Patient with Acute Promyelocytic Leukemia / 대한혈액학회지

Acute promyelocytic leukemia (APL) is characterized by a specific chromosome translocation t(15;17), which fuses the promyelocytic leukemia (PML) gene to the retinoic acid receptor alpha (RARalpha) gene, and by a unique response to the differentiating agent all-trans retinoic acid (ATRA). Although ATRA does not exhibit the conventional side effects of anticancer agents, it has its own unique side effects including retinoic acid syndrome, Sweet's syndrome, and myositis. Muscular involvement associated with ATRA therapy in APL has been rarely reported. We report a case of isolated myositis induced by ATRA in the induction treatment of APL. ATRA- induced myositis has distinctive clinical features and radiologic findings that should allow its recognition in order to treat promptly with steroid therapy.