Appropriate Rest Time after Repetitive Sleep Deprivation Suppresses Apoptosis and Cell Proliferation in the Hippocampus

PURPOSE: Sleep deprivation may exert many negative effects on hippocampus-dependent cognitive function, such as learning and memory. The present study was conducted in order to investigate the effects of repetitive sleep deprivation on cognition, apoptotic neuronal cell death, and cell proliferation in the hippocampus, using mice. METHODS: To induce sleep deprivation, mice were placed in a water cage containing six platforms (3 cm in diameter), surrounded by water up to 1 cm beneath the surface of the platform for 24 h. Mice were randomly divided into four groups (n=20 in each group): control group, 24 h rest after 24 h sleep deprivation group, 48 h rest after 24 h sleep deprivation group, and 72 h rest after 24 h sleep deprivation group. This cycle was continued for 36 days. Novel objective recognition test and immunohistochemistry for 5-bromo-2'-deoxyuridine (BrdU), western blot for expression of Bax, Bcl-2, brain-derived neurotrophic factor (BDNF), and caspase-3 were performed. RESULTS: Results of the novel objective recognition test showed decreased cognition in the 24 h rest after 24 h sleep deprivation group, while a similar effect was observed in other groups, compared to the control group. Increased cell proliferation and enhanced expression of BDNF and Bax protein were observed in the 24 h rest after 24 h sleep deprivation group and the 48 h rest after 24 h sleep deprivation group, compared to the control group. Expression of Bcl-2 showed a decrease in the 24 h and 48 h rest groups, compared to the control group. Expression of caspase-3 in the dentate gyrus of the hippocampus showed a significant increase in the 24 h rest after 24 h sleep deprivation group and in the 48 h rest after 24 h sleep deprivation group, compared to the control group. CONCLUSION: Results of the present study indicate that insufficient rest after sleep deprivation may induce impairment of cognitive function. After sleep deprivation, at least 72 hr of rest time is needed for recovery.

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.

Isolated Dizziness. Admission? or Discharge?

PURPOSE: Dizziness is a common chief complaint in patients presenting at emergency deparments. As central dizziness can be life-threatening, it is important to differentiate central from peripheral dizziness. VBI (vertebrobasilar insufficiency) or PICA (posterior inferior cerebellar artery) infarction can present as only isolated dizziness without other neurologic symptoms, thus mimicking peripheral dizziness. It is difficult to differentiate from isolated dizziness in emergency departments because of limitations attendant to time, space, laboratory tests and diagnostic procedures. This study was performed with the goal of devising a protocol to positively identify isolated dizziness at the bedside in emergency departments. METHODS: We retrospectively reviewed the medical records of 384 patients with isolated dizziness who visited the emergency department of Kyunghee Medical Center from January 1, 2006 to December 31, 2006. We analyzed age, gender, the risk factors of cerebral vascular accident, neurologic examinations, and features of dizziness and performed a logistic regression analysis. RESULTS: In logistic regression analysis, age of at least 65 years, cerebral vascular accident history, disequilibrium character, cranial nerve system, and tandem gait abnormality were significantly associated with central dizziness. Negative predictive value and sensitivity of the protocol were 99.6% and 98.7%, respectively. CONCLUSION: In patients presenting with isolated dizziness in the emergency department, patients less than 65 years old, and without history of cerebral vascular accident, disequilibrium character, cranial nerve system, or tandem gait abnormality can be safely discharged after conservative management without further evaluation.

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.

Pilot Study of Web-based PBL in Emergency Medicine Clinical Education

PURPOSE: Problem-based learning (PBL) has been used in medical schools due to its educational effectiveness in terms of critical thinking, problem-solving skills, integration of theory and practice, and enculturation of the community of practice. In the digital age, however, ICT (information and communication technology)-based PBL, especially, webbased PBL seems more appropriate to meet socio-educational needs when the features of web, such as multimedia based rich information, multichannel links and navigation, connectivity (interaction and collaboration), and conservation of messages posted on the online board are considered. In this context, this case study attempted to apply 'blended learning' mode that combined both on-site and on-line classrooms, and to maximize the educational purposes of PBL. This case study examined students' perception about web-based PBL to provide basic information and data for further development and implementation of the web-based PBL METHOD: As a pilot test of the web-based PBL mode, we developed a pre-case module on the web was to provide the students with a chance to experience web-based PBL before it was fully applied to the whole class. The content of the pre-case was 'panperitonits due to gastric perforation', what a primary physician should know about. This project included two collaborative teams: 1) The development team from the graduate school of education which was in charge of the web-based PBL module development and the evaluation of the pilot test, and 2) the case development team from the Emergency Department of the school of Medicine, which dealt with the simulation (patient and doctor interaction) development, the preparation of the learning resources, and the tutor sheet. RESULTS: The participating students were mostly quite satisfied with the web-based PBL class, particularly pointing out the effectiveness of integrating theory and practice, the authentic learning tasks, and the student-directed learning environments. CONCLUSION: The highly positive responses from the students indicate that further practices using web-based PBL for classes should be more seriously considered for a more proper medical-school educational environment in the 21st Century.

The Efficacy of Unilateral Rectus Resection in the Reoperation of Strabismus

PURPOSE: To study the efficacy of unilateral rectus resection in the surgical treatment of undercorrected or recurrent strabismus. METHODS: A retrospective chart review of patients who had undergone a unilateral rectus resection with at least 6 months (mean 35.6 months) of postoperative follow-up was performed. RESULTS: A resection of a single rectus muscle was undergone by 92 patients: 70 underwent a unilateral resection of the medial rectus and 22 underwent a unilateral resection of the lateral rectus. The mean preoperative deviations of patients were 23.6+/-5.9 prism diopters (PD). The amount of unilateral medial rectus resection ranged from 3 to 7 mm and unilateral lateral rectus resection ranged from 5 to 10 mm. The satisfactory surgical result was considered to be any deviation within 8 PD. The success rates were 81.4% in the unilateral medial rectus resection group and 72.7% in the unilateral lateral rectus resection group. The satisfactory surgical result of the group of preoperative deviation less than or equal to 20 PD was 93.2%, the group of greater than 20 PD and less than or equal to 25 PD was 65.6% and the group of greater than 25 PD was 68.8%. This difference in results between three groups was statistically significant (p=0.006). CONCLUSIONS: The unilateral rectus resection is an effective procedure for the treatment of undercorrected or recurrent strabismus with small to moderate preoperative deviations.

Retrospective Clinical Review of Deep Neck Infections (abscesses)

PURPOSE: This study was performed to review our experience with deep neck infections (DNI) in an emergency center. METHODS: Over a 60-month period, 32 consecutive patients with DNI were included in the study. Variables included in the data analysis were age, sex, clinical symptoms and signs, and laboratory findings on initial presentation. Both DNI and NDNI (Non-deep neck infections; acute tonsillitis, acute oropharyngitis) groups were examined clinically, and blood samples were taken and studied for several parameters associated with infection, including C-reactive protein levels; the findings were analyzed statistically for differences between the groups. RESULTS: A retrospective review was conducted of 32 patients with deep neck infections. Based on clinical and radiologic findings, these patients were categorized as retropharyngeal space, parapharyngeal space, sublingual space, submandibular space, or multiple space. The most common symptoms were fever (78%) and sore throat (53%), followed by dysphagia (47%), trismus (38%), and neck swelling (31%). No particular background variables were associated with DNI; however, a particularly high CRP level on admission was found to be associated with DNI (p<0.05). CONCLUSION: We should distinguish deep neck infections from non deep neck infections in the emergency department. This study showed that determination of the CRP level may be useful in making a clinical diagnosis of deep neck infections.

Mutational Analysis of FOXL2 Gene in Blepharophimosis-Ptosis-Epicanthus Inversus Syndrome (BPES) Patients

PURPOSE: The purpose of this paper is to identify the forkhead transcription factor gene (FOXL2) mutations in Korean patients with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). METHODS: We have analyzed the mutations of FOXL2 gene in genomic DNAs extracted from 16 BPES patients and their families by PCR, PCR-SSCP, and sequencing. RESULTS: No deletion in exon 1 to 3 of the FOXL2 gene was observed by PCR. The PCR products were subjected to SSCP analysis and 9 patients showed SSCP shifts. The PCR products showing SSCP shifts were subcloned into plasmid vectors and sequenced to confirm the FOXL2 mutation. In total, 7 mutations (1 nonsense mutation, 1 deletion, and 5 duplications) in exon 2 were identified. CONCLUSIONS: The FOXL2 gene mutations were identified in the Korean BPES patients. Some of the mutations were previously reported and some were new mutations. This study will contribute to the molecular analysis and clinical counseling of BPES patients.

Evaluation for Prognosis and Complication at Violation of Treatment with rtTA in Acute Ischemic Stroke

PURPOSE: In many other countries, based on research, recombinant tissue plasminogen activator (r-tPA) has been approved for the treatment of acute ischemic strokes. However, in Korea, little research has been done till now, in spite of using r-tPA widely. We sought to assess the feasibility and the efficacy of treatment and to evaluate the prognosis and complications at the violation of using r-tPA. Our study was compared with other previous studies. METHODS: A retrospective review is presented of 25 the cases of patients with acute ischemic stroke treated with rtPA according to the National Institutes of Neurological Disorders and Strokes (NINDS) protocol. We classified the groups by protocol violation (time, blood pressure, and computed tomography). We then analyzed neurologic outcomes by using the National Institutes of Health Strokes Scale (NIHSS) and complications based on whether or not intracerebral hemorrhage (ICH) had occurred. RESULTS: Of the 25 patients (mean age: 57 males: 19), 6 had time violation (onset time > 180 min), 4 had blood-pressure violation (systolic BP > 185 mmHg), 5 had CT violation (low density at initial CT). The NIHSS score improved in 64% of all patients after 24 hours. However, improvement was lower in the case of deviation present than it was in the case of deviation absent (time, blood pressure, and CT, respectively, 20%, 50%, and 40%; p-value respectively 0.0274, 0.8350, and 0.4125). ICH occurred in 6 cases, but in cases of deviation present, ICH occurred at a greater frequency. CONCLUSION: Our safety and feasibility of outcome compared favorably with NINDS and other previous studies. In addition, we confirmed that the presence of protocol deviation was associated a poor outcome.

Murine Typhus Presenting as Hemorrhagic Vesicles and Dyspnea: A case report

Murine (endemic) typhus is a zoonotic infection caused by Rickettsia typhi (formerly known as Rickettsia mooseri). Rickettsia typhi is an obligate intracellular organism that multiplies within the cytoplasm of mainly endothelial cells. It is transmitted from rats by injection of contaminated flea feces into the skin of the host. The disease manifests itself with the gradual onset of fever, myalgia, and headache appearing 7-14 days after infection. A maculopapular rash is found in some patients (proportions ranging from 20 to 80% in different series). We report a rare case of murine typhus with presentation of hemorrhagic vesicles and dyspnea which was treated at our emergency department, and we give a brief review of the literature.

Rhabdomyolysis Associated with Cerivastatin-Gemfibrozil Combination Therapy: 1 case

Most currently available statins are associated with an increase with risk of myositis, including rhabdomyolysis. Myopathy is believed to be caused by interference in the cytochrome P450 3A4 enzyme system, which results in a marked increase in reductase activity. Cerivastatin, a new synthetic HMG-CoA reductase inhibitor, is a safe, well-tolerated effective drug for the treatment of patients with dyslipidemia. The drug is metabolized by the cytochrome P450 3A4 and cytochrome P450 2C8 hepatic isoenzymes. Because of this dual metabolic pathway, it has been suggested that cerivastatin is less subject to drug-todrug interactions. We describe a 60-year-old woman with rhabdomyolysis and localized myositis, after she had taken cerivastatin(lipobay, 0.3 mg/day) and gemfibrozil(lopid, 500 mg/day) for 1month.