Application of deep learning algorithm to detect COVID-19 pneumonia in chest X-ray

Objective@#This study evaluated the deep learning (DL) algorithm performance to detect lesions that suggest pneumonia in chest X-rays (CXR) of suspected coronavirus disease 2019 (COVID-19) patients. @*Methods@#This retrospective study included consecutive patients who visited a screening clinic in Daegu, and were suspected to be afflicted with the COVID-19 during the COVID-19 epidemic. CXR were analyzed using the commercial artificial intelligence product that provides free online DL algorithms to the public for COVID-19. Computerized tomography was used as the standard reference. Performance of the DL algorithm was evaluated by the sensitivity and specificity, and results were compared to the CXR records of emergency physicians (EP) in charge of the actual screening triage clinic during the COVID-19 epidemic. @*Results@#Totally, 114 patients were evaluated, of which 38 patients were positive for COVID-19. In 85 CXRs examined (36 COVID-19 and 49 non-COVID-19) with findings of pneumonia in computerized tomography, the DL algorithm showed significantly higher sensitivity as compared to the EP (DL, 98.8% [93.6%-99.9%] vs. EP, 85.9% [76.6%-92.5%]; P<0.01). Moreover, the DL algorithm showed significantly higher sensitivity for detecting CXRs with COVID-19 pneumonia, as compared to the EP (DL, 100.0% [90.3%-100%] vs. EP, 91.7% [77.5%-98.3%]; P=0.08). @*Conclusion@#We conclude that for examining the CXR of patients with suspected COVID-19, sensitivity of the DL algorithm is superior than the EP for detecting lesions suggesting pneumonia. Thus, the application of the DL algorithm is potentially useful in screening triage clinics to detect COVID-19 pneumonia.

Application of deep learning algorithm to detect COVID-19 pneumonia in chest X-ray

Objective@#This study evaluated the deep learning (DL) algorithm performance to detect lesions that suggest pneumonia in chest X-rays (CXR) of suspected coronavirus disease 2019 (COVID-19) patients. @*Methods@#This retrospective study included consecutive patients who visited a screening clinic in Daegu, and were suspected to be afflicted with the COVID-19 during the COVID-19 epidemic. CXR were analyzed using the commercial artificial intelligence product that provides free online DL algorithms to the public for COVID-19. Computerized tomography was used as the standard reference. Performance of the DL algorithm was evaluated by the sensitivity and specificity, and results were compared to the CXR records of emergency physicians (EP) in charge of the actual screening triage clinic during the COVID-19 epidemic. @*Results@#Totally, 114 patients were evaluated, of which 38 patients were positive for COVID-19. In 85 CXRs examined (36 COVID-19 and 49 non-COVID-19) with findings of pneumonia in computerized tomography, the DL algorithm showed significantly higher sensitivity as compared to the EP (DL, 98.8% [93.6%-99.9%] vs. EP, 85.9% [76.6%-92.5%]; P<0.01). Moreover, the DL algorithm showed significantly higher sensitivity for detecting CXRs with COVID-19 pneumonia, as compared to the EP (DL, 100.0% [90.3%-100%] vs. EP, 91.7% [77.5%-98.3%]; P=0.08). @*Conclusion@#We conclude that for examining the CXR of patients with suspected COVID-19, sensitivity of the DL algorithm is superior than the EP for detecting lesions suggesting pneumonia. Thus, the application of the DL algorithm is potentially useful in screening triage clinics to detect COVID-19 pneumonia.

Revised Triage and Surveillance Protocols for Temporary Emergency Department Closures in Tertiary Hospitals as a Response to COVID-19 Crisis in Daegu Metropolitan City

Background@#When an emergency-care patient is diagnosed with an emerging infectious disease, hospitals in Korea may temporarily close their emergency departments (EDs) to prevent nosocomial transmission. Since February 2020, multiple, consecutive ED closures have occurred due to the coronavirus disease 2019 (COVID-19) crisis in Daegu. However, sudden ED closures are in contravention of laws for the provision of emergency medical care that enable the public to avail prompt, appropriate, and 24-hour emergency medical care. Therefore, this study ascertained the vulnerability of the ED at tertiary hospitals in Daegu with regard to the current standards. A revised triage and surveillance protocol has been proposed to tackle the current crisis. @*Methods@#This study was retrospectively conducted at 6 level 1 or 2 EDs in a metropolitan city where ED closure due to COVID-19 occurred from February 18 to March 26, 2020. The present status of ED closure and patient characteristics and findings from chest radiography and laboratory investigations were assessed. Based on the experience from repeated ED closures and the modified systems that are currently used in EDs, revised triage and surveillance protocols have been developed and proposed. @*Results@#During the study period, 6 level 1 or 2 emergency rooms included in the study were shut down 27 times for 769 hours. Thirty-one confirmed COVID-19 cases, of whom 7 died, were associated with the incidence of ED closure. Typical patient presentation with respiratory symptoms of COVID-19 was seen in less than 50% of patients, whereas abnormal findings on chest imaging investigations were detected in 93.5% of the study population. The chest radiography facility, resuscitation rooms, and triage area were moved to locations outside the ED, and a new surveillance protocol was applied to determine the factors warranting quarantine, including symptoms, chest radiographic findings, and exposure to a source of infection. The incidence of ED closures decreased after the implementation of the revised triage and surveillance protocols. @*Conclusion@#Triage screening by emergency physicians and surveillance protocols with an externally located chest imaging facility were effective in the early isolation of COVID-19 patients. In future outbreaks of emerging infectious diseases, efforts should be focused toward the provision of continued ED treatment with the implementation of revised triage and surveillance protocols.

Comparison of the new and conventional injury severity scoring systems for predicting mortality in severe geriatric trauma

Objective@#This study compared the prognostic performance of the following five injury severity scores: the Geriatric Trauma Outcome Score (GTOS), the Injury Severity Score (ISS), the New Injury Severity Score (NISS), the Revised Trauma Score (RTS), and the Trauma and Injury Severity Score (TRISS) for in-hospital mortality in severe geriatric trauma patients. @*Methods@#A retrospective, cross-sectional, observational study was conducted using a database of severe geriatric trauma patients (age ≥65 years and ISS ≥16) who presented to a single regional trauma center between November 2016 and October 2018. We compared the baseline characteristics between the survivor and mortality groups and the predictive ability of the five scoring systems. @*Results@#A total of 402 patients were included in the analysis; the in-hospital mortality rate was 25.6% (n=103). The TRISS had the highest area under the curve of 0.953 (95% confidence interval [CI], 0.927-0.971); followed by RTS, 0.777 (95% CI, 0.733-0.817); NISS, 0.733 (95% CI, 0.687-0.776); ISS, 0.660 (95% CI, 0.612-0.707); and GTOS, 0.660 (95% CI, 0.611-0.706) in severe geriatric trauma. The TRISS also had the highest area under the curve of 0.961 (0.919-0.985) among the injury severity scoring systems in polytrauma. The predictive ability of TRISS was significantly higher than the other four scores with respect to overall trauma and polytrauma (P<0.001). @*Conclusion@#The TRISS showed the highest prognostic performance for predicting in-hospital mortality among all the injury severity scoring systems in severe geriatric trauma.

Confirmation of COVID-19 in Outof-Hospital Cardiac Arrest Patients and Postmortem Management in the Emergency Department during the COVID-19 Outbreak

Background@#There is currently a lack of evidence-based postresuscitation or postmortem guidelines for patients with out-of-hospital cardiac arrest (OHCA) in the setting of an emerging infectious disease. This study aimed to develop and validate a multimodal screening tool that aids in predicting the disease confirmation in emergency situations and patients with OHCA during a coronavirus disease 2019 (COVID-19) outbreak. @*Materials and Methods@#We conducted a retrospective, multicenter observational study of adult patients with OHCA in Daegu, Korea. To identify the potential predictors that could be used in screening tools in the emergency department, we applied logistic regression to data collected from March 1 to March 14. The prediction performance of the screening variables was then assessed and validated on the data of patients with OHCA who were treated between February 19 and March 31, 2020. General patient characteristics and hematological findings of the COVID-19-negative and COVID-19-positive groups were compared. We also evaluated confirmation test criteria as predictors for COVID-19 positivity in patients with OHCA. @*Results@#Advanced age, body temperature, and abnormal chest X-ray (CXR) revealed significant predictive ability in the derivation cohort. Of the 184 adult patients with OHCA identified in the validation cohort, 80 patients were included in the analysis. Notably, 9 patients were positive and 71 were negative on the COVID-19 reverse transcription polymerase chain reaction test. Five patients (55.6%) in the COVID-19-positive group had a fever before OHCA, and 12 (16.9%) of the COVID-19-negative group had a fever before OHCA (P = 0.018).Eight patients (88.9%) in the COVID-19-positive group had a CXR indicating pneumonic infiltration. Of the criteria for predicting COVID-19, fever or an abnormal CXR had a sensitivity of 100% (95% confidence interval [CI]: 65.4 – 100) and a specificity of 22.5% (95% CI: 13.5 – 34.0). @*Conclusion@#The screening tools that combined fever or abnormal CXR had a good discriminatory ability for COVID-19 infection in adult patients with OHCA. Therefore, during the COVID-19 outbreak period, it is recommended to suspect COVID-19 infection and perform COVID-19 test if patients present with a history of fever or show abnormal findings in postmortem CXR

Comparison of the new and conventional injury severity scoring systems for predicting mortality in severe geriatric trauma

Objective@#This study compared the prognostic performance of the following five injury severity scores: the Geriatric Trauma Outcome Score (GTOS), the Injury Severity Score (ISS), the New Injury Severity Score (NISS), the Revised Trauma Score (RTS), and the Trauma and Injury Severity Score (TRISS) for in-hospital mortality in severe geriatric trauma patients. @*Methods@#A retrospective, cross-sectional, observational study was conducted using a database of severe geriatric trauma patients (age ≥65 years and ISS ≥16) who presented to a single regional trauma center between November 2016 and October 2018. We compared the baseline characteristics between the survivor and mortality groups and the predictive ability of the five scoring systems. @*Results@#A total of 402 patients were included in the analysis; the in-hospital mortality rate was 25.6% (n=103). The TRISS had the highest area under the curve of 0.953 (95% confidence interval [CI], 0.927-0.971); followed by RTS, 0.777 (95% CI, 0.733-0.817); NISS, 0.733 (95% CI, 0.687-0.776); ISS, 0.660 (95% CI, 0.612-0.707); and GTOS, 0.660 (95% CI, 0.611-0.706) in severe geriatric trauma. The TRISS also had the highest area under the curve of 0.961 (0.919-0.985) among the injury severity scoring systems in polytrauma. The predictive ability of TRISS was significantly higher than the other four scores with respect to overall trauma and polytrauma (P<0.001). @*Conclusion@#The TRISS showed the highest prognostic performance for predicting in-hospital mortality among all the injury severity scoring systems in severe geriatric trauma.

Confirmation of COVID-19 in Outof-Hospital Cardiac Arrest Patients and Postmortem Management in the Emergency Department during the COVID-19 Outbreak

Background@#There is currently a lack of evidence-based postresuscitation or postmortem guidelines for patients with out-of-hospital cardiac arrest (OHCA) in the setting of an emerging infectious disease. This study aimed to develop and validate a multimodal screening tool that aids in predicting the disease confirmation in emergency situations and patients with OHCA during a coronavirus disease 2019 (COVID-19) outbreak. @*Materials and Methods@#We conducted a retrospective, multicenter observational study of adult patients with OHCA in Daegu, Korea. To identify the potential predictors that could be used in screening tools in the emergency department, we applied logistic regression to data collected from March 1 to March 14. The prediction performance of the screening variables was then assessed and validated on the data of patients with OHCA who were treated between February 19 and March 31, 2020. General patient characteristics and hematological findings of the COVID-19-negative and COVID-19-positive groups were compared. We also evaluated confirmation test criteria as predictors for COVID-19 positivity in patients with OHCA. @*Results@#Advanced age, body temperature, and abnormal chest X-ray (CXR) revealed significant predictive ability in the derivation cohort. Of the 184 adult patients with OHCA identified in the validation cohort, 80 patients were included in the analysis. Notably, 9 patients were positive and 71 were negative on the COVID-19 reverse transcription polymerase chain reaction test. Five patients (55.6%) in the COVID-19-positive group had a fever before OHCA, and 12 (16.9%) of the COVID-19-negative group had a fever before OHCA (P = 0.018).Eight patients (88.9%) in the COVID-19-positive group had a CXR indicating pneumonic infiltration. Of the criteria for predicting COVID-19, fever or an abnormal CXR had a sensitivity of 100% (95% confidence interval [CI]: 65.4 – 100) and a specificity of 22.5% (95% CI: 13.5 – 34.0). @*Conclusion@#The screening tools that combined fever or abnormal CXR had a good discriminatory ability for COVID-19 infection in adult patients with OHCA. Therefore, during the COVID-19 outbreak period, it is recommended to suspect COVID-19 infection and perform COVID-19 test if patients present with a history of fever or show abnormal findings in postmortem CXR

Single-Incision, Two-Port Laparoscopic Appendectomy as an Alternative to Transumbilical Single-Port Laparoscopic Appendectomy

PURPOSE: We designed a modified technique to perform an advanced procedure using conventional instruments and did not employ specialized single-incision laparoscopic surgery (SILS) port equipment. We compared postoperative results for transumbilical, single-port laparoscopic appendectomy (TUSPLA) and single-incision, 2-port laparoscopic appendectomy (SITPLA). METHODS: This retrospective study enrolled 77 patients who underwent TUSPLA or SITPLA to provide more minimally invasive surgery between May 2017 and April 2018. TUSPLA was performed in 39 patients and 38 underwent SITPLA. In the SITPLA group, two 5-mm trocars were inserted through the umbilicus and an extra puncture site was used for a left-handed instrument. Demographic characteristics, operative data, and postoperative outcomes were collected and compared between the groups. RESULTS: The mean total operative time in the SITPLA group was shorter than in the TUSPLA group (p=0.003). The mean laparoscopic instrumental time was also shorter (p<0.001) in the SITPLA. The number of postoperative analgesics in the SITPLA group was less than in the TUSPLA group (p=0.002). The length of hospital day after surgery was shorter in the SITPLA group than in the TUSPLA group (p=0.008). There were no other significant differences between the groups. CONCLUSION: SITPLA had a shorter operative time, required less pain management, and had a similar cosmetic outcome when compared with TUSPLA.

Analysis of the clinical features and laboratory findings according to the outcome for detecting early prognostic factors of heat stroke patients

OBJECTIVE: Heat stroke is a serious heat-related illness characterized by elevated core body temperature and an impaired central nervous system. Heat stroke can also cause various complications and lead to irremediable results. However, early prediction of its outcome remains difficult. In this study, we analyzed clinical features and laboratory findings according to the outcome of heat stroke patients and tried to identify factors that predict their prognosis in the acute stage. METHODS: In this retrospective observational study, we enrolled 40 heat stroke patients who arrived at five emergency departments in Daegu within three hours from the time at which heat stroke occurred every June 1 to August 31 from 2011 to 2016. In addition, we compared the clinical features and laboratory findings according to the outcome. RESULTS: The mean ages were 72.0 (53.0–76.0) in the good outcome group (GOG) and 57.0 (39.5–84.8) in the poor outcome group (POG). In addition, there were 23 (71.9%) and five (62.5%) men in the GOG and the POG, respectively. Among clinical characteristics, initial neurological status and endotracheal intubation differed significantly by prognosis (P=0.019 and P=0.001, respectively). Among laboratory findings, arterial bicarbonate ion level, platelet count, and aspartate aminotransferase level were differed significantly by prognosis (P=0.003, P=0.005, and P=0.009, respectively). CONCLUSION: An initial decline in consciousness, conducting endotracheal intubation, decreased arterial bicarbonate ion level or platelet count, as well as increased aspartate aminotransferase levels were poor prognosis factors of heat stroke patients in the acute stage. Emergency physicians should be careful when managing these patients.

Splenic artery aneurysm with the double-rupture phenomenon

Splenic artery aneurysm is the third most common type of intra-abdominal aneurysm, with a prevalence rate of 0.01% to 10.4% in the general population. Splenic artery aneurysm is usually asymptomatic and is typically detected by chance and does not require surgical management; however, if rupture occurs, although rare, the patient's situation can become critical. We report our experience with a man who presented with left flank and left shoulder pain. His symptoms were caused by multiple hematomas confined to the spleen, but 2 days after admission, he developed delayed hemoperitoneum and required surgical management. We believe that his condition was due to delayed intraperitoneal bleeding called the double-rupture phenomenon; emergency physicians must consider this phenomenon when taking care of splenic artery aneurysm patients.