Factors affecting incorrect interpretation of abdominal computed tomography in non-traumatic patients by novice emergency physicians

Objective@#Accurate interpretation of computed tomography (CT) scans is critical for patient care in the emergency department. We aimed to identify factors associated with an incorrect interpretation of abdominal CT by novice emergency residents and to analyze the characteristics of incorrectly interpreted scans. @*Methods@#This retrospective analysis of a prospective observational cohort was conducted at three urban emergency departments. Discrepancies between the interpretations by postgraduate year-1 (PGY-1) emergency residents and the final radiologists’ reports were assessed by independent adjudicators. Potential factors associated with incorrect interpretation included patient age, sex, time of interpretation, and organ category. Adjusted odds ratios (aORs) for incorrect interpretation were calculated using multivariable logistic regression analysis. @*Results@#Among 1,628 eligible cases, 270 (16.6%) were incorrect. The urinary system was the most correctly interpreted organ system (95.8%, 365/381), while the biliary tract was the most incorrectly interpreted (28.4%, 48/169). Normal CT images showed high false-positive rates of incorrect interpretation (28.2%, 96/340). Organ category was found to be a major determinant of incorrect interpretation. Using the urinary system as a reference, the aOR for incorrect interpretation of biliary tract disease was 9.20 (95% confidence interval, 5.0–16.90) and the aOR for incorrectly interpreting normal CT images was 8.47 (95% confidence interval, 4.85–14.78). @*Conclusion@#Biliary tract disease is a major factor associated with incorrect preliminary interpretations of abdominal CT scans by PGY-1 emergency residents. PGY-1 residents also showed high false-positive interpretation rates for normal CT images. Emergency residents’ training should focus on these two areas to improve abdominal CT interpretation accuracy.

Factors affecting incorrect interpretation of abdominal computed tomography in non-traumatic patients by novice emergency physicians

Objective@#Accurate interpretation of computed tomography (CT) scans is critical for patient care in the emergency department. We aimed to identify factors associated with an incorrect interpretation of abdominal CT by novice emergency residents and to analyze the characteristics of incorrectly interpreted scans. @*Methods@#This retrospective analysis of a prospective observational cohort was conducted at three urban emergency departments. Discrepancies between the interpretations by postgraduate year-1 (PGY-1) emergency residents and the final radiologists’ reports were assessed by independent adjudicators. Potential factors associated with incorrect interpretation included patient age, sex, time of interpretation, and organ category. Adjusted odds ratios (aORs) for incorrect interpretation were calculated using multivariable logistic regression analysis. @*Results@#Among 1,628 eligible cases, 270 (16.6%) were incorrect. The urinary system was the most correctly interpreted organ system (95.8%, 365/381), while the biliary tract was the most incorrectly interpreted (28.4%, 48/169). Normal CT images showed high false-positive rates of incorrect interpretation (28.2%, 96/340). Organ category was found to be a major determinant of incorrect interpretation. Using the urinary system as a reference, the aOR for incorrect interpretation of biliary tract disease was 9.20 (95% confidence interval, 5.0–16.90) and the aOR for incorrectly interpreting normal CT images was 8.47 (95% confidence interval, 4.85–14.78). @*Conclusion@#Biliary tract disease is a major factor associated with incorrect preliminary interpretations of abdominal CT scans by PGY-1 emergency residents. PGY-1 residents also showed high false-positive interpretation rates for normal CT images. Emergency residents’ training should focus on these two areas to improve abdominal CT interpretation accuracy.

Association between compliance with Surviving Sepsis Campaign guidelines and outcomes among sepsis and septic shock patient in accordance with Sepsis-3 definitions

Objective@#The Surviving Sepsis Campaign (SSC) guidelines have been associated with reduced mortality in sepsis patients. On the other hand, previous studies were performed using the Sepsis-2 definitions and past guidelines. This study assessed the association between compliance with the 2016 SSC guidelines and the outcomes of patients with sepsis and septic shock in accordance with the latest Sepsis-3 definitions. @*Methods@#Three hundred and fifteen patients with sepsis and septic shock were enrolled in this study. The patients were stratified according to their compliance with the SSC guidelines bundle. The characteristics and outcomes of the compliance and non-compliance groups were compared. In the overall patients, the risk factors for all-cause mortality were assessed using Cox proportional hazards models. @*Results@#Among the patients, 172 and 143 patients were in the compliance group and non-compliance group, respectively. The baseline characteristics and disease severity were similar in the two groups. The all-cause mortality rates were 27.3% and 38.5% in the compliance group and non-compliance group, respectively (P=0.035). The all-cause mortality was significantly lower in the compliance group than in the non-compliance group (log-rank test, P=0.025). The risk factors for the all-cause mortality were age (adjusted hazard ratio [aHR], 1.025; 95% confidence interval [CI], 1.008-1.042; P=0.004), septic shock (aHR, 3.14; 95% CI, 1.98-4.98; P<0.001), and lactate levels (aHR, 1.08; 95% CI, 1.03-1.14; P=0.002). The overall compliance with the guidelines protected against all-cause mortality (aHR, 0.66; 95% CI, 0.45-0.98; P=0.040). @*Conclusion@#Compliance with the SSC guidelines bundle was associated with a lower all-cause mortality among patients with sepsis and septic shock

Effect of rapid influenza diagnostic tests on patient management in an emergency department

OBJECTIVE: We evaluated the effect of rapid influenza diagnostic tests (RIDTs) on patient management in an emergency department for 3 years after 2009, and also identified factors associated with the choice of treatment for patients with influenza-like illnesses.METHODS: The study period consisted of three influenza epidemic seasons. Patients older than 15 years who underwent RIDTs in the emergency department and were then discharged without admission were included.RESULTS: A total of 453 patients were enrolled, 114 of whom had positive RIDT results and 339 had negative results. Antiviral medication was prescribed to 103 patients (90.4%) who had positive RIDT results, while 1 patient (0.3%) who tested negative was treated with antivirals (P<0.001). Conservative care was administered to 11 RIDT-positive patients (9.6%) and 244 RIDT-negative patients (72.0%) (P<0.001). Symptom onset in less than 48 hours, being older than 65 years, and the presence of comorbidities were not associated with the administration of antiviral therapy.CONCLUSION: RIDT results had a critical effect on physician decision-making regarding antiviral treatment for patients with influenza-like illnesses in the emergency department. However, symptom onset in less than 48 hours, old age, and comorbidities, which are all indications for antiviral therapy, were not found to influence the administration of antiviral treatment.

Satisfaction surveys on major subjects in emergency medical system in Korea: joint investigation of the Korean Society of Emergency Medicine and Korean Science Journalists Association

OBJECTIVE: This study was conducted to investigate satisfaction surveys of the emergency medical system in Korea administered to both members of the Korean Society of Emergency Medicine and patients and their guardians. METHODS: The joint survey was conducted by the Korea Scientist Journalists Association and the Public Affairs Committee of the Korean Society of Emergency Medicine. Questionnaires administered to each group included questions about the general environment, safety, and overcrowding. Satisfaction of medical staffs and awareness of cardiopulmonary resuscitation were only included in the patient questionnaire, while public health was only surveyed in the member questionnaire. The satisfaction was evaluated on a 5-point scale. RESULTS: Patient questionnaires were answered by 20 of 413 national emergency medical centers, and about 4.3% of the medical institutions participated in the questionnaire. A total of 704 reply sheets were returned by patients. Member questionnaires were answered by 280 of the 1,108 members (25%). Among patients, the lowest satisfaction was the item of “medical expenses,” followed by “waiting time”. Among providers, the lowest satisfaction was “appropriateness of medical staff”, while the highest complaint was “overcrowding.” CONCLUSION: Emergency care users had the lowest satisfaction with “medical expenses,” while members had the lowest satisfaction with “lack of manpower” and were most dissatisfied with “violence” and “overcrowding.”

The Current Status of Death Certificate Written in an Academic Hospital and the Degree of Agreement in Interpretation: A Single Center Observational Study

PURPOSE: This study aims to review the appropriateness of the issued death certificates and autopsy reports and to evaluate the improvement points of these documents in accordance with the guidelines of the Korean Medical Association and the National Statistical Office. Moreover, this study also examines why the guideline is necessary for the credibility of these documents. METHODS: The death certificates and autopsy reports written by a training hospital were analyzed for a 12-month period, between December 2014 and November 2015. The reference to analysis was the “guidelines to medical certificate 2015” written by the Korean Medical Association, “World Health Organization (WHO) death certificate principle”, and “guideline leaflet,” as provided by the National Statistical Office. Two researchers analyzed the documents that were against the guidelines, and suggested improvement points. The analyzed variables were age, sex, issued date, direct cause of death, manner of death, location of death, and types of accident. The primary goal was to see the rate of issued documents written correctly according to the guidelines and to suggest possible improvement points. The secondary goal was to analyze the reason for accordance and discordance between researchers. RESULTS: There were a total of 603 death certificates and autopsy reports issued during the research period; 562 (93.2%) and 41 (6.8%) cases, respectively. As for the manner of death, 521 cases were “death from disease,” 64 were “external causes,” and 18 were “others or unknown” (86.4%, 10.6%, and 3.0%, respectively). As for the issued department, internal medicine and emergency medicine issued 301 (49.9%) and 126 (20.9%) documents, respectively. Of these, 139 (23.1%) cases were regarded to be in accordance with the guidelines, while 304 (50.4%) were considered to be discordant cases. Among the discordant cases, there were 177 (29.4%) cases that were the mode of death directly written to cause of death. As for the records of “period of occurrence to death” were recorded only 70 (11.7%) cases (including “unknown” 65 cases) and the others were blank. The Kappa number of analysis regarding the evaluation correspondence of the two researchers was 0.44 (95% confidence interval, 0.38 to 0.51). CONCLUSION: The most frequent error was ‘the condition of death to direct cause of death’ with the ratio of 29.4%. This may have been because the rate of concordance between the researchers based on the guidelines was not high enough. There is a need to provide specific guidelines for each case, and also promote and educate regarding significant errors.

Postnatal Treadmill Exercise Alleviates Prenatal Stress-Induced Anxiety in Offspring Rats by Enhancing Cell Proliferation Through 5-Hydroxytryptamine 1A Receptor Activation / 대한배뇨장애요실금학회지

PURPOSE: Stress during pregnancy is a risk factor for the development of anxiety-related disorders in offspring later in life. The effects of treadmill exercise on anxiety-like behaviors and hippocampal cell proliferation were investigated using rats exposed to prenatal stress. METHODS: Exposure of pregnant rats to a hunting dog in an enclosed room was used to induce stress. Anxiety-like behaviors of offspring were evaluated using the elevated plus maze test. Immunohistochemistry for the detection of 5-bromo-2'-deoxyuridine and doublecortin (DCX) in the hippocampal dentate gyrus and 5-hydroxytryptamine 1A receptors (5-HT(1A)) in the dorsal raphe was conducted. Brain-derived neurotrophic factor (BDNF) and tyrosine kinase B (TrkB) levels in the hippocampus were evaluated by western blot analysis. RESULTS: Offspring of maternal rats exposed to stress during pregnancy showed anxiety-like behaviors. Offspring also showed reduced expression of BDNF, TrkB, and DCX in the dentate gyrus, decreased cell proliferation in the hippocampus, and reduced 5-HT(1A) expression in the dorsal raphe. Postnatal treadmill exercise by offspring, but not maternal exercise during pregnancy, enhanced cell proliferation and expression of these proteins. CONCLUSIONS: Postnatal treadmill exercise ameliorated anxiety-like behaviors in offspring of stressed pregnant rats, and the alleviating effect of exercise on these behaviors is hypothesized to result from enhancement of cell proliferation through 5-HT(1A) activation in offspring rats.

Current State of Abdominal Computed Tomography Performed in Emergency Department of a Tertiary University Hospital and Development of a Preliminary Interpretation Checklist

PURPOSE: Abdominal computed tomography (CT) is a widely recognized method to diagnose patients with acute abdominal pain in the emergency departments (EDs). We aimed to investigate the current state and interpretations of abdominal CT performed in the ED of a tertiary university hospital. METHODS: This was a retrospective study based on an abdominal CT database and medical records of patients over 15 years of age, who had visited our ED between January 1 and December 31, 2013. The data collected included CT types, final interpretations, characteristics of the patients, and location of pain at the time of CT. RESULTS: A total of 1,978 abdominal CTs were performed among 1,923 patients during the research period. The most frequent organs involved in the major diagnosis were those in the urinary system, followed by the appendix, liver, large intestine, and gallbladder. The most frequently interpreted diagnoses in these organs were in the order of urinary stone, appendicitis, liver cirrhosis, infectious colitis, and acute cholecystitis. The most frequent location of pain was the right lower quadrant (429 cases, 21.7%), and the most frequently performed CT types were contrast-enhanced abdominal and pelvic CT (1,260 cases, 63.7%). CONCLUSION: Various interpretations were derived based on the abdominal CTs, ranging from critical to mild diseases and from common to rare diseases. Based on this study, we have developed a preliminary interpretation checklist for abdominal CTs.

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.

Availability of Toxicologic Screening Tests in the Emergency Department

PURPOSE: The role of a point of care test (POCT) is currently becoming important when treating patients and making decisions in the emergency department. It also plays a role for managing patients presenting with drug intoxication. But the availability of the test has not yet been studied in Korea. Therefore, we investigated the utility and the availability of POCT for drug screening used in the emergency department. METHODS: This was a retrospective study for those patients with drug intoxication between January 2007 and December 2010 in an urban emergency department. RESULTS: Between the study period, 543 patients were examined with a Triage(R)-TOX Drug Screen. Among those, 248 (45.7%) patients showed negative results and 295 (54.3%) patients showed positive results. The sensitivity of the test for benzodiazepine, acetaminophen and tricyclic antidepressants were 85.9%, 100%, 79.2%, respectively. CONCLUSION: POCT of drug screening in emergency department showed good accuracy especially in patient with benzodiazepine, acetaminophen and tricyclic antidepressant intoxication. Therefore, it can be useful diagnostic tool for the management of intoxicated patients.

An Analysis of How Sleep Patterns after Duty Affect Wellness in Interns Working on 24 Hour Shifts in an Emergency Medical Center: A Pilot Study

PURPOSE: We conducted a pilot study to investigate the effects of sleep patterns on wellness in interns working in the emergency department (ED). We also looked at various factors interns considered in deciding specialties and aspects of the ED they dislike, to collect the basic data necessary for quality improvement. METHODS: We conducted a prospective observational study of interns who worked a 25 h shifts every other day by evaluating various aspects of their ellness (stress, fatigue, burnout), using questionnaires and vital signs. The questionnaires were completed four times by each subject at each shift. In total, 62 interns were assigned to teams comprised of three interns each. Each team participated in the study four times each day, once every week for 4 weeks, yielding a total of 992 questionnaires to be analyzed. RESULTS: The participating interns were 26 years of age on average. Thirty-six (58%) were male, and twenty-six (41%) were female. Systolic and diastolic blood pressure (BP) both tended to fall as time passed, as demonstrated by relatively higher BP at 8 a.m. and 4 p.m., as compared to BP measured at 3 a.m. and 9 a.m. (systolic BP p=0.003, diastolic BP p<0.0001). Similarly, pulse rate was in the normal range at 8 a.m. and 4 p.m. but tended to fall from 3 a.m. to 9 a.m. (p<0.0001). Sleep at night-time after duty was positively correlated to the degree of stress, fatigue, and burnout, with longer night-time sleep resulting in higher scores for each. Four hours or more of daytime sleep also resulted in a statistically significant increase in stress and fatigue scores. CONCLUSION: More than 4 hours daytime sleep after duty resulted in more stress and fatigue the next day. An increase in night-time sleep as well as total sleeping hours positively correlated with and resulted in increased stress, fatigue, and burnout scores.