Characteristics of children hospitalized through the pediatric emergency department and effects of pediatric emergency ward hospitalization

Purpose@#To evaluate the efficiency of the pediatric emergency ward (PEW) through the outcomes of children hospitalized to the ward by the department of pediatric emergency medicine (PEM). @*Methods@#A chart review was completed for children (< 15 years) who were hospitalized to the PEW via the pediatric emergency center from March through May 2021. We compared the general characteristics and details regarding the outcomes depending on the departments they were hospitalized to, namely PEM, pediatrics (PED), and others. @*Results@#We analyzed a total of 606 hospitalized children: PEM, 91; PED, 456; and others, 59. In the order listed above, their median ages were 2 years (interquartile range, 1-6), 1 year (0-4), and 9 years (7-14) (P < 0.001). The numbers of children with Korean Triage and Acuity Scale of 1-3 were 71 (78.0%), 400 (87.7%), and 33 (55.9%) (P < 0.001). Median length of stay (LOS) in the emergency department (ED) and hospital tended to be shorter in PEM (ED LOS: PEM, 4.3 hours vs. PED and others, 4.0-6.3 hours; hospital LOS: PEM, 19.0 hours vs. PED and others, 58.5-63.8 hours; all Ps < 0.001). The differences in the LOS were prominent between others and PEM (ED LOS, 1.538 [95% confidence interval, 1.353-1.749]; hospital LOS, 3.375 [2.741-4.157]). Transfers to other departments occurred only in PEM (4.4%) and PED (3.9%) whereas intensive care was performed only in others (27.1%). Return visits showed no difference among the 3 departments. Top 5 chief complaints and primary diagnoses of the children hospitalized to PEM were vomiting, fever, abdominal pain, head injury, and poisoning, and gastroenteritis, concussion, syncope, poisoning, and upper respiratory infection, respectively. @*Conclusion@#Hospitalization to PEWs for short-term treatment or observation may relieve overcrowding in EDs or in hospitals, with comparable frequency of return visits.

Technology trends and applications of deep learning in ultrasonography: image quality enhancement, diagnostic support, and improving workflow efficiency

In this review of the most recent applications of deep learning to ultrasound imaging, the architectures of deep learning networks are briefly explained for the medical imaging applications of classification, detection, segmentation, and generation. Ultrasonography applications for image processing and diagnosis are then reviewed and summarized, along with some representative imaging studies of the breast, thyroid, heart, kidney, liver, and fetal head. Efforts towards workflow enhancement are also reviewed, with an emphasis on view recognition, scanning guide, image quality assessment, and quantification and measurement. Finally some future prospects are presented regarding image quality enhancement, diagnostic support, and improvements in workflow efficiency, along with remarks on hurdles, benefits, and necessary collaborations.

Occult bacteremia in children with simple febrile seizure in the post-pneumococcal conjugate vaccine era

Purpose@#The authors aimed to investigate the utility of blood culture (BC) for children with simple febrile seizure (SFS) in the emergency department (ED) in the post-10/13-valent pneumococcal conjugate vaccine (PCV) era. @*Methods@#This study was performed at the ED of a tertiary care university-affiliated women and children’s hospital, and involved 3,237 previously healthy children aged 6-60 months who visited the ED with SFS from January 2013 through December 2017. The SFS was defined according to the International Classification of Diseases, 11th Revision codes related to seizure. The children were divided into 2 groups according to the vaccination rates of the period of their visit: the 70-PCV (70%, 2013-2014) and 97-PCV (97%, 2015-2017) groups. The primary outcome was the yield, defined as a true positivity of BC. In addition, we collected information on baseline characteristics, ED length of stay, inflammatory biomarkers, and ED outcomes. @*Results@#Of the 1,578 children with SFS who underwent BC, 1,357 belonged to the 97-PCV group. The median age of the study population was 22 months (interquartile range, 16.0-30.0), and 935 children (59.3%) were boys. Of the 41 children (2.6%) with positive BC results, 3 had the yield (0.2%): Staphylococcus aureus in 2 children and Streptococcus pneumoniae in the other. All 3 children belonged to the 97-PCV group. There were 38 contaminated BCs (2.4%; 95% confidence interval, 1.6%-3.2%). The 97-PCV group showed a shorter median ED length of stay (166.0 minutes [108.0-279.5] vs. 143.0 [109.5-209.5]; P = 0.010) and a lower rate of hospitalization (39.4% vs. 12.8%; P < 0.001). No differences between the 2 groups were found in the baseline characteristics and biomarkers. @*Conclusion@#This study suggests a low utility of BC in previously healthy children with SFS in emergency settings in the post-10/13-valent PCV era.

Is renal replacement therapy necessary in deceased donor liver transplantation candidates with hepatorenal syndrome?: a 2-year experience at a high-volume center

PURPOSE: Hepatorenal syndrome (HRS) is a fatal complication in patients with end-stage liver disease awaiting liver transplantation (LT). HRS often develops in patients with high model for end-stage liver disease (MELD) score. This study investigated the outcomes of peritransplant management of HRS in a high-volume LT center in Korea for 2 years.METHODS: A total of 157 recipients that deceased donor liver transplantation (DDLT) from January 2017 to December 2018 were included. In-hospital mortality (IHM) was analyzed in relation to pre- and posttransplant application of renal replacement therapy (RRT).RESULTS: Primary diagnoses for DDLT were alcoholic liver disease (n = 61), HBV-associated liver cirrhosis (n = 48), retransplantation for chronic graft failure (n = 24), and others (n = 24). Mean MELD score was 34.6 ± 6.2 with 72 patients at Korean Network for Organ Sharing MELD status 2 (45.9%), 43 at status 3 (27.4%), 36 at status 4 (22.9%), and 6 at status 5 (3.8%). Pretransplant RRT was performed in 16 patients (10.2%) that did not show IHM. Posttransplant RRT was performed in 69 patients (44.0%), for whom IHM incidence was 15.9%. In 53 patients that had undergone de novo posttransplant RRT, IHM incidence increased to 20.8%. IHM in the 88 patients not requiring RRT was 2.3%.CONCLUSION: The majority of adult DDLT recipients in Korean MELD score-based allocation system have very high MELD scores, which is often associated with HRS. Pretransplant RRT appears to improve posttransplant survival outcomes. We thereby recommend that, if indicated, pretransplant RRT be performed while awaiting DDLT.

Appropriateness of rabies post-exposure prophylaxis in pediatric patients visiting the emergency department due to animal bite

Purpose@#To study the appropriateness of rabies post-exposure prophylaxis (rPEP) for children with animal bite who visited the emergency department (ED). @*Methods@#The study enrolled children younger than 18 years with animal bite who visited the National Medical Center ED between January 2014 and October 2017. The children’ electronic medical records were retrospectively reviewed. Data for analysis included age, sex, body parts bitten by animals, species of animals, regions where animal bites occurred, history of recent antibiotics therapy and tetanus vaccination, and justification by the 2017 Guidelines for Rabies Control in Korea and implementation of rPEP. In children who underwent unjustified rPEP or did not undergo justified one, we recorded their guardians’ opinion for or against rPEP. @*Results@#Of the 63 enrolled children, rPEP was justified for 38 children by the Korean guidelines. Of the 38 children, 35 actually underwent rPEP. Among the remaining 3 children, 2 did not undergo the prophylaxis as per the guardians’ requests. Among the 25 children whose rPEP was not justified, 8 underwent the prophylaxis. Of these 8 children, 7 did based on the guardians’ requests. @*Conclusion@#In this study, inappropriate rPEP was usually affected by the guardians’ requests, regardless of the criteria for such prophylaxis. Thus, their requests for or against rPEP should be discussed with emergency physicians who are aware of the relevant criteria to prevent occurrence of rabies or unnecessary use of medical resources.

Bilateral Persistent Sciatic Arteries Complicated with Aneurysmal Dilatation and Thrombotic Occlusion: A Case Report

Persistent sciatic artery (PSA), a rare congenital vascular anomaly, increases susceptibility to aneurysms and accounts for 40–61% of the cases. Here, we describe a case of PSA in a 70-yearold man with a history of alcoholic liver cirrhosis. Bilateral complete PSAs were detected incidentally on computed tomography angiography during evaluation for spontaneous intramuscular bleeding in the thigh due to cirrhosis-related coagulopathy. Selective angiography of the left PSA revealed aneurysmal dilatation and thrombotic occlusion of the PSA, which was partially removed with aspiration thrombectomy. Intramuscular bleeding was succesfully managed with empirical embolization of the deep femoral artery.

Gender differences in characteristics of adolescents with suicide attempt at the emergency department

Purpose@#This study was performed to investigate the gender differences in suicide attempts in adolescents. @*Methods@#We reviewed the medical records of adolescents (≤ 18 years) who had visited a university hospital emergency department (ED) for suicide attempts from January 2018 through December 2019. General characteristics of the adolescents, details of the attempt, and outcomes were analyzed. The characteristics were age, gender, the Korean Triage and Acuity Scale, previous attempts, and psychiatric history. The details were initial Glasgow Coma Scale, attempt-arrival time, living alone, method, place, and motivation of the attempt, and concurrent use of alcohol. The outcomes included psychiatric consultation, ED length of stay, and ED outcomes. @*Results@#A total of 86 adolescents were included. Their age ranged from 13 to 18 years, and girls accounted for 65.1%. The girls had more frequent psychiatric history than boys (66.1% vs. 30.0%; P = 0.001) without a significant difference in previous attempts (55.4% vs. 46.7%; P = 0.442). The most common methods of the attempt in the girls and boys were poisoning and sharp objects (53.3% [16 of the 30 boys] vs. 60.7% [34 of the 56 girls]; P = 0.002), respectively. No differences were found in the other details of the attempt and in the rate of psychiatric consultation. The girls had longer ED length of stay (247.0 minutes vs. 186.5; P = 0.033), a lower rate of discharge against medical advice, and higher rates of hospitalization (discharge against medical advice, 53.6% vs. 76.7%; non-psychiatric, 23.2% vs. 3.3%; psychiatric, 12.5% vs. 0%; P = 0.003). @*Conclusion@#Girls may make suicide attempts, usually by poisoning, and undergo relevant hospitalization, more often than boys. In contrast, boys usually use sharp objects, with a higher rate of discharge against medical advice and lower rates of the attempt and hospitalization.

Pretransplant Hepatic Malignancy Increases Risk of De Novo Malignancy after Liver Transplantation

BACKGROUND@#Hepatocellular carcinoma (HCC) recurrence and development of de novo malignancy (DNM) after liver transplantation (LT) are the major causes of late recipient death.@*METHODS@#We analyzed the incidence of extrahepatic DNM following living donor LT according to the status of pretransplant hepatic malignancy. We selected 2,076 adult patients who underwent primary LDLT during 7 years from January 2010 to December 2016.@*RESULTS@#The pretransplant hepatic malignancy group (n = 1,012) showed 45 cases (4.4%) of the following extrahepatic DNMs: posttransplant lymphoproliferative disease (PTLD) in 10; lung cancer in 10; stomach cancer in 6; colorectal cancer in 5; urinary bladder cancer in 3; and other cancers in 11. The pretransplant no hepatic malignancy group (n = 1,064) showed 25 cases (2.3%) of the following extrahepatic DNMs: colorectal cancer in 3; stomach cancer in 3; leukemia in 3; lung cancer in 3; PTLD in 2; prostate cancer in 2; and other cancers in 9. Incidences of extrahepatic DNM in the pretransplant hepatic malignancy and no hepatic malignancy groups were as follows: 1.1% and 0.5% at 1 year, 3.2% and 2.0% at 3 years, 4.6% and 2.5% at 5 years, and 5.4% and 2.8% at 8 years, respectively (P = 0.006). Their overall patient survival rates were as follows: 97.3% and 97.2% at 1 year, 91.6% and 95.9% at 3 years, 89.8% and 95.4% at 5 years, and 89.2% and 95.4% at 8 years, respectively (P < 0.001). Pretransplant hepatic malignancy was the only significant risk factor for posttransplant extrahepatic DNM.@*CONCLUSION@#Our results suggest that patients who had pretransplant hepatic malignancy be followed up more strictly because they have a potential risk of primary hepatic malignancy recurrence as well as a higher risk of extrahepatic DNM than patients without pretransplant hepatic malignancy.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Pretransplant Hepatic Malignancy Increases Risk of De Novo Malignancy after Liver Transplantation

BACKGROUND: Hepatocellular carcinoma (HCC) recurrence and development of de novo malignancy (DNM) after liver transplantation (LT) are the major causes of late recipient death.METHODS: We analyzed the incidence of extrahepatic DNM following living donor LT according to the status of pretransplant hepatic malignancy. We selected 2,076 adult patients who underwent primary LDLT during 7 years from January 2010 to December 2016.RESULTS: The pretransplant hepatic malignancy group (n = 1,012) showed 45 cases (4.4%) of the following extrahepatic DNMs: posttransplant lymphoproliferative disease (PTLD) in 10; lung cancer in 10; stomach cancer in 6; colorectal cancer in 5; urinary bladder cancer in 3; and other cancers in 11. The pretransplant no hepatic malignancy group (n = 1,064) showed 25 cases (2.3%) of the following extrahepatic DNMs: colorectal cancer in 3; stomach cancer in 3; leukemia in 3; lung cancer in 3; PTLD in 2; prostate cancer in 2; and other cancers in 9. Incidences of extrahepatic DNM in the pretransplant hepatic malignancy and no hepatic malignancy groups were as follows: 1.1% and 0.5% at 1 year, 3.2% and 2.0% at 3 years, 4.6% and 2.5% at 5 years, and 5.4% and 2.8% at 8 years, respectively (P = 0.006). Their overall patient survival rates were as follows: 97.3% and 97.2% at 1 year, 91.6% and 95.9% at 3 years, 89.8% and 95.4% at 5 years, and 89.2% and 95.4% at 8 years, respectively (P < 0.001). Pretransplant hepatic malignancy was the only significant risk factor for posttransplant extrahepatic DNM.CONCLUSION: Our results suggest that patients who had pretransplant hepatic malignancy be followed up more strictly because they have a potential risk of primary hepatic malignancy recurrence as well as a higher risk of extrahepatic DNM than patients without pretransplant hepatic malignancy.

Pretransplant Hepatic Malignancy Increases Risk of De Novo Malignancy after Liver Transplantation

BACKGROUND@#Hepatocellular carcinoma (HCC) recurrence and development of de novo malignancy (DNM) after liver transplantation (LT) are the major causes of late recipient death.@*METHODS@#We analyzed the incidence of extrahepatic DNM following living donor LT according to the status of pretransplant hepatic malignancy. We selected 2,076 adult patients who underwent primary LDLT during 7 years from January 2010 to December 2016.@*RESULTS@#The pretransplant hepatic malignancy group (n = 1,012) showed 45 cases (4.4%) of the following extrahepatic DNMs: posttransplant lymphoproliferative disease (PTLD) in 10; lung cancer in 10; stomach cancer in 6; colorectal cancer in 5; urinary bladder cancer in 3; and other cancers in 11. The pretransplant no hepatic malignancy group (n = 1,064) showed 25 cases (2.3%) of the following extrahepatic DNMs: colorectal cancer in 3; stomach cancer in 3; leukemia in 3; lung cancer in 3; PTLD in 2; prostate cancer in 2; and other cancers in 9. Incidences of extrahepatic DNM in the pretransplant hepatic malignancy and no hepatic malignancy groups were as follows: 1.1% and 0.5% at 1 year, 3.2% and 2.0% at 3 years, 4.6% and 2.5% at 5 years, and 5.4% and 2.8% at 8 years, respectively (P = 0.006). Their overall patient survival rates were as follows: 97.3% and 97.2% at 1 year, 91.6% and 95.9% at 3 years, 89.8% and 95.4% at 5 years, and 89.2% and 95.4% at 8 years, respectively (P < 0.001). Pretransplant hepatic malignancy was the only significant risk factor for posttransplant extrahepatic DNM.@*CONCLUSION@#Our results suggest that patients who had pretransplant hepatic malignancy be followed up more strictly because they have a potential risk of primary hepatic malignancy recurrence as well as a higher risk of extrahepatic DNM than patients without pretransplant hepatic malignancy.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Gender differences in characteristics of adolescents with suicide attempt at the emergency department

Purpose@#This study was performed to investigate the gender differences in suicide attempts in adolescents. @*Methods@#We reviewed the medical records of adolescents (≤ 18 years) who had visited a university hospital emergency department (ED) for suicide attempts from January 2018 through December 2019. General characteristics of the adolescents, details of the attempt, and outcomes were analyzed. The characteristics were age, gender, the Korean Triage and Acuity Scale, previous attempts, and psychiatric history. The details were initial Glasgow Coma Scale, attempt-arrival time, living alone, method, place, and motivation of the attempt, and concurrent use of alcohol. The outcomes included psychiatric consultation, ED length of stay, and ED outcomes. @*Results@#A total of 86 adolescents were included. Their age ranged from 13 to 18 years, and girls accounted for 65.1%. The girls had more frequent psychiatric history than boys (66.1% vs. 30.0%; P = 0.001) without a significant difference in previous attempts (55.4% vs. 46.7%; P = 0.442). The most common methods of the attempt in the girls and boys were poisoning and sharp objects (53.3% [16 of the 30 boys] vs. 60.7% [34 of the 56 girls]; P = 0.002), respectively. No differences were found in the other details of the attempt and in the rate of psychiatric consultation. The girls had longer ED length of stay (247.0 minutes vs. 186.5; P = 0.033), a lower rate of discharge against medical advice, and higher rates of hospitalization (discharge against medical advice, 53.6% vs. 76.7%; non-psychiatric, 23.2% vs. 3.3%; psychiatric, 12.5% vs. 0%; P = 0.003). @*Conclusion@#Girls may make suicide attempts, usually by poisoning, and undergo relevant hospitalization, more often than boys. In contrast, boys usually use sharp objects, with a higher rate of discharge against medical advice and lower rates of the attempt and hospitalization.

Hepatic Artery Occlusion after Liver Transplantation in Patients with Doppler Ultrasound Abnormality: Increasing Sensitivity of Contrast-Enhanced Ultrasound Diagnosis

OBJECTIVE: To investigate whether diagnostic performance of contrast-enhanced ultrasound (CEUS) could be improved with modified criteria to diagnose significant hepatic artery occlusion (HAO) and to determine the role of CEUS in patients with a tardus-parvus hepatic artery (HA) pattern on Doppler US. MATERIALS AND METHODS: Among 2679 adult liver transplantations performed over 7 years, HAO was suspected in 288 recipients, based on Doppler ultrasound. Among them, 130 patients underwent CEUS. After excluding two technical failures, 128 CEUS images were retrospectively reviewed to search for abnormal findings, such as no HA enhancement, abnormal HA enhancement (delayed, faint, and discontinuous enhancement), and perfusion defect in the liver parenchyma. The performance CEUS abnormalities were assessed in the patients overall and in subgroups based on Doppler ultrasound abnormality (group A, no flow; group B, tardus-parvus pattern) and were compared based on the area under the receiver operating characteristic curve (AUC). RESULTS: HAO were diagnosed in 41 patients by surgery, angiography, or follow-up abnormality. By using the conventional criterion (no HA enhancement) to diagnose HAO in patients overall, the sensitivity, specificity, and AUC were 58.5%, 100%, and 0.793, respectively. Modified criteria for HAO (no HA enhancement, abnormal enhancement, or parenchymal perfusion defect) showed statistically significantly increased sensitivity (97.6%, 40/41) and AUC (0.959) (p < 0.001), although the specificity (95.4%, 83/87) was slightly decreased. The sensitivity and specificity of the modified criteria in Groups A and B were 97.1% (33/34) and 95.7% (22/23), and 100% (7/7) and 95.3% (61/64), respectively. CONCLUSION: Modified criteria could improve diagnostic performance of CEUS for HAO, particularly by increasing sensitivity. CEUS could be useful for diagnosing HAO even in patients with a tardus-parvus HA pattern on Doppler US, using modified criteria.

Determination of Hepatitis B Immunoglobulin Infusion Interval Using Pharmacokinetic Half-life Simulation for Posttransplant Hepatitis B Prophylaxis

BACKGROUND: Prophylaxis for hepatitis B virus (HBV) recurrence is essential after liver transplantation (LT) in HBV-associated recipients. This study established an individualized HBV prophylaxis protocol, through optimization of hepatitis B immunoglobulin (HBIG) administration, with application of simulative half-life (SHL). METHODS: This study involved five parts: Part 1 developed the SHL estimation method with 20 patients; Parts 2 and 3 assessed the SHL variability and developed a simulation model to apply SHL in 100 patients; Part 4 validated the simulation model in 114 patients, and Part 5 was a cross-sectional study on the current status of HBIG infusion intervals in 660 patients. RESULTS: In Part 1, infusion of 10,000 IU HBIG induced add-on rise hepatitis B surface antibody (anti-HBs) titer of 5,252.5 ± 873.7 IU/L, which was 4.4% lower than actual measurement. Mean SHL of 20.0 ± 3.7 days was 2.2% longer than actual measurement. In Part 2, the medians of the intra- and inter-individual coefficient of variation in SHL were 13.5% and 18.5%, respectively. Pretransplant HBV DNA load and posttransplant antiviral therapy did not affect SHL. In Part 3, a simulation model was developed to determine the interval of HBIG infusion, by using SHL. In Part 4, all 114 patients were successfully managed with regular HBIG infusion intervals of ≥ 8 weeks, and the interval was prolonged to ≥ 12 weeks in 89.4%, with a target trough anti-HBs titer ≥ 200 IU/L. In Part 5, 47.4% of our patients received HBIG excessively, at a target trough titer of 500 IU/L. CONCLUSION: SHL estimation using only clinically available parameters seems to be reliably accurate when compared with actual measurements. We believe that SHL estimation is helpful to establish a personalized HBV prophylaxis protocol for optimizing HBIG administration.

A Ruptured Metastatic Hepatic Gastrointestinal Stromal Tumor Treated by Angiographic Embolization / 대한소화기학회지

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumor of the gastrointestinal tract and occur most frequently in the stomach. The liver is the most common metastatic site of a GIST, and spontaneous rupture of the hepatic metastasis of a malignant gastric GIST is rare. We report the case of a 70-year-old man who presented with sudden right lower quadrant abdominal pain and was diagnosed with a spontaneously ruptured hepatic metastasis of a malignant gastric GIST. The patient was successfully managed with transcatheter arterial embolization of the hepatic artery.

Efficient utilization of the limited number of emergency medicine specialists and statistics related to clinical outcomes in the emergency department

OBJECTIVE: The supply of emergency medicine (EM) specialists has not been able to meet demand in the past decade. This study comparatively analyzed clinical findings to provide fundamental data to inform efficient utilization of a limited number of EM specialists. METHODS: This retrospective study included 54,204 patients who visited the emergency department of a tertiary care medical center from March 1 to December 31, 2012. The experimental specialist-supervised (SS) group included patients supervised by an EM specialist, while the control specialist-on-call (SOC) group included patients attended by a senior resident of EM with an EM specialist on call. RESULTS: The mean length of stay in the emergency department was longer in the SS group than in the SOC group for all levels of severe-to-moderate (levels 1 to 3) and mild (levels 4 and 5) patient conditions (P<0.05). The mortality rate of severe-to-moderate patients in the SOC group was 1.63 times higher than that in patient in the SS group. CONCLUSION: Supervision by EM specialists significantly decreased mortality in patients with severe-to-moderate condition. Therefore, EM specialists should focus on this patient group, while training residents should concentrate on patients with relatively mild conditions.

Computed Tomography Findings of Community-Acquired Stenotrophomonas Maltophilia Pneumonia in an Immunocompetent Patient: A Case Report

Stenotrophomonas maltophilia (S. maltophilia) is a rare, but globally emerging gram-negative multiple-drug-resistant organism usually found in a nosocomial setting in immunocompromised patients. To our best knowledge, computed tomography (CT) features of community-acquired S. maltophilia pneumonia have not been previously reported in an immunocompetent patient. Herein, we presented the CT findings of a previous healthy 56-year-old male with S. maltophilia pneumonia.

Spontaneous Bleeding from Internal Pudendal Artery associated with Abciximab after Primary Percutaneous Coronary Intervention: Successful Treatment with Percutaneous Gel-Foam Embolization

We describe a case of spontaneous bleeding from a branch of the right internal pudendal artery that resulted in massive scrotal swelling in a patient who had underwent primary percutaneous coronary intervention with the use of abciximab concurrent with conventional anticoagulation and dual antiplatelet therapies for the treatment of acute ST-segment elevation myocardial infarction. This unusual complication was promptly identified by percutaneous peripheral arteriography and successfully treated with gel-foam embolization.