Effect of Patient Safety Culture and Patient Safety Competence on Safety Nursing Activity among Nurses working in Anesthetic and Recovery Rooms / 임상간호연구

Purpose@#This study was to investigate the relationships among patient safety culture, safety competence and safety nursing activity among nurses in anesthetic and recovery rooms, and to identify the factors contributing to safety nursing activity. @*Methods@#A descriptive correlational study was conducted. Participants were 156 nurses from 13 hospitals. Data were collected from February 11 to March 15th, 2019, and analyzed using descriptive statistics, t-test, Mann-Whitney U test, one-way ANOVA, Pearson's correlation and multiple regression analysis with SPSS statistics 24.0 Program. @*Results@#Safety nursing activity was significantly different in relation to nurses’ level of education, position at work, clinical career, clinical career at anesthetic and recovery rooms, and work experience in patient safety. Safety nursing activity demonstrated a significant positive correlation with patient safety culture and patient safety competence. Factors contributing to safety nursing activity were patient safety knowledge, skill and attitude, clinical career, clinical career at anesthetic and recovery rooms, and the patient safety improvement system which explained 57.0% of total variance of safety nursing activity. @*Conclusion@#To improve safety nursing activities at anesthetic and recovery rooms, it is necessary to develop patient safety programs with enhanced knowledge, skill and attitude to take patient safety as a top priority.

Expression of Neurotrophic Factors, Tight Junction Proteins, and Cytokines According to the Irritable Bowel Syndrome Subtype and Sex

Background/Aims@#Emerging evidence shows that the mechanism of irritable bowel syndrome (IBS) is associated with neurotrophic factors and tight junction proteins (TJPs). It is known that there are sex differences in the pathophysiology of IBS. The aim of the present study is to determine expression levels of neurotrophic factors, TJPs, and cytokines according to IBS subtype and sex. @*Methods@#From 59 IBS (33 IBS-constipation, 21 IBS-diarrhea, and 5 IBS-mixed) and 36 control patients, colonic mucosa mRNA expression levels of transient receptor potential vanilloid-1 (TRPV1), nerve growth factor (NGF), glial cell-derived neurotrophic factor (GDNF), and various TJPs were assessed by real-time polymerase chain reaction. Western blot was performed to determine levels of zonular occludens-1 (ZO-1). Serum levels of cytokines were measured by enzyme-linked immunosorbent assay. @*Results@#TRPV1, GDNF, and NGF mRNA levels were significantly increased in those with IBS-constipation compared to those in controls (all P < 0.05). However, they showed no significant difference between those with IBS-diarrhea and controls. Expression level of TRPV1 correlated with that of GDNF (r = 0.741, P < 0.001) and NGF (r = 0.935, P < 0.001). ZO-1 RNA expression levels were lower (P = 0.021) in female IBS-diarrhea than those in controls, although they showed no significant differences between male IBS-diarrhea and controls. Serum IL-1β levels in female IBS were significantly higher than those of male IBS, especially in IBS-constipation (P < 0.001). @*Conclusion@#Our results suggest that neurotrophic factors and IL-1β are closely related to IBS-constipation and that decrease of ZO-1 is an important factor in female with IBS-diarrhea.

Primary Gastric Small Cell Carcinoma (Presenting as Linitis Plastica) Diagnosed Using Endoscopic Ultrasound-Guided Biopsy: A Case Report

Small cell carcinomas are the most aggressive, highly malignant neuroendocrine tumors; among these, gastric small cell carcinoma (GSCC) is extremely rare. Here we report a case of a patient with primary GSCC, presenting as linitis plastic, who was diagnosed using endoscopic ultrasound (EUS)-guided biopsy. With undiagnosed linitis plastica, an 80-year-old woman was referred to our institution. Abdominal computed tomography revealed irregular wall thickening extending from the gastric body to the antrum. Endoscopy suspected to have Borrmann type IV advanced gastric cancer. EUS of the stomach showed diffuse submucosal thickening of the gastric wall, mainly the antrum. EUS-guided bite-on-bite biopsy confirmed the diagnosis of GSCC. In general, GSCC is difficult to diagnose and careful examination is necessary to determine the therapeutic strategy; however, EUS is particularly helpful in the differential diagnosis of a lesion presenting as linitis plastica.

Outcomes of patients treated with Sengstaken-Blakemore tube for uncontrolled variceal hemorrhage

BACKGROUND/AIMS: The aim of this study was to investigate the mortality, bleeding control rate, and their associated predictors in patients treated with Sengstaken-Blakemore (SB) tube for uncontrolled variceal hemorrhage associated with hemodynamic instability or failure of endoscopic treatment. METHODS: The clinical data of 66 consecutive patients with uncontrolled variceal hemorrhage treated with SB tube at Gyeongsang National University Hospital from October 2010 to October 2015 were retrospectively analyzed. RESULTS: The overall success rate of initial hemostasis with SB tube was 75.8%, and the independent factors associated with hemostasis were non-intubated state before SB tube (odds ratio, 8.50; p = 0.007) and Child-Pugh score < 11 (odds ratio, 15.65; p = 0.022). Rebleeding rate after successful initial hemostasis with SB tube was 22.0%, and esophageal rupture occurred in 6.1%. Mortality within 30 days was 42.4%, and the related independent factors with mortality were failure of initial hemostasis with SB tube (hazard ratio, 6.24; p < 0.001) and endotracheal intubation before SB tube (hazard ratio, 2.81; p = 0.018). CONCLUSIONS: Since the era of endoscopic band ligation, SB tube might be a beneficial option as a temporary salvage treatment for uncontrolled variceal hemorrhage. However, rescue therapy had a high incidence of fatal complication and rebleeding.

Comparison of Tight Junction Protein-Related Gene mRNA Expression Levels between Male and Female Gastroesophageal Reflux Disease Patients

BACKGROUND/AIMS: Male predominance has been observed in the erosive reflux disease (ERD), but reverse finding in nonerosive reflux disease (NERD). This suggests sex-specific medicine approach is needed but its mechanism is remained to be elucidated. We aimed to compare clinical characteristics and mRNA expression levels of tight junction-related proteins between male and female gastroesophageal reflux disease (GERD). METHODS: Sixteen healthy controls, 45 ERD, and 14 NERD patients received upper endoscopies and completed questionnaires. Quantitative real-time polymerase chain reactions of occludin (OCLN), zonal occludens (ZO) 1, claudin-1 (CLDN1) and claudin-4 (CLDN4), and neurokinin 1 receptor (NK1R) were performed in the distal esophageal mucosal specimen. These results were analyzed by sex. RESULTS: Female GERD patients were affected more by reflux symptoms than males. The impairment of overall quality of life was more prominent in female patients with reflux symptoms than male patients (5.6±0.2 vs 4.9±0.6, p=0.009). The levels of OCLN mRNA expression were significantly lower in the male ERD group. On the other hand, those of CLDN1, CLDN4, and NK1R except ZO-1 were significantly higher in the male ERD group. CONCLUSIONS: We demonstrated that female ERD/NERD patients were affected more by GERD and male ERD patients showed significant changes of tight junction protein mRNA expression levels.

Erratum: Moderate to Severe Left Ventricular Ejection Fraction Related to Short-term Mortality of Patients with Post-cardiac Arrest Syndrome after Out-of-Hospital Cardiac Arrest / 대한구급학회지

The author's affiliation should be corrected. We apologize for any inconvenience that may have caused.

Comparison of the Accuracy of Syringes Washed with Heparin, Manually and Heparin Coated Product for Arterial Blood Gas Analysis on Electrolytes and Hemoglobin

PURPOSE: The results of arterial blood gas analysis using conventional liquid sodium heparin syringes are inaccurate due to the dilution effect, chelation of heparin and the electrolyte, and interference of the heparin electrolyte measurement. This study compared the accuracy of using heparin with a liquid sodium heparin syringe (LHs) and balanced lithium/zinc heparin syringe (BHs). METHODS: This study evaluated 6,778 cases who underwent an arterial blood gas test, serum electrolytes test, and complete blood count test among patients aged 18 years or older who visited the emergency room from November 1, 2016 to March 3, 2017. Finally, there were 2,383 cases using LHs and 2,584 cases using BHs. The results were compared between the groups using the LHs and BHs for sodium, potassium, and hemoglobin, and the agreement was compared using the Bland-Altman plot. RESULTS: Sodium difference value was the 5.714±5.696 mmol/L in the LHs group, -1.549±3.339 mmol/L in the BHs group. The potassium difference value was -0.650±0.494 mmol/L (LHs group) and -0.257±0.367 mmol/L (BHs group). The hemoglobin difference values were -0.556±1.116 g/dL (LHs group) and -0.170±1.062 g/dL (BHs group). The results showed that the BHs group was improved compared to the LHs group (p<0.001). CONCLUSION: The results of arterial blood gas analysis of sodium, potassium, and hemoglobin were more accurate for the BHs group than the LHs group based on the serum electrolytes and complete blood counts.

Erratum: Moderate to Severe Left Ventricular Ejection Fraction Related to Short-term Mortality of Patients with Post-cardiac Arrest Syndrome after Out-of-Hospital Cardiac Arrest / 대한중환자의학회지

The author's affiliation should be corrected. We apologize for any inconvenience that may have caused.

The Characteristics of First Suicide Attempt Patients with Self-poisoning: Comparison of Patients with Self-injury

PURPOSE: This study was conducted to compare the characteristics of first suicide attempt patients with self-poisoning with those of self-injured patients. METHODS: In this retrospective data analysis, data were collected from emergency department patients who made a first suicide attempt between October 2013 and January 2017. Data included demographic, socioeconomic, physical and mental health status, method of suicide attempt, and authenticity of suicide intent. Patients were classified into a self-poisoning and self-injury group. RESULTS: Among 2,252 patients, 788 patients were making their first suicide attempt. Of these patients, 443 were self-poisoning patients. Males were less common among the self-poisoning group. Cohabitants (303 [89.4%] vs. 193 [81.4%]; p=0.010), married state (214 [57.4%] vs. 108 [41.2%]; p<0.001), and asking for help after suicide attempt (136 [86.1%] vs. 103 [73.6%]; p=0.009) was more common in the self-poisoning group than the self-injury group. However, planned suicide attempt was more frequent in the self-injury group (26 [16.0%] vs. 9 [4.7%]; p=0.001). Moreover, authenticity of suicide intent was higher in the self-injury group (12 [11.3%] vs. 42 [40.4%]; p<0.001). CONCLUSION: In the self-poisoning group, there was a higher rate of females, married people, existing cohabitants, and tendency to ask for help after suicide attempt. There were also more impulsive suicide attempts in this group. The results presented herein will help prevent self-poisoning suicide attempts among high risk patients.

Comparison of Epidemiology and Outcomes of Patients with Intentional Poisoning by Age Groups: Single Center Observation Study

PURPOSE: This study was conducted to compare demographic and characteristic differences in self-poisoned patients by age groups using a comprehensive trauma database. METHODS: This study included 1,823 patients who were admitted to the emergency room following self-poisoning. Three age groups were defined: young patients (less than 19 years), adult patients (19 to 64 years) and elderly patients (65 years and old). From January 2011 to December 2015, data were obtained from in a single emergency medical center. We investigated the materials of poisoning, ingestion time, GCS, systolic blood pressure, heart rate, and outcomes of patients. RESULTS: A total of 1,823 self-poisoned patients visited the hospital during 5 years. Among these, 130 (7.1%) were categorized as young, 1,460 (80.1%) were adults and 233 (12.8%) were elderly. The most common drug of self-poisoning substances was antipyretics (50.0%) for those in the young group, sedative drugs (45.0%) for adults, and pesticides (41.2%) for the elderly. Mortality was 2.7% in the adult group and 14.6% in the elderly group. After adjusting for all factors related to mortality, the odds ratio (OR) of mortality was 2.63 in the elderly group (95% confidence interval [CI]: 1.44-4.81). CONCLUSION: There were definite differences in the characteristics of three groups. The younger patients used drugs that could be easily obtained while older patients used more lethal drugs.

Moderate to Severe Left Ventricular Ejection Fraction Related to Short-term Mortality of Patients with Post-cardiac Arrest Syndrome after Out-of-Hospital Cardiac Arrest / 대한구급학회지

BACKGROUND: The aim of this study was to investigate the relationships between left ventricular ejection fraction (LVEF) and mortality and neurologic outcomes with post-cardiac arrest syndrome (PCAS) after out-of-hospital cardiac arrest (OHCA). METHODS: Patients with PCAS after OHCA admitted to the intensive care unit between January 2014 and December 2015 were analyzed retrospectively. RESULTS: total of 104 patients were enrolled in this study. The mean age was 54.4 ± 15.3 years, and 75 of the patients were male (72.1%). Arrest with a cardiac origin was found in 55 (52.9%). LVEF 55% was measured in 39 (37.5%), 18 (17.3%), and 47 (45.2%) of patients, respectively. In multivariate analysis, severe LV dysfunction (LVEF < 45%) was significantly related to 7-day mortality (odds ratio 3.02, 95% Confidence Interval 1.01-9.0, p-value 0.047). CONCLUSIONS: In this study, moderate to severe LVEF within 48 hours after return of spontaneous circulation was significantly related to 7-day short-term mortality in patients with PCAS after OHCA. Clinicians should actively treat myocardial dysfunction, and further studies are needed.

Moderate to Severe Left Ventricular Ejection Fraction Related to Short-term Mortality of Patients with Post-cardiac Arrest Syndrome after Out-of-Hospital Cardiac Arrest / 대한중환자의학회지

BACKGROUND: The aim of this study was to investigate the relationships between left ventricular ejection fraction (LVEF) and mortality and neurologic outcomes with post-cardiac arrest syndrome (PCAS) after out-of-hospital cardiac arrest (OHCA). METHODS: Patients with PCAS after OHCA admitted to the intensive care unit between January 2014 and December 2015 were analyzed retrospectively. RESULTS: total of 104 patients were enrolled in this study. The mean age was 54.4 ± 15.3 years, and 75 of the patients were male (72.1%). Arrest with a cardiac origin was found in 55 (52.9%). LVEF 55% was measured in 39 (37.5%), 18 (17.3%), and 47 (45.2%) of patients, respectively. In multivariate analysis, severe LV dysfunction (LVEF < 45%) was significantly related to 7-day mortality (odds ratio 3.02, 95% Confidence Interval 1.01-9.0, p-value 0.047). CONCLUSIONS: In this study, moderate to severe LVEF within 48 hours after return of spontaneous circulation was significantly related to 7-day short-term mortality in patients with PCAS after OHCA. Clinicians should actively treat myocardial dysfunction, and further studies are needed.

The Prognostic Factors of Pneumonia with Septic Shock in Patients Presenting to the Emergency Department / 대한구급학회지

BACKGROUND: Pneumonia is the most common cause of death among patients with infectious disease in Korea. However, studies of pneumonia with septic shock in patients presenting to the emergency department are limited. The aim of this study was to investigate the prognostic factors associated with pneumonia with septic shock in patients presenting to the emergency department. METHODS: From January 2008 to September 2014, patients with pneumonia with septic shock admitted through the emergency department were retrospectively examined. RESULTS: Of the 561,845 patients who visited the emergency department, 398 were admitted for pneumonia with septic shock. The 28-day mortality rate in these patients was 36.4%. The independent prognostic factors were old age (>70 yrs) (odds ratio [OR], 2.42; 95%, confidence interval [CI], 1.35-4.32), Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 1.04; 95% CI, 1.01-1.08), leukopenia (OR, 3.63; 95% CI, 1.48-8.94), prolonged PT-INR (OR, 2.53; 95% CI, 1.41-4.54), and hypoxemia (OR, 2.88; 95% CI, 1.30-6.38). CONCLUSIONS: A poor prognosis of patients with pneumonia is associated with old age (>70 yrs), increased APACHE II score, leukopenia, prolonged PT-INR, and hypoxemia.

Brain Magnetic Resonance Imaging in Patients with Favorable Outcomes after Out-of-Hospital Cardiac Arrest: Many Have Encephalopathy Even with a Good Cerebral Performance Category Score / 대한구급학회지

BACKGROUND: The aim of this study was to retrospectively evaluate and analyze the brain magnetic resonance imaging (B-MRI) findings of patients with a favorable neurological outcome following cerebral performance category (CPC) after out-of-hospital cardiac arrest (OHCA) at single university hospital emergency center. METHODS: Patients with return of spontaneous circulation (> 24 h) after OHCA who were older than 16 years of age and who had been admitted to the emergency intensive care unit (EICU) for over a 57-month period between July 2007 and March 2012 and survived with a favorable neurological outcome were enrolled. B-MRI was taken after recovery of their mental status. RESULTS: Fifty-two patients among the 305 admitted patients had a good CPC, and 33 patients' B-MRI were analyzed (CPC 1: 26 patients, CPC 2: 7 patients). Among these, 18 (54.5%) patients had a normal finding on B-MRI. On the other hand, ischemia/infarction/microangiopathy compatible with hypoxic-ischemic encephalopathy (HIE) were found on various brain areas including subcortical white matter (7/13), cerebral cortex, central semiovlae, basal ganglia, putamen, periventricular white matter, and cerebellum. CONCLUSIONS: Survivors with a favorable neurological outcome from OHCA showed HIE on B-MRI, especially all of the patients with a CPC 2. More detail neurologic category including brain imaging would be needed to categorize patients with favorable outcome after OHCA.

Disaster Medical Responses to the Disaster Scene of Long-distance on Highway-Field Triage and Disaster Communication by Social Media for 106-vehicle Chain Collision in Yeong- Jong Grand Bridge

PURPOSE: This study describes the disaster medical responses to the disaster scene of long-distance on a highway; 106-vehicle chain collision on Yeong-Jong Grand Bridge on February 11, 2015 and we discuss the disaster communication by social media. METHODS: Records of disaster medical responses from records of relevant organizations and messages of social media were collected. Medical records and the results of triage were reviewed retrospectively. Casualties were categorized into four groups according to results of triage; Red- Yellow-Green-Black. Kappa statistics were used to measure agreement between results of triage and casualties' outcome. RESULTS: Disaster Medical Assistant Team (DMAT) arrived on the scene one hour after accidents occurred. DMAT settled in a temporary base camp in the middle part of the scene and did not build an emergency air shelter. DMATs from four hospitals were separated into four mobile units of DMAT and they joined the rescue team. Disaster communication by social media was useful. Seventy six casualties were transported and two died; 28.9% of casualties were transported to the nearest regional emergency medical center; 20.0% of red casualties were transported to a higher level of care again. Kappa statistics were 0.122 (95% CI, - 0.049~0.291; p=0.094). CONCLUSION: In the disaster scene of long-distance on a highway, adequate location of triage and treatment area may be the front or rear of the scene and separation of DMATs can be helpful. Disaster communication by social media was helpful. Education and policies will be required for more effective triage and dispersion of casualties.

Differences in Hands-off Time According to the Position of a Second Rescuer When Switching Compression in Pre-hospital Cardiopulmonary Resuscitation Provided by Two Bystanders: A Randomized, Controlled, Parallel Study

The change of compressing personnel will inevitably accompany hands off time when cardiopulmonary resuscitation (CPR) is performed by two or more rescuers. The present study assessed whether changing compression by a second rescuer located on the opposite side (OS) of the first rescuer can reduce hands-off time compared to CPR on the same side (SS) when CPR is performed by two rescuers. The scenario of this randomized, controlled, parallel simulation study was compression-only CPR by two laypersons in a pre-hospital situation. Considering sex ratio, 64 participants were matched up in 32 teams equally divided into two gender groups, i.e. , homogenous or heterogeneous. Each team was finally allocated to one of two study groups according to the position of changing compression (SS or OS). Every team performed chest compression for 8 min and 10 sec, with chest compression changed every 2 min. The primary endpoint was cumulative hands-off time. Cumulative hands-off time of the SS group was about 2 sec longer than the OS group, and was significant (6.6 +/- 2.6 sec vs. 4.5 +/- 1.5 sec, P = 0.005). The range of hands off time of the SS group was wider than for the OS group. The mean hands-off times of each rescuer turn significantly shortened with increasing number of turns (P = 0.005). A subgroup analysis in which cumulative hands-off time was divided into three subgroups in 5-sec intervals revealed that about 70% of the SS group was included in subgroups with delayed hands-off time > or = 5 sec, with only 25% of the OS group included in these subgroups (P = 0.033). Changing compression at the OS of each rescuer reduced hands-off time compared to the SS in prehospital hands-only CPR provided by two bystanders.

The Prognostic Factors of Pneumonia with Septic Shock in Patients Presenting to the Emergency Department / 대한중환자의학회지

BACKGROUND: Pneumonia is the most common cause of death among patients with infectious disease in Korea. However, studies of pneumonia with septic shock in patients presenting to the emergency department are limited. The aim of this study was to investigate the prognostic factors associated with pneumonia with septic shock in patients presenting to the emergency department. METHODS: From January 2008 to September 2014, patients with pneumonia with septic shock admitted through the emergency department were retrospectively examined. RESULTS: Of the 561,845 patients who visited the emergency department, 398 were admitted for pneumonia with septic shock. The 28-day mortality rate in these patients was 36.4%. The independent prognostic factors were old age (>70 yrs) (odds ratio [OR], 2.42; 95%, confidence interval [CI], 1.35-4.32), Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 1.04; 95% CI, 1.01-1.08), leukopenia (OR, 3.63; 95% CI, 1.48-8.94), prolonged PT-INR (OR, 2.53; 95% CI, 1.41-4.54), and hypoxemia (OR, 2.88; 95% CI, 1.30-6.38). CONCLUSIONS: A poor prognosis of patients with pneumonia is associated with old age (>70 yrs), increased APACHE II score, leukopenia, prolonged PT-INR, and hypoxemia.

Brain Magnetic Resonance Imaging in Patients with Favorable Outcomes after Out-of-Hospital Cardiac Arrest: Many Have Encephalopathy Even with a Good Cerebral Performance Category Score / 대한중환자의학회지

BACKGROUND: The aim of this study was to retrospectively evaluate and analyze the brain magnetic resonance imaging (B-MRI) findings of patients with a favorable neurological outcome following cerebral performance category (CPC) after out-of-hospital cardiac arrest (OHCA) at single university hospital emergency center. METHODS: Patients with return of spontaneous circulation (> 24 h) after OHCA who were older than 16 years of age and who had been admitted to the emergency intensive care unit (EICU) for over a 57-month period between July 2007 and March 2012 and survived with a favorable neurological outcome were enrolled. B-MRI was taken after recovery of their mental status. RESULTS: Fifty-two patients among the 305 admitted patients had a good CPC, and 33 patients' B-MRI were analyzed (CPC 1: 26 patients, CPC 2: 7 patients). Among these, 18 (54.5%) patients had a normal finding on B-MRI. On the other hand, ischemia/infarction/microangiopathy compatible with hypoxic-ischemic encephalopathy (HIE) were found on various brain areas including subcortical white matter (7/13), cerebral cortex, central semiovlae, basal ganglia, putamen, periventricular white matter, and cerebellum. CONCLUSIONS: Survivors with a favorable neurological outcome from OHCA showed HIE on B-MRI, especially all of the patients with a CPC 2. More detail neurologic category including brain imaging would be needed to categorize patients with favorable outcome after OHCA.

The Analysis of Factors Related to Reaching to Therapeutic Range in Patients with Receiving Therapeutic Hypothermia after Return of Spontaneous Circulation after Out-of hospital Cardiac Arrest

PURPOSE: The relationship between prognostic factors and outcomes of post-cardiac arrest patients treated with therapeutic hypothermia was analyzed. METHODS: We conducted a tertiary center retrospective study of post-cardiac arrest patients treated with therapeutic hypothermia between January 2008 and December 2012. We investigated the association of the following factors with outcomes: BMI, time to ROSC, number of vasoactive drugs, smoking, alcohol, and short time to therapeutic range in hypothermia. RESULTS: A total of 251 patients were enrolled in this study. Large number of vasoactive drugs was a prognostic factor of 3-month mortality (adjusted OR 1.96, 95% CI:1.41-2.71, p or =25 kg/m2) was not associated with delayed time to therapeutic range in hypothermia. Both univariate and multivariate analysis showed that high initial BT (beta(SE)=63.64 (11.53), p<0.001) and a small number of vasoactive drugs (beta(SE)=18.66(8.74), p=0.034) were independent predictors of delayed time to therapeutic range in hypothermia. CONCLUSION: In this study, a small number of vasoactive drugs showed a significant influence on delayed time to therapeutic range in patients receiving therapeutic hypothermia after return of spontaneous circulation after out-of-hospital cardiac arrest.

Primary Non-ampullary Duodenal Adenocarcinoma: A Single-center Experience for 15 Years / 대한소화기학회지

BACKGROUND/AIMS: Primary non-ampullary duodenal adenocarcinomas (PNADAs) comprise or =2 mg/dL (OR, 85.28; 95% CI, 3.77-1,938.79; p=0.005) and distant metastasis (OR, 26.74; 95% CI, 3.13-2,328.14; p=0.003) at the time of diagnosis were independent poor prognostic factors. CONCLUSIONS: The majority of patients were diagnosed at an advanced stage. Presence of distant metastasis was independent prognostic factor of PNADA together with elevated total bilirubin.