Current status of and problems in the Korean Medical Association’s governance

The year 2020 marks the 112th year of the Korean Medical Association (KMA), which is a historic organization of medical experts. Since its foundation the KMA has contributed to the promotion of the health and medical care environment as well as the establishment and development of related policies. In times of health and medical care crises in the country, the KMA has always fought at the front lines. However, recent internal conflicts in the medical community have caused a lack of consistency and persistence in responding to or pursuing various health and medical policies. It weakens the KMA’s social status and influence, raising demands for its improvement. The first step for the betterment of the KMA is to analyze its critical situation. This study assumes that the internal conflicts are caused by the KMA’s governance. Through an analysis of how the KMA is currently governed, this study highlights the problems and suggests a direction for improvement.

Comparative and retrospective evaluation of the predictive performance of optic nerve sheath thickness and optic nerve sheath diameter for traumatic brain injury using facial computed tomography

Objective@#To evaluate the predictive performance of optic nerve sheath thickness (ONST) on the outcomes of traumatic brain injury (TBI) and to compare the inter-observer agreement To evaluate the predictive performance of optic nerve sheath thickness (ONST) for traumatic brain injury (TBI) and to compare the predictive performance and inter-observer agreement between ONST and optic nerve sheath diameter (ONSD) on facial computed tomography (CT). @*Methods@#We retrospectively enrolled patients with a history of facial trauma and who underwent both facial CT and brain CT. Two reviewers independently measured ONST and ONSD of each patient using facial CT images. Final brain CT with clinical outcome was used as the reference standard for TBI. Multivariate logistic regression analyses, receiver operating characteristic (ROC) curves, and intraclass correlation coefficients were used for statistical analyses. @*Results@#Both ONST (P=0.002) and ONSD (P=0.001) on facial CT were significantly independent factors to distinguish between TBI and healthy brains; an increase in ONST and ONSD values corresponded with an increase in the risk of TBI by 8.9- and 7.6-fold, respectively. The predictive performances of the ONST (sensitivity, 96.2%; specificity, 94.3%; area under the ROC curve, 0.968) and ONSD (sensitivity, 92.6%; specificity, 90.2%; area under the ROC curve, 0.955) were excellent and exhibited similar sensitivity, specificity, and area under the curve (P=0.18–0.99). Interobserver and intraobserver intraclass correlation coefficients for ONST were significantly higher than those for ONSD (all P<0.001). @*Conclusion@#ONST on facial CT is a feasible predictor of TBI and demonstrates similar performance and superior observer agreement than ONSD. We recommend using ONST measurements to assess the need for additional brain CT scans in TBI-suspected cases.

Clinical Manifestations of Contrast Media Extravasation in the Emergency Department and the Ward

PURPOSE@#Contrast media extravasation (CME) is an adverse reaction after administration of contrast media during CT examinations. The purpose of this study was to evaluate the frequency, management, and outcomes of extravasations and to assess the risk factors for CME in the emergency department (ED) and the ward.@*MATERIALS AND METHODS@#This retrospective study was conducted at a single academic urban hospital from January 2013 to December 2015. We analyzed the medical records of all patients who experienced CME after undergoing a CT scan. We compared the patients' age, sex, underlying disease, injection site, injection flow rate, time of CT examination, type of CT examination, and severity of injury between those in the ED and the ward.@*RESULTS@#CME occurred in 41 (0.36%) of 114767 patients, which included 16 (0.34%) in the ED and 25 (0.37%) in the ward. Both groups were more frequent in those aged older than 60 years and in female. Additionally, the abdominopelvic CT type and 2–3 mL/s as the injection rate were more common in both groups. However, CME was more frequent during the nighttime (10, 62.5%) in the ER, while it was more common in the daytime (14, 56.0%) in the ward. Severe complications were more frequent in the ER (9, 56.3%) compared with the ward (8, 32.8%). There were no significant differences in CME between the ED and the ward. When comparing the clinical manifestations in the mild and severe groups, the antecubital fossa (33.3% and 0%, respectively; p = 0.013) for the injection site and abdominopelvic CT (41.7% and 82.4%, respectively; p = 0.012) and CT angiography (41.7% and 5.87%, respectively; p = 0.014) for the CT examination showed significant differences between the mild and severe groups.@*CONCLUSION@#In this study, there were no significant clinical differences in CME between the ED and ward. Thus, prevention is more important than the place of admission. Radiologists and emergency physicians should pay attention to CME in the ED because it frequently occurs at night and results in more severe complications.

Risk factors for hospital admission in revisiting patients to the emergency department with abdominal pain

OBJECTIVE: The aim of this study was to identify the clinical characteristics and risk factors associated with the admission of patients in the emergency department (ED) within 30 days after discharge. METHODS: A retrospective, observational study was conducted on adult patients presenting with abdominal pain to the ED of a single, urban, university hospital, between January 2014 and December 2015, who revisited the ED within 30 days after discharge. Data was collected on the emergency severity index level, time to contact doctors, physical examination, laboratory tests, use of computed tomography (CT), and patient disposition on revisitation. The primary outcome was hospital admission following an ED revisit in the 30-day period after the first visit. RESULTS: During the study period, 19,480 patients visited the ED with the chief complaint of abdominal pain, and 13,577 were discharged. A total of 251 patients (1.29%) revisited the ED within 30 days, of which 89 were eligible for the study. The primary outcome was associated with not performing a CT scan on the initial visit and an increased C-reactive protein (CRP) value. Receiver operating characteristic curve analysis showed that a cut-off baseline CRP value of >0.35 mg/dL can predict the primary outcome with a sensitivity and specificity of 75% and 62.1%, respectively (area under the curve, 0.701; 95% confidence interval, 0.569–0.833; P=0.007). CONCLUSION: An increased CRP value and not performing abdominal CT were associated with a higher rate of admission following ED revisits of patients with abdominal pain. Future prospective studies on the role of abdominal CT imaging in patients presenting to the ED with abdominal pain will be needed.

Neutrophil-to-lymphocyte Ratio as A Predictor of Aspiration Pneumonia in Drug Intoxication Patients

PURPOSE: To evaluate the association between neutrophil-to-lymphocyte ratio (NLR) and occurrence of aspiration pneumonia in drug intoxication (DI) patients in the emergency department (ED) and to evaluate the relationship between NLR and length of hospital admission/intensive care unit (ICU) admission. METHODS: A total of 466 patients diagnosed with DI in the ED from January 2016 to December 2017 were included in the analysis. The clinical and laboratory results, including NLR, were evaluated as variables. NLR was calculated as the absolute neutrophil count/absolute lymphocyte count. To evaluate the prognosis of DI, data on the development of aspiration pneumonia were obtained. Also, we evaluated the relationship between NLR and length of hospital admission and between NLR and length of ICU admission. Statistically, multivariate logistic regression analyses, receiver-operating characteristic (ROC) curve analysis, and Pearson's correlation (ρ) were performed. RESULTS: Among the 466 DI patients, 86 (18.5%) developed aspiration pneumonia. Multivariate logistic regression analysis revealed NLR as an independent factor in predicting aspiration pneumonia (odds ratio, 1.7; p=0.001). NLR showed excellent predictive performance for aspiration pneumonia (areas under the ROC curves, 0.815; cut-off value, 3.47; p 3.47).

Cervical Spine Epidural Hematoma Disguised as Acute Ischemic Stroke: A Case Report

Cervical spine epidural hematoma is a rare disease, which can sometimes be misdiagnosed as acute ischemic stroke when a patient shows hemiparesis. A 68-year-old woman visited the emergency department with right side motor weakness without signs of facial palsy or cranial nerve deficit. She also complained of accompanying neck pain. Acute ischemic stroke was suspected initially and a non-contrast computed tomography of the brain was taken, which showed no cerebral hemorrhage. Brain and cervical spine magnetic resonance imaging (MRI) was performed for further evaluation. No evidence of cerebral infarction. However, an epidural hematoma was detected on cervical spine MRI. The patient was consulted to the neurosurgery department and decompressive laminectomy and hematoma evacuation was performed. Emergency physicians should consider cervical spine epidural hematoma in cases of sudden onset hemiparesis with accompanying neck pain.

Cervical Spine Epidural Hematoma Disguised as Acute Ischemic Stroke: A Case Report

Cervical spine epidural hematoma is a rare disease, which can sometimes be misdiagnosed as acute ischemic stroke when a patient shows hemiparesis. A 68-year-old woman visited the emergency department with right side motor weakness without signs of facial palsy or cranial nerve deficit. She also complained of accompanying neck pain. Acute ischemic stroke was suspected initially and a non-contrast computed tomography of the brain was taken, which showed no cerebral hemorrhage. Brain and cervical spine magnetic resonance imaging (MRI) was performed for further evaluation. No evidence of cerebral infarction. However, an epidural hematoma was detected on cervical spine MRI. The patient was consulted to the neurosurgery department and decompressive laminectomy and hematoma evacuation was performed. Emergency physicians should consider cervical spine epidural hematoma in cases of sudden onset hemiparesis with accompanying neck pain.

A Study on the Patients with Hansen's Disease who Experienced Suicidal Urge and Overcame Suicide / 나학회지

This research analyzed the structural dynamics about neglected and isolated patients with Hansen's disease who experienced suicidal urge and overcame suicide. The research found the way to prevent them from killing themselves by searching what triggered the suicidal urge and how they got over the temptation. The participants were 6 members who lived in the group home. They had been excluded from the community and their family. They were trafficked for forced labor from their group home. This experience had caused suicidal urge before they came to the group home. To know how they overcame suicidal urge, they were interviewed by using semi-structured opened ended questions. According to the interview, there are four reasons that stopped the suicidal urge. The participants said that the first reason to stop thinking about death is the belief. This is a reliance on almighty God. Because the place where they live together is run by the Catholic Foundation, the community spirit and their belief are thought as the particular reason. Second, they got an economical and emotional support from their group home. Their group home provided food, clothing, and shelter, which were never provided from their family and society. By living together with other patients, they strengthened their emotional relationship and made a new social community. Next, they were getting generous when they belonged here. They accepted social prejudice without confronting unreasonable issues. Last, they changed their aim of life. They decided to live happily for good. They thought it could be the only way to take revenge to people who ignored and excluded them from the society. That is, they found the certain goal of their life by making new social relationship from the group home which could be called their real home. Also, they were helping one another in their community in various ways. As a result, this facility provided emotional and financial support and cooperating systems to people who were living together. From the investigation going along, social relationship is thought as the main factor of overcoming suicide. So, it is necessary to build social relationship to interact with other people who are in the same oven. It is also important to make well established motional and financial support from the society. On the basis of data furnished by this research, it is essential to develop infrastructure for overcoming suicide of the neglected people beside patients with Hansen's disease.

Spontaneous Uterine Perforation from Pyometra: A Case Report

Pyometra is the accumulation of pus in the uterine cavity. The incidence of pyometra in elderly patients is approximately 13.6%. Abdominal pain, fever, and vaginal discharge are the usual symptoms, but about half of the cases of uncomplicated pyometra have no specific symptoms. Spontaneous uterine rupture, resulting from complications of pyometra, is extremely rare. We report a case of spontaneous uterine rupture due to pyometra. A 77-year-old female patient who complained of nausea, abdominal pain, and poor oral intake (which started the day before) was transferred from the local hospital after having taken an abdominal CT. She had been bedridden for a year and had a history of hypertension, cerebral infarction, and colon cancer (for which she had a successful operation 12 years prior). Upon arrival, the patient was alert and her vital signs were: blood pressure of 113/78 mmHg, temperature of 36.9degrees C, respiratory rate of 22/min, and a pulse rate of 99/min. Her bowel sound was normal and physical examinations indicated a rigid abdomen with tenderness and rebound tenderness. Free air was observed in the abdominal CT and panperitonitis, due to uterine perforation resulting from pyometra, was also suggested. Hence, an emergency operation was undertaken. During the operation, the fundus of the uterus was found to be perforated with a 1 cmx1 cm-sized passage and a purulent discharge was apparent. Both the adnexa and bowel showed adhesion, but there was no bowel perforation or evident cancerous lesion. Entercoccus faecalis was cultured from both the cervical discharge and tissue obtained during operation. In summary, emergency physicians may consider uterine perforation due to pyometra in elderly woman with peritonitis.

Leg Weakness After An Automobile Accident Due To Spinal Cord Ischemia: A Case Report

Anterior spinal artery syndrome, also known as Beck's syndrome, is defined as ischemia or infarction of the spinal cord. Beck's syndrome occurs from aortic thrombus, embolism, or dissection blocking the blood flow to the great radicular artery (GRA) of Adamkiewicz. Abdominal artery embolism due to trauma is relatively rare and urgent detection of vascular injury is substantial to fair clinical outcome of the patient, therefore, we report on a case of traumatic artery dissection presenting as lower leg weakness.

The Influence of Wearing a Helmet on Facial Fractures Patterns in Injured Motorcycle Riders

PURPOSE: This study was undertaken in order to identify the influence of wearing a head protective device (helmet) on facial fracture patterns in injured motorcycle riders. METHODS: We retrospectively reviewed the medical records of patients who underwent facial bone computed tomography (CT) resulting from motorcycle riding injuries between May 2009 and July 2011. Data collected included age, gender, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), status of helmet use, alcohol intake, time of accident, seating position of the rider, traumatic head injury (THI) measure and facial fracture patterns. Facial fracture patterns were grouped as fracture of the upper-face (orbits), mid-face (maxilla, zygoma, nose) and lower-face (mandible). We assessed the association between facial fracture patterns and helmet use. RESULTS: Of the 180 patients included in this study, 163 (90.6%) were male, 60 (33.3%) suffered facial fracture, 85 (47.2%) wore a helmet and 30 (16.7%) suffered THI. Their mean age was 28.7+/-14.6 years. Between the helmeted and unhelmeted groups, there was statistically significant difference in age, GCS, RTS and THI. There was no significant association between wearing a helmet and type of facial fracture. Multivariate logistic regression analysis demonstrated that age was the only factor influencing helmet use. CONCLUSION: Wearing a helmet prevented traumatic head injury but did not prevent any particular type of facial fractures in the injured motorcycle riders assessed in this study.

Retrospective Validation of the San Francisco Syncope Rule for Predicting Serious Outcomes in a Korean Emergency Department

PURPOSE: Syncope in a common condition that is typically benign but is occasionally associated with mortality. We conducted a retrospective validation of the San Francisco Syncope Rule (SFSR) for use in identifying emergency department (ED) syncope patients with short-term serious outcomes. METHODS: We studied 131 syncope patients who were admitted to or visited the out-patient department within 1 month of an ED visit related to syncope from January to December 2010. Patients meeting the inclusion criteria as defined in the SFSR derivation were evaluated for 5 previously derived predictor variables: abnormal electrocardiography (ECG), shortness of breath, hematocrit <30%, triage systolic blood pressure <90 mm Hg, and a history of congestive heart failure. Predetermined outcome measures as defined by the SFSR included death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing or likely to cause a return ED visit and hospitalization, or related event. RESULTS: The patient group consisted of 63 males and 68 females with an average age of 56 years. 35(26.7%) patients met the predetermined criteria for serious outcome. 10 of 35(28.6%) patients with a serious outcome were not identified as high risk using the rule. The rule performance for predicting serious outcomes included a sensitivity of 71.4% (95% confidence interval (CI), 56% to 86%), specificity of 69.8% (95% confidence interval (CI), 69% to 70%) and positive predictive value of 47.3%. CONCLUSION: In this retrospective validation study in Korea, the SFSR performed with comparable specificity but with significantly lower sensitivity than reported in the original study. Implementing the rule would significantly increase admission rates.

Bronchial Ruptures after Blunt Trauma in Two Patients: Different Time of Diagnosis and Different Prognosis

Bronchial injury due to blunt trauma is often associated with other significant injuries; as a result, making a rapid diagnosis can be difficult. Delay of early diagnosis and surgical treatment can result in a fatal course, including persistent pneumothorax, soft tissue emphysema, lung collapse, recurrent infection, or death. Bronchoscopy remains a reliable diagnostic method; however, it is difficult to perform in the emergency department. In some cases, suspicion of emergency physicians, depending on findings observed on computed tomography scan, can be more helpful than bronchoscopy. In this article, we present two cases of bronchial injury after blunt chest trauma; differences in prognosis were dependent on the time taken to make a decision.

Decision Factors in Performance of Intravenous Contrast-enhanced Computed Tomography for Patients with Acute Flank Pain in an Emergency Department

PURPOSE: The aim of this study is to determine decision factors for performance of intravenous (IV) contrast-enhanced computed tomography (CT) for patients with acute flank pain in an emergency department. METHODS: We evaluated patients who presented with acute flank pain and underwent IV contrast-enhanced CT from January 2010 to June 2011. The IV contrast-enhanced CT useful group was defined as patients whose CT findings were equal to the final diagnosis. But urolithiasis was an exception, because enhanced CT is not useful in making the final diagnosis. We conducted a comparison of clinical characteristics and laboratory findings between the IV contrast-enhanced CT useful group and the not useful group. We then performed logistic regression analysis for analysis of independent predictors. RESULTS: A total of 166 patients were enrolled in this study. The IV contrast-enhanced CT useful group included 41 (24.7%) patients. Results of logistic regression analysis demonstrated that right upper quadrant tenderness (p=0.023), right lower quadrant tenderness (p=0.037), and negative hematuria (p=0.007) were independent predictors for the IV contrast-enhanced CT useful group. CONCLUSION: In patients with acute flank pain, performance of IV contrast-enhanced CT is useful for detection of alternative findings in the presence of right upper quadrant tenderness, right lower quadrant tenderness, and negative hematuria.

Spontaneous Intramural Intestinal Hematoma: A Rare Complication of Anticoagulation

Spontaneous intramural intestinal hematoma is a rare complication resulting from over-anticoagulation. We report on three uncommon cases of spontaneous intramural small bowel hematoma due to oral anticoagulation. The patients received conservative treatment with bowel rest, hydration and vitamin K infusion, and transfusion of fresh frozen plasma (FFP). Computed tomography (CT) scan was performed for diagnostic confirmation. Patients recovered within a few days. Because there are no specific symptoms or clinical signs, diagnosis of this condition is difficult. Therefore, clinical suspicion and experience are important. This case report represents an attempt to share information on this rare condition by presentation of the case and literature review.

Factors Related to Subarachnoid Hemorrhage as a Cause of Out-of-Hospital Cardiac Arrest

PURPOSE: Subarachnoid hemorrhage (SAH) is a common cause of out-of-hospital cardiac arrest (OHCA). Early identification of patients with SAH induced OHCA may be helpful to emergency physicians when making therapeutic decisions. We conducted an investigation of the incidence and characteristics of patients with OHCA caused by non-traumatic SAH. METHODS: We conducted a retrospective review of cases of 236 OHCA survivors who had visited the emergency department (ED) of an urban tertiary care university hospital from January 2004 to December 2010. We excluded patients for whom there was an obvious cause or trauma. Clinical characteristics of SAH induced OHCA survivors were compared with those of SAH negative OHCA survivors. RESULTS: A total of 26 patients (19.11%) had been diagnosed with SAH. Compared with SAH negative survivors, SAH positive survivors were more likely to be female (odds ratio OR, 1.262; 95% confidence interval CI, 1.300-9.605), not to have Diabetes mellitus (OR, 0.180; 95% CI, 0.037-0.879), and to have a short duration of CPR time (OR, 1.074; 95% CI, 1.003-1.150). Results of the Cardiac Troponin T assay were less likely to be positive in patients with SAH induced OHCA, compared to those with SAH negative OHCA (OR, 0.071; 95% CI, 0.008-0.526). CONCLUSION: SAH is a more frequent cause of OHCA than originally believed. Immediate brain CT scan is useful in diagnosis of SAH when patient characteristics include: female, non diabetes mellitus, short duration of CPR time, or negative TnT.

New Onset Cigarette Smoking-Induced Acute Eosinophilic Pneumonia: Case Report and Review of the Literature

Acute eosinophilic pneumonia is characterized by an acute fever, respiratory distress, bilateral pulmonary infiltrate on chest radiograph, an increase of eosinophils in bronchoalveolar lavage and good response to corticosteroid therapy. The cause of this disease is not well-known, although cigarette smoking may be an associated factor. We present the case of a 19-year-old woman suspected to have cigarette smoking-induced acute eosinophilic pneumonia. The patient had commenced smoking 14 days prior to this event. At first, the patient was diagnosed with infectious pneumonia that was not responsive to antibiotics. Based on broncho-alveolar lavage findings, acute eosinophilic pneumonia was diagnosed. Symptoms improved after corticosteroid therapy. Emergency physicians should be aware of the possibility of acute eosinophilic pneumonia in young patients with new onset smoking history.

A Case of Lemierre Syndrome as a Cause of Revisiting the Emergency Department

Lemierre syndrome is a rare, but potentially life-threatening complication of oropharyngeal infection. This syndrome is characterized by oropharyngeal infection leading to internal jugular vein thrombosis and multiple pulmonary septic emboli. It is commonly caused by an anaerobic pathogen such as Fusobacterium necrophorum. Early diagnosis and appropriate antibiotic treatment make a world of difference in preventing fatal outcomes. Here we present the case of a 25-year-old man with acute tonsillitis that was complicated with Lemierre syndrome. Emergency physicians should consider the possibility of Lemierre syndrome in young patients with initial oropharyngeal infection with neck swelling and pulmonary symptoms.

Effect of Alcohol on Base Deficit in Trauma

PURPOSE: Alcohol intake is commonly found in injured patients, and alcohol affects base deficit independently with trauma. The purpose of this study was to evaluate the effect of alcohol on base deficit in trauma patients. METHODS: Data was retrospectively collected from trauma patients over 18 years of age who were admitted at the emergency center between October 2005 and July 2006. Blood sampling for alcohol level, base deficit evaluation were done within first hour for all patients. Patients were divided according to the serum alcohol level into an alcohol group(serum alcohol level> or =10 mg/dl) and a non-alcohol group. The patients were also stratified into minor (ISS or =16) injury groups according to their injury severity score (ISS). RESULTS: The study enrolled 63 patients of whom 37 fell into the alcohol group and 26 into the non-alcohol group. The mean alcohol level within the alcohol group was 210+/-85 mg/dl. Base deficit and serum lactate were not found to be significantly different in minor and major injuries, and ISS, base deficit were not significantly different with serum alcohol level. Base deficit was somewhat higher on average but not statistically significant in the non-alcohol group than in the alcohol group (-3.0+/-4.5 vs. -1.8+/-6.7 mmol/L, p=0.444). The base deficit was higher for the major injury-alcohol group than for the major injury-non-alcohol group, but this difference also did not achieve statistical significance (-4.6 +/-5.8 vs -2.4+/-8.1 mmol/L, p=0.117) CONCLUSION: In the severely injured patients, base deficit appears to be increased with alcohol but we found no statistically significant differences in base deficit and ISS between alcohol group and non-alcohol group of injured patients.

Factors Related to Patient Satisfaction in an Outpatient Clinic

BACKGROUND: Recently, physicians have been challenged to see more patients per office session while maintaining patient satisfaction. We examined the variables related to patient satisfaction with the time spent with physician during office visit. METHODS: In the department of family medicine of an university hospital, a trained researcher observed patient visits by VTR and collected additional data using medical record reviews and patient exit questionnaires from July 1 to July 31, 2002 The data was analyzed statistically by SPSS ver11.0/PC . RESULTS: Visits by 103 patients were observed in this study. Age, functional health status, time of Dr.'s talking to patients and the ratio of Dr.'s talking time to visit length were significantly associated with patient satisfaction (P<0.05). Sex, marital status, education level, new vs. established patient, reason for visit, visit length, number of problems, number of medications, body mass index, and satisfaction for time spent were not significantly associated with patient satisfaction. According to logistic regression analysis, greater patient satisfaction were associated with better perceived health status, with more ratio of Dr.'s talking time to visit length and with age younger than 40 years. CONCLUSION: Physician can enhance patient satisfaction during an office visit by spending sufficient time to talk with patients during each visit and should take an interest in elderly patients and patients with multiple problems.