D-dimer as a Prognostic Tool in Patients with Normotensive Pulmonary Embolism / 결핵및호흡기질환

BACKGROUND: D-dimer testing is widely applied as a first step in the diagnostic work-up of pulmonary embolism (PE). Although this is the most sensitive assay for ruling out PE, the prognostic implications of D-dimer testing in patients with normotensive PE are not well known. The aim of this study was to determine if D-dimer testing on admission predicts major adverse cardiac events (MACE) in patients with normotensive PE. METHODS: A total of 180 consecutive patients with normotensive PE admitted between January 2003 and June 2009 were included. The group was divided into quartiles on the basis of their D-dimer levels. We compared the frequency of MACE by quartile of D-dimer level and estimated sensitivity, specificity, and predictive values for MACE in the first and fourth quartile. RESULTS: In the 37 (20.6%) patients with MACEs, the median D-dimer level (7.94 [IQR: 4.03~18.17] microgram/mL) was higher than in patients with a benign course (5.29 [IQR: 2.60~11.52] microgram/mL, p<0.01). The occurrence of MACEs was increased with increasing D-dimer level (p=0.017). In the first quartile (D-Dimer <2.76 microgram/mL) sensitivity, specificity, and positive and negative predictive values for predicting MACEs were, respectively, 91.9%, 29.4%, 25.2%, and 93.3%. CONCLUSION: Patients with D-dimer levels below 2.76 microgram/mL have a low risk of MACEs. Our study suggest that D-dimer level may be used to identify low risk patients with normotensive PE.

Initial Electrocardiographic Changes associated with Clinical Severity in Acute Organophosphate Poisoning

PURPOSE: Various electrocardiogram (ECG) changes can occur in patients with acute organophosphate poisoning (OPP) and may be associated with the clinical severity of poisoning. The present study aimed to evaluate the extent and frequency of ECG changes and cardiac manifestations, and their association with acute OPP clinical severity. METHODS: Seventy-two adult patients admitted to our emergency department with a diagnosis of acute OPP were studied retrospectively. ECG changes and cardiac manifestations at admission were evaluated. ECG changes between respiratory failure (RF) group and no respiratory failure (no RF) groups were compared. RESULTS: Prolongation of QTc interval (n=40, 55.6%) was the most common ECG change, followed by sinus tachycardia (n=36, 50.0%). ST-T wave changes such as ST segment elevation or depression and T wave change (inversion or non-specific change) were evident in 16 patients (22.2%). Prolongation of QTc interval was significantly higher in the RF group compared with the no RF group (p=0.03), but was not an independent predictor for RF in acute OPP (OR; 4.00, 95% CI; 0.70-23.12, p=0.12). CONCLUSION: While patients with acute OPP can display ECG changes that include prolongation of QTc interval, sinus tachycardia, and ST-T wave changes at admission, these changes are not predictors of respiratory failure.

Clinical Utility of Abdominal MDCT in Elderly Patients with Non-traumatic Acute Abdominal Pain

PURPOSE: The purposes of this study are to determine the degree of diagnostic consistency among the primary diagnosis in the emergency department (ED), abdominal multidetector computed tomography (MDCT) findings, and the final diagnosis at hospital discharge in elderly patients with non-traumatic acute abdominal pain; to describe common disease entities in these patients; and to determine the extent of agreement between management plans before and after abdominal MDCT. METHODS: We undertook the retrospective review of the charts of 109 patients, 65 years or older with non-traumatic acute abdominal pain. The measure of agreement between diagnostic phases and between planned and actual management was evaluated by Cohen's kappa statistic. RESULTS: Value of the kappa statistic for agreement between primary diagnosis in the ED and final diagnosis at hospital discharge and between MDCT findings and final diagnosis were 0.408 and 0.776, respectively. The most common MDCT findings were biliary disease (17.4%), ischemic bowel disease (16.5%) and malignancy (16.5%). At the time of final diagnosis at hospital discharge, the order of frequency was malignancy (16.5%), biliary disease (15.6%), and ischemic bowel disease (12.8%). The degree of agreement between before and after abdominal MDCT in management plans was 0.154. CONCLUSION: Abdominal MDCT can skew diagnosis and management plans significantly in elderly patients with nontraumatic acute abdominal pain.

Extent of Work Satisfaction of Telephone Advisers in Emergency Medical Information Center: Focus on the Content of Work and the Working Environment

PURPOSE: This research investigated the extent of telephone advisers'satisfaction with respect for giving telephone advice and the working environment at 12 emergency medical information centers. METHODS: During July 2004, we approached 12 emergency medical information centers. We sent a three page postal questionnaire to each worker. The questionnaire had three parts questions about the working environment, giving telephone advice, and demographic characteristics. RESULTS: The response rate was 81.8%. The hundred (100) workers selected for this study were telephone advisers. As to the working environment, they were unsatisfied with the small workspace and the poor ventilation. Sixty-three (63) workers had telephone advice education. They felt that 'callers' overstatements' and 'not seeing the patients' left them stressed when giving telephone advice. They anticipated that 'protocol' and 'education about medical knowledge' were necessary for improving telephone advice. Seventy-three (73) workers had experienced burnout syndrome. CONCLUSION: Based on this survey on the extent of satisfaction with giving telephone advice and with the working environment, we think that improvements in the working environment and in the professional education for telephoneadvice skills are necessary. Also, we suggest that education to improve advisers'medical knowledge, development of advice protocols, and a program to prevent and manage burnout syndrome are required for enhanced work satisfaction in the future.

Injury Patterns of Front-seat Passengers without Seat Belts in Traffic Crashes

PURPOSE: This study aimed to investigate the injury patterns of unrestrained front-seat passengers in traffic crashes. METHODS: Using 2000~2003 data from the Jeonbuk Provincial Police Agency and medical-chart review, we estimated the relationship between crash patterns and individual variables, such as age, sex, Injury Severity Score, prehospital care, outcome, injury types, passenger seats, velocity, and alcohol consumption. We also investigated whether the Injury Severity Score correlated with crash patterns, passenger seats, velocity, prehospital care, and alcohol consumption. RESULTS: The mean Injury Severity Scores in frontal and rollover crashes were 15.0(+/-0.7) and 22.6(+/-3.3), respectively and the difference was statistically significant (p<0.05). The mortality rate was higher in rollover crashes than in frontal crashes (p<0.05). The most common type of injury in unrestrained passengers during frontal and rollover crashes was head and face injury. In addition, chest and lumbar spine injuries were more common in rollover crashes than in frontal crashes, and this difference had statistical significance (p<0.05). The Injury Severity Score correlated with the crash patterns (rho=0.25, p<0.01), overspeeding (rho=0.44, p<0.01), prehospital care (rho=0.25, p<0.01), and alcohol consumption (rho=0.18, p<0.05). CONCLUSION: We estimate that rollover crashes are associated with an increased risk of injury to and death for frontseat passengers compared to frontal collisions. Knowledge of injury mechanisms should help emergency physicians to promptly evaluate all areas at risk, as well as the potential for fatality.