Does the use of bedside ultrasonography reduce emergency department length of stay for patients with renal colic?: a pilot study

OBJECTIVE: The aim of this study was to evaluate the effect of adding bedside ultrasonography to the diagnostic algorithm for nephrolithiasis on emergency department (ED) length of stay. METHODS: A prospective, randomized, controlled pilot study was conducted from October 2014 to December 2014 with patients with acute flank pain. In the non-ultrasonography group (NUSG), non-contrast computed tomography was selected based on clinical features and hematuria in the urinalysis. In the ultrasonography group (USG), non-contrast computed tomography was selected based on clinical features and hydronephrosis on bedside ultrasonography. The primary outcome was ED length of stay. The secondary outcomes were radiation exposure, amount of analgesics, proportion of patients with diseases other than ureteral calculus, and proportion of patients with unexpected ED revisits within 7 days from the index visit. RESULTS: A total of 103 patients were enrolled (NUSG, 51; USG, 52). The ED length of stay for the USG (89.0 minutes) was significantly shorter than that for the NUSG (163.0 minutes, P<0.001). There were no significant differences between the two groups in the radiation exposure dose (5.29 and 5.08 mSv, respectively; P=0.392), amount of analgesics (P=0.341), proportion of patients with diseases other than ureteral calculus (13.0% and 6.8%, respectively; P=0.486), and proportion of patients with unexpected ED revisits within 7 days from the index visit (7.8% and 9.6%, respectively; P=1.000). CONCLUSION: The use of early bedside ultrasonography for patients with acute flank pain could reduce the ED length of stay without increasing unexpected ED revisits.

Therapeutic Effects of S-Petasin on Disease Models of Asthma and Peritonitis

To explore the anti-allergic and anti-inflammatory effects of extracts of Petasites genus, we studied the effects of s-petasin, a major sesquiterpene from Petasites formosanus (a butterbur species) on asthma and peritonitis models. In an ovalbumin-induced mouse asthma model, s-petasin significantly inhibited the accumulations of eosinophils, macrophages, and lymphocytes in bronchoalveolar fluids. S-petasin inhibited the antigen-induced degranulation of beta-hexosamidase but did not inhibit intracellular Ca2+ increase in RBL-2H3 mast cells. S-petasin inhibited the LPS induction of iNOS at the RNA and protein levels in mouse peritoneal macrophages. Furthermore, s-petasin inhibited the production of NO (the product of iNOS) in a concentration-dependent manner in the macrophages. Furthermore, in an LPS-induced mouse model of peritonitis, s-petasin significantly inhibited the accumulation of polymorpho nuclear and mononuclear leukocytes in peritoneal cavity. This study shows that s-petasin in Petasites genus has therapeutic effects on allergic and inflammatory diseases, such as, asthma and peritonitis through degranulation inhibition in mast cells, suppression of iNOS induction and production of NO in macrophages, and suppression of inflammatory cell accumulation.

An Analytical Study of Mammalian Bite Wounds Requiring Inpatient Management

BACKGROUND: Mammalian bite injuries create a public health problem because of their frequency, potential severity, and increasing number. Some researchers have performed fragmentary analyses of bite wounds caused by certain mammalian species. However, little practical information is available concerning serious mammalian bite wounds that require hospitalization and intensive wound management. Therefore, the purpose of this study was to perform a general review of serious mammalian bite wounds. METHODS: We performed a retrospective review of the medical charts of 68 patients who were referred to our plastic surgery department for the treatment of bite wounds between January 2003 and October 2012. The cases were analyzed according to the species, patient demographics, environmental factors, injury characteristics, and clinical course. RESULTS: Among the 68 cases of mammalian bite injury, 58 (85%) were caused by dogs, 8 by humans, and 2 by cats. Most of those bitten by a human and both of those bitten by cats were male. Only one-third of all the patients were children or adolescents. The most frequent site of injury was the face, with 40 cases, followed by the hand, with 16 cases. Of the 68 patients, 7 were treated with secondary intention healing. Sixty-one patients underwent delayed procedures, including delayed direct closure, skin graft, composite graft, and local flap. CONCLUSIONS: Based on overall findings from our review of the 68 cases of mammalian bites, we suggest practical guidelines for the management of mammalian bite injuries, which could be useful in the treatment of serious mammalian bite wounds.

Combining Tissue Doppler Echocardiography and Lung Rockets Sign in the Differential Diagnosis of Acute Dyspnea

PURPOSE: We tried (1) to determine the discriminating ability of lung rockets sign in lung ultrasound and E/Ea (the ratio of peak early diastolic mitral inflow velocity to peak early mitral annular velocity measured by tissue Doppler echocardiography) known as an indicator of pulmonary edema in acute dyspnea and (2) to develop a new algorithm using two variables. METHODS: This prospective observational study was performed in an urban emergency department. For the patient with dyspnea at rest, we performed bedside emergency ultrasound assessing the presence of lung rockets sign and measuring the E/Ea. Patients were divided into two groups depending on the cause of dyspnea: pulmonary edema or other cause. We compared the two variables and developed an algorithm using decision tree analysis. RESULTS: A total of 66 patients (39 pulmonary edema, 27 other causes) were enrolled. By univariate analyses, there were significant differences between the two groups in the presence of lung rockets sign (p 13.27 had 100% specificity and positive predictive value for pulmonary edema. CONCLUSION: Lung rockets sign in lung ultrasound and measurement of E/Ea could be helpful in the differential diagnosis of shortness of breath quickly and easily in ED.

Usefulness of Bedside Emergency Ultrasound for Detecting Significant Dehydration in Children

PURPOSE: Using bedside emergency ultrasonography (EUS), measurement of the ratio of inferior vena cava (IVC) to abdominal aorta (Ao) diameter may be useful in objectively assessing children with dehydration. The objectives of this study were (1) to analyze the predictability of the ratio of IVC to Ao diameters (IVC/Ao) in dehydrated children and (2) to determine which measurement method would be best to detect significant dehydration in children. METHODS: This prospective observational study was performed in an urban emergency department. Children between 6 months and 6 years of age with clinical suspicion of dehydration and who were admitted to the hospital were enrolled. Using bedside EUS, measurement of IVC and Ao diameters and body weight check were done before IV hydration. We followed up on their body weight during hospitalization. Dividing subjects into (1) a moderate and severely dehydrated group, which was defined as weight change more than 5% during hospitalization, and (2) a non-dehydrated group, we compared the IVC/Ao ratios of the two groups. RESULTS: A total of 59 patients were enrolled. There were significant differences between dehydrated and nondehydrated groups in IVC/Ao on longitudinal views and in the major diameter of IVC/Ao on transverse views (p=0.010 and <0.01, respectively). Its area under the curve in ROC analysis was 0.69 and 0.81, respectively. The cut-off value for the major diameter of IVC/Ao was 0.879 with 85% sensitivity and 79.9% specificity. Laboratory tests such as the BUN/Cr ratio, total CO2, and bicarbonate didn't show any differences between the two groups. CONCLUSION: The IVC/Ao ratio measured in transverse views by bedside EUS could help the emergency physician identify significant dehydration in clinically suspected pediatric patients.

An Emergency Ultrasound (EUS)-Enhanced Scoring System for Diagnosing Acute Appendicitis in Patients with Right Lower Quadrant (RLQ) Pain; Constant or Aggravated Pain, Male Sex, and Ultrasound (CAMUS) Scores

PURPOSE: We hypothesized that a new scoring system that included emergency ultrasound (EUS) and clinical or laboratory predictors for diagnosing acute appendicitis (AA) in patients with right lower quadrant (RLQ) pain could decrease the false negative rate when EUS is performed alone. METHODS: During a 10 month period, patients with RLQ pain were evaluated with EUS just after history taking and physical examination. We also checked the 17 well-known predictors of AA. Univariate analyses for each predictor including EUS findings identified 11 predictors. We then tested those predictors with logistic regression analysis. RESULTS: A total 397 patients (mean age=31.13+/-18.25 years: 196 males, 201 females) were enrolled in this study. Among the 397, 247 underwent an operation, but 14 turned out to have normal appendices. Among 233 patients with appendicitis, 75 had a perforated appendix. Four independent correlates of AA (constant pain, aggravated pain, male sex, and positive EUS findings) were identified with logistic regression analysis. We developed a novel scoring system using regression coefficients as follows: 6 points for a positive EUS, 3 points for aggravated pain, 2 points for constant pain, and 2 points for being male. We named the new scoring system "CAMUS" for "Constant or Aggravated pain, Male sex, and UltraSound score". The area under the receiver-operating characteristic curve (ROC) for the CAMUS score for AA was 0.93(95% confidence interval: 0.871 to 0.959). CONCLUSION: Our new CAMUS scoring system can help emergency physicians diagnose AA accurately and rapidly.

A Cause Analysis of Missed Fractures in an Emergency Medical Center

PURPOSE: A missed fracture is a very common occurrence in the Emergency Department (ED) and can have serious results because of delays in treatment, resulting in long-term disability. It is also one of the most common causes leading to medical legal issues. We analyzed the causes of missed fractures by using a bone scan which is known to be an effective tool for diagnosing bony lesions. METHODS: We reviewed the medical records of trauma patients who underwent a bone scan after being discharged the ED from September 2006 to March 2008. Cases of missed fractures were identified by using electronic medical records to review each diagnosis. Definition of missed fracture was read after bone scan by radiologist. We decided that there was no fracture if we read 'trauma-related lesion' or 'cannot rule out fracture' on a bone scan read by a radiologist. Enrolled patients were analyzed by age, sex, time until bone scan and Injury Severity Score (ISS). Patients were divided into two groups, alert mentality and not-alert mentality, so there were split between a diagnosis group and a missed fracture group. ISS was also used in determining the severity of the patient's injury upon discharge from the ED. RESULTS: A total of 532 patients were enrolled in this study. Of those, 487 patients were in the diagnosis group, and 45 patients (8.4%) were discovered to have had a fracture. Of the 45 missed fracture patients, 34 patients (6.4%) had one-site fractures, 8 patients (1.5%) had two-site fractures, and 3 patients (0.6%) had threesite fractures. The most commonly missed fracture was multiple rib fractures (18 patients, 30.5%), followed by lumbosacral (LS) spine fractures (10 patients, 16.9%), thoracic spine fractures (8 patients, 13.6%), and clavicle fractures (6 patients, 10.2%). Mean age was 50.12+/-18.54 years in the diagnosis group and 57.38+/-16.88 years in the missed fracture group. For the diagnosis group, the mean ISS was 9.03+/-8.26, but in the missed fracture group it was 17.53+/-9.69. Missed fractures were much more frequent in the not-alert mentality (p or =16) group (p<0.01). CONCLUSION: Missed fractures occur most frequent in patients of old age, not-alert mentality, and high ISS. Multiple rib and spine fractures were found to be the most frequent missed fractures, regardless of trauma severity. This study also shows a high possibility of clavicle and scapula fractures in patients with severe trauma.

Treatment of Chronic Ankle Lateral Instability using Modified Brostrom Procedure / 대한정형외과학회잡지

Purpose: To analyze the results of modified Brostrom procedure for chronic ankle lateral instability. Materials and Methods: Twenty six patients were followed up for more than 1 year after performing the modified Brostrom procedure. The mean age was 35.3 years, and the mean follow-up period was 2.4 years. Anterior and varus stress radiographs were taken in all cases, and a preoperative MRI was taken in 22 cases. Clinically, the Karlsson scale and Sefton grading were used. The effects of age, injury pattern and associated injury such as osteochondral fracture on the clinical results were analyzed. Results: Radiologically the difference in anterior displacement between the affected side and contralateral side was 3.1 mm, and that of the varus tilt was 4.2degrees. At the last follow-up, the Karlsson scale had increased from preoperative 47.5 points to 90.3 points. There were 14 excellent, 8 good, 3 fair and 1 poor results according to the Sefton grading. The results were significantly worse in patients over 50 years of age. An osteochondral fracture or degenerative changes also lowered the level of patient satisfaction. Conclusion: The modified Brostrom procedure appears to be a safe and highly satisfactory procedure. However, a more careful approach is needed for patients over 50 years of age or with associated degenerative changes.

Reversed Adipofascial Flap for Hindfoot Soft Tissue Defect combined with Open Calcaneal Fracture: A Case Report / 대한족부족관절학회지

Open calcaneal fractures are potentially devastating hindfoot injuries, in which the status of soft tissue envelope is very important. The reversed adipofascial flap has a merit of simplicity and minimal complication compared to free tissue transfer. We report of a case of open calcaneal fracture with soft tissue defect of hindfoot, which was successfully treated with reversed adipofascial flap.

Clinical Analysis of Subdural Hygroma

We have analysed 111 cases of subdural hygroma that were development after various neurosurgical conditions including head injuries. The results were summarized as follows. 1) The peak incidence was the age of 50's and occured most frequently in male. 2) Causes were head injuries(91 cases), traumatic intracranial hematoma removal(10 cases), operation for intracranial aneurysms(4 cases), hypertensive intracerebral hemorrhage evacuation(2 cases), ventriculoperitoneal shunt(2 cases), brian tumor removal(1 cases), arachnoid cyst excision(1 cases), and cerebral infarction(1 cases). 3) Acute subdural hematoma was most often associated with complex subdural hygrom. 4) Clinical manifestations were headache, altered mental state, disorientation, nausea in order. 5) Operation were underwent in 27 cases and surgical complications were reaccumulation and pneumocephalus in order. 6) Mortality rate was 6.3%. 7) The prognois of the simple hygroma was very good, but the complex was not.

Delayed Traumatic Intracranial Lesion

A retrospective analysis of 33 cases with operated delayed intracranial lesion who were admitted to EU1 Ji General Hospital from January 1990 to December 1992 was made according to their age and sex, etiology, lesion site, time interval to finding delayed intracrainal lesion, brain CT findings, relationship of GCS in initial and delayed lesion, associated injuries, treatment and prognosis(GOS). The results were follows : 1) The young males on first to second decade were most frequently affected. 2) The most common caused was pedestrian accident by motor vehicle, followed by fall down. 3) The most common associated injury was skull fracture, followed by skeletal injury of extremity. 4) The most common delayed intracranial lesion was delayed epidural hematoma on youth. 5) The most frequent time interval when the delayed intracranial lesion may be occurred was from 12 hr to 24 hr after admission. 6) The most possible intial lesion which the delayed epidural hematoma may be occurred was scanty hematoma with pnumocephalus or CSF leakage. 7) The GOS(Glasgow Outcome Scale) of analysed 33cases were good in 60% and poor in 40%, i.e good recovery(42%), moderate disability(18%), severe disability(15 %), vegetative state(12%), death(12%).

Hypoplastic lumbar kidney with single vaginal ectopic ureter; a case report / 대한비뇨기과학회지

Lumbar kidney is one of renal ectopia which rests opposite the sacral promontory in the iliac fossa and anterior to the iliac vessels. We have experienced a case of hypoplastic kidney associated with ipsilateral vaginal ectopic urethral opening which had been discovered by abdominal exploration.