A Randomized Controlled Trial for Doing vs. Omitting Intraoperative Frozen Section Biopsy for Resection Margin Status in Selected Patients Undergoing Breast-Conserving Surgery (OFF-MAP Trial) / 한국유방암학회지

Purpose@#Intraoperative frozen section biopsy is used to reduce the margin positive rate and re-excision rate and has been reported to have high diagnostic accuracy. A majority of breast surgeons in the Republic of Korea routinely perform frozen section biopsy to assess margins intraoperatively, despite its long turnaround time and high resource requirements. This study aims to determine whether omitting frozen section biopsy for intraoperative margin evaluation in selected patients is non-inferior to performing frozen section biopsy in terms of resection margin positivity rate. @*Methods@#This study is a phase III, randomized controlled, parallel-group, multicenter non-inferiority clinical trial. Patients meeting the inclusion criteria and providing written informed consent will be randomized to the “frozen section biopsy” or “frozen section biopsy omission” group after lumpectomy. Patients with clinical stage T1–T3 disease who are diagnosed with invasive breast cancer by core-needle biopsy and plan to undergo breast-conserving surgery will be included in this study. If a daughter nodule, non-mass enhancement, or microcalcification is identified on preoperative imaging, these features must be within 1 cm of the main mass for inclusion in the trial. The target sample size is 646 patients per arm. The primary endpoint will be the resection margin positive rate, and the secondary endpoints include the reoperation rate, operating time, residual cancer after reoperation, residual cancer after re-excision according to the frozen section biopsy result, resection volume, patient quality of life, and cost-effectiveness.Discussion: This is the first randomized clinical trial utilizing frozen section biopsy for intraoperative margin evaluation and aims to determine the non-inferiority of omitting frozen section biopsy in selected patients compared to performing frozen section biopsy.We expect that this trial will help surgeons perform the procedure more efficiently while ensuring patient safety.

Impact of the COVID-19 Pandemic on the Diagnosis and Surgery of Breast Cancer: A Multi-Institutional Study / 한국유방암학회지

Purpose@#The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the rates of screening, case identification, and referral for cancer diagnosis. We investigated the diagnosis and surgery status of breast cancer before and after the COVID-19 pandemic at a multi-institutional level. @*Methods@#We collected breast cancer data from the clinical data warehouse which contained the medical records of patients from six academic institutions in South Korea. Patients were divided into two groups: February to April (period A) and May to July (period B). The data from the two groups were then compared against the same periods in 2019 and 2020. The primary objective was to investigate the differences in breast cancer stages before and after the COVID-19 pandemic. @*Results@#Among 3,038 patients, there was a 9.9% reduction in the number of diagnoses in 2020. This decrease was more significant during period A than period B. The breast cancer stage was not statistically different in period A (p = 0.115), but it was in period B (p = 0.001). In the subset analysis according to age, there was a statistical difference between 2019 and 2020 in period B for patients under the age of 65 years (p = 0.002), but no difference was observed in the other groups. @*Conclusion@#The number of breast cancer cases declined during the pandemic, and the staging distribution has changed after the pandemic peak.

The Effect of Reproductive Factors on Breast Cancer Presentation in Women Who Are BRCA Mutation Carrier / 한국유방암학회지

PURPOSE: Germline mutations in the BRCA1 and BRCA2 genes confer increased risks for breast cancers. However, the clinical presentation of breast cancer among women who are carriers of the BRCA1 or BRCA2 (BRCA1/2 carriers) mutations is heterogenous. We aimed to identify the effects of the reproductive histories of women with the BRCA1/2 mutations on the clinical presentation of breast cancer. METHODS: We retrospectively analyzed clinical data on women with proven BRCA1 and BRCA2 mutations who were recruited to the Korean Hereditary Breast Cancer study, from 2007 to 2014. RESULTS: Among the 736 women who were BRCA1/2 mutation carriers, a total of 483 women had breast cancers. Breast cancer diagnosis occurred at significantly younger ages in women who experienced menarche at ≤14 years of age, compared to those who experienced menarche at >14 years of age (37.38±7.60 and 43.30±10.11, respectively, p<0.001). Additionally, the number of full-term pregnancies was significantly associated with the age of diagnosis, especially in women with the BRCA2 mutation. The prevalence of advanced stages (stage II or III vs. stage I) of disease in parous women was higher than in nulliparous women (68.5% vs. 55.2%, p=0.043). This association was more pronounced in women with the BRCA2 mutation (hazard ratio, 2.67; p=0.014). CONCLUSION: Our results suggest that reproductive factors, such as the age of onset of menarche and the presence of parity, are associated with the clinical presentation patterns of breast cancer in BRCA1/2 mutation carriers.

Can We Skip Intraoperative Evaluation of Sentinel Lymph Nodes? Nomogram Predicting Involvement of Three or More Axillary Lymph Nodes before Breast Cancer Surgery / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The American College of Surgeons Oncology Group Z0011 trial reported that complete dissection of axillary lymph nodes (ALNs) may not be warranted in women with clinical T1-T2 tumors and one or two involved ALNs who were undergoing lumpectomy plus radiation followed by systemic therapy. The present study was conducted to identify preoperative imaging predictors of ≥ 3 ALNs. MATERIALS AND METHODS: The training set consisted of 1,917 patients with clinical T1-T2 and node negative invasive breast cancer. Factors associated with ≥ 3 involved ALNs were evaluated by logistic regression analysis. The validation set consisted of 378 independent patients. The nomogram was applied prospectively to 512 patients who met the Z0011 criteria. RESULTS: Of the 1,917 patients, 204 (10.6%) had ≥ 3 positive nodes. Multivariate analysis showed that involvement of ≥ 3 nodes was significantly associated with ultrasonographic and chest computed tomography findings of suspicious ALNs (p < 0.001 each). These two imaging criteria, plus patient age, were used to develop a nomogram calculating the probability of involvement of ≥ 3 ALNs. The areas under the receiver operating characteristic curve of the nomogram were 0.852 (95% confidence interval [CI], 0.820 to 0.883) for the training set and 0.896 (95% CI, 0.836 to 0.957) for the validation set. Prospective application of the nomogram showed that 60 of 512 patients (11.7%) had scores above the cut-off. Application of the nomogram reduced operation time and cost, with a very low re-operation rate (1.6%). CONCLUSION: Patients likely to have ≥ 3 positive ALNs could be identified by preoperative imaging. The nomogram was helpful in selective intraoperative examination of sentinel lymph nodes.

Comparison of Injury Patterns between All-terrain Vehicles and Motorbike Riders in Jeju Island

PURPOSE: As the usage rate of all-terrain vehicles (ATV) the number of injuries caused by ATVs is also surging. This has led to an increase in social attention to the safety of ATVs and the law for ATV safety standards was revised in 2009 and 2011. The purpose of this study was to evaluate the characteristics of ATV injury compared with motorbike injury after implementation of the ATV safety policy. METHODS: A retrospective cross-sectional observation study was conducted using emergent department (ED)-based indepth injury surveillance system data from 2011 January to 2014 December. Demographics, injury-related characteristics, injury severity, and outcomes of patients related to ATV and motorbike injury visiting our ED were analyzed. Multivariate logistic regression was used for major adverse event (MAE), which was defined as any intensive care, emergent operation, or death between ATV and motorbike related injury adjusted for covariates. RESULTS: During the study period, there were 101 ATV- and 584 motorbike-related injuries. Females had more ATV-related injuries (63.4% vs 32.9%, p<0.001) during leisure activities (93.1%) with higher helmet usage (73.3% vs 62.0%, p=0.01) and lower usage in terms of emergency medical service (23.8% vs 46.4%, p<0.001), automobile insurance (10.9% vs 54.1%, p<0.001) compared with motorbike-related injuries. MAE in ATV-related injuries was less likely in a univariate logistic model (unadjusted odd ratios [ORs] 0.489, 95% confidential intervals [Cis] 0.282 to 0.848), but the multivariate logistic model showed no significant difference (adjusted ORs 1.018, 95% CIs 0.376 to 1.414). CONCLUSION: Results of this study showed no significant difference in occurrence of clinical major adverse events between motorbikes and ATVs-related injury on Jeju Island. However, considering the high injury prevalence in young age, female, and passengers during leisure activities, development of an education and injury prevention program will be needed for this vulnerable population.

Risk Factors Associated with Distant Metastasis and Survival Outcomes in Breast Cancer Patients with Locoregional Recurrence / 한국유방암학회지

PURPOSE: To decide the optimal treatment for breast cancer patients with locoregional recurrence (LRR), it is important to determine which group has the highest risk of subsequent distant metastasis (DM). We aimed to investigate the factors associated with DM in patients with LRR. METHODS: We reviewed the data of 208 patients with LRR as the first event after primary surgery for breast cancer at our institution between 1997 and 2010, to identify significant factors associated with DM. Subsequently, Kaplan-Meier curves and the Cox regression method were used to analyze the correlation between clinical factors and survival. RESULTS: DM occurred in 33.2% (68/208) of LRR patients. The median DM-free interval was 23 months. Some clinical factors were associated with DM in univariate analysis, including the type of primary surgery (p=0.026), tumor size (p=0.005), nodal status (p=0.011), and administration of initial adjuvant chemotherapy (p=0.001). In addition, regional rather than local recurrence and a disease-free interval (DFI; duration between primary surgery and LRR) < or =30 months were also significant (p<0.001 for both). However, only a shorter DFI reached significance in multiple logistic regression analysis. Cox regression analysis of DM-free survival showed that both a shorter DFI and regional recurrence were significant factors with hazard ratios of 2.1 (95% confidence interval [CI], 1.21-3.65) and 1.85 (95% CI, 1.04-3.28), respectively. CONCLUSION: DFI was the most important factor associated with subsequent DM in patients with LRR as a first event of failure.

The Demand and Causes of Emergency Medical Service Utilization of Visitors on Jeju Island, South Korea

PURPOSE: Providing proper emergency medical services (EMS) for domestic or international visitors to popular destinations is becoming increasingly important. Jeju Island is the most visited spot in South Korea. The number of people visiting Jeju Island has increased every year, and this was over ten times the registered population on Jeju Island. The purpose of this study was to describe EMS use behavior and to estimate demand for EMS for visitors on Jeju Island. METHODS: A retrospective observational study was conducted on Jeju Island, with 580,000 citizens. EMS is a fire-based system with a single tiered intermediate service level by a single centralized dispatch center, 29 ambulances, and approximately 130 EMS providers. We collected all ambulance run-sheet data, which included comprehensive information as well as patients' address identification, monthly number of visitors, and census data of Jeju Island from January, 2010 to December, 2012. RESULTS: Among 90,674 EMS transports, 7,209 (8%) were excluded because of unknown address of patients, and of all 83,456 (100%) patients using EMS, 9,733 (12%) were visitors and 73,732 (88%) were residents. The percentage of females was higher for visitors than residents (45% vs. 43%, p<0.001) and the mean age was younger in visitors (38+/-19 vs. 54+/-22, p<0.001). Injury was much higher for visitors than residents (63% vs. 38%, p<0.001). The estimated monthly number of EMS use per 10,000 people was 3.7 (95% CI 3.5 to 3.9) in visitors and 35.7 (95% CI 34.9 to 36.5) in residents, with a ratio of 0.104 (95% CI 0.099 to 0.108). The trend of ratio by year was not significant (p=0.630). The correlation between monthly EMS use in visitors and monthly number of unregistered population was significant (Pearson's correlation 0.844). CONCLUSION: Determining EMS use behavior and the demand of EMS in visitors is a critical task. Our results are of interest in preparing and providing the provision of EMS for visitors.

Factors Associated with Advanced Life Support Simulation Performance of Senior Medical Students

PURPOSE: Although use of simulation for medical students in medical education has increased, little is known about factors associated with performance on advanced life support simulation. The goal of this study was to determine which educational and psychosocial factors are associated with performance of senior medical students using a simulation resuscitation model. METHODS: Fourth year medical students enrolled in the study were divided into six groups. Subjects in each group underwent training in emergency medicine for a period of two weeks. This was a consecutive study conducted from March to July of 2009. Each student underwent an advanced cardiac life support (ACLS) simulation performance test while performance was graded by two ACLS instructors who were certified by the American Heart Association. The scores of the followings were collected: basic life support (BLS) practice, personality characteristics survey, case presentation, one post-training written test, and two planned tests for the Korean Medical Licensing Examination (KMLE). RESULTS: A total of 46 students participated in the study. As measured by the post-training written test and two planned tests for the KMLE, no association was observed between ACLS performance scores and personality type, BLS skills, or medical knowledge. However, scores on case presentations showed a moderate association with ACLS performance scores: r=0.390 (p<0.01). CONCLUSION: Results of this study demonstrated an association of ACLS simulation performance with case presentations. These results support the idea that the ability to manage resuscitation is associated with aptitude for analysis and coordination of patient management. These results provide guidance that can be applied to education of medical students.

Basal Level of Cholinesterase in a Population of Residents Over 60 Years Old in Jeju

PURPOSE: Measurement of pseudocholinesterase (PChE) is a simple test for evaluation of the severity of intoxication with organophosphate and carbamate insecticides, because they inhibit PChE; however, as demonstrated in several studies, PChE does not reflect severity and mortality. The basal level of PChE in patients who attempt suicide with insecticides could be low, because they are exposed to insecticides for a long period of time, as they are engaged in agriculture. This is part of the reason that PChE level does not reflect severity. No research on the basal level of PChE in the normal population in South Korea has been conducted. The authors of this study investigated the characteristics of residents of Jeju, Korea who have a low level of PChE. METHODS: Residents of Jeju over 60 years of age were randomly enrolled. Level of PChE, demographic data, medical history, and occupation were investigated. Groups (higher level vs lower level) were divided on the basis of the median value of PChE. Mann-Whitney test, Pearson chi square, or Fisher's exact test was used for comparison between the two groups. Logistic regression was used for evaluation of factors having an effect on low level of PChE. RESULTS: Of a total of 353 residents, 28(7.9%) residents were engaged in agriculture, and had recently used insecticide. Sixteen (4.5%) residents had lower PChE levels out of normal range (5,400~13,200 U/L), and the lower group included 177 residents. Age of residents in the lower group was older, and the level of high-density lipoprotein (HDL) was lower, compared with those of the higher group. Older age and lower HDL levels indicated a risk of lower PChE in univariate logistic regression, however, the only risk factor in multivariate logistic regression was age. CONCLUSION: Many potential causes of lower PChE must be considered; genetics, chronic disease, hepatic failure, liver cirrhosis, malnutrition, tumor, infection, and pregnancy. In this study, the only risk factor was age. Future investigation of genetic factors and other risk factors contributing to lower PChE level in residents under 60 years of age will be necessary.

Risk Factors of Injured Patients with Frequent Emergency Department Visits: A Single Center Study in Jeju Island

PURPOSE: For patients who suffer frequent injury, there could be several causes contributing to repeated occurrence of injury. Occupation, alcohol, substance, age, socioeconomic status, etc could be related to recidivism. In order to perform an analysis of preventable causes, we investigated the characteristics of injured patients who visited the emergency department (ED) frequently, compared with patients who visited the ED only once. METHODS: A retrospective cohort study was conducted. Data for this study were obtained from the injury surveillance system of the ED at Jeju National University Hospital. Patients who visited the ED between March 2009 and March 2011 were enrolled, and were observed over a period of 18 months. The Once group (OG) was defined as patients who visited the ED once, and the frequent group (FG) as patients who visited the ED more than twice. The following factors were investigated: demographic data, medical condition, drug misuse and abuse, intention of injury, alcohol use, mechanism of injury, place of occurrence, and activity when injured. Chi square test/t-test and logistic regression analysis were performed for analysis of risk factors of FG patients. RESULTS: A total of 12,520 injured patients included: 11,895(95.01%) patients in the OG and 625(4.99%) patients in the FG. The total number of injuries in the FG was 1,352. The mean age of patients in the FG was younger than that of patients in the OG by approximately six years (27.96 vs 34.61). Patients in the FG suffered a greater number of falls, blunt trauma than those in the OG, and injuries occurred more frequently at home. Risk factors for frequent visits to the ED included a younger age, alcohol associated injury, intentional injury, hypertension, diabetes, liver disease, mental illness, dementia, Parkinson's disease, and epilepsy. CONCLUSION: In order to prevent another injury, patients with medical conditions associated with injury recidivism and young people, and alcohol users should undergo screening and should receive education in the ED. In part, on the basis of our results, emergency medical service associated organizations can plan multidirectional injury prevention programs.

Multicenter Survey of Intoxication Cases in Korean Emergency Departments: 2nd Annual Report, 2009

PURPOSE: The purpose of this study was to examine the occurrence of toxic exposure cases in Korean emergency centers using a toxic exposure surveillance system-based report form and to provide guidelines for the prevention and treatment of toxic exposures. METHODS: We retrospectively reviewed the medical records of toxic exposure patients who had visited emergency centers from January 2009 to December 2009. Epidemiology data points for the toxic exposure cases included age, gender, type of exposure, number and kind of substances involved, reason and route of poison exposure, management of the patients in the emergency departments, and the clinical outcome. RESULTS: A total of 3,501 patients from 12 emergency departments were enrolled in the study. 50.0% of the total exposure patients were male and 63.0% of the total cases were fatal. Acute intoxication occurred in 91.3% of the total patients and suicidal intent was the most common (43.3%) reason for exposure. The most common route of exposure was ingestion (75.9%). Of the total cases, pesticides were involved in 26.3%, sedatives/hypnotics/antipsychotics were involved in 22.0%, and bites and envenomations were involved in 15.7%. CONCLUSION: We provided a database of patients who were admitted to emergency departments after poisoning incidents. We recommend that toxicology professionals develop a classification scheme for toxicants which is adequate for Korean domestic circumstances and initiate a toxic surveillance system for all types of exposures. With support of a psychiatric surveillance system for suicidal patients and establishment of social mediation for pesticide poisoning, major reductions in poison exposures can be achieved.

A Multicenter Study on the Tetanus Antibody Titers of Elderly Koreans

BACKGROUND: Although tetanus infections have diminished dramatically since the advent of tetanus vaccination, this disease has not disappeared. Those 60 years and older are still very much at risk for this infection. Thus, we investigated the tetanus antibody titers in people 60 years and older in Korea. METHODS: Our subjects included those visiting eight emergency departments from March 2009 to February 2010 after an injury with stable vital signs and without acute disease. Samples obtained were tested using the tetanus immunoglobulin enzyme-linked immunosorbent assay method. The resultant tetanus antibody titers were analyzed. RESULTS: The number of subjects enrolled was 462. The mean titer was 0.09+/-0.14 IU/mL. Twenty-two percent of the subjects had a safe titer level (>0.1 IU/mL). Males and urban subjects had higher tetanus antibody titers than did females and suburban subjects. Subjects living in Incheon, Gangwon-do, Chungcheong-do, and Jeju-do had lower titers. CONCLUSION: The results of this study showed that Koreans 60 years and older did not have a protective mean level of tetanus antibody titer and that 78% of the subjects did not have a seroprotective level after tetanus exposure. Therefore, a national effort to administer tetanus vaccination to elderly Koreans is needed.

Characteristics of Emergency Patients Transported by Helicopter on Jeju Island

PURPOSE: The study investigated the present state of helicopter patient transport system on Jeju Island with the aim of improving the helicopter emergency medical service system. METHODS: Electrical medical records of patients transported to Jeju National University Hospital by coast guard helicopter from March 2009 to November 2010 were retrospectively reviewed. The followings were analyzed in terms of patient demography, pre-hospital treatment and monitoring during transport, emergency severity index (ESI) score, outcomes and appropriateness of transportation. RESULTS: During the 19 months of the study, 35 patients were helicopter-transported. There were 18 illness patients (51%) and 17 trauma patients (49%). There were 11 ESI level I patients (31.4%) and 8 ESI level II patients (11.4%). Treatment and monitoring during transportation were rare. 15 patients (43%) were hospitalized and 10(28%) died. 16 (45.7%) patients were indicated to the helicopter transportation. CONCLUSION: The near-absence of treatment and monitoring during helicopter transportation is thought to be associated with the absence of firefighting helicopter and trained medical staff. Appropriate emergency patient transportation protocols are needed.

Reduction of Length of Stay in Emergency Room by Using Critical Pathway for Stroke Patients / 간호행정학회지

PURPOSE: The purpose of this study was to demonstrate effects of a critical pathway (CP) for stroke patients seen in emergency rooms (ER). METHODS: The CP developed by the CP committee consisted of 8 criteria: behavior of doctors and nurses, laboratory tests, Image testing, medication, treatment, activity, and nutrition. According to application of CP, a control group (n=17) and experimental group (n=17) were defined. Time was checked by the electronic medical records. RESULTS: Use of CP for stroke patients in the ER, resulted in a decreased length of stay in ER (t=2.341, p=.026), and time required for image testing (t=2.623, p=.021), and an increased number of patients using rtPA (chi2=4.802, p=.049). Time required for neurology doctor contact, for neurology doctor to see patient in the ER, and for report of blood tests decreased, but there were no statistical significance. CONCLUSION: Quick responses are most important in the ER, so CP for these patients is a very effective patient management tool. To reduce delay in stroke diagnosis, continuous education programs for similar symptoms are necessary. CPs for other patients in the ER should be developed, and studies on cost and satisfaction, as well as length of stay, should be done.

Outcome of Decompressive Hemicraniectomy for Treating Malignant Cerebral Infarction / 대한뇌혈관외과학회지

OBJECTIVE: This study is aimed to describe our experience with performing hemicraniectomy for treating patients with malignant cerebral infarction. This study also aimed at describing the difference between our experience and that of the published articles. METHODS: Ten patients who had anterior circulation territory cerebral infarction underwent decompressive hemicraniectomy for treating their life threatening brain swelling between August 2004 and October 2007. We retrospectively analyzed the patients' medical records and radiological films and we described the patients' clinical and radiological details. The outcomes were measured according to the case fatality rate at 2 weeks and the modified Rankin scale (mRS) at 9 months. We compared our institution's outcomes with the pooled analysis result of three randomized controlled trials (DESTINY, DECIMAL, HAMLET trial). RESULTS: Nine men and one woman were included in this study. Their mean age was 61.5 +/- 11.9 years, and the mean National Institute of Health Stroke Scale (NIHSS) score on admission was 17.3 +/- 6.0. Five patients died within 2 weeks after operation. Four patients had a mRS of 5 and one had a mRS of 4 at 9 months. Our series included elder patients (mean difference : 9.9~18.3 years) who had a low NIHSS score on admission (mean difference : -4.8~-6.8) as compared to that of the pooled analysis group. Our series revealed a higher proportion of an unfavorable outcome (mRS > or = 4) compared to that of the pooled analysis results (p=0.01). No patient in our series would have been eligible, according to the inclusion criteria, for inclusion in the pooled analysis studies. CONCLUSION: We think that the higher proportion of an unfavorable outcome in our series was a consequence of the elder age of our patients.

Problems of Trauma Care and Rate of Preventable Trauma Death in Jeju, South Korea

PURPOSE: This study was undertaken to investigate preventable trauma death and trauma care errors contributing to death on Jeju Island. METHODS: A retrospective study was conducted on all trauma deaths between January 2008 and May 2010 at five emergency departments (ED) in Jeju. Of the 165 deaths, 101 patients included for study after excluding death within one hour or after one week. Injury severity was scored according to the Injury Severity Score (ISS) and survival probability (Ps) was calculated. Trauma care errors were coded to six categories: pre-hospital, ED, operating room, intensive care unit, general ward, and inter-hospital transfer. In addition, system inadequacy, problems in treatment, diagnosis, and procedures were analyzed. Patient records were reviewed independently and preventability was determined by agreement. RESULTS: The preventable death rate was 35.6%, and the mean ISS was 25.25+/-10.78. Of all 149 inappropriate cares, 66.4% contributed to death. Of the 121 treatment-related problems, 88 problems occurred in the ED. Of the 18 system-related problems, 12 were in the pre-hospital phase. Seventy of the 96 problems associated with deaths occurred in the ED, and 12 of 29 problems in the pre-hospital phase. CONCLUSION: The preventable death rate was high. Inappropriate care rendered in the treatment process in the ED and system-related errors in the pre-hospital phase were major contributors to preventable trauma deaths. To reduce preventable deaths, more efforts are required on organizing trauma team management and improving care errors during the pre-hospital and inter-hospital transfer.

Can an EMT Apply the Ottawa Ankle Rules to Patients with Ankle Injury?

PURPOSE: The Ottawa ankle rule (OAR) is a clinical decision rule to detect bony injury in patients with a recent ankle injury. We evaluated the ability of emergency medical technicians (EMTs) to accurately apply and interpret the OAR. METHODS: This prospective study was done from October 2009 to February 2010 in a secondary teaching hospital. Patients >18 years of age presenting at the emergency department within 48 hours of a single ankle injury were included. Seven EMTs and three emergency medicine residents were trained in the application of the OAR through one hour educational session prior to this study. They examined the patient's ankle and recorded the data separately. Sensitivity and specificity of the OAR and interobserver agreement using the Kappa statistic were determined. RESULTS: Fifty-one patients were enrolled, mean age was 40.9 years, and 33 (64.7%) were male. Substantial to good agreement were found for all criteria of the OAR (p<0.001). The sensitivity of the OAR was 100% with a specificity of 27.8% in both of them. CONCLUSION: To the best of our knowledge, our study is the first to assess the ability of EMTs working in an emergency center to evaluate and interpret the OAR in adult patients with acute ankle injury. Even less-experienced EMTs can accurately apply and interpret the OAR. The incorporation of the OAR into the EMT's assessment of ankle-injury patients may be a useful physical examination tool for prehospital and hospital triage.

A Case of Penetrating Eye Injury Induced by Taser Gun

Taser guns are considered less lethal weapon than pistols. However, several cases and animal experiments reported injuries associated with Taser guns. This report describes the case of a patient who suffered a penetrating eye injury after being shot by a Taser gun. It is important for the emergency physician to understand potential injuries that can be caused by Taser guns.

A case of variceal bleeding of the ascending colon associated with alcoholic liver cirrhosis / 대한내과학회지

We report a very rare case of colonic varix with massive bleeding. A 43-year-old male patient was transferred to our hospital for hematochezia. The patient had a history of chronic liver disease associated with alcohol use. The initial blood pressure was 93/73 mmHg, and the hemoglobin level was 8.4 g/dL. Severe hepatomegaly and periportal fatty infiltration were seen on abdominal computed tomography. Markedly ectatic veins protruded from the luminal side of the proximal ascending colon and drained to the dilated ileocecal and retroperitoneal veins. Emergent colonoscopy failed because of continuous hematochezia and hypovolemic shock, despite massive transfusion. Markedly dilated colonic varices were noticed around the ileocecal and ascending colon on superior mesenteric arteriography. An emergent right hemicolectomy was performed. The presumed bleeding focus was a protruding varix with a red clot on the top of a denuded vein on the anteromedial wall of the proximal ascending colon.

Overnight Preliminary Interpretations of CT and MR Images by Radiology Residents in ER: How Accurate Are They?

PURPOSE: At many institutes in Korea, preliminary interpretations of after-hours CT and MR images are performed by radiology residents, with the attending radiologist's reviewing the interpretations the next day. The purpose of this study was to assess the rate of discrepancy between residents' interpretations and the final interpretations performed by attending radiologists. METHODS: We reviewed the interpretations of 1381 CT and 404 MRI scans that were obtained at the emergency department of our institute over three months. Any discrepancies between the preliminary and final interpretations were categorized as either major or minor discrepancies with a major discrepancy defined as one resulting in a change in diagnosis and treatment plans. We conducted patient follow-up via a retrospective review of the medical records to evaluate the clinical outcomes of the discrepancies. RESULTS: The rate of major discrepancies was 2.5%, and the rate of minor discrepancies was 11.4%. Major discrepancies led to a change in diagnosis or patient treatment plans, but did not lead to any increase in patient morbidity. CONCLUSION: The discrepancy rate at our institution was relatively insignificant, and patient care at the emergency department was not adversely affected by having radiology residents interpret CT and MRI scans after-hours and the attending radiologist review the interpretations the next morning. Still, further efforts are needed in order to reduce the frequency of major discrepancies.