The clinical usefulness of radiologic report monitoring system of CT and MRI in emergency department: analysis of missed and incidental findings

Objective@#This study was undertaken to establish a radiologic report monitoring system (RRMS) for missed and incidental findings (MIFs) in computed tomography (CT) and magnetic resonance imaging (MRI) reports, to help determine the clinical significance of MIFs in the emergency department (ED). @*Methods@#Patients presenting to our ED in 2017 were subjected to RRMS. Preliminary reports and final reports were subsequently compared based on the clinical significance of the MIFs. If required, the patient was contacted and instructed to revisit the ED. @*Results@#Totally, 12,132 CT and MRI exams were performed during the study period, and 321 cases (2.6%) encompassed MIFs. We attempted to contact 228 cases (1.9%) who had clinically significant MIF findings; 9 patients were instructed to return to the ED, whereas 105 cases were instructed to report to the outpatient department. Hospitalization was required for 12 patients: 2 cases required surgical intervention, 2 cases had an additional procedure, and 8 cases required medical hospitalization. @*Conclusion@#This study applied RRMS for a timely assessment of MIFs, determine rearrangements required, and present an active response to the MIFs determined in the ED. To improve patient care and safety, we hereby propose monitoring MIFs using the RRMS or similar methods.

Does the large amount of ascites lateralize the inferior epigastric artery in liver cirrhosis?

OBJECTIVE: The most common cause of hemorrhage after paracentesis is direct needle puncture of the inferior epigastric artery (IEA). This study examined the relationship between the amount of the ascites and the location of the IEA in liver cirrhosis. METHODS: Abdominal computed tomography (CT) examinations of patients with liver cirrhosis were reviewed retrospectively and divided into two groups according to the amount of ascites. The distances between the midline and the IEAs of both sides were measured at the umbilicus, McBurney's point, anterior superior iliac spine, and mid-inguinal level. Branching of the IEAs, abdominal wall and mesenteric varices in the abdomen below the umbilicus level were recorded. RESULTS: A total of 120 abdominal CTs were reviewed. The distances from the midline to the IEA in the large ascites group were longer than those in the small ascites group at the level of the right McBurney's point (44.5±14.6 mm vs. 39.6±11.8 mm, P=0.043) and left McBurney's point (48.6±15.3 mm vs. 43.3±11.5 mm, P=0.035). The incidence of abdominal wall varices was higher in the large ascites group (21.7% vs. 5.0%, P=0.014). CONCLUSION: In patients with liver cirrhosis, the large amount of ascites might be associated with lateralizing the location of the IEA. Moreover, it may be necessary to confirm the blood vessels in the abdominal wall and mesentery near the puncture site by bedside ultrasound before the paracentesis.

Effectiveness of limited airway ultrasound education for medical students: a pilot study

OBJECTIVE: The point-of-care ultrasound of the airway (POCUS-A) is a useful examination method but there are currently no educational programs for medical students regarding it. We designed a POCUS-A training curriculum for medical students to improve three cognitive and psychomotor learning domains: knowledge of POCUS-A, image acquisition, and image interpretation.METHODS: Two hours of training were provided to 52 medical students in their emergency medicine (EM) rotation. Students were evaluated for cognitive and psychomotor skills before and immediately after the training. The validity measures were established with the help of six specialists and eight EM residents. A survey was administered following the curriculum.RESULTS: Cognitive skill significantly improved after the training (38.7±12.4 vs. 91.2±7.7) and there was no significant difference between medical students and EM residents in posttest scores (91.2±7.7 vs. 90.8±4.6). The success rate of overall POCUS-A performance was 95.8%. The students were confident to perform POCUS-A on an actual patient and strongly agreed to incorporate POCUS-A training in their medical school curriculum.CONCLUSION: Cognitive and psychomotor skills of POCUS-A among medical students can be improved via a limited curriculum on EM rotation.

Adverse Drug Reactions in Adult Patients Visiting an Emergency Department: Based on Spontaneous Reporting System

PURPOSE: Adverse drug reaction (ADR) is known to be a substantial reason for emergency departments (ED) visits. Additionally, it also is a frequent occurrence in ED. The aim of the study was to compare the characteristics between ADRs that occurred in ED and ADRs that occur elsewhere based on the spontaneous reporting system in a hospital. METHODS: In this retrospective observational study, the data was collected by the spontaneous ADR reporting system within an electronic medical record system during a 24-month period. ADR of patients aged more than 18 years were included in this study. RESULTS: Patients with ADR was older in ED (42.6±14.5 vs. 53.9±17.2, p<0.001) and they were administered with less medications (2.0±1.3 vs. 4.4±4.4, p<0.001). The proportion of ADR reported by doctors in ED was higher than that in non-ED (41.2% vs. 28.2%, p<0.001). The proportion of the severe ADR was not significantly different between the ED and non-ED groups (2.9% vs. 3.8%, p=0.701). The most common symptom of ADRs in ED and non-ED groups were cutaneous (52.9%) and gastrointestinal (42.2%), respectively; the most common implicated medication was analgesics (62.7%) and analgesics (41.5%), respectively. CONCLUSION: The characteristics of ADR in ED is different from that in non-ED locations. Further studies are needed to differentiate education and prevention strategies of ADR in ED from those in non-ED locations.

Rectal Perforation with Pneumoperitoneum Caused by Compressed Air

Compressed air can cause serious damage to internal organs. The stomach is an organ that is rarely perforated due to its elasticity. However, intestines are weaker and thinner compared to the stomach. A 40-year-old male came to the emergency room with severe abdominal pain due to dyspnea. The patient experienced abdominal pain right after his coworker shot compressed air into the patient's pants. The patient suffered from a rigid abdomen, and bed-side ultrasonography was carried out as soon as possible. Pneumoperitoneum was diagnosed by portable X-ray. After computed tomography, emergency paracentesis was carried out for decompression. After emergency paracentesis, the patient's symptoms and vital signs were stabilized. After the procedure, the patient had an emergency laparotomy.

Clinical Features of Acute Epiglottitis in Adults in the Emergency Department

PURPOSE: Acute epiglottitis is a potentially fatal condition that can result in airway obstruction. The aim of this study is to examine the clinical features of adult patients who visited the emergency department (ED) with acute epiglottitis. METHODS: This retrospective observational study was conducted at a single tertiary hospital ED from November 2005 to October 2015. We searched our electronic medical records (EMR) system for a diagnosis of "acute epiglottitis" and selected those patients who visited the ED. RESULTS: A total of 28 patients were included. There was no pediatric case with acute epiglottitis during the study period. The mean age of the patients was 58.0+/-14.8 years. The peak incidences were in the sixth (n=7, 25.0%) and eighth (n=8, 28.6%) decades. The male-to-female ratio was 2.1:1. The most common symptom was sore throat (n=23, 82.1%), followed by dyspnea (n=15, 53.6%), hoarseness (n=7, 25.0%), fever (n=6, 21%), and dysphagia (n=5, 17.9%). The diagnosis of acute epiglottitis was confirmed when edema and hyperemia of the epiglottis were visualized by laryngoscopy. Twenty-six patients were treated conservatively with antibiotics and steroids without definite airway management. Two patients were intubated, but no patients required tracheostomy. CONCLUSION: In adult patients with acute epiglottitis, sore throat and dyspnea were the most common symptoms but fever was infrequent. Most patients improved with conservative management only. Definite airway management was required in only two patients in whom endotracheal intubations were performed successfully in the ED by emergency physicians, and surgical airway management was not required.

Early Prognostic Factors of Patients with Septic Shock

PURPOSE: To identify prognostic factors during the first 6-hour period of therapy associated with the 28-day survival of patients with septic shock. METHODS: We enrolled consecutive patients admitted to the emergency intensive care unit with septic shock. According to the mortality within 28 days, enrolled patients were divided into survivor and non-survivor groups. We compared patients data obtained at 6 hours after therapy between the two groups. Multivariate analysis was performed to find prognostic factors during the first 6 hours of therapy that were associated with the 28-day survival. RESULTS: Among the 138 enrolled patients, 78 survived and 60 died. Amount of fluid which was infused during the first 6 hours of therapy (odds ratio (OR)=1.005; 95% CI, 1.002-1.008; p=0.002) and the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (OR=0.859; 95% CI, 0.772-0.955; p=0.005) were independently associated with 28-day survival of patients with septic shock. Area under curve (AUC) of fluid volume for predicting 28-day survival was 0.940 (95% CI, 0.905-0.975) and the optimal cutoff value was 3000 mL. In the survival analysis, patients who received more than 3000 mL of fluid during the first 6 hours of therapy displayed a higher survival rate than patients receiving <3000 mL (p<0.001). CONCLUSION: The amount of fluid infused during the first 6 hours of therapy was independently associated with 28-day survival in patients with septic shock.

Early Prognostic Factors of Patients with Septic Shock

PURPOSE: To identify prognostic factors during the first 6-hour period of therapy associated with the 28-day survival of patients with septic shock. METHODS: We enrolled consecutive patients admitted to the emergency intensive care unit with septic shock. According to the mortality within 28 days, enrolled patients were divided into survivor and non-survivor groups. We compared patients data obtained at 6 hours after therapy between the two groups. Multivariate analysis was performed to find prognostic factors during the first 6 hours of therapy that were associated with the 28-day survival. RESULTS: Among the 138 enrolled patients, 78 survived and 60 died. Amount of fluid which was infused during the first 6 hours of therapy (odds ratio (OR)=1.005; 95% CI, 1.002-1.008; p=0.002) and the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (OR=0.859; 95% CI, 0.772-0.955; p=0.005) were independently associated with 28-day survival of patients with septic shock. Area under curve (AUC) of fluid volume for predicting 28-day survival was 0.940 (95% CI, 0.905-0.975) and the optimal cutoff value was 3000 mL. In the survival analysis, patients who received more than 3000 mL of fluid during the first 6 hours of therapy displayed a higher survival rate than patients receiving <3000 mL (p<0.001). CONCLUSION: The amount of fluid infused during the first 6 hours of therapy was independently associated with 28-day survival in patients with septic shock.

The Properties of Antibiotic and NSAIDs Administration Before Extract of the Impacted Mandibular Third Molar

A Clinical Study of Mandible Fracture for 10 Years at Chuncheon City

Case of a Spindle Cell Metaplastic Carcinoma of the Breast

A metaplastic carcinoma of the breast is a histologically diverse type of malignancy in which an adenocarcinoma is found to co-exist with an admixture of spindle cell, squamous, chondroid, or bone-forming neoplastic cells. Metaplastic breast cancer is rare and accounts for less than 1% of all mammary tumors. An adenocarcinoma with spindle cell metaplasia is one of the least often recognized variants of a metaplastic carcinoma. The clinical behavior of this variant of metaplastic carcinoma has not yet been clearly defined. Herein, we report a case of spindle cell metaplastic carcinoma of the breast. We also present a review of the literature.

A Case of Metastatic Malignant Melanoma of the Gallbladder and Small Bowel

Malignant melanoma is a rare entity that accounts for approximately 1-3% of all malignant tumors, but shows an increasing incidence. Malignant melanoma has a well-documented tendency to metastasize to the gastrointestinal tract, an affinity significantly higher than that of other primary malignant lesions. Involvement of the gallbladder in cases of widespread metastasis is uncommon in the Asian area. We report a malignant melanoma which involved multiple organs, the gallbladder and the small bowel. We also present a review of literature.

Alteration of Sensory Nerve Action Potentials According to the Interelectrode Separation

OBJECTIVE: Distance between the active and reference electrodes can affect the waveform configuration and amplitude of sensory nerve action potential (SNAP). This study was purposed to determine the change of SNAP parameters with varying interelectrode distance. METHOD: Median sensory nerve conduction study was performed in the middle finger of 40 young healthy subjects by antidromic method. To ensure firm contact with skin, strip adhesive electrode was used for recording responses. The active electrode was fixed on 1 cm distal to the proximal flexion crease of middle finger and interelectrode separation was increased from 1 to 5 cm by 1.0 cm increments. Bar electrode was fixed 14 cm proximal from active electrode for stimulation in the wrist area. RESULTS: As the interelectrode distance increased from 1 cm to 5 cm, onset latency remained unchanged. The peak latency increased with increasing the distance up to 3 cm but didn't change beyond 3 cm (1 cm: 2.89 0.89 msec, 2 cm: 2.97 0.89 msec, 3 cm: 3.02 0.19 msec, 4 cm: 3.02 0.19 msec, 5 cm: 3.02 0.20 msec). Base-to-peak amplitude significantly increased only up to 3 cm (1 cm: 30.3 6.7 microvolt, 2 cm: 43.7 8.6 microvolt, 3 cm: 50.8 10.4 microvolt, 4 cm: 51.1 10.9 microvolt, 5c m: 51.3 11.4 microvolt) but peak-to-peak amplitude sequentially increased to 5 cm (1 cm: 49.6 12.1 microvolt, 2 cm: 72.8 14.4 microvolt, 3 cm: 83.6 19.4 microvolt, 4 cm: 91.3 22.5 microvolt, 5 cm: 93.4 23.9 microvolt)(p<.05). CONCLUSION: This study showed that changing interelectrode distance altered some parameters of SNAP, especially the peak-to peak amplitude.

A Case of Osteogenesis Imperfecta associated with Aortic Regurgitation / 대한내과학회지

Osteogenesis imperfecta is one of the groups of hereditary disorders of connective tissue which includes the Ehlers-Danlos syndrome, the Marfan syndrome, pseudoxanthoma elasticum, and Hurler syndrome. While cardiovascular involvement is associated with each of these disorders, it is least common in osteogenesis imperfecta and is overshadowed by the bony, ocular, otologic, cutaneous, and dental manifestations that are characteristic of the disorder. In evaluating patients with osteogenesis imperfecta, careful attention should be paid to cardiovascular findings and if valvular lesions are noted, patients should be instructed regarding the need for antibiotic prophylaxis for dental and surgical procedures. We report a case of osteogenesis imperfecta associated with aortic regurgitation.

A Newly Designed Cervical Pillow and Comparative Study

OBJECTIVE: Poor head and neck support during sleep can exacerbate the neck pain. Based on the ideal sleep posture and pillow suggested by Cyriax, we designed a new cervical pillow and compared the degree of pain reduction, quality of sleep and pillow satisfaction with a low hospital pillow and a high pillow. METHOD: The newly designed pillow has a built-in pressure-adjustable air bag in the cervical area and provides normal cervical lordotic curve in supine position and maintains cervical and thoracic vertebrae to form a horizontal line in side-lying position. Thiry-four patients with cervical pain used low hospital pillows for the first week of 3-week randomized crossover design study. They were subsequently randomly assigned to use each of the other two pillows for 1-week period. Outcomes were measured using visual analog scale, sleep questionnaire and a pillow satisfaction scale. RESULT: Compared with the other 2 types of pillows, subjects using the newly designed pillow showed much reduced pain intensity, increased duration of sleep and sleep quality and better pillow satisfaction. CONCLUSION: We designed a cervical pillow with built-in pressure adjustable air bag and it can significantly reduce pain intensity and improve quality of sleep in patients with cervical pain.

The Clinical Feature and Pressure Threshold in a Chest Wall Syndrome

Thirty-eight patients with a musculoskeletal chest wall syndrome were evaluated for the musculoskeletal findings of chest wall. All patients had the chest wall tenderness and the typical chest pain could be reproduced by the palpation. There was no significant difference in the diagnostic features of the pain for the onset, location, characteristics, duration, radiation, and area of references for chest pain among the different groups of the patients. However, a reproduction of pain by palpation and the pressure threshold difference between the lesion and control points by using pressure algometry was a reliable and specific diagnostic tool. Pressure threshold difference was correlated with numerical rating scale by the correlation coefficient 0.96. The common causes of the chest wall syndrome were the myofascial pain syndrome, chostochondritis, sternalis syndrome, rib-tip syndrome, xiphodynia in order. Six patients had chest wall disorders in conjunction with other associated intrathoracic condition. Thirty-two patients had an isolated chest wall syndrome. Chest wall syndrome should be considered in all patients with the chest pain, as its recognition could help the patient management.

Clinical Investigation in Husbands of Infertile Couples / 대한비뇨기과학회지

A clinical investigation was undertaken on Infertile males who seen our department during the period from 1978 to 1982. The results obtained sub as follows : 1. A total of 275 Infertile male corresponds to 1.8% of total male out-patients for the period of 5 years. 2. Numbers of Infertile male patients are increasing yearly. 3. Duration of infertile marital life ranged the mean being 3.8 years. It was 6.10% of the total infertile males that the patient had been visited psycho-dept because of neurosis(94%) 4. Susceptive etiological factors in the oligospermia, azoospermia are listed as follow : 1) epididymitis, 16.4% 2) cryptorchidism, 5.6% 3) Varicocele, 2.8% 4) Undetermined, 70.9% It was 35.9% of the total undetermined cases(l51 cases) that the past history of patient had suffered from prostatitis, urethritis. 6. Judging from the results of semen analysis(265 cases) is azoospermia was found in 21.5% oligospermia, in 58.5%, normospermia, in 20.0% 7. Findings of testicular biopsies of azoospermias(25 cases) showed that spermatogenic arrest was found in 32%, germ cell aplasia; in 24% hypospermatogenesis ; in 20% , peritubular or tubular fibrosis ; in 12%.