Comparison of Clinical Feature and Prognosis between Unilateral and Bilateral Acute Pyelonephritis

PURPOSE: Acute pyelonephritis (APN) usually presents as a mild disease. However, it has been shown to cause substantial morbidity and mortality on occasion. Therefore, it is important to distinguish between the complicated and uncomplicated APN. The purpose of this study was to determine the clinical significance of bilateral APN compared with unilateral APN in the emergency department (ED). METHODS: We analyzed the data of 303 consecutive patients with APN who underwent a abdominal computed tomography (CT) examination in the ED from January 2012 to December 2014. We compared the clinical presentation, progress, and outcomes between the unilateral and bilateral APNs that were identified on the CT scan. RESULTS: Of these 303 patients, 110 patients (36.3%) were confirmed as bilateral APN by the CT. The proportion of male was higher in the bilateral APN group (20.0% vs. 10.9%, p=0.029). Moreover, patients in the bilateral group visited the ED post symptom onset (6.5±7.8 vs. 3.6±3.1, p<0.001). However, symptom, sign, laboratory test, and CT findings were not statistically different between the two groups. In addition, severity, resistant pathogen, and outcomes such as occurrence of septic shock, hospital days, and mortality were also not different. CONCLUSION: This study suggests that bilateral APN, as determined by a CT, does not have clinical significance compared with unilateral APN.

Do We Have to Check Pulmonary Thromboembolism in Patients with Deep Vein Thrombosis in Emergency Department?

PURPOSE: Deep vein thrombosis (DVT) is a risk factor of pulmonary thromboembolism (PTE), however it is not clear who should be evaluated for a PTE and a DVT at the same time. The purpose of this study is to determine the clinical characteristics of PTE in patients with DVT who visited the emergency department (ED). METHODS: This was a retrospective cohort study of ED patients who visited with DVT and were simultaneously evaluated for a PTE from January 2012 to December 2013. We compared clinical characteristics between non-PTE and PTE patients with confirmed DVT in the ED. RESULTS: Of these 166 patients, 96 patients (57.8%) were confirmed PTE by computed tomography. In multivariate analysis, patients with PTE had more systemic neoplasm (OR 2.03, 95% CI 1.04-3.93, p=0.037) and right heart strain pattern in electrocardiography (OR 5.29, 95% CI 1.71-16.36, p=0.004) than patients without PTE. Femoral DVT was more likely in the non-PTE group (87.1% vs. 65.6%, p=0.002) and popliteal DVT was more likely in the PTE group (62.9% vs. 80.2%, p=0.013). However the number of DVT sites including both femoral and popliteal vein was not statistically different. CONCLUSION: In patients with systemic neoplasm or right heart strain patterns in electrocardiography, simultaneous PTE evaluation may be required in patients with DVT.

Etiology of Pleural Effusions in Cancer Patients

PURPOSE: The purpose of this study is to examine the causes of Pleural effusion (PE) in cancer patients and to compare the clinical characteristics between malignant PE (MPE) and non-MPE. METHODS: All consecutive cancer patients with PE who underwent diagnostic thoracentesis from January 1, 2008 to March 31, 2011 were analyzed retrospectively. RESULTS: A total of 719 patients were included; mean age was 58.4+/-13.6 years and 44.5% were female. The most common cause of PE was MPE (57.7%), followed by parapneumonic or empyema in 16.3%. However, the etiology was significantly different according to primary tumor origin and subtypes of lung cancer. While MPE was most common in lung, breast, and gynecologic cancer, hepatic hydrothorax was the main cause in Hepatocellular carcinoma (HCC). MPE accounted for 85.2% in adenocarcinoma, and 30.2% and 58.8% in squamous cell and small cell carcinomas, respectively. Patients with MPE were younger (57.0 vs. 60.2 years) and female-dominant (55.4% vs. 29.6%) compared to those with non-MPE. MPE had the large size (53.5% vs. 34.9%) and left location of PE (31.3% vs. 19.4%) more frequently than non-MPE, and fewer neutrophils (15.4% vs. 30.6%) and more lymphocytes (32.2% vs. 28.2%), higher levels of pH (7.33 vs. 7.29), and lower levels of glucose (111.5 vs. 129.7 mg/dL) than non-MPE (p<0.001 for all). CONCLUSION: Overall, MPE was the most common cause of PE in cancer patients. However the etiology of PE was significantly different according to primary tumor origin and subtypes of lung cancer. A difference in age, gender, size and location of PE, cell count, pH, and glucose was observed between MPE and non-MPE.

Clinical Features of Acute Aortic Dissection Patients Initially Diagnosed with ST-segment Elevation Myocardial Infarction

PURPOSE: Acute myocardial infarction (AMI) concomitant with acute aortic syndrome (AAS) is rare but prompt recognition of concomitant AAS is critical, particularly in patients with ST-segment elevation myocardial infarction (STEMI) because misdiagnosis with early thrombolytic or anticoagulant treatment may result in catastrophic consequences. This study examined the clinical features of patients of STEMI concomitant with AAS that may be a diagnostic clue. METHODS: Between January 1, 2010 and December 31, 2014, 22 patients who had the initial diagnosis of acute coronary syndrome (AMI and unstable angina) and AAS (aortic dissection, intramural hematoma, and ruptured thoracic aneurysm) in our emergency department were reviewed. Among them, 10 patients who were transferred from other hospitals and 4 patients with non-STEMI were excluded, leaving 8 patients of STEMI concomitant with AAS for analysis. RESULTS: The mean age of study patients was 57.5+/-16.31 years and five patients were Stanford type A and three patients were type B aortic dissection. Six patients had ST-segment elevation in anterior leads and 2 patients in inferior leads. Most patients had acute onset and severe chest pain, but none had dissecting nature chest pain. Serum troponin I was elevated in three patients but all patients had Ddimer elevation. Aortic regurgitation or regional wall motion abnormality was detected in four patients, and widened mediastinum was observed in all study patients. CONCLUSION: Concomitant AAS might be suspected in patients with STEMI who have elevated D-dimer and widened mediastinum.

Clinical Validity Comparison Study of Patients Severity Triage System in the Emergency Department: Modified Emergency Severity Index (mESI) and modified Canadian Triage Acuity System (mCTAS)

PURPOSE: This study was conducted to identify better methods of determining the severity of triage by comparing triage results and clinical outcome of patients categorized by the modified Canadian Triage Acuity Scale (mCTAS) and modified Emergency Severity Index (mESI). METHODS: Subjects enrolled in this study consisted of 1,000 adult patients (age 16 years or older) who visited the emergency room of a university affiliated hospital between September 15, 2011 and September 30, 2011 and were categorized into five levels by mCTAS and mESI. RESULTS: 1) Good confidence was verified based on weighted kappa values of 0.70 between the physicians group and nurses group. 2) Upon evaluation of triage by mESI, the majority of patients were at level 3 among 5, followed by level 4, 2, 1 and 5 in order. The same level orders were shown upon evaluation of triage by mCTAS beside differences in patient numbers. 3) Comparing clinical outcome according to the mCTAS and the mESI revealed similar results in both triage tools, with a higher triage level being associated with a higher admission rate and lower triage level and the discharge rate became higher. CONCLUSION: Triage by mESI showed good agreement among asserters and high agreement between physicians and nurses. Clinical results based on mCTAS and mESI triage showed similar rates of admission to the ward or intensive care unit and rates of discharge. Although these two triage protocols are similar in many aspects, the use of mESI is perceived as a better because mCTAS requires knowledge of various diseases and mESI has a short training period.

Survival in Neoplastic Meningitis as a Function of Diagnostic Modalities

PURPOSE: Neoplastic meningitis (NM) is diagnosed by the presence of malignant cells within cerebrospinal fluid (CSF), or brain and spinal cord imaging with magnetic resonance imaging (MRI). Patients with NM were divided into three diagnostic subcategories, and overall survival as a function of diagnostic modalities was analyzed. METHODS: A total of 150 patients with a solid tumor or lymphoma diagnosed as NM in an emergency department between 2003 and 2010 were included. Patients were divided into three groups: positive cytology and MRI (n=64), positive cytology with negative MRI (n=43), and negative cytology with positive MRI (n=43). RESULTS: Overall median survival from NM was eight weeks. CSF was positive for malignant cells in 107(71.3%) patients, and MRI was positive in 107(71.3%) patients. Survival did not vary significantly among the three groups [CSF(+), MRI(-): median 12 weeks, range 1-80(95% CI, 7-17); CSF(-), MRI(+): median 12 weeks, range 1-66 (95% CI, 7-17); CSF(+), MRI(+): median 6 weeks, range 1-64(95% CI, 3-9), p=0.306]. CONCLUSION: When considering diagnostic modalities, examination of CSF and MRI showed the same sensitivities, and the survival of NM was similar in patients with different diagnostic modalities.

Analysis of Clinical Outcome and Effectiveness of Steroid and Antiviral Treatment in Patients with Bell's Palsy in the Emergency Department

PURPOSE: This study was conducted for investigation of the recovery rate and prognostic factors of Bell's palsy treated with steroid and antiviral agents in the emergency department (ED). METHODS: A retrospective review of electronic medical records of patients with acute, unilateral Bell's palsy within 72 hrs of onset who were admitted from the ED between March 2008 and February 2010 was conducted. All patients were treated uniformly with high-dose steroid and valaciclovir. The House-Brackmann (HB) grading system was used for evaluation of the severity of facial palsy. Satisfactory recovery was defined as facial palsy that recovered to Grade I on the HB grading scale. RESULTS: During the three-year period, 231 patients (age, 51+/-15) with confirmed Bell's palsy were included in this study. Initial grade of paralysis was as follows: 43 patients (18.6%) were HB grade II, 107 patients (46.3%) were grade III, 72 patients (31.2%) were grade IV, and nine patients (3.9%) were grade V. The satisfactory recovery rate was 77.9% at three months, and 88.3% at 12 months from diagnosis. Satisfactory recovery rate was significantly lower in patients with initial HB grade III/IV (85.2% vs. 92.7%, p<0.01), and age over 40 years (85.72% vs. 95.2%, p=0.04). CONCLUSION: The satisfactory recovery rate of patients with Bell's palsy treated with steroid and antiviral agents was 77.9% at three months, and 88.3% at 12 months, and initial severity was found to be an important factor in predicting the long term prognosis of Bell's palsy.

The Usefulness of Procalcitonin and C-Reactive Protein as Early Diagnostic Markers of Bacteremia in Cancer Patients with Febrile Neutropenia / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Procalcitonin (PCT) and C-reactive protein (CRP) are well known inflammatory markers. This study was designed to determine whether PCT and CRP are useful as early diagnostic markers for bacteremia in cancer patients with febrile neutropenia (FN) in the emergency department (ED). MATERIALS AND METHODS: In this retrospective study, 286 episodes of FN in the ED were consecutively included between June 2009 and August 2010. From medical records, clinical characteristics including PCT and CRP were extracted and analyzed. RESULTS: Bacteremia was identified in 38 (13.3%) of the 286 episodes. The median values of PCT (2.8 ng/mL vs. 0.0 ng/mL, p=0.000) and CRP (15.9 mg/dL vs. 5.6 mg/dL, p=0.002) were significantly higher in the group with bacteremia compared to the group without bacteremia. In univariate analysis, elevated PCT (>0.5 ng/mL) and CRP (>10 mg/dL) as well as older age, hypotension, tachycardia, tachypnea, and high body temperature were significantly associated with bacteremia. On multivariate analysis, elevated PCT (>0.5 ng/mL) (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.4 to 9.2; p<0.01) and tachypnea (OR, 3.4; 95% CI, 1.4 to 8.5; p<0.01) were independent early diagnostic markers for bacteremia in FN patients. The area under the curve of PCT was 74.8% (95% CI, 65.1 to 84.6%) and that of CRP was 65.5% (95% CI, 54.8 to 76.1%). With a PCT cut-off value of 0.5 ng/mL, sensitivity and specificity were 60.5% and 82.3%, respectively, while the sensitivity and specificity were 57.6% and 67.3%, respectively, with a CRP cutoff of 10 mg/dL. CONCLUSION: These findings suggest that PCT is a useful early diagnostic marker for the detection of bacteremia in FN at the ED and has better diagnostic value than CRP.

The Usefulness of Procalcitonin and C-Reactive Protein as Early Diagnostic Markers of Bacteremia in Cancer Patients with Febrile Neutropenia / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Procalcitonin (PCT) and C-reactive protein (CRP) are well known inflammatory markers. This study was designed to determine whether PCT and CRP are useful as early diagnostic markers for bacteremia in cancer patients with febrile neutropenia (FN) in the emergency department (ED). MATERIALS AND METHODS: In this retrospective study, 286 episodes of FN in the ED were consecutively included between June 2009 and August 2010. From medical records, clinical characteristics including PCT and CRP were extracted and analyzed. RESULTS: Bacteremia was identified in 38 (13.3%) of the 286 episodes. The median values of PCT (2.8 ng/mL vs. 0.0 ng/mL, p=0.000) and CRP (15.9 mg/dL vs. 5.6 mg/dL, p=0.002) were significantly higher in the group with bacteremia compared to the group without bacteremia. In univariate analysis, elevated PCT (>0.5 ng/mL) and CRP (>10 mg/dL) as well as older age, hypotension, tachycardia, tachypnea, and high body temperature were significantly associated with bacteremia. On multivariate analysis, elevated PCT (>0.5 ng/mL) (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.4 to 9.2; p<0.01) and tachypnea (OR, 3.4; 95% CI, 1.4 to 8.5; p<0.01) were independent early diagnostic markers for bacteremia in FN patients. The area under the curve of PCT was 74.8% (95% CI, 65.1 to 84.6%) and that of CRP was 65.5% (95% CI, 54.8 to 76.1%). With a PCT cut-off value of 0.5 ng/mL, sensitivity and specificity were 60.5% and 82.3%, respectively, while the sensitivity and specificity were 57.6% and 67.3%, respectively, with a CRP cutoff of 10 mg/dL. CONCLUSION: These findings suggest that PCT is a useful early diagnostic marker for the detection of bacteremia in FN at the ED and has better diagnostic value than CRP.

Clinical Analysis of Puffer Fish Poisoning Cases

PURPOSE: Ingestion of puffer fish can be poisonous due to the presence of potent neurotoxins such as tetrodotoxin (TTX) found in its tissues. There are few clinical reports related to TTX. We performed this study to evaluate the clinical characteristics of TTX poisoning. METHODS: We conducted a retrospective study of the 41 patients diagnosed with TTX poisoning who visited the Seoul Asan medical center from July 2004 and December 2010. A review of patients'electronic medical records and patient telephone interviews were conducted. Diagnosis of TTX poisoning was confirmed by observing the casual link between puffer fish consumption and the development of typical TTX intoxication symptoms. RESULTS: The mean age of the patients included in the study was 46.6 years. The highest incidence of intoxication was observed in patients in their 50s (10 patients). Seasonal distribution of intoxication events included 10 in spring, 7 in summer, 10 in fall, and 14 in winter. In most cases, symptoms occurred within 1 hour of ingestion. A wide range of symptoms were associated with puffer fish ingestion affecting multiple body systems including neuromuscular (27 patients), gastrointestinal (19 patients), and cardiopulmonary/vascular (19 patients). All patients were treated with symptomatic and supportive therapy and recovered completely, without sequelae, within 48 hours. In three cases, ventilator support was required. CONCLUSION: TTX poisoning is not seasonally related, and patients admitted to the emergency room were observed with a wide range of symptoms. Where TTX poisoning is diagnosed, supportive therapy should be performed. Early intubation and ventilation is important, especially is cases of respiratory failure.

Use of Point-of-Care Blood gas Analyzer for Potassium Measurement in Cardiac Arrest Cases

PURPOSE: The aim of this study was to assess agreement of potassium test results between the point-of-care-testing (POCT) blood gas analyzer and central laboratory (CL) biochemistry analysis associated with cardiopulmonary resuscitation (CPR) cases. METHODS: This was a prospective, comparative study of 108- paired results conducted between January 2009 and December 2010. Blood specimens were collected within 5 minutes of arrival to the emergency department from the femoral artery of cardiac arrest patients, and specimens were used for both arterial blood gas and routine laboratory analysis. Arterial blood gas analysis samples were immediately analyzed using a POCT blood gas machine [GEM Premier 3000 analyzer (Instrumentation Laboratory, Lexington, MA)]. Potassium levels obtained from the POCT arterial blood gas analyzer and subsequent CL biochemistry analysis were then compared. RESULTS: Mean values of potassium measured were 5.17+/-1.72 mmol/l using POCT and 5.37+/-1.79 mmol/l using CL. The mean difference+/-SD between simultaneous POCT and CL measurements was 0.19+/-0.66 mmol/l, with 95% limits of agreement of -1.48 to 1.10 mmol/l. The sensitivity, specificity, positive predictive value, and negative predictive value of POCT in diagnosing life threatening hyperkalaemia (> 6.5 mmol/l) were 85%, 97%, 85%, and 97%, respectively. CONCLUSION: The mean difference between the results obtained from the POCT blood gas analyzer and CL analysis were small. POCT is a thus a useful method for rapidly detecting life-threatening hyperkalaemia during CPR. However, due to wide limits of agreements, caution in interpretation of POCT results is necessary.

Analysis of the Korean Emergency Department Syndromic Surveillance System: Mass Type Acute Diarrheal Syndrome / 대한의료정보학회지

OBJECTIVES: This study was designed to compare the data from the emergency department syndromic surveillance system of Korea in detection and reporting of acute diarrheal syndrome (mass type) with the data from the Korea Food and Drug Administration. And to offer fundamental materials for making improvements in current surveillance system was our purpose. METHODS: A study was conducted by reviewing the number of cases reported as acute diarrheal syndrome (mass type) from the Korean Center for Disease Control and Prevention between June, 2002 and July, 2008. And the data were compared with the number of mass food poisoning cases during the same period, reported from the Korea Food and Drug Administration. The difference between two groups was measured and their transitions were compared. RESULTS: The emergency department syndromic surveillance system's reports of the numbers of acute diarrheal syndrome (mass type) cases were different from the transition of mass food poisonings, reported by the Korea Food and Drug Administration. Their reports were not accurate and they could not follow the trends of increase in mass food poisonings since 2002. CONCLUSIONS: Current problems in the emergency department syndromic surveillance system in Korea are mostly related to inaccuracies of daily data reporting system. Manual data input by the reporters could play a big role in such inaccuracies. There need to be improvements in the ways of reporting data, such as automated information transport system linking electronic medical record.

Predictors of Bacteremia in Cancer Patients with Febrile Neutropenia

PURPOSE: Febrile neutropenia (FN) still remains a life-threatening cancer treatment-related toxicity and may compromise further chemotherapy in individual cancer patients. In this study, we sought to determine predictors of bacteremia in cancer patients with FN at the time of their visiting the emergency department. METHODS: Between January 1, 2007 and December 31, 2008, 392 episodes of FN in 342 cancer patients were retrospectively reviewed. We assessed clinical and laboratory features, and MASCC risk-index scores at admission to the emergency department. Statistical analysis was done using SPSS ver. 11.0. RESULTS: Among a total of 392 episodes, 34 (8.7%) showed bacteremia. There was a significant difference between bacteremic episodes and non-bacteremic episodes in tachycardia (56% vs. 31%), tachypnea (24% vs. 8%), high temperature (36% vs. 16%), hemoglobin (9.4 vs. 10.1 g/dL), platelet (73.3 vs. 117.5 x 10(3)/mm3), BUN (24 vs. 13 mg/dL), creatinine (1.2 vs. 0.8 mg/dL), and CRP (12.6 vs. 8.5 mg/dL). On multivariate analysis, low platelet count (OR 5.6, 95% CI 2.5-12.5, p<0.001), elevated BUN (OR 4.8, 95% CI 2.1-11.0, p<0.001), tachypnea (OR 3.2, 95% CI 1.2-8.3, p=0.020), and high temperature (OR 2.7, 95% CI 1.2-6.2, p=0.019) were independent factors associated with bacteremia. MASCC score < 21 was more frequent in bacteremic than non-bacteremic patients (32% vs. 10%, p=0.001). CONCLUSION: Low platelet count, elevated BUN, tachypnea, and high temperature are independent predictors of bacteremia in cancer patients with FN. Also, the MASCC risk-index score is a useful predictor of bacteremia.

Effectiveness of a Specialized Emergency Department Unit for Cancer Patients in Management of Febrile Neutropenia

PURPOSE: Our medical institute developed an emergency department (ED) cancer unit that specialized in the management of oncologic emergencies; it was named the cancer emergency room (CER). The object of our study was to determine improvements in patient management, especially management of febrile neutropenia (FN). METHODS: This was a retrospective study of 137 febrile neutropenic episodes, including 70 episodes occurring between May 2008 and August 2008, and 67 episodes between May 2009 and August 2009. Episodes were grouped into two categories: those managed in the CER and those managed in the existing ED main treatment area of the main emergency room (MER). The time interval between presentation at the ED and first antibiotic administration, termed the door-to-needle time, clinical outcomes, and length of inpatient hospital stay were analyzed for those admitted. RESULTS: The median door-to-needle time in the CER was 2 hours (0.3-5.1), faster than the time, 3.5 hours (0.9-6.9) in the MER (p=0.000). The length of inpatient hospital stay in the CER was 4 days (1-16), shorter than that, 6 days (1-51), in the MER (p=0.034). Twelve episodes (26.1%) had adverse events in the CER and 42 (46.2%) in the MER (p=0.023). CONCLUSION: Management of FN in a unit specialized for oncologic emergencies showed faster antibiotic delivery time, more favorable outcomes and shorter duration of admission. This specialized cancer unit in the ED enables prompt and relevant management in oncologic emergencies, including events related to chemotherapy toxicity.

Rapid Diagnosis of Human Immunodeficiency Virus Infection Using OraQuick(r) Advance Rapid HIV-1/2 Antibody Test / 감염과화학요법

BACKGROUND: From medical care perspective regarding HIV, early detection of HIV is critical in effectively managing its sequelae. People who are aware of the fact that they are infected with HIV significantly reduce high risk behaviors, thus limiting transmission to others compared to individuals who are unaware of their HIV serostatus. MATERIALS AND METHODS: HIV rapid test validation study was conducted at Asan medical center using OraQuick Advance Rapid HIV-1/2 Antibody Test which uses oral fluid specimens for the diagnosis of HIV infection. A total of 57 subjects were tested; 53 individuals were confirmed to have HIV infection by the Western blot analysis and 4 individuals were negative for HIV. RESULTS: The oral fluid specimens from 52 of 53 infected individuals showed positive reaction to the OraQuick Advance Rapid HIV-1/2 Antibody Test. The test results were negative for the 4 subjects who were negative for HIV. OraQuick Advance Rapid HIV-1/2 Antibody Test's sensitivity was 98.1%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 80%. CONCLUSION: The recently approved OraQuick Advance Rapid HIV-1/2 Antibody Test has the ability to detect HIV antibodies comparable to that of confirmatory tests such as Western blot analysis.

Rapid Diagnosis of Human Immunodeficiency Virus Infection Using OraQuick(r) Advance Rapid HIV-1/2 Antibody Test / 감염과화학요법

BACKGROUND: From medical care perspective regarding HIV, early detection of HIV is critical in effectively managing its sequelae. People who are aware of the fact that they are infected with HIV significantly reduce high risk behaviors, thus limiting transmission to others compared to individuals who are unaware of their HIV serostatus. MATERIALS AND METHODS: HIV rapid test validation study was conducted at Asan medical center using OraQuick Advance Rapid HIV-1/2 Antibody Test which uses oral fluid specimens for the diagnosis of HIV infection. A total of 57 subjects were tested; 53 individuals were confirmed to have HIV infection by the Western blot analysis and 4 individuals were negative for HIV. RESULTS: The oral fluid specimens from 52 of 53 infected individuals showed positive reaction to the OraQuick Advance Rapid HIV-1/2 Antibody Test. The test results were negative for the 4 subjects who were negative for HIV. OraQuick Advance Rapid HIV-1/2 Antibody Test's sensitivity was 98.1%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 80%. CONCLUSION: The recently approved OraQuick Advance Rapid HIV-1/2 Antibody Test has the ability to detect HIV antibodies comparable to that of confirmatory tests such as Western blot analysis.

The Clinical Characteristics and Mortality Factors of Patients with Hemorrhagic Complications after Anticoagulation Therapy with Warfarin

PURPOSE: The number of patients who take warfarin is growing and so is the number of complications. Hemorrhage is the major complication, but the clinical characteristics and outcomes have not been determined for Korean patients. Therefore, we tried to evaluate the characteristics of the patients with hemorrhagic complications after taking warfarin as anticoagulation therapy. METHODS: We retrospectively reviewed the medical records of the patients who visited the emergency room with bleeding complications after taking warfarin anticoagulation at the out-patient clinic for 1 year from 1st January 2008. We compared between two groups (the major hemorrhage group vs. the minor hemorrhage group) according to the clinical criteria, the unstable vital signs that required blood transfusion, transfusion more than 2 units of blood, the need for further laboratory follow-up, the need for interventional treatment and the development of critical complications or death due to bleeding. RESULTS: There were 150 patients who met the criteria and had acute hemorrhagic complications (the major group: 90 patients and the minor group: 60 patients). In the major hemorrhage group, the frequent sites of bleeding were the gastro-intestinal system (40 patients), lung (14 patients) and intracranium (7 patients). At the emergency room, the major group showed a higher initial INR of the activated prothrombin time than did the minor group (p=0.02). The bleeding sites of the fatal cases were the gastro-intestinal system (3 patients), lung (3 patients) and intracranium (3 patients), but the percentage of fatality was the highest for intracranium bleeding. CONCLUSION: In the major hemorrhage group, gastrointestinal bleeding was the most frequent complication and fatality was the highest for intracranium bleeding. An initially higher INR showed a greater risk of major bleeding, but not more fatalities.

Age-related Injury Profile in Childhood

PURPOSE: Injuries are the most important cause of morbidity and mortality in the childhood population worldwide. Thus, this study was down to investigate the type and the severity of injuries according to the age group in childhood. METHODS: A survey of injury information and a chart review were done on 378 children (257 boys, 121 girls) who visited the Emergency Departments of Asan Medical Center from March 1, 2009, to March 31, 2009. To determine differences in injury mechanism, accident place, injury site, New Injury Severity Score (NISS) and Pediatric Trauma Score (PTS), we divided the 378 patients into 4 group: under 1 year, 1 to 4 years, 5 to 9 years, and 10 to 15 years. RESULTS: The mean (+/-SD) age of the study group was 5.1 (+/-4.4) years. Two year olds formed the largest group of injured children, with 77 cases (20.4% of the total). The most common cause of injury in childhood was being hit by an object (26.2%). Falls were frequent in the under-1-year group (22.2%) and slip downs (30.1%) were more frequent in 1-to-4-year group. More than half (53.4%) of the injuries occurred in the home, and the most common places of home-related injuries were the living room (41.1%) and the bedroom (31.2%). The mean (+/-SD) NISS was 1.5 (+/-1.8), and traffic accidents had the highest NISS (2.8+/-5.1). Injuries occurred most frequently during the evening. The peak period was 4:00 PM to 8:00 PM (33.7%). CONCLUSION: Patterns of childhood injury by age group were considerably different, and less severe and nonhospitalized injuries were common. Thus, need to improve surveillance of a variety of injuries, promote intersectional collaboration, build institutional capacities and mobilize community support and policy as an investment in prevention.

Clinical outcomes and predictive factors of spontaneous survival in patients with fulminant hepatitis A / 대한간학회지

BACKGROUNDS/AIMS: The occurrence of acute hepatitis A is increasing and its progression to fulminant hepatic failure (FHF) is frequent. We investigated the frequency and clinical outcomes of fulminant hepatitis A and also analyzed the predictive factors of spontaneous survival. METHODS: A total of 568 patients presented with acute hepatitis A from January 2003 to June 2008, of which the 35 (6.2%) patients with FHF were divided into two groups: spontaneous survival and transplant/death. These two groups were compared according to various clinical features including the MELD score and King's College Hospital (KCH) criteria. RESULTS: The rate of FHF development increased over time among patients with acute hepatitis A: 0% in 2003, 3.4% in 2004, 3.2% in 2005, 6.0% in 2006, 7.7% in 2007, and 13.0% in 2008. Twenty patients (57.1%) showed spontaneous survival, 13 (37.1%) received liver transplantation, and 5 (14.3%) died during hospitalization. The two groups of spontaneous survival (N=20) and transplant/death (N=15) showed significant differences in prothrombin time at admission and at its worst value, albumin at its worst value, and hepatic encephalopathy grade at admission and at its worst value. The MELD score was lower in the spontaneous-survival group than in the transplant/death group (27.0+/-7.8 vs. 37.0+/-7.1, mean+/-SD; P=0.001). However, KCH criteria did not differ significantly between the two groups. On multivariate analysis, HEP grade was the only significant predictive factor, being negatively correlated with spontaneous survival (OR=0.068, P=0.025). CONCLUSIONS: FHF due to hepatitis A has increased in recent years, and in our cohort the HEP grade was closely associated with spontaneous survival.

S-100B Protein as a Useful Serologic Marker of Acute Stroke with Nonspecific Neurologic Symptoms

PURPOSE: There is a distinct probability of severe complications with stroke unless patients are administered proper treatment at the optimal time. S-100B protein has been reported to be elevated in brain injuries. The current study investigates the efficacy of serum S-100B protein administration during the diagnostic process for patients who have had an acute stroke. METHODS: We prospectively recruited the patients with nonspecific neurological symptoms. Non-specific neurological symptoms were defined as no focal neurological deficits or stroke suspected symptoms with NIHSS score zero. We grouped the patients according to the presence of a brain lesion (positive vs negative group) by computed tomography or magnetic resonance imaging. Using serum S-100B protein together with CT/MRI imaging at the time of diagnosis, the cutoff value, sensitivities, and specificities were calculated in making a diagnosis of acute stroke. RESULTS: Thirty one patients were enrolled. The level of serum S-100B protein was higher in positive group (median 0.201, interquartile range 0.134-0.469) than in negative group (0.085, 0.060-0.106, p=0.001). In diagnosing acute stroke, the sensitivity was 90.9% at a cutoff value for serum S-100B protein of 0.10 microgram/L . At the cutoff level of serum S-100B protein and the specificity was 75.0%. CONCLUSION: The current results suggest that serum S-100B protein may be a useful serologic marker for detecting acute stroke that is suspected with non-specific neurological abnormalities. Further studies are necessary to use the marker as a screening method for acute strokes.