Clinical analysis of direct medical oversight for the national pilot program of expanding scope of firefighter emergency medical services providers in a Korean metropolitan city

Objective@#The fire department-based emergency medical services (EMS) system and centralized direct medical oversight (DMO) system are well-established in Korea. In 2019, the government launched a national pilot program for expanding the scope of work of EMS providers. This study was undertaken to clinically examine DMO for the ‘specialized EMS squad’ in the Seoul Metropolitan City. @*Methods@#This is a descriptive analysis of the current status of the EMS of the city and DMO. The basic statistics of firefighter EMS providers and the DMO physicians, as well as the number of ambulance runs, were investigated during the study period (July to December 2019). Records of the DMO physicians were also reviewed, to assess intervention of the ‘specialized EMS squad’. @*Results@#Totally, 1,109 patients transferred to hospitals by the ‘specialized EMS squad’ were provided DMO (out-of-hospital cardiac arrest 833, chest pain 229, multiple injured trauma 21, anaphylaxis 17, unplanned out-of-hospital birth 4.; excluding 5 cases of insufficient records). In out-of-hospital cardiac arrest, intravenous epinephrine was implemented by 538 cases (64.6%). Single dose of intravenous epinephrine was used in 218 cases (40.5%), whereas two doses were administered in 163 cases (30.3%). In patients with chest pain, 12-lead electrocardiography was achieved in 226 cases (98.7%). The epinephrine autoinjector (0.3 mg) was applied for 10 cases of anaphylaxis (61.1%). Umbilical cord cutting was executed during 2 births (50%). @*Conclusion@#The national pilot program to expand the scope of firefighter EMS providers was successfully implemented in the Seoul Metropolitan City. Emergency physicians played critical roles for the application. The firefighter EMS providers were able to accomplish advanced life support level practices in the prehospital setting by DMO.

The Influence of Vertical Location of Cardiac Arrest and Application of Mechanical Cardiopulmonary Resuscitation Device on out of Hospital Cardiac Arrest in a Community: A Retrospective Observational Study

PURPOSE: The use of mechanical compression devices may be considered as an alternative method to treat cardiac arrest. This study aimed to assess the influence of vertical location of cardiac arrest scene to survival rate. Furthermore, it set out to examine the effect of mechanical compression devices on the survival rate. METHODS: This is retrospective, observational study of cardiac arrest patients from Gangdong-gu, Seoul between September 2015 and February 2016. The data were collected by 119 rescue records and cardiac arrest summary list, and the resuscitation result variables were analyzed. We also conducted a survey on 119 paramedics regarding the subjective valuation and drawback of using mechanical compression devices. RESULTS: The odd ratio of return of spontaneous circulation (ROSC) in vertical location of cardiac arrest scene was 0.40 (95% confidence interval, 0.17 to 0.98; p=0.044). The odd ratio of survival to admission comparing manual compression with mechanical compression was 0.73 (95% confidence interval, 0.26 to 1.99; p=0.532). A total of 54 paramedics completed the survey, and 46 (85.2%) of them answered that there was a decrease in the quality of chest compression if the scene was other than the 1st floor. Fifty-three (93.1%) replied that mechanical compression devices can be a counter-measure. CONCLUSION: Vertical location of cardiac arrest scene independently effects ROSC of out of hospital cardiac arrest. However, there was no difference in the survival rate between manual and mechanical compressions.

The Prevalence and Significance of Overt Disseminated Intravascular Coagulation in Patients with Septic Shock in the Emergency Department According to the Third International Consensus Definition / 대한구급학회지

BACKGROUND: The prevalence and prognostic value of overt disseminated intravascular coagulation (DIC) in patients with septic shock presenting to emergency departments (EDs) is poorly understood, particularly following the release of a new definition of septic shock. The purpose of this study was to investigate the prevalence and prognostic value of DIC in septic shock. METHODS: We performed retrospective review of 391 consecutive patients with septic shock admitting to the ED of tertiary care, university-affiliated hospital during a 16-month. Septic shock was defined as fluid-unresponsive hypotension requiring vasopressor to maintain a mean arterial pressure of 65 mmHg or greater, and serum lactate level ≥ 2 mmol/L. Overt DIC was defined as an International Society on Thrombosis and Hemostasis (ISTH) score ≥ 5 points. The primary endpoint was 28-day mortality. RESULTS: Of 391 patients with septic shock, 290 were included in the present study. The mean age was 65.6 years, the 28-day mortality rate was 26.9%, and the prevalence of overt DIC was 17.6% (n = 51) according to the ISTH score. The median DIC score was higher in non-survivors than in survivors (5.0 vs. 2.0, p = 0.001). Significant higher risk of mortality was observed in overt DIC patients compared to those without (28.2% vs. 13.7%, p = 0.005). Multivariable logistic regression analysis identified DIC to be independently associated with 28-day mortality (odds ratio, 2.689 [95% confidence interval, 1.390-5.201]). CONCLUSIONS: Using the ISTH criteria of DIC, overt DIC in septic shock was found to be common among patients admitting to the ED and to be associated with higher mortality when it is accompanied with septic shock. Efforts are required to identify presence of overt DIC during the initial treatment of septic shock in patients presenting the the ED.

The Prevalence and Significance of Overt Disseminated Intravascular Coagulation in Patients with Septic Shock in the Emergency Department According to the Third International Consensus Definition / 대한중환자의학회지

BACKGROUND: The prevalence and prognostic value of overt disseminated intravascular coagulation (DIC) in patients with septic shock presenting to emergency departments (EDs) is poorly understood, particularly following the release of a new definition of septic shock. The purpose of this study was to investigate the prevalence and prognostic value of DIC in septic shock. METHODS: We performed retrospective review of 391 consecutive patients with septic shock admitting to the ED of tertiary care, university-affiliated hospital during a 16-month. Septic shock was defined as fluid-unresponsive hypotension requiring vasopressor to maintain a mean arterial pressure of 65 mmHg or greater, and serum lactate level ≥ 2 mmol/L. Overt DIC was defined as an International Society on Thrombosis and Hemostasis (ISTH) score ≥ 5 points. The primary endpoint was 28-day mortality. RESULTS: Of 391 patients with septic shock, 290 were included in the present study. The mean age was 65.6 years, the 28-day mortality rate was 26.9%, and the prevalence of overt DIC was 17.6% (n = 51) according to the ISTH score. The median DIC score was higher in non-survivors than in survivors (5.0 vs. 2.0, p = 0.001). Significant higher risk of mortality was observed in overt DIC patients compared to those without (28.2% vs. 13.7%, p = 0.005). Multivariable logistic regression analysis identified DIC to be independently associated with 28-day mortality (odds ratio, 2.689 [95% confidence interval, 1.390-5.201]). CONCLUSIONS: Using the ISTH criteria of DIC, overt DIC in septic shock was found to be common among patients admitting to the ED and to be associated with higher mortality when it is accompanied with septic shock. Efforts are required to identify presence of overt DIC during the initial treatment of septic shock in patients presenting the the ED.

Reexpansion Pulmonary Edema after Initial Treatment of Primary Spontaneous Pneumothorax: Small Bore Catheterization versus Chest Tube Thoracostomy

PURPOSE: Reexpansion pulmonary edema (REPE) is a rare but potentially lethal complication of treatment for pneumothorax. This study was designed to compare the frequency of REPE after treatment of primary spontaneous pneumothorax (PSP) with 6 French (Fr) small bore catheterization and 14-20 Fr chest tube thoracostomy. METHODS: The medical records of PSP patients treated with thoracostomy from January 2010 to May 2015 were reviewed retrospectively. We compared the group treated using a 6 Fr small bore catheter with the group treated using a 14-20 Fr chest tube for clinical and demographic factors. The main outcome was the frequency of REPE between the two groups. RESULTS: A total of 196 patients were enrolled. No significant differences in catheter indwelling time, lengths of hospital stay, and treatment failures were observed between the two groups. REPE developed in 21 patients (10.7%). The frequencies of REPE after 6 Fr small bore catheter and 14-20 Fr chest tube were 6.0% (7 of 114 patients) and 17.1% (14 of 82 patients), respectively (p=0.015). In logistic regression analysis, drainage via 14-20 Fr chest tube showed significant correlation with the occurrence of REPE (odds ratio=3.03, p=0.038). CONCLUSION: A 6 Fr small bore catheter offers a safe and effective alternative to a chest tube for treatment of pneumothorax. We suggest that drainage via a small bore catheter should be considered as the initial treatment of choice for PSP patients in terms of frequency of development REPE.

An Association between the Inflammatory Marker and Short-term Risk of Stroke in Patients with Transient Ischemic Attack and Low ABCD2 Score

PURPOSE: A transient ischemic attack (TIA) is a brief episode of neurological dysfunction resulting from focal cerebral ischemia not associated with permanent cerebral ischemia and short-term risk of stroke after TIA is high. Inflammatory markers play an important role in acute brain ischemia. The purpose of this study was to investigate the association between the inflammatory markers and short-term risk of stroke in patients with TIA and low ABCD2 score. METHODS: The authors conducted a retrospective study of patients diagnosed with TIA in the emergency department (ED) from June 2006 to April 2013. A total of 282 patients diagnosed as TIA with low ABCD2 score were enrolled. Patients were divided into two groups according to occurrence of stroke within 90 days. We analyzed demographic characteristics, laboratory data, and comorbidities of each group. RESULTS: The median age of patients was 50.0(45.8-58.0) years, with 44.3% males. Based on the occurrence of stroke within 90 days, the patients were divided into 42 patients with stroke and 240 patients with non-stroke. Patients with stroke showed a high median age (p=0.027), white blood cell count (p=0.031), neutrophil to lymphocyte ratio (NLR) (p=0.033), C-reactive protein (p=0.005), and glucose (p=0.010). Results of multivariate analysis showed that NLR was a significant predictor of short-term prognosis (odds ratio 2.785, 95% confidence interval 1.453-5,340). CONCLUSION: NLR in the ED may be used as a rapid and easy to measure inflammatory marker for prediction of short-term prognosis in patients with transient ischemic attack and low ABCD2 score.

An Association between the Inflammatory Marker and Short-term Risk of Stroke in Patients with Transient Ischemic Attack and Low ABCD2 Score

PURPOSE: A transient ischemic attack (TIA) is a brief episode of neurological dysfunction resulting from focal cerebral ischemia not associated with permanent cerebral ischemia and short-term risk of stroke after TIA is high. Inflammatory markers play an important role in acute brain ischemia. The purpose of this study was to investigate the association between the inflammatory markers and short-term risk of stroke in patients with TIA and low ABCD2 score. METHODS: The authors conducted a retrospective study of patients diagnosed with TIA in the emergency department (ED) from June 2006 to April 2013. A total of 282 patients diagnosed as TIA with low ABCD2 score were enrolled. Patients were divided into two groups according to occurrence of stroke within 90 days. We analyzed demographic characteristics, laboratory data, and comorbidities of each group. RESULTS: The median age of patients was 50.0(45.8-58.0) years, with 44.3% males. Based on the occurrence of stroke within 90 days, the patients were divided into 42 patients with stroke and 240 patients with non-stroke. Patients with stroke showed a high median age (p=0.027), white blood cell count (p=0.031), neutrophil to lymphocyte ratio (NLR) (p=0.033), C-reactive protein (p=0.005), and glucose (p=0.010). Results of multivariate analysis showed that NLR was a significant predictor of short-term prognosis (odds ratio 2.785, 95% confidence interval 1.453-5,340). CONCLUSION: NLR in the ED may be used as a rapid and easy to measure inflammatory marker for prediction of short-term prognosis in patients with transient ischemic attack and low ABCD2 score.

Analysis of Factors Related to Delayed Answer in Interhospital Transfer Refer

PURPOSE: The purpose of this study is to determine the factors related to delayed answer in interhospital transfer in order to reduce the time required to determine interhospital transfer and to provide optimal care for emergency patients. METHODS: This was a retrospective observational study. Data on request for interhospital transfer of emergency patients were collected from July, 2013 to October, 2013 in an urban emergency department with approximately 40,000 annual visits. Time required for determination, receptionist's department and position, decision maker's department and position, patient's general characteristics, and requesting hospital's characteristics were collected. The SPSS package with Student's t-test, Chi-square, one-way ANOVA, and multivariate logistic regression analysis was used for analysis of the data. RESULTS: When the decision maker's department was emergency medicine, the time required to determine inter-hospital transfer was shortest (p<0.001), and position of emergency medicine member was non-significant (p=0.109). When the decision maker's department was non-emergency medicine, specialist had a shorter time required to determine interhospital transfer than resident (p<0.001), but influence of the position of receptionist was non-significant. CONCLUSION: Decision maker for interhospital transfer request should be an emergency medicine member. If one cannot make a decision, one should consult a specialist, not a resident. Hospitals should implement an organized system to shorten the time for interhospital transfer.

An Association Between the Prolonged Heart Rate-corrected QT Interval and Global Functional Outcome in Patients with Subarachnoid Hemorrhage

PURPOSE: Autonomic dysfunctions after subarachnoid hemorrhage (SAH) may lead to various arrhythmias, electrocardiographic abnormalities, and myocardial dysfunction. Prolongation of the heart rate-corrected QT (QTc) interval is frequently observed in patients with SAH. The aim of this study was to examine the associations between the QTc interval and global functional outcome in patients with SAH. METHODS: We studied 413 adult patients admitted via the emergency department within 48 hours after the onset of spontaneous SAH from January 2007 to December 2011. Among 413 patients with SAH, there were 154 male and 258 female patients whose mean age was 58.8+/-12.4 years. QT intervals were measured by standard 12-lead electrocardiography (ECG) and corrected by Bazett formulae. The QTc interval were considered prolonged at >450 ms in men and >470 ms in women. Outcomes were assessed using the length of hospital stay and the Modified Rankin scale (MRS) at discharge. RESULTS: One or more repolarization abnormalities occurred in 61.9% of patients. The most frequently observed ECG abnormality was QTc prolongation (54.9%), followed by non-specific ST-T changes(16.2%), ST-depression(9.2%), T-wave inversion(11.4%), U-wave(2.7%), and ST-segment elevation(1.7%). No correlations were found between age, sex, body mass index (BMI), location of aneurysm, and QTc interval. Multiple logistic regression analysis showed a relationship between prolonged QTc and Hunt Hess grades (p=0.012) in men, length of hospital stay (p=0.038) in women, Fisher grade (p=0.001), and MRS (p=0.006, p=0.011) in both. CONCLUSION: The prolonged QTc interval is more frequently observed in patients with severe hemorrhage and an unfavorable functional outcome (MRS 4-6) in SAH patients.

Representations of Cardiopulmonary Resuscitation on Korean Medical Dramas: Fiction Versus Reality

PURPOSE: We evaluated the differences between the clinical characteristics, procedure and results of real life cardiopulmonary resuscitation versus how CPR is portrayed in Korean medical dramas. METHODS: We watched 58 episodes of Korean television medical dramas including , and , broadcast during the period 2007 to 2010. We identified all occurrences of CPR in each episode and collected the fictional patients' age, sex, location, presumed cause of cardiac arrest, and return of spontaneous circulation rate for the CPR performed, and then compared these with actual, published resuscitation statistics. Whether or not the procedure employed in a fictional CPR scene adhered to current CPR guidelines was also evaluated. RESULTS: There were 39 occurrences of CPR in the 58 television episodes viewed, with the most common cause being cardiac arrest. The fictional ROSC rate after CPR (71.8%) differed significantly from published real life figures (p=0.072). The resuscitation process did not appear to follow current guidelines in 64.1% of the cases. Contrary to reality, the average age of patients was 41.3 years. CONCLUSION: The CPR provided to fictional patients in medical dramas televised in Korea is generally different than what would be provided to a patient in reality. In addition, the ROSC rate appears higher on television than what can be expected in the real world.

Biochemical Markers (Multimarker Index) in the Diagnosis of Acute Cerebral Infarction with a Combination of Usability Tests: A Prospective Randomized Controlled Study

PURPOSE: We examined the utility of biochemical markers in the diagnosis of acute cerebral infarction and the relationship between panel results and the extent and severity of the infarct. METHODS: Group-wise comparisons were made between a group (Group 1) consisting of 38 subjects who were shown through medical screening between April 2007 and March 2008 to have no past history of cerebral disorders and a group (Group 2) consisting of 55 subjects who had visited the ER (during the same period) within 24 hours after the onset of neurologic symptoms and who were diagnosed with stroke through magnetic resonance imaging. Tests were carried out using the Multimarker Index, which is based on the principle of immunofluorescence. B-type natriuretic peptide, D-dimer, matrix metalloproteinase-9, and S100beta were examined, and the Multimarker Index (MMX) was derived. The extent of the infarct lesion was assessed using a volumetry program. RESULTS: The average MMX value was 2.27 in group I and 4.14 in group II, and the difference was statistically significant (p<0.05). For group II, the MMX value had a statistically significant correlation with both the extent of infarct lesion (r=0.46, p<0.001) and its severity (r=0.39, p<0.001). CONCLUSION: We believe that biomarker tests using the MMX should provide useful data in diagnosing strokes, and be of utility in making decisions regarding additional diagnostic tests and early treatment.

A Rare but Fatal Instance of Gastrointestinal Bleeding: Primary Aortoenteric Fistula

Primary aortoenteric fistula (PAEF) is a rare but catastrophic cause of gastrointestinal bleeding. The diagnosis of PAEF is difficult to make. The classic triad of symptoms, i.e. gastrointestinal bleeding, abdominal pain, and a pulsating abdominal mass is overemphasized, as it occurs in less than 11~25% of the patients. For two thirds of the patients, the diagnosis is made in the operating room. Endoscopic and radiographic studies are very helpful, but the absence of abnormalities can not exclude the diagnosis. PAEF is a clinical and surgical challenge associated with high mortality. A high index of suspicion, early diagnosis and prompt and appropriate surgical intervention are essential to patient survival. Two primary aortoenteric fistulas (aortoduodenal and aortoesophageal) cases are presented and the related literature are reviewed.

The Degree and Duration of Pain Caused by Nasogastric Tube Insertion and Urinary Catheterization

PURPOSE: This study was designed to determine pain severity and duration caused by procedures [nasogastric tube insertion and urinary catheterization] that are frequently performed in the ER. METHODS: The subjects (n=443) were patients who had experienced either nasogastric tube insertion or urinary catheterization in the ED between January 2008 and December 2008. The control group (n=351) consisted of those who visited the ED for acute tonsillitis or whiplash injury and were administered NSAIDs for pain control during the same period. After the procedures (nasogastric tube insertion and urinary catheterization) were done, the patients were directed to indicate the degree of pain that they experienced using a visual analog scale (VAS, 0 to 10 cm, with 10 indicationg the most pain). RESULTS: The average displacements along the VAS were 61, 55, 47, and 42 mm for patient experiences at 30 minutes, 12 hours, 24 hours and 36 hours after nasogastric tube insertion; they were 54, 47, 41, and 38 mm after urinary catheterization. The degree of pain was comparable to that of the control group. Pain scores at 30 min and 12 hours after nasogastric tube insertion were significantly higher than scores for acute tonsillitis or whiplash injury but pain scores were equivalent or lower after 24 hours (p<0.05). Urinary catheterization led to significantly higher pain scores directly after insertion of the catheter compared with the control group, but, again, revealed equivalent or lower scores after 12 hours (p<0.05). CONCLUSION: Pain scores observed up to 24 hours after nasogastric tube insertion or urinary catheterization are higher (within 12 hours) but equivalent (after 24 hours) to scores for ED patients not undergoing these procedures.

Extensive Tension Pneumocephalus Caused by Spinal Tapping in a Patient with Basal Skull Fracture and Pneumothorax

Tension pneumocephalus may follow a cerebrospinal fluid (CSF) leak communicating with extensive extradural air. However, it rarely occurs after diagnostic lumbar puncture, and its treatment and pathophysiology are uncertain. Tension pneumocephalus can develop even after diagnostic lumbar puncture in a special condition. This extremely rare condition and underlying pathophysiology will be presented and discussed. The authors report the case of a 44-year-old man with a basal skull fracture accompanied by pneumothorax necessitating chest tube suction drainage, who underwent an uneventful lumbar tapping that was complicated by postprocedural tension pneumocephalus resulting in an altered mental status. The patient was managed by burr hole trephination and saline infusion following chest tube disengagement. He recovered well with no neurologic deficits after the operation, and a follow-up computed tomography (CT) scan demonstrated that the pneumocephalus had completely resolved. Tension pneumocephalus is a rare but serious complication of lumbar puncture in patients with basal skull fractures accompanied by pneumothorax, which requires continuous chest tube drainage. Thus, when there is a need for lumbar tapping in these patients, it should be performed after the negative pressure is disengaged.

Delayed Splenic Rupture and Pancreatic Pseudocyst Following Extracorporeal Shock Wave Lithotripsy for a Urolithiasis

Extracorporeal shock wave lithotripsy (ESWL) has revolutionized the management of urolithiasis since 1980. Although it has proved to be a safe, effective treatment modality, it is not free of complications. As this procedure has become more widely available, complications as a result of injury to the kidney and the surrounding organs are being increasingly recognized. Those reported complications include hepatic hematoma, biliary obstruction, pancreatitis, colonic and splenic injury, bowel perforation, psoas abscess, aortic aneurysm rupture, portal and iliac vein thrombosis, retroperitoneal and brain hemorrhage, gastric erosions, pulmonary contusions and cardiac arrhythmias. Physicians caring for these patients should be mindful of these complications and keep an eye open to spot them. We report here on a case of a young male patient who developed splenic rupture and a pancreatic pseudocyst after undergoing extracorporeal shock wave lithotripsy (ESWL) for treating a left upper ureter stone.

The Diagnostic Method and Importance of Intracranial Pseudoaneurysm Developed by Head trauma: Case report

Traumatic intracranial pseudoaneurysms are rare and it is easy to overlook the evaluation of intracranial vascular injury in head trauma patients in the emergency room. If the result of missing an intracranial aneurysm however is catastrophic. I describe a case of a patient with intracranial internal carotid artery (ICA) pseudoaneurysm after head trauma and stress the importance of obtaining a three-dimensional-computed tomogram angiography (3DCTA) in cases of patients with skull base fracture or eyeball pain. We report a case which a patient complained of severe headache and right eyeball pain after head trauma. 3D-CTA revealed carotid-cavernous fistula and pseudoaneurysm of the right ICA. After performing transfemoral carotid angiography (TFCA) and a balloon occlusion test, we carried out endovascular trapping of ICA and extracranial-intracranial (EC-IC) bypass surgery. Afterward, the patient was discharged without neurological deficit after two weeks. We recommended 3D-CTA in cases of head trauma when the patient has skull base fracture or sphenoid sinus fracture.

Pilot Study of Web-based PBL in Emergency Medicine Clinical Education

PURPOSE: Problem-based learning (PBL) has been used in medical schools due to its educational effectiveness in terms of critical thinking, problem-solving skills, integration of theory and practice, and enculturation of the community of practice. In the digital age, however, ICT (information and communication technology)-based PBL, especially, webbased PBL seems more appropriate to meet socio-educational needs when the features of web, such as multimedia based rich information, multichannel links and navigation, connectivity (interaction and collaboration), and conservation of messages posted on the online board are considered. In this context, this case study attempted to apply 'blended learning' mode that combined both on-site and on-line classrooms, and to maximize the educational purposes of PBL. This case study examined students' perception about web-based PBL to provide basic information and data for further development and implementation of the web-based PBL METHOD: As a pilot test of the web-based PBL mode, we developed a pre-case module on the web was to provide the students with a chance to experience web-based PBL before it was fully applied to the whole class. The content of the pre-case was 'panperitonits due to gastric perforation', what a primary physician should know about. This project included two collaborative teams: 1) The development team from the graduate school of education which was in charge of the web-based PBL module development and the evaluation of the pilot test, and 2) the case development team from the Emergency Department of the school of Medicine, which dealt with the simulation (patient and doctor interaction) development, the preparation of the learning resources, and the tutor sheet. RESULTS: The participating students were mostly quite satisfied with the web-based PBL class, particularly pointing out the effectiveness of integrating theory and practice, the authentic learning tasks, and the student-directed learning environments. CONCLUSION: The highly positive responses from the students indicate that further practices using web-based PBL for classes should be more seriously considered for a more proper medical-school educational environment in the 21st Century.

Is There Any Relationship Between Hematuria in Rhabdomyolysis and Renal Injury?

PURPOSE: In previous literature, urinalysis in rhabdomyolysis has been known to be positive for occult blood, but without overt hematuria. Recently, however, we have reported hematuria in patients with doxylamine overdose in association with rhabdomyolysis. We wanted to determine whether the hematuria resulted from the toxicity of doxylamine itself or from rhabdomyolysis, and further to investigate the relationship between hematuria, acute renal failure (ARF), and the presence of urine alkalinization. METHODS: The medical records of 167 patients diagnosed with rhabdomyolysis who were admitted to Kyung Hee Medical Center between 2000 and 2004 were retrospectively examined. Patients without laboratory results 3 times a day, patients with inaccurate records, and patients with diseases that could cause hematuria were excluded, leaving 79 patients for evaluation. The relationship between laboratory results, occurrences of ARF and urine alkalinization were compared and assessed. RESULTS: Hematuria was observed in 76 of 79 patients with rhabdomyolysis, irrespective to the cause of rhabdomyolysis. The percentage of dysmorphic RBC was 58% and MCV (mean corpuscular volume) was 76+/-15 fL found in hematuria. Urine alkalinization was not associated with the presence of hematuria. The laboratory results of ARF patients compared to those of non-ARF patients showed a significant difference in the average urine pH, and ARF with rhabdomyolysis was not associated with muscle enzyme levels but rather was associated with the duration of hematuria. CONCLUSION: Hematuria was found in patients with rhabdomyolysis irrespective of the cause of rhabdomyolysis. Therefore, hematuria is associated with rhabdomyolysis rather than doxylamine intoxication. The occurrence of hematuria in rhabdomyolysis is unrelated to urine alkalinization. The duration of hematuria in ARF group was significantly longer than in non-ARF group. It is therefore important to bear in mind the possibility that ARF will develop when hematuria lasts for a long time. Furthermore, we feel that additional prospective studies and investigations into the mechanism of hematuria in rhabdomyolysis should be done.

Delayed Presentation of Mitral Valve Leaflet Perforation Following Blunt Chest Trauma: A Case Report

Mitral regurgitation originating from mitral valve leaflet perforation secondary to blunt chest trauma is a rare condition. The mechanisms related with valvular injury are rapid acceleration- deceleration movements of the thorax, compression of the heart between the sternum and vertebrae during early systole or late diastole, and abrupt increase of the intrathoracic pressure followed by cardiac rupture. Transesophageal echocardiography (TEE) is a recommended diagnostic tool and is superior to transthoracic echocardiography (TTE) for diagnosing valvular lesions. Valvular injury causing sudden and severe mitral regurgitation will lead to congestive heart failure and death without operative correction. A high index of suspicion with appropriate diagnostic methods will provide a diagnosis and allow the possibility of operative correction. We report the case of a 45-year-old man with delayed presentation of traumatic mitral valve perforation and review previous reports of blunt traumatic mitral valve injury.

A Pilot Study for beta-fibrinogen G/A-455 Polymorphism in Ischemic Stroke Patients

PURPOSE: The aim of this pilot study was to determine the relationship between the beta-fibrinogen G/A-455 single nucleotide polymorphism and the risk of ischemic stroke in Korea because there are racial differences in polymorphisms and Koreans have never been studied before. METHODS: From March to September 2003, we compared 80(male : female=1.2 : 0.8) patients who were diagnosed with ischemic stroke at Kyung Hee university hospital emergency center had been to 150 control subjects. The genotypes of the beta-fibrinogen G/A-455 polymorphism were confirmed by using the polymerase chain reaction (PCR) followed by HaeIII restriction enzyme digestion. RESULTS: The results showed that the patient group had a much higher rate of heterozygotism (GA or AG). A statistical analysis of the genotype frequency showed chi2 to be 6.24, indicating a significant difference between the patient and the control groups (p=0.044). For the allele frequency, the odds ratio was 1.88(95% CI 1.16-3.04), indicating a significant difference between the two groups, and also allele frequency in ischemic stroke patient with or without hyperfibrinogenemia, male sex and smoking history showed odds ratio to be 2.38(95% CI 1.26~4.49), 1.78(95% CI 1.01~3.14)and 1.94(95% CI 1.12~3.35) indicating significant difference. CONCLUSION: The high rate of polymorphisms of the AA genotype of beta-fibrinogen G/A-455 in ischemic stroke patients in our study leads us to the belief of the possibility that beta-fibrinogen G/A-455 polymorphisms in males with a smoking history and hyperfibrinogenemia, if found in advance, could lead to an improved prognosis and reduced clinical expenses by allowing early diagnosis and preventive management.