Determining the correlation between outdoor heatstroke incidence and climate elements in Daegu metropolitan city / 영남의대학술지

BACKGROUND@#Heatstroke is one of the most serious heat-related illnesses. However, establishing public policies to prevent heatstroke remains a challenge. This study aimed to investigate the most relevant climate elements and their warning criteria to prevent outdoor heatstroke (OHS).@*METHODS@#We investigated heatstroke patients from five major hospitals in Daegu metropolitan city, Korea, from June 1 to August 31, 2011 to 2016. We also collected the corresponding regional climate data from Korea Meteorological Administration. We analyzed the relationship between the climate elements and OHS occurrence by logistic regression.@*RESULTS@#Of 70 patients who had heatstroke, 45 (64.3%) experienced it while outdoors. Considering all climate elements, only mean heat index (MHI) was related with OHS occurrence (p=0.019). Therefore, the higher the MHI, the higher the risk for OHS (adjusted odds ratio, 1.824; 95% confidence interval, 1.102–3.017). The most suitable cutoff point for MHI by Youden’s index was 30.0°C (sensitivity, 77.4%; specificity, 73.7%).@*CONCLUSION@#Among the climate elements, MHI was significantly associated with OHS occurrence. The optimal MHI cutoff point for OHS prevention was 30.0°C.

Determining the correlation between outdoor heatstroke incidence and climate elements in Daegu metropolitan city / 영남의대학술지

BACKGROUND: Heatstroke is one of the most serious heat-related illnesses. However, establishing public policies to prevent heatstroke remains a challenge. This study aimed to investigate the most relevant climate elements and their warning criteria to prevent outdoor heatstroke (OHS).METHODS: We investigated heatstroke patients from five major hospitals in Daegu metropolitan city, Korea, from June 1 to August 31, 2011 to 2016. We also collected the corresponding regional climate data from Korea Meteorological Administration. We analyzed the relationship between the climate elements and OHS occurrence by logistic regression.RESULTS: Of 70 patients who had heatstroke, 45 (64.3%) experienced it while outdoors. Considering all climate elements, only mean heat index (MHI) was related with OHS occurrence (p=0.019). Therefore, the higher the MHI, the higher the risk for OHS (adjusted odds ratio, 1.824; 95% confidence interval, 1.102–3.017). The most suitable cutoff point for MHI by Youden’s index was 30.0°C (sensitivity, 77.4%; specificity, 73.7%).CONCLUSION: Among the climate elements, MHI was significantly associated with OHS occurrence. The optimal MHI cutoff point for OHS prevention was 30.0°C.

Scorecard for early recognition of patients at high risk of delirium in emergency department

OBJECTIVE: This study was conducted to evaluate scorecards for early recognition of high-risk patients of delirium in the emergency department (ED). METHODS: Data from 399 consecutive patients aged 65 years or older between January 1, 2015 and December 31, 2015 were retrospectively analyzed. Delirium was identified by reviewing medical records and was confirmed by a psychiatrist. The study population was divided into a training and validation group. Predisposing factors were evaluated and validated by multivariate logistic regression analysis and a calibration plot, after which a scorecard was constructed using these factors and applying points to double odds to each regression coefficient. RESULTS: Dementia, transfer from a long-term care facility, acute acid-base imbalance, moderate pain, and stroke were independent predisposing factors for delirium in ED, with assigned scores in the scorecard of 3, 2, 2, 2, and 2, respectively. The total score of the scorecard for delirious patients was significantly higher than that for non-delirious patients in both the training and validation groups. The coefficient of determination (R²) of the calibration plot was 0.74 and 0.68 in the training and validation group, respectively. In the receiver operation characteristic curve, the cut-off point of the scorecard for delirium was 2.5 and the sensitivity, specificity, and accuracy were 75.0%, 87.8%, and 86.7% in training group, while they were 76.9%, 85.1%, and 84.2% in the validation group, respectively. CONCLUSION: The scorecard was a useful screening tool for early recognition of patients with a high-risk of developing delirium in the ED.

Analysis of the clinical features and laboratory findings according to the outcome for detecting early prognostic factors of heat stroke patients

OBJECTIVE: Heat stroke is a serious heat-related illness characterized by elevated core body temperature and an impaired central nervous system. Heat stroke can also cause various complications and lead to irremediable results. However, early prediction of its outcome remains difficult. In this study, we analyzed clinical features and laboratory findings according to the outcome of heat stroke patients and tried to identify factors that predict their prognosis in the acute stage. METHODS: In this retrospective observational study, we enrolled 40 heat stroke patients who arrived at five emergency departments in Daegu within three hours from the time at which heat stroke occurred every June 1 to August 31 from 2011 to 2016. In addition, we compared the clinical features and laboratory findings according to the outcome. RESULTS: The mean ages were 72.0 (53.0–76.0) in the good outcome group (GOG) and 57.0 (39.5–84.8) in the poor outcome group (POG). In addition, there were 23 (71.9%) and five (62.5%) men in the GOG and the POG, respectively. Among clinical characteristics, initial neurological status and endotracheal intubation differed significantly by prognosis (P=0.019 and P=0.001, respectively). Among laboratory findings, arterial bicarbonate ion level, platelet count, and aspartate aminotransferase level were differed significantly by prognosis (P=0.003, P=0.005, and P=0.009, respectively). CONCLUSION: An initial decline in consciousness, conducting endotracheal intubation, decreased arterial bicarbonate ion level or platelet count, as well as increased aspartate aminotransferase levels were poor prognosis factors of heat stroke patients in the acute stage. Emergency physicians should be careful when managing these patients.

Splenic artery aneurysm with the double-rupture phenomenon

Splenic artery aneurysm is the third most common type of intra-abdominal aneurysm, with a prevalence rate of 0.01% to 10.4% in the general population. Splenic artery aneurysm is usually asymptomatic and is typically detected by chance and does not require surgical management; however, if rupture occurs, although rare, the patient's situation can become critical. We report our experience with a man who presented with left flank and left shoulder pain. His symptoms were caused by multiple hematomas confined to the spleen, but 2 days after admission, he developed delayed hemoperitoneum and required surgical management. We believe that his condition was due to delayed intraperitoneal bleeding called the double-rupture phenomenon; emergency physicians must consider this phenomenon when taking care of splenic artery aneurysm patients.

A Case of Unknown Cause of Subcutaneous Emphysema Presented by Generalized Edema

Subcutaneous emphysema and pneumomediastinum are commonly derived from trauma or injury of respiratory or gastrointestinal tracts, but occasionally the origin of air was not determined at evaluation. We report on a case of severe subcutaneous emphysema detected using simple X-ray films in the emergency department, which extended to almost all of the bodies, with a review of the literature.

Comparison of the Clinical Characteristics of the Patients Visited in Emergency Department with Pandemic 2009 Influenza A (H1N1) Virus Infection during the First Three Years; An Observational Study at a Single Emergency Department

PURPOSE: Daegu, Korea was severely affected by pandemic and post-pandemic H1N1 infection during August 2009 to March 2012. The aim of this study was to analyze various clinical characteristics of patients who visited the emergency department with H1N1 infection during the first three years, and to compare the results for each year. We then performed an evaluation of the differences. METHODS: The medical records of patients who visited our emergency department and conformed to H1N1 virus infection by conventional rRT-PCR during the pandemic wave from August 2009 to March 2010(wave 1) and post-pandemic waves from August 2010 to March 2011(wave 2) and from August 2011 to March 2012(wave 3) were reviewed. A total of 986 patients (wave 1; 840, wave 2; 144, wave 3; 2) were included in this study. We analyzed the clinical characteristics, proportions of pneumonia, admission rate, relationships with underlying medical conditions, and requirement for mechanical ventilation of the infected patients, and then performed a statistical evaluation of the differences between wave 1 and wave 2 that was severely affected. RESULTS: During wave 1,840 patients, during wave 2, 144 patients, and during wave 3, two patients were diagnosed as novel influenza. Age 18-39 showed a significantly higher rate(78.7%) in the wave 1 patients group. Main clinical symptoms were cough and febrile sense in both waves. Patients with underlying medical conditions in wave 2(97 cases, 67.4%) showed a higher rate than those of wave 1(101 cases, 12.0%). Chronic obstructive pulmonary disorder was the most closely related underlying disorder in wave 2(18.8%). Patients requiring admission(37.5%) and ventilatory care(6.9%) due to severe pneumonic symptoms showed a significantly higher rate in wave 2. Only two young patients were diagnosed as novel influenza. Both complained of mild fever and cough, which recovered spontaneously. CONCLUSION: Most cases of influenza A (H1N1) infection were uncomplicated, characterized by influenza-like symptoms and spontaneous recovery. The number of patients showed a marked decreased year by year, however, the severity of clinical presentations increased in wave 2. Young adults who did not have cross-reactive antibodies to novel influenza A (H1N1) from previous infection or immunization were dominant in wave 1. Older patients with underlying medical conditions were more likely to admitted and present fatal progress in wave 1 and wave 2. Because influenza viruses are unpredictable, continued national preparedness, flexible response, and careful monitoring are essential.

Comparison of the Clinical Characteristics of the Patients Visited in Emergency Department with Pandemic 2009 Influenza A (H1N1) Virus Infection during the First Three Years; An Observational Study at a Single Emergency Department

PURPOSE: Daegu, Korea was severely affected by pandemic and post-pandemic H1N1 infection during August 2009 to March 2012. The aim of this study was to analyze various clinical characteristics of patients who visited the emergency department with H1N1 infection during the first three years, and to compare the results for each year. We then performed an evaluation of the differences. METHODS: The medical records of patients who visited our emergency department and conformed to H1N1 virus infection by conventional rRT-PCR during the pandemic wave from August 2009 to March 2010(wave 1) and post-pandemic waves from August 2010 to March 2011(wave 2) and from August 2011 to March 2012(wave 3) were reviewed. A total of 986 patients (wave 1; 840, wave 2; 144, wave 3; 2) were included in this study. We analyzed the clinical characteristics, proportions of pneumonia, admission rate, relationships with underlying medical conditions, and requirement for mechanical ventilation of the infected patients, and then performed a statistical evaluation of the differences between wave 1 and wave 2 that was severely affected. RESULTS: During wave 1,840 patients, during wave 2, 144 patients, and during wave 3, two patients were diagnosed as novel influenza. Age 18-39 showed a significantly higher rate(78.7%) in the wave 1 patients group. Main clinical symptoms were cough and febrile sense in both waves. Patients with underlying medical conditions in wave 2(97 cases, 67.4%) showed a higher rate than those of wave 1(101 cases, 12.0%). Chronic obstructive pulmonary disorder was the most closely related underlying disorder in wave 2(18.8%). Patients requiring admission(37.5%) and ventilatory care(6.9%) due to severe pneumonic symptoms showed a significantly higher rate in wave 2. Only two young patients were diagnosed as novel influenza. Both complained of mild fever and cough, which recovered spontaneously. CONCLUSION: Most cases of influenza A (H1N1) infection were uncomplicated, characterized by influenza-like symptoms and spontaneous recovery. The number of patients showed a marked decreased year by year, however, the severity of clinical presentations increased in wave 2. Young adults who did not have cross-reactive antibodies to novel influenza A (H1N1) from previous infection or immunization were dominant in wave 1. Older patients with underlying medical conditions were more likely to admitted and present fatal progress in wave 1 and wave 2. Because influenza viruses are unpredictable, continued national preparedness, flexible response, and careful monitoring are essential.

A Case of Throwing Fracture of the Humerus in a Amateur Baseball Pitcher

Spiral fractures of the humerus that occur during throwing, such as in baseball, are not very common but have been well described in orthopedics and sports medicine. They are known to occur by sudden extreme muscular action while throwing balls. I report on a case of spiral fracture of the humerus shaft while pitching in a baseball game with a review of the literature.

Team dynamics and clinical performance of medical students in web-based and high-fidelity simulations / 한국의학교육

PURPOSE: The importance of team dynamics with regard to clinical performance is being emphasized to improve patient safety and the quality of health care. The aim of this study was to examine the correlation and differences in team dynamics and team clinical performance in a web-based simulation (WS) and high-fidelity simulation (HS) in the medical students. METHODS: The simulations were held for 15 teams of fourth year medical students (n=52). They were given two clinical cases, dyspnea (case 1) and chest pain (case 2) by WS and then HS. The scores on the team dynamics and the team's clinical performance were analyzed by paired t-test and multiple regression using SPSS version 21.0 (IBM Corp.). RESULTS: The teamwork scores on case 2 (22.67+/-6.58) were higher than for case 1 in the HS (20.47+/-7.22). Team clinical performance scores were the same the WS and HS. Team clinical performances were significantly associated with team dynamics in both cases by HS. Teamwork scores of team dynamics were each explanation on case 1 (74.9%), case 2 (63.4%) in the HS. CONCLUSION: The team dynamics and clinical performance can improve if undergraduate medical students have more opportunities. They should be trained in these endeavors to become future doctors for which scenario-based simulations could be valuable.

Risk Factors for Delirium in Elderly Patients Visiting an Emergency Department

PURPOSE: Delirium is a common and worrisome problem among elder hospitalized patients. Many studies have sought to evaluate the risk factors of delirium. Most of these studies have dealt with the intensive care unit, with virtually nothing known about the emergency room. Our study was designated to evaluate the risk factors in an emergency department. METHODS: We retrospectively reviewed 414 cases of elder patients admitted to the general ward of internal medicine via the emergency room between January 2009 and December 2009. We divided these patients into a delirium group and non-delirium group. We statistically evaluated 31 known risk factors of delirium in these two groups. RESULTS: Using chi-square test, 14 of 31 known risk factors of delirium were proven as risk factors of delirium in an emergency room. Using logistic regression, three of the 14 proven risk factors were revealed as prior factors. CONCLUSION: A variety of factors of delirium are risk factors of delirium in an emergency room. A few important known risk factors are failed to pass statistically evaluation. These results are influenced by cultural pecularities of South Korea. Also, the small sample size limited conclusive evaluation. Nonetheless, the importance of patients' past medical history, laboratory results, and choice of medication when treating elder hospitalized patients to prevent delirium is likely important in reducing mortality and morbidity.

A Case of Carbon Dioxide Poisoning from Dry Ice Inhalation

Carbon dioxide (CO2) poisoning is rare, but its clinical features of acute exposure include cardiovascular, respiratory, neurologic and metabolic aspects. CO2 can also have a direct toxicological effect. At very high concentrations (>9%), CO2 induces respiratory depression and narcotic-like effects on the central nervous system. Especially, acute poisoning from dry ice is caused by CO2 gas inhalation and asphyxiation, and may impose excess load on the myocardium. This case was an acute CO2 poisoning from dry ice gas inhalation. In spite of an initial severe status, the male patient rapidly improved with no complications following the application of highly concentrated oxygen and fluid therapy.

Appropriateness of the use of Emergency Medical Services and Propensities Toward Choice by Local Residents of Hospitals

PURPOSE: Inappropriate use or misuse of emergency medical services (EMS) is a potential waste of resources and a possible diversion of needed service from another patient in need. One of the most serious consequences of inappropriate use of EMS is emergency department crowding. The purpose of this study was to evaluate the appropriateness of EMS use and the propensity of local residents in Daegu to choose particular hospitals. METHODS: We obtained study data from Jan. to Feb. 2009 using a prospective survey of patients or their companies that had used EMS. The survey was done by a senior emergency physician who rode in an ambulance with 119 crew members during on-scene assessments and en route to the hospital. The severity of illness/injury was evaluated using the START system/CRAMS scale. We analyzed the appropriateness of EMS use and hospital transport in relation to the severity of the patients problem. We also identified factors that directly influence choice of hospitals. RESULTS: Forty-six cases (36.8%) chose an inappropriate hospital. In 89 cases (71.2%), choice of hospital was done by the patient or his guardian. The most common factor that directly influenced hospital choice was the hospital the patients identified with (50%). Appropriateness of transport to the hospital correlated with problem severity evaluated by the EMS team and by trauma patients (p<0.05). Transport to a higher level hospital (39%) was selected about ten fold more often than transport to a lower level hospital (4%). CONCLUSION: The appropriateness of local EMS use should be improved with respect to many factors. Local residents have a propensity to choose a large or university hospital for a variety of reasons. Local residents should be continuously educated for appropriative EMS use.

Effectiveness of a Pneumonia Severity Index (PSI) as a Predictor of Mortality in Emergency Department Patients with Community-Acquired Pneumonia

PURPOSE: Pneumonia is the most common cause of death among infectious diseases. Community-acquired pneumonia is the sixth leading cause of death in Korea. This study was designed to analyze the relationship of risk factors and mortality, especially the pneumonia severity index (PSI) in patients with community-acquired pneumonia diagnosed in the emergency department of a referral hospital. METHODS: The medical records of patients admitted to the Yeungnam University Hospital between March 2006 and March 2008 for community-acquired pneumonia were reviewed retrospectively. The demographic data, comorbidity, laboratory results, PSI score and class of PSI, all of which might influence the prognosis of pneumonia, were analyzed. RESULTS: Among 123 patients admitted for community-acquired pneumonia, 18 died (mortality rate of 15%). Laboratory data showed that sodium, glucose, blood urea nitrogen, albumin, platelets, hematocrit and arterial pH were related to the prognosis. For the pneumonia severity index, the mortality rate increased in a step-wise manner from class I through class V. Comorbidities such as neoplasms (p=0.000), cerebrovascular accidents (p=0.005) and liver disease (p=0.003), as well as systolic blood pressure (p=0.003), respiratory rate (p=0.024), sodium (p=0.000), glucose (p=0.000), blood urea nitrogen (p=0.000), albumin (p=0.003), hematocrit (p=0.000) and arterial pH (p=0.042) were the important risk factors for mortality in patients with community-acquired pneumonia. CONCLUSION: The pneumonia severity index could be used as a valuable index for predicting mortality of patients and the prognosis of community-acquired pneumonia in the emergency department.

Comparison of the Macintosh Laryngoscope and the GlideScope(R) Video Laryngoscope in Easy and Simulated Difficult Airway Scenarios: A Manikin Study

PURPOSE: To compare the usefulness of Macintosh laryngoscope with GlideScope(R) video laryngoscope in five airway scenarios on Simman(R) manikin. METHODS: Forty medical students, 20 males and 20 females, were enrolled and performed endotracheal intubation with Macintosh laryngoscope and GlideScope(R) video laryngoscope in five airway scenarios: normal airway, cervical rigidity, tongue edema, pharyngeal obstruction and combined tongue edema with pharyngeal obstruction. We studied the laryngeal view, ease of intubation, time for intubation, success rate and number of attempts in the five airway scenarios. RESULTS: VAS for the ease of intubation showed that intubation with GlideScope(R) video laryngoscope was easier than intubation with Macintosh laryngoscope in each scenario except the cervical rigidity scenario (p<0.05). The laryngeal view with GlideScope(R) video laryngoscope was better than that with Macintosh laryngoscope in each scenario except the pharyngeal obstruction scenario (p<0.05). The time for visualizing epiglottis with Macintosh laryngoscope was shorter than with GlideScope(R) video laryngoscope except the tongue edema and pharyngeal obstruction scenario (p<0.05). The time from visualizing epiglottis to insertion of endotracheal tube with Macintosh laryngoscope was shorter than with GlideScope(R) video laryngoscope except the tongue edema and combined scenario (p<0.05). The total time for endotracheal intubation with Macintosh laryngoscope was shorter than with GlideScope(R) video laryngoscope except the tongue edema scenario (p<0.05). The success rate with GlideScope(R) video laryngoscope was higher than with Macintosh laryngoscope in the tongue edema and combined scenario (p<0.05). There was no statistical significance for the number of attempts between GlideScope(R) video laryngoscope and Macintosh laryngoscope. CONCLUSION: Endotracheal intubation with GlideScope(R) video laryngoscope had better results than with Macintosh laryngoscope in most scenarios. Endotracheal intubation with GlideScope(R) video laryngoscope promises to be a useful device for non-skilled personnel.

Clinical Features of Tsutsugamushi Disease in the Emergency Department

PURPOSE: Many of the febrile diseases developing in Korea during the autumn are tsutsugamushi disease. The pathogen of the disease is rickettsia of oriental tsutsugamushi. The aim of this research was to help in the early diagnosis and treatment by analyzing the clinical features of patients with tsutsugamushi disease and the factors affecting the duration of antibiotic use and admission. METHODS: A total of 177 patients diagnosed with tsutsugamushi disease who visited the emergency department between 2004 and 2008 were included. We retrospectively reviewed the medical records on OCS by comparing the relationship between clinical features and the duration of antibiotic use or admission. RESULTS: In the outbreaks occurring in 2005 and 2007 no significant clinical differences were seen. Tsutsugamushi disease occurred in females(61.0%), the elderly (over 60 years old, 66.1%), and urban areas(56.5%). Common clinical findings were eschar(80.8%) and skin rash(96.6%). Complications(58.8%) included pneumonia, meningitis, DIC, and acute renal failure. The duration of antibiotic use was increased with increasing age over 60 years old and with increasing body temperature. The duration of admission was significantly correlated with the absence of eschar, age over 40 years old, and abnormal findings of BUN/Cr, PT/PTT, albumin. CONCLUSION: In conclusion, several factors such as age, hemoglobin, eschar, BUN/Cr, albumin and PT/PTT were correlated with the duration of antibiotic use and admission. Therefore, efforts to reduce them are required

Two Year Experiences of the International Elective Clerkship for Medical Students / 영남의대학술지

BACKGROUND: The aims of medical education have recently been changing in Korea, which has been accompanied by efforts to modify the rotating clerkship courses, improve the quality of clinical education, and make global doctors. We report the experiences of medical students going through an international elective clerkship for during past two years. MATERIALS AND METHODS: Third year medical students could apply to the international elective clerkship course during a 4 week period after their third-year rotating clerkship at a university hospital. This was done twice-in 2008 and in 2009. Applicant students were allowed to select hospitals anywhere in the world. We analyzed their choices including data on nation, state or city, hospital or institute, contacted hospitals by medical college, differences of two years, etc. RESULTS: Twelve students (10.9%) of a total of 75 third-year students applied to 3 nations and 4 hospitals in 2008. Nine students applied to the Tampa General Hospital at the University of South Florida (USF) in the USA, which was arranged by their medical college. In 2009, a total of five (4.2%) of 77 students applied to 2 nations and 3 hospitals, including three at the University of South Florida, one in another city in the USA, and one in another nation because of the increased financial burden due to a higher exchange rate. CONCLUSION: Medical students started their first international elective clerkship courses during the past two years. Experiences were interesting and meaningful to the students and the medical college. Greater effort and support to developing a new paradigm and to enlarge the scope of the program for making global doctors are required in the future.

Study of Out-of-hospital Cardiac Arrest Patients for whom 119 Rescuers used an Automated External Defibrillator in the Metropolitan Area

PURPOSE: To report characteristics of out-of-hospital cardiac arrest (OHCA) patients in whom 119 rescuers used an automated external defibrillator (AED) in the metropolitan area METHODS: 1,689 OHCA patients were transferred to hospitals by 119 rescuers between 1 January and 31 December, 2006. Among them, 106 OHCA patients for whom 119 rescuers used an AED were enrolled retrospectively. RESULTS: Shockable rhythm with AED use was 70.8%, witnessed arrest was 46.2%, and bystander cardiopulmonary resuscitation (CPR) was 6.6%. The most common location of cardiac arrest was in the home, at 74.5%. Response time was 7.1(+/-3.9) minutes. Chest compression during transport was done by 119 rescuers in 87.7% of cases, and assisted ventilations such as advanced airway management and bag valve mask ventilation were performed by 119 rescuers in 17.0%. Initial ECG findings at ED were asystole(59.4%), PEA(25.5%), VF/pulseless VT(8.5%), sinus rhythm(4.7%), and others(1.9%). The most common etiology of cardiac arrest was presumed cardiac origin in 68.9% of cases. Sustained return of spontaneous circulation (ROSC) was 26.4%. The proportion of patients discharged alive was 11.3%. CONCLUSION: The performance of bystander CPR and usage of AED, and appropriate CPR done by 119 rescuers were unsatisfactory in metropolitan Daegu. There is a marked need to establish basic life support education in the areas of bystander CPR, and a quantitative and qualitative development of 119 rescue capability.

Prehospital Status of the Patients with Ischemic Chest Pain before Admitting in the Emergency Department / 영남의대학술지

BACKGROUND: The causes of chest pain vary but the leading cause of chest pain is ischemic heart disease. Mortality from ischemic chest pain has increased more than two fold over the last ten years. The purpose of this study was to determine the data necessary for rapid treatment of patients with signs and symptoms of ischemic chest pain in the emergency department (ED). MATERIALS AND METHODS: We interviewed 170 patients who had ischemic chest pain in the emergency department of Yeungnam University Hospital over 6 months with a protocol developed for the evaluation. The protocol used included gender, age, arriving time, prior hospital visits, methods of transportation to the hospital, past medical history, final diagnosis, and outcome information from follow up. RESULTS: Among 170 patients, there were 118 men (69.4%) and the mean age was 63 years. The patients diagnosed with acute myocardial infarction (AMI) were 106 (62.4%) and with angina pectoris (AP) were 64 (37.6%). The patients who had visited another hospital were 68.8%, twice the number that came directly to this hospital (p0.05). The patients who had a total time delay of over 6 hours was similar 54.8% in the AMI group and 57.9% in the AP group (p>0.05). As a result, only 12.2% of the patients with an AMI received thrombolytics, and 48.8% of them had a simultaneous percutaneous coronary intervention (PCI). In the emergency department 8.5% of the patients with an AMI died. CONCLUSION: Timing is an extremely important factor for the treatment of ischemic heart disease. Most patients arrive at the hospital after a long time lapse from the onset of chest pain. In addition, most patients present to a different hospital before they arrive at the final hospital for treatment. Therefore, important time is lost and opportunities for treatment with thrombolytics and/or PCI are diminished leading to poor outcomes for many patients in the ED. The emergency room treatment must improve for the identification and treatment of ischemic heart disease so that patients can present earlier and treatment can be started as soon as they present to an emergency room.

Correlation Between Chemokine Production and Injury Type in Acute Brain Injury Patients

PURPOSE: Cytokines and chemokines are essential in neuronal development and play important roles in both acute and chronic inflammatory reactions in the central nerve system and peripheral tissues. Thus, they may perform key functions in the pathophysiology of acute ischemic and hemorrhagic brain injury. The aim of this study was to evaluate the production of chemokines following acute brain injury (ABI) in humans. The correlations between the three main types of ABI(traumatic, ischemic and spontaneous hemorrhagic brain injury) and the plasma levels of three chemokines-CXCL8 (IL-8), CCL4 (MIP-1beta) and CCL5 (MIP-1beta)-were analyzed. METHODS: Enrolled in this study were 25 patients with isolated severe head trauma, 31 patients with spontaneous intracranial hemorrhage (SIH), and 34 patients with cerebral infarction. The AIS(abbreviated injury scale) was used to identify the isolated severe head trauma patients. The severities of several types of injury were assessed by ISS (injury severity score) in trauma, GCS (Glasgow coma scale) in SIH, and NIHSS(national institute of health stroke scale) in cerebral infarction. Blood samples from 9 healthy blood donors were analyzed as controls. Protein concentrations of CXCL8, CCL4, and CCL5 were measured by ELISA(enzyme-linked immunosorbent assay), and mRMA levels of XCL1(lymphotactin, Ltn), CCL5, CXCL10 (IP-10), CCL4, CCL3(MIP-alpha), CCL2 (MCP-1), CXCL8, and CCL1 (I-309) were evaluated using the RPA(multi-probe RNase protection assay) system in plasma and in peripheral blood mononuclear cells (PBMCs) from patients' venous blood obtained with 24 hours after injury. RESULTS: The expression patterns of XCL1, CCL5, CXCL8, CCL4, and CCL5 mRNA were similar in the three groups of ABI, without differences related to patterns of ABI or trauma severity. Concentrations of the three proteins CXCL8, CCL4, and CCL5 in plasma from all three ABI groups were higher than in the control group. The level of CXCL8 was significantly elevated in the TBI(traumatic brain injury) group (3.57+/-5.93 pg/ml, p<0.05), and this high level of IL-8 was significantly correlated with increased injury severity (high ISS and low GCS score) (p<0.05). The concentration of CCL4 was highest (29.82+/-17.94 pg/ml) in the ischemic brain injury group and was significantly higher than in the SIH group (p<0.05). The protein level of CCL4 was also elevated significantly with high ISS (p<0.05). The level of CCL5 was highest (7692+/-3603 pg/ml) in the SIH group and was significantly higher than in the TBI group (p<0.05). CONCLUSION: ABI resulted in a modest activation of CXCL8, CCL4 and CCL5, and the statistically significant correlations were found between the plasma levels of these chemokines and ABI. In addition, significant correlations were found between the plasma protein levels of CXCL8 and CCL4 and trauma severity in TBI group. Therefore, the continuous monitoring of various chemokine concentrations may provide a useful adjunct to assigning grouping and to gauging severity or prognosis in ABI.