Changes in characteristics of drug intoxication after COVID-19 pandemics: a retrospective study in a tertiary university-affiliated hospital

Objective@#The coronavirus disease 2019 (COVID-19) virus has adversely affected people in socioeconomic fields as well as mental health, thereby increasing suicidal attempts. This study analyzes the altered characteristics of drug-poisoned patients visiting the emergency department (ED) during the COVID-19 pandemic era in South Korea. @*Methods@#This was a retrospective observational study using medical records of adults who visited the ED for intoxication. Data obtained were compared before and after the COVID-19 pandemic era. @*Results@#In all, data from 1,102 drug-poisoned patients (586/516 during the pre-/post-COVID-19 periods, respectively) were included in the study. Despite a decrease in total ED visits, the pandemic period saw an increase in the proportion of poisoned patients visiting the ED. Young, female, and psychiatric patients accounted for a significant portion. Months, holidays, time zones, and urbanization showed no difference in the incidence of intoxication. Financial difficulty and couple and family troubles were determined to be frequent causes of intoxication during the COVID-19 pandemic. Comparing the drugs intoxicated, pesticide ingestion was decreased, while the ingestion of other less-fatal drugs was comparatively increased. Although there was an increase in the admission rate of poisoned patients, the severity during admission and outcomes at discharge were not worse after the COVID-19 pandemic era. @*Conclusion@#The COVID-19 crisis has seriously impacted people, especially female, young-aged, and psychiatric patients.

Pediatric application of cuffed endotracheal tube: a secondary publication translated into Korean

A young child’s larynx was formerly believed to be narrowest at the cricoid level, circular in section, and funnel shaped. This supported the routine use of uncuffed endotracheal tubes in young children despite the benefits of cuffed tubes, such as lower risk for air leakage and aspiration. In the late 1990s, evidence supporting the pediatric use of cuffed tubes emerged largely from anesthesiology studies, while some technical flaws of the tubes remained a concern. Since the 2000s, imaging-based studies have clarified laryngeal anatomy, revealing that it is narrowest at the glottis, elliptical in section, and cylindrical in shape. The update was contemporaneous with technical advances in the design, size, and material of cuffed tubes. The American Heart Association currently recommends the pediatric use of cuffed tubes. In this review, we present the rationale for using cuffed tubes in young children based on our updated knowledge of pediatric anatomy and technical advances.

Incidence and clinical course of septic shock in neutropenic patients during chemotherapy for gynecological cancers / 부인종양

Objective@#To identify the incidence and clinical course of septic shock combined with neutropenia during chemotherapy in gynecological cancer patients. @*Methods@#We retrospectively reviewed the medical records of all gynecological cancer patients who received intravenous chemotherapy between March 2009 and March 2018.Patients diagnosed with neutropenic septic shock (NSS) during the course of chemotherapy were identified. We calculated the overall incidence and mortality rate of NSS, and analyzed risk factors and clinical course. @*Results@#A total of 1,009 patients received 10,239 cycles of chemotherapy during the study period. Among these, 30 (3.0%) patients had 32 NSS events, of which 12 (1.2%) died. With respect to patient age during the first course of chemotherapy, the incidence of NSS after the age of 50 was significantly higher than that in patients under 50 (3.9% vs. 1.4%, p=0.034).As the number of chemotherapy courses increased, the incidence of NSS increased, and linear-by-linear association analysis showed a positive correlation (p=0.004). NSS events occurred on average 7.8 days after the last cycle of chemotherapy, and the median duration of vasopressor administration was 23.3 hours. The median age (64.0 vs. 56.5, p=0.017) and peak heart rate (149.5 min −1 vs. 123.5 min −1 , p=0.015) were significantly higher in the group of patients who subsequently died of NSS than in those who survived. @*Conclusion@#The overall incidence of NSS in gynecological cancer patients receiving chemotherapy was 3.0%, which is higher than previously estimated. Peak heart rate during NSS events may be an indicator for predicting survival.

The frequencies of disease entities that cause acute abdominal pain in end-stage renal disease: focused on differences between hemodialysis and peritoneal dialysis patients

Objective@#The aim of this study was to investigate the frequency of disease entities that cause abdominal pain in endstage renal disease (ESRD) patients who visited an emergency department (ED) and to compare differences in diagnoses between hemodialysis (HD) and peritoneal dialysis (PD) patients. @*Methods@#This retrospective observational study included 179 ESRD patients over the age of 18 years who visited an ED with abdominal pain from January 2013 to December 2018. All electronic medical record data were collected and reviewed by a single physician. @*Results@#The most common pathologies regardless of dialysis methods were peritonitis (n=51, 28.5%), nonspecific abdominal pain (NSAP; n=30, 16.8%), acute gastroenteritis (AGE; n=16, 8.9%), gastritis (n=16, 8.9%), and cholecystitis/biliary colic (n=11, 6.1%). In HD patients, the most common diseases were NSAP (n=25, 22.7%), AGE (n=15, 13.6%), gastritis (n=13, 11.8%), and cholecystitis/biliary colic (n=11, 10.0%). In PD patients, peritonitis (n=47, 68.1%), NSAP (n=5, 7.2%), kidney rupture (n=4, 5.8%), and gastritis (n=3, 4.3%) were the most common. The statistically significant disease entities between the two groups were peritonitis (HD: n=4, 4.6%; PD: n=47, 68.1%; P<0.001), cholecystitis/biliary colic (HD: n=11, 10.0%; PD: n=0, 0%; P=0.007), NSAP (HD: n=22, 22.7%; PD: n=5, 7.2%; P=0.007), and AGE (HD:n=15, 13.6%; PD: n=1, 1.4%; P=0.006). @*Conclusion@#In PD patients, peritonitis was the most common disease entity, whereas in HD patients, cholecystitis was relatively more common. Except for these two disease entities, the pathologies between the two groups were similar, with NSAP and AGE being the most common.

Incidence and clinical course of septic shock in neutropenic patients during chemotherapy for gynecological cancers / 부인종양

Objective@#To identify the incidence and clinical course of septic shock combined with neutropenia during chemotherapy in gynecological cancer patients. @*Methods@#We retrospectively reviewed the medical records of all gynecological cancer patients who received intravenous chemotherapy between March 2009 and March 2018.Patients diagnosed with neutropenic septic shock (NSS) during the course of chemotherapy were identified. We calculated the overall incidence and mortality rate of NSS, and analyzed risk factors and clinical course. @*Results@#A total of 1,009 patients received 10,239 cycles of chemotherapy during the study period. Among these, 30 (3.0%) patients had 32 NSS events, of which 12 (1.2%) died. With respect to patient age during the first course of chemotherapy, the incidence of NSS after the age of 50 was significantly higher than that in patients under 50 (3.9% vs. 1.4%, p=0.034).As the number of chemotherapy courses increased, the incidence of NSS increased, and linear-by-linear association analysis showed a positive correlation (p=0.004). NSS events occurred on average 7.8 days after the last cycle of chemotherapy, and the median duration of vasopressor administration was 23.3 hours. The median age (64.0 vs. 56.5, p=0.017) and peak heart rate (149.5 min −1 vs. 123.5 min −1 , p=0.015) were significantly higher in the group of patients who subsequently died of NSS than in those who survived. @*Conclusion@#The overall incidence of NSS in gynecological cancer patients receiving chemotherapy was 3.0%, which is higher than previously estimated. Peak heart rate during NSS events may be an indicator for predicting survival.

Validation of Glasgow-Blatchford score, Pre-Rockall score, and AIMS65 score to predict active bleeding in patients with upper gastrointestinal bleeding in normotensive patients and suggestion for developing new predictors

OBJECTIVE: The aim of this study was to validate the Glasgow-Blatchford score (GBS), Pre-Rockall score (PRS), and AIMS65 score to predict active bleeding in patients with normotension and upper gastrointestinal bleeding (UGIB), and analyze the variables that can predict active bleeding to help develop new predictive factors. METHODS: Data were collected retrospectively from January 2015 to December 2017. A systolic blood pressure ≥90 mmHg were defined as normotension, and the patients were divided into active bleeding and not-active bleeding groups based on an esophagogastroduodenoscopy and levin-tube irrigation. The GBS, PRS, and AIMS65 of each group were calculated. The receiver operator characteristic (ROC) curve and area under the curve (AUC) were also calculated to obtain the predictive power for active bleeding. Furthermore, the factors that can predict active bleeding were analyzed by multivariate logistic regression. The ROC curve and AUC were calculated using the variables that were adopted as useful factors. RESULTS: Of the 250 patients included, 85 were active bleeding and 165 were not-active bleeding. The ROC curve showed GBS (AUC, 0.54; 95% confidence interval [CI], 0.47–0.61), PRS (AUC, 0.58; 95% CI, 0.50–0.65), and AIMS65 (AUC, 0.51; 95% CI, 0.43–0.59) to have low predictive power for active bleeding. Multivariate logistic regression revealed the lactate (odds ratio [OR], 1.10; 95% CI, 1.01–1.20) and shock indices (OR, 4.15; 95% CI, 1.12–15.40) to be significant predictors of active bleeding. When calculating the probability of predicting active bleeding through these variables, AUC 0.64 (95% CI, 0.57–0.71) showed higher prediction power than the previous scores. CONCLUSION: The conventional scoring systems that predict the prognosis of UGIB showed low predictability in predicting active bleeding in UGIB patients with a systolic blood pressure ≥90 mmHg. Further study suggests the development of new score using factors, such as the lactate and shock indices.

Pilot study for a novel delta carotid sinus massage in increasing parasympathetic tone: a randomized, prospective, cross-over, comparative study with conventional method

OBJECTIVE: This study examined the efficacy of new delta carotid sinus massage (CSM) versus conventional CSM (CM). METHODS: This prospective, cross-over study was conducted on 26 healthy volunteers with a normal sinus rhythm. CM and delta CSM (DM) were performed in all participants. In both cases, the CSM was performed, where the maximal carotid pulse was palpated. DM differed from CM in that the physician moves the palpating finger in the opposite direction of the carotid pulse at least twice. The mean and longest R-R intervals and mean and lowest heart rates (HRs) at the baseline and during the procedure for each technique were compared. The mean differences between the baseline and procedure R-R intervals and the HRs for each technique were also evaluated. RESULTS: The baseline mean and longest R-R intervals and baseline mean and lowest HRs were similar both groups (P>0.05). The procedure DM mean and longest R-R intervals (22.7±3.1, 26.4±4.9) were significantly greater than the CM corresponding values (22.0±3.1, 24.6±3.5; P<0.001, P=0.003). Procedure DM mean and lowest HRs (67.3±9.7, 58.6±10.7) were significantly lower than the CM corresponding values (69.4±10.0, 61.8±8.9; P=0.001, P=0.003). The differences in the R-R interval and HR between the procedure and baseline were significant (mean and longest R-R intervals with CM [1.3±1.5 and 2.1±1.9] vs. DM [2.0±1.4 and 3.8±3.1], P<0.001, P=0.004; mean and lowest HRs with CM [4.2±4.3 and 5.8±4.6] vs. DM [6.3±4.6 and 9.1±6.5], P<0.001, P=0.005). CONCLUSION: DM is more effective in generating a more potent vagal tone than CM.

Challenging management of chorioamnionitis with placental listeriosis: lessons from 2 cases

Listeriosis is a rare foodborne infection caused by Listeria monocytogenes. It is 12–20 times more prevalent in pregnant women compared to the general population, with a 20–40% mortality rate in neonates. Early treatment with appropriate antimicrobial agents is critical for pregnancy outcomes; however, the infection is difficult to control because the nonspecific clinical manifestations and rarity of the disease often preclude early diagnosis. We encountered 2 cases of pregnancy-associated listeriosis that occurred at 29 and 37 weeks of gestation. Both neonates were delivered by emergent cesarean section due to fetal condition, and one of the preterm infants died immediately after birth. Pregnancy-associated listeriosis should be considered in the management of unexplained fever or inflammatory conditions in pregnant women.

Symptomatic isolated superior mesenteric artery dissection: focusing on the morphologic type associated with invasive treatment

OBJECTIVE: This study was conducted to investigate the relationship between invasive treatments and computed tomographic (CT) classification or findings in symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD). METHODS: This retrospective observational study included 30 patients with SISMAD from Jan 2012 to Dec 2016. Demographic data, risk factor, treatment modalities, and CT findings including morphological classification, dissection length, and true lumen relative diameter (TLRD) were reviewed. The enrolled patients were classified into two groups (conservative management group, CG; invasive management group, IG). RESULTS: Based on CT classifications, one patient was type I (CG, n=1; IG, n=0), two were type IIa (CG, n=2; IG, n=0), five were type IIIa (CG, n=5; IG, n=0), 10 were type IIIb (CG, n=9; IG, n=1), and 12 were type IIIc (CG, n=1; IG, n=11). There was a high tendency to undergo invasive treatment among type IIIc (P < 0.001). The TLRD, distance from the aorta to dissection point, and dissection length were 18.3% (range, 0%–29.8%), 1.7 cm (range, 0–3.5 cm), and 7.3 cm (range, 4.9–10.0 cm), respectively. There TLRD (CG, 26.8% [range, 22.2%–48.8%]; IG, 0%; P < 0.001) and distance from the aorta to dissection point (CG, 1.0 cm [range, 0–2.1 cm]; IG, 3.5 cm [range, 0.8–5.4 cm]; P=0.024) differed significantly between groups. However, there was no significant difference in dissection length between CG and IG (P=0.527). CONCLUSION: The TLRD, distance from the aorta to dissection point, and CT classification such as type IIIc were associated with invasive management. Further studies on extended natural course of the disease from a larger number of subjects are necessary to draw a strong conclusion.

Can clinical scoring systems improve the diagnostic accuracy in patients with suspected adult appendicitis and equivocal preoperative computed tomography findings?

OBJECTIVE: Adult appendicitis (AA) with equivocal computed tomography (CT) findings remains a diagnostic challenge for physicians. Herein we evaluated the diagnostic performance of several clinical scoring systems in adult patients with suspected appendicitis and equivocal CT findings. METHODS: We retrospectively evaluated 189 adult patients with equivocal CT findings. Alvarado, Eskelinen, appendicitis inflammatory response, Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA), and adult appendicitis score (AAS) scores were evaluated, receiver operating characteristic analysis was conducted, and the optimal, low, and high cut-off values were determined for patient classification into three groups: low, intermediate, or high. RESULTS: In total, 61 patients were included in the appendicitis group and 128 in the non-appendicitis group. There were no significant differences between the area under the curve of the clinical scoring systems in the final diagnosis of AA for equivocal appendicitis on CT (Alvarado, 0.698; Eskelinen, 0.710; appendicitis inflammatory response, 0.668; RIPASA, 0.653; AAS, 0.726). A RIPASA score greater than 7.5 had a high positive predictive value (90.9) and an AAS score less than or equal to 5 had a high negative predictive value (91.7) in the diagnosis of AA. CONCLUSION: The accuracy of clinical scoring systems in the diagnosis of AA with equivocal CT findings was moderate. Therefore, a high RIPASA score may assist in the diagnosis of AA in patients with equivocal CT findings, and a low AAS score may be used as a criterion for patient discharge. Most patients presented with intermediate scores. The patients with equivocal CT findings may be considered as a third diagnostic category of AA.

Does the use of bedside ultrasonography reduce emergency department length of stay for patients with renal colic?: a pilot study

OBJECTIVE: The aim of this study was to evaluate the effect of adding bedside ultrasonography to the diagnostic algorithm for nephrolithiasis on emergency department (ED) length of stay. METHODS: A prospective, randomized, controlled pilot study was conducted from October 2014 to December 2014 with patients with acute flank pain. In the non-ultrasonography group (NUSG), non-contrast computed tomography was selected based on clinical features and hematuria in the urinalysis. In the ultrasonography group (USG), non-contrast computed tomography was selected based on clinical features and hydronephrosis on bedside ultrasonography. The primary outcome was ED length of stay. The secondary outcomes were radiation exposure, amount of analgesics, proportion of patients with diseases other than ureteral calculus, and proportion of patients with unexpected ED revisits within 7 days from the index visit. RESULTS: A total of 103 patients were enrolled (NUSG, 51; USG, 52). The ED length of stay for the USG (89.0 minutes) was significantly shorter than that for the NUSG (163.0 minutes, P<0.001). There were no significant differences between the two groups in the radiation exposure dose (5.29 and 5.08 mSv, respectively; P=0.392), amount of analgesics (P=0.341), proportion of patients with diseases other than ureteral calculus (13.0% and 6.8%, respectively; P=0.486), and proportion of patients with unexpected ED revisits within 7 days from the index visit (7.8% and 9.6%, respectively; P=1.000). CONCLUSION: The use of early bedside ultrasonography for patients with acute flank pain could reduce the ED length of stay without increasing unexpected ED revisits.

Acute Myocardial Infarction with Elevated ST-segment Only in Lead aVR

Lead aVR ST segment elevation in patients with clinically suspected acute coronary syndrome strongly suggests the possibility of occlusion of the left main coronary artery (LMCA), and stenosis or occlusion in this area can cause severe life-threatening left ventricular dysfunction or malignant arrhythmias. Thus, it could be a sign suggestive of a poor prognosis for patients. In this study, we report on the case of a 67-year-old male who presented to the emergency department with total occlusion of LMCA with ST-segment elevation in only lead aVR, and without ST-segment elevation in other leads.

A Telephone Method for Helping Lay Rescuers Perform High Quality Cardiopulmonary Resuscitation

PURPOSE: Dispatcher-assisted telephone instruction during cardiopulmonary resuscitation (CPR) improves the quality of CPR performed by laypersons. However, in Korea, CPR instruction guidelines for bystanders have not made. We therefore studied the effects of verbal instruction on the quality of chest compression. METHODS: Data from two randomized, double-blinded, controlled trials using identical methodology were combined to obtain 175 records for analysis. Subjects were randomized into either a "push as hard as you can and fast" (n=87) or "push down 5~6 cm, 100~120 rate/min" (n=88), verbal instructions in the 2011 Korea Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). Data were recorded via a Resusci(R) Anne SkillReporter(TM), Laerdal Medical mannequin. Primary outcome measures included chest compression depth and chest compression rate per minute. RESULTS: The average compression depth and speed of chest compressions did not significantly differ between the two verbal instructions. CONCLUSION: The verbal istructions provided by telephone based on the 2011 Korean Guidelines for CPR and ECC are not effective. The instructions for high quality CPR of layperson should therefore be studied.

Center of the Chest Versus Inter-nipple Line in the Selection of a Chest Compression Site by Novice Rescuers

PURPOSE: The aim of this study was to compare the distribution and risk from hand positions applied at the center of the chest (CoC) versus the inter-nipple line (INL) during external chest compression by novice rescuers. METHODS: This simulation study included 105 participants. The participants were given photographs of the unexposed male chest and asked to mark a cross at the center of the chest and at the midpoint of the inter-nipple line. The range of contact with the chest was estimated by measuring the participants' palm width. The median and distribution of the two points were then compared and analyzed to determine whether the range in contact with the chest involved the xiphoid process. RESULTS: The level of the INL was approximately 0.8 cm higher at the sternum than the CoC (p<0.001), while the standard deviation of the CoC [1.8(0.6-3.8)] was higher than that of the INL [1.2(0.4-2.4)] (p<0.001). There were more cases in which the palm range involved the xiphoid process in the CoC group [15(14.3%)] than the INL group [1(0.9%)] (p<0.001). CONCLUSION: For male adult patients, chest compression at the level of the INL by novice rescuers is safer and more intensive than compression at the level of the CoC.

The Usefulness of the Hot Pack as a Complementary Technique for the Treatment of Non-specific Abdominal Pain or Acute Gastroenteritis in an Emergency Department

PURPOSE: The aim of this study was to determine the effectiveness of the hot pack as a complementary technique for the treatment of nonspecific abdominal pain or acute gastroenteritis in a hospital emergency department. METHODS: This study was conducted as a prospective case-controlled trial of patients with nonspecific abdominal pain or acute gastroenteritis who visited an emergency department. A total of 166 participants, from 18 to 75 years old, were divided into two groups: patients treated with antispasmodics and hot pack (WH) group (n=83) and patients treated with antispasmodics without a hot pack (WOH) group (n=83). Patients rated their pain using the 10 cm numerical rating scale (NRS). Pain NRS was assessed four times: first on arrival and then at 1, 2, and 3 hours after treatment. The frequency of tramadol use and residence time was also assessed. RESULTS: The two groups did not significantly differ in age or gender distribution. The mean NRS score also did not significantly differ between the groups upon arrival (p=0.847). The NRS scores at 1 hour and 2 hours after treatment in the WH group were significantly lower than NRS scores in the WOH group (p<0.001). There was no significant difference, however in NRS scores after 3 hours for both groups (p=0.091). There was a significant difference in NRS scores between admission and after 1 hour (p=0.005) and a significant difference in NRS scores between 2 hours and 3 hours (p<0.001). The frequency of tramadol use significantly differed between groups (p<0.01) but there was no significant difference in residence time in each group. CONCLUSION: The hot pack is an effective complementary technique for reducing abdominal pain in the hospital emergency department.

The Usefulness of a Scoring System as a Predictor of Acute Coronary Syndrome in Chest Pain with an Unclear Diagnosis in the Emergency Department

PURPOSE: The aim of this study was to investigate the usefulness of several risk scoring systems, such as TIMI, GRACE, HEART, and PERSUIT as predictors for acute coronary syndrome (ACS) in chest pain with an unclear diagnosis. METHODS: This study was conducted as a retrospective and observational study. Enrolled patients were classified into two groups depending on the cause of chest pain: ACS group (CG; N=80) and non-ACS group (NCG; N=42). Clinical variables, including age, gender, past history, characteristics of chest pain, final diagnosis, and risk score were analyzed according to each group. Risk scoring systems for prediction of acute coronary syndrome were compared using receiver operating characteristic curve (ROC) analysis and area under the curve (AUC). RESULTS: Significant differences in age (p<0.001), diabetes mellitus (p=0.049), prior ischemic heart disease (p<0.001), continuous chest pain (p=0.035), and severe chest pain (p=0.001) were observed between the two groups. Results of ROC analysis for each scoring system for prediction of ACS were as follows: HEART (AUC; 0.878, 95% Confidence Interval, CI; 0.806~0.930, cut-off value; 4 points, sensitivity; 90.48%, specificity; 71.25%), TIMI (AUC; 0.839, 95% CI; 0.762~0.899, cut-off value; 1 point, sensitivity 83.33%, specificity 77.50%), PERSUIT (AUC; 0.748, 95% CI; 0.661~0.822, cut-off value; 11 points, sensitivity 61.90%, specificity 77.50%), and GRACE (AUC; 0.698, 95% CI, 0.608~0.778, cut off value 102 points, sensitivity 83.33, specificity 53.75%). CONCLUSION: In comparative analysis of each scoring system, the HEART scoring system was found to be a strong predictor of ACS in chest pain with an unclear diagnosis, followed by the TIMI, PURSUIT, and GRACE scoring systems.

The Efficacy of Discharge Instructions Provided by a Tablet Personal Computer for Aiding the Comprehension and Satisfaction of Patients with Ureteral Stones

PURPOSE: This study was conducted in order to evaluate the possibility of improving the comprehension and satisfaction of patients discharged after receiving discharge instructions using a tablet personal computer (tablet PC), compared with conventional discharge instructions. METHODS: A randomized, prospective, consecutive, exploratory study was conducted on patients with ureteral stones in an emergency department (ED). The patients' objective comprehension, satisfaction, and subjective comprehension regarding their discharge instructions were compared with regard to discharge instruction (traditional verbal method, N=53 versus tablet PC method, N=53). RESULTS: No statistically significant differences in age, gender, or level of education were observed between the two groups. The mean number of correct answers regarding ureteral stones on the questionnaire was 2.35+/-1.02 in the conventional group (CG) and 3.37+/-0.9 in the tablet PC group (TG) (p0.05). The subjective comprehension score was 7.42 in the CG and 7.8 in the TG (p>0.05). CONCLUSION: Objective comprehension of ureteral stones showed improvement in the group with discharge instructions provided by the tablet PC. However, satisfaction and subjective comprehension did not show improvement.

Educational Needs and Perceptions of School Nurses Regarding Emergency Situations in School: Focus on Differences Based on the General Characteristics of School Nurses

PURPOSE: The study investigated the educational needs and perceptions of school nurses regarding emergency situations in the school and compared differences in the educational needs and perceptions about emergency situations according to the general characteristics of school nurses. METHODS: Using a written survey of randomly selected sample, we questioned 100 school nurses over a 3-month period from January 2011 to March 2011. The survey involved 11 medical conditions and 16 injury-related conditions. It contained questions about the need for education and perceptions of emergency situations. We also determined school nurses' general characteristics including sex, age, grades of school where they worked, years of teaching career, years of clinical experience, number of classes, marital status, number of children, gender of their children, age of their children, the existence of older families. RESULTS: Two hundred two (84%) school nurses responded. For most conditions, there were significant differences between the scores of educational needs regarding, and perceptions about, emergency situations, except for three conditions (fracture of extremity, cerebral contusion, and tooth trauma). According to the general characteristics of school nurses, only the grade of school where they worked influenced the educational needs for cerebral contusion and orbital contusion. CONCLUSION: The emergency conditions that need first aid education in Korean school nurses are different from the conditions identified in other foreign countries. Primary education and promotion of first aid is considered necessary. The perceptions about emergency situations and the educational need regarding emergency situations show consistency. Only the grade of school where nurses worked affected the educational needs of school nurses. Further studies about the frequency of emergency situations in each school grade are required.

Veiled Paraquat Poisoning: A Focus on Clinical Characteristics

PURPOSE: Most paraquat poisonings are easily diagnosed by history taking on physical examination, however, some are failed to be diagnosed initially if the poisoning was veiled. The purpose of this study was to explore the clinical characteristics of veiled paraquat poisoning. METHODS: We retrospectively reviewed the medical records of patients whose discharge diagnosis was paraquat poisoning in one university teaching hospital between 1 Jan, 2001 and 31 Dec, 2010. Veiled paraquat poisoning was determined when there was a positive urine paraquat kit in patients who did not mention paraquat poisoning in an initial physical examination or had unknown cause of pulmonary fibrosis, acute renal failure, or multi-organ failure. RESULTS: Of the 117 patients with paraquat poisoning during the study period, 6 patients (5.1%) had veiled paraquat poisoning. The clinical characteristics were 1) proteinuria - 6 (100%), 2) increased creatinine - 4 (66.7%), 3) green skin stains - 2 (33.3%), 4) mucosal ulcer - 3 (50%). Blood chemistry results were variable. CONCLUSION: We should suspect veiled paraquat poisoning for patients who have proteinuria, increased creatinine, green skin stain, mucosal ulcer and vomiting, or if they have rapidly progressing acute renal failure or multi-organ failure with unknown cause, even if patients didn't mention about paraquat poisoning upon the initial physical examination. In cases with the above clinical conditions, a thorough repeated physical examination including history taking and use of urine paraquat kits should be performed.

The Applicability and Usefulness of Emergency Department Syndromic Surveillance Using a Computed Data Source for Epidemic Keratoconjunctivitis and Meningitis

PURPOSE: This study was designed to evaluate the applicability and usefulness of emergency department (ED) syndromic surveillance using a computerized data source for highly contagious, public health related diseases such as conjunctivitis and meningitis. METHODS: Between Jan 1 2007 and Dec 31 2008 we conducted a retrospective, observational study through consecutive enrollment of individuals at a university hospital with an ED census of about 156,000. ED patient data were obtained from a computerized data system, the National Emergency Department Information System (NEDIS). Predefined symptoms including red eye, eye injection / discharge / itching, headache, nausea, vomiting and predefined signs such as fever comparable with conjunctivitis and meningitis and ED discharge diagnosis were used as data for syndromic surveillance. Data about spinal tapping were used for agreement analysis. RESULTS: We enrolled 714 patients for ED syndromic conjunctivitis and 1,889 for ED syndromic meningitis during the study period. A positive correlation was demonstrated between ED syndromic conjunctivitis data and national ophthalmologic sentinel survey data (Pearson correlation = 0.696; p<0.001). The agreement (kapha value) between ED syndromic meningitis using chief complaints and ED discharge diagnosis and ED syndromic meningitis using chief complaints and spinal tapping order was 0.665 (p<0.001). Real outbreaks were recognized 2 to 4 weeks early by both ED syndromic surveillance of conjunctivitis and meningitis. CONCLUSION: ED syndromic surveillance methods are applicable and useful for surveillance of conjunctivitis and meningitis. Further study is needed to clarify the effectiveness of ED syndromic surveillance and the likelihood of early recognition in highly contagious public health related diseases.