Re-evaluation of Pediatric Emergency Ultrasound Education for Emergency Medicine Residents

PURPOSE: As emergency ultrasound (EUS) can improve the management of emergency department patients, education in EUS has become an essential part of emergency medicine resident training. This study examined the efficacy of pediatric EUS education for resident physicians 6 months after training. METHODS: A survey was conducted on emergency medicine resident physicians who participated in the Pediatric Emergency Ultrasound Course in November 2014, which is a training program of pediatric EUS generated by Korean Society of Pediatric Emergency Medicine and Society of Emergency and Critical Care Imaging. The instructor checked the list to evaluate attendee after the course. After the course, resident physicians have been encouraged to use EUS at the patient's bedside, and the same list was checked 6 months after the course. At the same time, a survey of the number of experience of EUS during the 6 months was performed. RESULTS: Ten emergency resident physicians of Seoul National University of Hospital participated in the course and all attendees were re-evaluated 6 months after the course. The mean initial score immediately after the course and that at the 6 months follow-up was 28.6±3.13 and 20.8±3.79, respectively (p < 0.05). No significant relationship was observed between the difference score and the EUS experience number, including the observations of the other physician's EUS (p=0.603) and hands-on by themselves (p=0.771). CONCLUSION: Although a EUS education program could improve the resident physician's ability, the effect decreased with time. Hence, the resident physician's EUS ability cannot be maintained via simple emergency department duty. Therefore, the education program should be repeated regularly.

The Role of Spinal Dopaminergic Transmission in the Analgesic Effect of Nefopam on Rat Inflammatory Pain

BACKGROUND: Nefopam has been known as an inhibitor of the reuptake of monoamines, and the noradrenergic and/or serotonergic system has been focused on as a mechanism of its analgesic action. Here we investigated the role of the spinal dopaminergic neurotransmission in the antinociceptive effect of nefopam administered intravenously or intrathecally. METHODS: The effects of intravenously and intrathecally administered nefopam were examined using the rat formalin test. Then we performed a microdialysis study to confirm the change of extracellular dopamine concentration in the spinal dorsal horn by nefopam. To determine whether the changes of dopamine level are associated with the nefopam analgesia, its mechanism was investigated pharmacologically via pretreatment with sulpiride, a dopaminergic D2 receptor antagonist. RESULTS: When nefopam was administered intravenously the flinching responses in phase I of the formalin test were decreased, but not those in phase II of the formalin test were decreased. Intrathecally injected nefopam reduced the flinching responses in both phases of the formalin test in a dose dependent manner. Microdialysis study revealed a significant increase of the level of dopamine in the spinal cord by intrathecally administered nefopam (about 3.8 fold the baseline value) but not by that administered intravenously. The analgesic effects of intrathecally injected nefopam were not affected by pretreatment with sulpiride, and neither were those of the intravenous nefopam. CONCLUSIONS: Both the intravenously and intrathecally administered nefopam effectively relieved inflammatory pain in rats. Nefopam may act as an inhibitor of dopamine reuptake when delivered into the spinal cord. However, the analgesic mechanism of nefopam may not involve the dopaminergic transmission at the spinal level.

The Effects of Mental Fitness, Social Support and Psychological Distress on Suicidal Idea of People with Schizophrenia Using Community Mental Health Services / 신경정신의학

OBJECTIVES: The objective of this study was to analyze the relationships of psychological distress, social support, mental fitness and suicidal idea among patients of chronic schizophrenia using community mental health services. METHODS: This study was conducted in patients who visited the mental health services in Daejeon from October to December 2011. In total, 395 chronic schizophrenic patients were evaluated using Mental Fitness Scale (MFS), Kessler Psychological Distress Scale (K10), and Multidimensional Scale of Perceived Social Support (MSPSS). RESULTS: Results showed that 37% (n=146) of patients had suicidal ideas and 63% (n=249) of patients did not have suicidal ideas. The group that had suicidal ideas showed significantly lower scores on MFS, K10, and MSPSS than the group with no suicidal ideas (p=0.000). Logistic regression analysis showed a significantly lower score on MFS, K10 for the suicidal ideation group than the group with no suicidal ideas. CONCLUSION: These results suggest that health care providers should consider mental fitness and psychological distress, in order to prevent suicidal idea of schizophrenic patients.

Patients' Compliance for the Conservative Treatment of the Elbow Epicondylitis

PURPOSE: To measure the level of compliance to conservative treatment of epicondylitis and to identify factors affecting compliance. METHODS: This study included 104 patients who were treated non-operatively for epicondylitis of the elbow from 2009 to 2011. At the time of initial visit, all patients had thorough explanation about diagnosis, cause and pathophysiology of the disease, and were recommended to wait-and-see or to have steroid injection. At minimum of 6 month's follow-up, we performed telephone survey including patient's level of perception about the disease, maintenance of initial treatment method, and final symptom relief. Statistical analysis was performed using chi-square test, Fisher's exact test and logistic regression analysis. RESULTS: Of the 104 patients, 82 (78.8%) patients maintained initial treatment methods. 23 (22.1%) remembered exact diagnosis and mechanism of the disease, 49 (47.1%) remembered cause or mechanism but not about the diagnosis, and 32 (30.8%) didn't know about the diagnosis nor mechanism. Compliances of those groups were 73.9% (17/23), 79.6% (39/49), and 81.3% (26/32), respectively, and the differences were not statistically significant (p=0.7934). Initial pain (odds ratio=0.7, p=0.0293) and the compliance (odds ratio=6.13, p=0.0015) were significant predictors of final symptom relief. CONCLUSION: There were no factors including perception level that proved to affect the compliance. Since higher compliance led to more successful outcome, further research on factors that increase compliance may be needed.

Routine barium enema prior to closure of defunctioning ileostomy is not necessary / 대한외과학회지

PURPOSE: The use of barium enemas to confirm the anastomotic integrity prior to ileostomy closure is still controversial. The purpose of the study was to determine the utility of routine contrast enema prior to ileostomy closure and its impact on patient management in patients with a low pelvic anastomosis. METHODS: One hundred forty-five patients had a temporary loop ileostomy constructed to protect a low colorectal or coloanal anastomosis following low anterior resection for rectal cancer. All patients were evaluated by physical examination, proctoscopy, and barium enema prior to ileostomy closure. RESULTS: The median time from ileostomy creation to closure was 8 months. Five (3.5%) of the 144 patients were found to have clinically relevant strictures at the colorectal anastomosis on routine barium enema. One patient (0.7%) showed anastomotic leak on their barium enema. Overall, 141 patients (97.9%) had an uncomplicated postoperative course. Postoperative complication occurred in three patients (2.1%). None of them showed abnormal barium enema finding, which suggested that routine contrast enema examination did not predict postoperative complication. CONCLUSION: Routine barium enema evaluation of low pelvic anastomoses before loop ileostomy closure did not provide any additional information for postoperative colorectal anastomotic complication.

Comparison of the Effect of Hydroxyapatite and Allogenous Bone as an Adjunct to Autogenous Iliac Bone Grafting in Posterolateral Spinal Fusion / 대한정형외과학회잡지

PURPOSE: We wanted to analyze the efficacy of hydroxyapatite as a bone graft extender and we wanted to compare the bone fusion rate between hydroxyapatite and allogenous bone as an adjunct to autogenous iliac bone graft in posterolateral spinal fusion. MATERIALS AND METHODS: Our study included 19 patients who were treated with decompression and posterolateral spinal fusion using hydroxyapatite on right side and frozen allogenous bone on left side as an adjunct to autogenous iliac bone graft, and all the procedures were performed between May 2003 and August 2004. Fusion was determined by the final radiographic findings with using Christiansen's classification. RESULTS: There were 3 male and 16 female patients. Their average age was 65.5 years (range: 48-81) and the average follow-up period was 21.5 months (range: 12-36). Fusion was performed in 3.4 segments (range: 2-6) on average per patient. Of all the 65 segments that underwent fusion, 63 segments (96.9%) in group using hydroxyapatite and 54 segments (83.1%) in group using allogenous bone were determined to be fused, and the difference was not statistically significant (p=0.074). CONCLUSION: Hydroxyapatite as adjunct to autogenous iliac bone for use in posterolateral spinal fusion showed a high fusion rate and it seemed to be useful as a bone graft extender for reducing the volume of the autogenous iliac bone.

Does a Successful Total Mesorectal ExcisionRequire a Learning Curve?

PURPOSE: This study was conducted to determine whether a learning curve is necessary to obtain a successful total mesorectal excision (TME) for mid or low rectal cancer. METHODS: We retrospectively reviewed the records of 80 patients that underwent a total mesorectal excision for mid or low rectal cancer between 1994 and 1998 and between 1999 and 2002. We compared the results between the two period groups. Endpoints were postoperative urological functions and the local recurrence rate. RESULTS: There was no significant difference for age, gender, tumor differentiation and stage between patients in the two groups. Local recurrence (LR) developed in 23% of patients in the early group and 7.5% of patients in the late group. The cumulative LR risk at 60 months was 27.5% for the early period group and 9.9% for the late period group (P=0.082) and the difference between the two groups was significant for TNM III stage (29.8% vs. 9.8%, P=0.049). Postoperative urological complications were not significantly different between the two groups (P=0.75). CONCLUSION: Based on these results, TME seemed to require a learning curve. In clinical trials for rectal cancer surgery, the learning curve for qualified surgery from the standpoint of oncological outcome should be considered to minimize bias due to surgeon-associated factors. A more broad application of the TME concept to a larger number of patients with mid or low rectal cancer is warranted.

Usefulness of Urinary Trypsinogen-2 Dipstick Test for Diagnosis of Acute Pancreatitis / 대한소화기학회지

BACKGROUND/AIMS: The clinical usefulness of urinary trypsinogen-2 dipstick test is still in controversy. We evaluated the usefulness of urinary trypsinogen-2 dipstick test in patients with acute pancreatitis. METHODS: Urinary trypsinogen-2 dipstick test was prospectively performed in 50 patients with acute pancreatitis, 50 patients with non-pancreatic abdominal pain, and 50 healthy controls. RESULTS: On admission, urinary trypsinogen-2 dipstick test was positive in 36 of 50 patients with acute pancreatitis (sensitivity, 72%) and in 4 of 50 patients with non-pancreatic abdominal pain (specificity, 92%). On the other hand, it was all negative in controls. The sensitivity and specificity of serum lipase were 78% and 94%, respectively. At 24 hours after admission, the positive rate of urinary trypsinogen-2 dipstick test rose from 72% to 94% (p=0.02). The results of urinary trypsinogen-2 dipstick test was positive in 14 of 15 patients with severe pancreatitis and 22 of 35 patients with mild pancreatitis according to the criteria by Atlanta International Symposium, 1992. CONCLUSIONS: Urinary trypsinogen-2 dipstick test is comparable to serum lipase in diagnosing acute pancreatitis. Delayed measurement and severe pancreatitis are more likely to yield positive results with urinary trypsinogen-2 dipstick test. Thus, we suggest that the cut-off value of urinary trypsinogen-2 dipstick test should be lowered to increase its sensitivity.

A case of anaphylaxis to laminaria / 천식및알레르기

Anaphylaxis is a life - threatening syndrome elicited in a hypersensitive individual on subsequent exposure to a sensitizing antigen with, reactions ranging widely in severity from mild pruritus and criteria to shock and death. Anaphylaxis occurs in the United States at rates estimated to be as high as one in every 3000 inpatients and may account for more than 500 deaths annually. Preparations of kelp Laminaria digitata are used as tents in gynecologic procedures to dilate the cervix, and the kelp consists principally of a glucagon carbohydrate called laminarin. Laminarin is thought to function as the active ingredient in dilatation by changing osmotic pressure or uterine prostaglandin metabolism. The tent is inserted into the cervix several hours before the procedure. As the cervix desiccates and dilates, the tent develops an hourglass shape. Recently, we experienced one patient with anaphylaxis to laminaria diagnosed by skin test and showing good response to treatment.

A Case of Left Ventricular Outflow Obstruction Caused by Mitral Valve Replacement

The pathophysiology, clinical presentation and prognosis of left ventricular obstruction present an important cardiological problem. Various anatomical and functional abnormality can cause this phenomenon. Rarely, left ventricular outflow obstruction can result after mitral valve surgery. We experienced a case of left ventricular outflow obdtruction 13 years after mitral valve replavement. The diagnosis was made using two-dimensinal Doppler echocardiography and confirmed by cardiac catheterization. The pressure gradient across the left ventricular outflow obstruction was 96mmHg. A second mitral valve replacement was performed. Because severe fibrosis, pannis around the prosthetic mitral valve and a subaortic web were detected during the operation, the subaortic web was removes.