Effect of body mass index on the prognostic value of N-terminal pro-B-type natriuretic peptide in pneumonia: a comparative study between normal-weight and obese adults

Objective@#Body mass index (BMI) is a major determinant of N-terminal pro-brain natriuretic peptide (NT-proBNP). However, the relationship of BMI with pneumonia has not been entirely characterized. @*Methods@#Adult patients with pneumonia, who visited the emergency department from January 2017 to December 2019, were included. According to BMI, they were divided into two groups, including normal-weight and obesity groups. Data were retrospectively reviewed via the prospectively collected pneumonia registry and medical chart. NT-proBNP, BMI and pneumonia severity index (PSI) were determined for all subjects. The moderating effect between NT-proBNP and BMI was examined by entering interaction terms into the multivariable regression model predicting mortality. Using the area under the curve (AUC), the predictive performance of NT-proBNP was evaluated. @*Results@#Of 327 enrolled patients, 118 patients belonged to the obesity group. In a multivariable model including BMI, NT-proBNP was identified as an independent predictor of mortality. The AUC of the adjusted NT-proBNP including BMI, significantly increased the AUC of the adjusted NT-proBNP excluding BMI and tended to be superior to that of PSI. A positively significant BMI-by-NT-proBNP interaction for mortality was observed. NT-proBNP showed significant prognostic power in both BMI groups, but NT-proBNP of the obesity group had significantly higher AUC than that of the normalweight group. In the obesity group, the AUC of NT-proBNP tended to be higher than that of PSI. @*Conclusion@#BMI is a significant factor enhancing the prognostic power of NT-proBNP in pneumonia. The prognostic utility of NT-proBNP was significantly differed by BMI groups, which is more useful in the obesity group than the normalweight group.

QTc Prolongation due to Psychotropic Drugs Intoxication and Its Risk Assessment

Purpose@#The aims of the present study were twofold. First, the research investigated the effect of an individual’s risk factors and the prevalence of psychotropic drugs on QTc prolongation, TdP (torsades de pointes), and death. Second, the study compared the risk scoring systems (the Mayo Pro-QT risk score and the Tisadale risk score) on QTc prolongation. @*Methods@#The medical records of intoxicated patients who visited the emergency department between March 2010 and February 2019 were reviewed retrospectively. Among 733 patients, the present study included 426 psychotropic drug-intoxicated patients.The patients were categorized according to the QTc value. The known risk factors of QTc prolongation were examined, and the Mayo Pro-QT risk score and the Tisadale risk score were calculated. The analysis was performed using multiple logistic regression, Spearman correlation, and ROC (receiver operating characteristic). @*Results@#The numbers in the mild to moderate group (male: 470≤QTc<500 ms, female: 480≤QTc<500 ms) and severe group (QTc≥500 ms or increase of QTc at least 60ms from baseline, both sex) were 68 and 95, respectively. TdP did not occur, and the only cause of death was aspiration pneumonia. The statically significant risk factors were multidrug intoxications of TCA (tricyclic antidepressant), atypical antipsychotics, an atypical antidepressant, panic disorder, and hypokalemia. The Tisadale risk score was larger than the Mayo Pro-QT risk score. @*Conclusion@#Multiple psychotropic drugs intoxication (TCA, an atypical antidepressant, and atypical antipsychotics), panic disorder, and hypokalemia have been proven to be the main risk factors of QTc prolongation, which require enhanced attention. The present study showed that the Tisadale score had a stronger correlation and predictive accuracy for QTc prolongation than the Mayo Pro-QT score. As a result, the Tisadale risk score is a crucial assessment tool for psychotropic drug-intoxicated patients in a clinical setting.

Prognostic utility of N-terminal pro-B-type natriuretic peptide in adult and elderly patients with community acquired pneumonia

Objective@#N-terminal pro-B-type natriuretic peptide (NT-proBNP) is suggested as a prognostic biomarker for communityacquired pneumonia (CAP). However, its predictive value for an individual adult and elderly CAP patients has not been fully investigated. @*Methods@#Patients with CAP aged 18 years and older, who visited the emergency department (ED) from March 1, 2016 to March 31, 2019, were included in this study. Patients were divided into the adult group and the elderly group (age ≥70 years). Data was collected from the ED-based registry, and medical charts were retrospectively reviewed. The registry data included sociodemographic and past medical characteristics, as well as laboratory findings including NT-proBNP and C-reactive protein (CRP), Pneumonia Severity Index (PSI), and CURB65 (confusion, urea, respiratory rate, blood pressure, and aged 65 or more). The independent potential of NT-proBNP to predict mortality was assessed in both groups using multivariable logistic regression, and its predictive ability was evaluated in terms of performance (using areas under the curve [AUCs]) and goodness-of-fit (using the Bayesian information criterion [BIC]). @*Results@#Totally, 325 CAP patients were evaluated, of which 208 (64%) belonged to the elderly group. NT-proBNP was identified as an independent predictor of CAP mortality in elderly patients, but not in adult patients. Moreover, AUC of the NT-proBNP for mortality was comparable to AUC of the PSI, but was higher than that of the CURB65, in elderly CAP patients. Similarly, the NT-proBNP had a better overall fit (lower BIC value) compared to the CURB65, for mortality. Additionally, both AUC and overall fit of the NT-proBNP for mortality were significantly superior to values obtained for CRP. @*Conclusion@#For elderly CAP patients in the ED, the NT-proBNP is an independent and useful predictor of mortality.

QTc Prolongation due to Psychotropic Drugs Intoxication and Its Risk Assessment

Purpose@#The aims of the present study were twofold. First, the research investigated the effect of an individual’s risk factors and the prevalence of psychotropic drugs on QTc prolongation, TdP (torsades de pointes), and death. Second, the study compared the risk scoring systems (the Mayo Pro-QT risk score and the Tisadale risk score) on QTc prolongation. @*Methods@#The medical records of intoxicated patients who visited the emergency department between March 2010 and February 2019 were reviewed retrospectively. Among 733 patients, the present study included 426 psychotropic drug-intoxicated patients.The patients were categorized according to the QTc value. The known risk factors of QTc prolongation were examined, and the Mayo Pro-QT risk score and the Tisadale risk score were calculated. The analysis was performed using multiple logistic regression, Spearman correlation, and ROC (receiver operating characteristic). @*Results@#The numbers in the mild to moderate group (male: 470≤QTc<500 ms, female: 480≤QTc<500 ms) and severe group (QTc≥500 ms or increase of QTc at least 60ms from baseline, both sex) were 68 and 95, respectively. TdP did not occur, and the only cause of death was aspiration pneumonia. The statically significant risk factors were multidrug intoxications of TCA (tricyclic antidepressant), atypical antipsychotics, an atypical antidepressant, panic disorder, and hypokalemia. The Tisadale risk score was larger than the Mayo Pro-QT risk score. @*Conclusion@#Multiple psychotropic drugs intoxication (TCA, an atypical antidepressant, and atypical antipsychotics), panic disorder, and hypokalemia have been proven to be the main risk factors of QTc prolongation, which require enhanced attention. The present study showed that the Tisadale score had a stronger correlation and predictive accuracy for QTc prolongation than the Mayo Pro-QT score. As a result, the Tisadale risk score is a crucial assessment tool for psychotropic drug-intoxicated patients in a clinical setting.

Workplace violence experienced by emergency department workers and its association with stress and depression assessment

OBJECTIVE: This study examined the incidence of workplace violence (WPV) in an emergency department (ED), and its influence on ED workers' mental health. METHODS: A cross-sectional, anonymous survey was conducted on ED workers employed in a local emergency medical center during August 2018. The survey respondents' data on the demographic characteristics, WPV episode, Korean-translated Brief Encounter Psychosocial Instrument (BEPSI-K), stress questionnaire for Korean National Health and Nutrition Examination Survey (KNHANES), and Patient Health Questionnaire-9 (PHQ-9) were obtained. The results of the stress (BEPSI-K, KNHANES) and depression (PHQ-9) score were compared with the WPV experience of ED workers. RESULTS: A total of 104 of 120 ED workers (86.7%) were exposed to WPV. ED workers that experienced physical violence within the past year had higher KNHANES, BEPSI-K, and PHQ-9 than the workers, who did not experience such violence (P≤0.001). In addition, this survey demonstrated that a physical violence episode within the past year was associated with above moderate depression (P≤0.001; odds ratio, 19.597). CONCLUSION: Recent physical violence can cause psychiatric disorders in ED workers, such as depression or stress disorder. Therefore, policies are needed to prevent WPV in ED and support ED workers who have experienced WPV.

Identifying out-of-hospital cardiac arrest patients by using International Classification of Diseases codes and procedure code

OBJECTIVE: This study was conducted to evaluate the validity of the International Classification of Diseases, 10th revision (ICD-10) codes for identifying patients who suffered out-of-hospital cardiac arrest (OHCA). METHODS: Consecutive data pertaining to adult patients who suffered OHCA or received ICD-10 codes for cardiac arrest were collected. Patient characteristics and clinical data during the period from January 2015 to December 2016 were obtained. The sensitivity and positive predictive value (PPV) of each code for identifying OHCA were calculated and an optimal algorithm using diagnostic and procedure codes to detect OHCA patients was selected. The kappa coefficient was calculated to examine the agreement between algorithm-detected cases and true OHCA patients. RESULTS: A total of 397 patients were included in this study. The single use of ICD-10 codes was an insensitive method for identifying OHCA patients. Combination of diagnostic codes and procedure codes showed a good sensitivity (98.6%) and PPV (94.8%) for identifying OHCA patients. The agreement between the optimal algorithm and true OHCA was excellent (κ=0.970). CONCLUSION: Using ICD-10 codes for identifying OHCA patients is an insensitive method. The combination of ICD-10 codes and procedure codes can be an alternative search method.

Korean Shock Society septic shock registry: a preliminary report

OBJECTIVE: To evaluate the clinical characteristics, therapeutic interventions, and outcomes of patients with septic shock admitted to the emergency department (ED). METHODS: This study was a preliminary, descriptive analysis of a prospective, multi-center, observational registry of the EDs of 10 hospitals participating in the Korean Shock Society. Patients aged 19 years or older who had a suspected or confirmed infection and evidence of refractory hypotension or hypoperfusion were included. RESULTS: A total of 468 patients were enrolled (median age, 71.3 years; male, 55.1%; refractory hypotension, 82.9%; hyperlactatemia without hypotension, 17.1%). Respiratory infection was the most common source of infection (31.0%). The median Sepsis-related Organ Failure Assessment score was 7.5. The sepsis bundle compliance was 91.2% for lactate measurement, 70.3% for blood culture, 68.4% for antibiotic administration, 80.3% for fluid resuscitation, 97.8% for vasopressor application, 68.0% for central venous pressure measurement, 22.0% for central venous oxygen saturation measurement, and 59.2% for repeated lactate measurement. Among patients who underwent interventions for source control (n=117, 25.1%), 43 (36.8%) received interventions within 12 hours of ED arrival. The in-hospital, 28-day, and 90-day mortality rates were 22.9%, 21.8%, and 27.1%, respectively. The median ED and hospital lengths of stay were 6.8 hours and 12 days, respectively. CONCLUSION: This preliminary report revealed a mortality of over 20% in patients with septic shock, which suggests that there are areas for improvement in terms of the quality of initial resuscitation and outcomes of septic shock patients in the ED.

Prediction of the Likelihood of Surgical Management in Blow-out Fracture Patients: Using Two CT Measuring Method, DFD and CCD

PURPOSE: The purpose of this study was to evaluate the predictive value of the measured factors that can be used in an emergency department to assess patients with blow-out fractures (BOFs) who are expected to undergo surgical management. METHODS: This study was conducted on patients with BOFs who attended an emergency department in a tertiary teaching hospital from December 2013 to November 2016. The medical records and radiology findings, such as facial computed tomography (CT), were reviewed retrospectively. The depth of floor displacement (DFD) and cranial-caudal dimension (CCD), which were measured using facial CT, were evaluated to determine the power of the CT parameters as predictors expecting surgical management in BOF patients. Statistical analysis was conducted with SPSS statistics ver. 23.0. RESULTS: The final 44 BOF patients were included in the study. Among them, 21 patients had undergone surgery. From this study, using a threshold DFD value of 0.5 cm, the accuracy of DFD was 86.36%, and the sensitivity and specificity in predicting surgery in BOF patients was 100% and 73.91%, respectively. Using a threshold CCD value of 0.4 cm, the accuracy of CCD was 88.64%, and the sensitivity and specificity in predicting surgery in BOF patients was 100% and 78.26%, respectively. CONCLUSION: With the aid of DFD and CCD, which was measured from facial CT, BOF patients who may require surgical management can be detected easily and more promptly by emergency physicians in emergency settings.

Usefulness of Age Shock Index in Predicting the Severity of Acute Cholecystitis in Emergency Department Patients

PURPOSE: This study examined the availability of the age shock index in an assessment of high risk patients with acute cholecystitis in an emergency department. METHODS: Consecutive data of patients who presented to the emergency department with acute cholecystitis during the period, January 2012 and March 2017, were reviewed retrospectively. Univariate and multivariate analyses were performed to determine the relationship between the severity of acute cholecystitis and the clinical factors. RESULTS: A total of 242 patients with acute cholecystitis were included in this study. From univariate analyses, age, Murphy's sign, symptom duration, heart rate, respiratory rate, age shock index, hypertension, diabetes, leukocytes, C-reactive protein and blood urea nitrogen were found to be related to the severity of acute cholecystitis. From multivariate analysis, the symptom duration (OR, 4.271; 95% CI, 2.672-6.827), respiratory rate (OR, 1.482; 95% CI, 1.189-1.847), age shock index (OR, 1.609; 95% CI, 1.060-2.442, 10-point interval), leukocytes (OR, 1.283; 95% CI, 1.156-1.424), and diabetes (OR, 4.590; 95% CI, 1.507-13.976) had a positive relationship with the severity of acute cholecystitis. CONCLUSION: The age shock index, which is calculated easily using the patient's age, heart rate, and systolic blood pressure, can be a predicting factor of severe acute cholecystitis in an emergency department.

Association Study of Polymorphisms of Epidermal Growth Factor and Epidermal Growth Factor Receptor With Benign Prostatic Hyperplasia in a Korean Population / 대한배뇨장애요실금학회지

PURPOSE: Recent studies have suggested that specific single-nucleotide polymorphisms (SNPs) contribute to the clinical features of benign prostatic hyperplasia (BPH). In this study, we investigated the relationships of genetic polymorphisms of the epidermal growth factor (EGF) gene and the epidermal growth factor receptor (EGFR) gene with BPH. METHODS: A total of 218 patients with BPH were enrolled in this study. We evaluated the relationship between eight SNPs in the EGF and EGFR genes and prostate volume, prostate-specific antigen (PSA), and International Prostate Symptom Score of BPH patients. Each SNP was genotyped by direct sequencing. Statistical analysis applying codominant, dominant, recessive, and log-additive models was performed via logistic regression. RESULTS: The rs11568943 and rs11569017 SNPs in the EGF gene showed significant associations with prostate volume (rs11568943: P=0.038 in the log-additive model, P=0.024 in the allele distribution; rs11569017, P=0.031 in the dominant model, P=0.028 in the log-additive model, P=0.020 in the allele distribution). Additionally, the rs3756261, rs11568943, and rs11569017 SNPs of the EGF gene and the rs2293347 SNP of the EGFR gene were associated with PSA levels (P<0.05 in each model, respectively). CONCLUSIONS: These results suggest that the EGF gene may affect prostate volume. In addition, the EGF and EGFR genes may be associated with PSA levels in patients with BPH.

Pentoxifylline Alleviates Perinatal Hypoxic-Ischemia-Induced Short-term Memory Impairment by Suppressing Apoptosis in the Hippocampus of Rat Pups / 대한배뇨장애요실금학회지

PURPOSE: Perinatal hypoxic-ischemic brain damage is a major cause of acute mortality and chronic neurologic morbidity in infants and children. We investigated the effects of pentoxifylline, a methylxanthine derivative and type-4 phosphodiesterase inhibitor, on short-term memory and apoptotic neuronal cell death in the hippocampus following perinatal hypoxic-ischemia in newborn rats. METHODS: We used a step-down avoidance task to evaluate short-term memory and 3ʹ-5ʹ-cyclic adenosine monophosphate (cAMP) assay to detect cAMP levels. We evaluated apoptosis using a terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assay for evidence of DNA fragmentation, immunohistochemistry for caspase-3 levels, and western blot for Bcl-2 and Bax. RESULTS: Perinatal hypoxic-ischemic injury increased apoptotic cell death in the hippocampus, resulting in impaired short-term memory with decreased cAMP levels. Pentoxifylline treatment improved short-term memory by suppressing apoptotic cell death in the hippocampus with elevated cAMP levels. CONCLUSIONS: Pentoxifylline ameliorated perinatal hypoxic-ischemia in rat pups. This alleviating effect could be ascribed to the inhibition apoptosis due to increased cAMP production by pentoxifylline.

A Randomized Controlled Trial of Compression Rates during Cardiopulmonary Resuscitation

The objective of this study was to compare the efficacy of cardiopulmonary resuscitation (CPR) with 120 compressions per minute (CPM) to CPR with 100 CPM in patients with non-traumatic out-of-hospital cardiac arrest. We randomly assigned patients with non-traumatic out-of-hospital cardiac arrest into two groups upon arrival to the emergency department (ED). The patients received manual CPR either with 100 CPM (CPR-100 group) or 120 CPM (CPR-120 group). The primary outcome measure was sustained restoration of spontaneous circulation (ROSC). The secondary outcome measures were survival discharge from the hospital, one-month survival, and one-month survival with good functional status. Of 470 patients with cardiac arrest, 136 patients in the CPR-100 group and 156 patients in the CPR-120 group were included in the final analysis. A total of 69 patients (50.7%) in the CPR-100 group and 67 patients (42.9%) in the CPR-120 group had ROSC (absolute difference, 7.8% points; 95% confidence interval [CI], -3.7 to 19.2%; P = 0.183). The rates of survival discharge from the hospital, one-month survival, and one-month survival with good functional status were not different between the two groups (16.9% vs. 12.8%, P = 0.325; 12.5% vs. 6.4%, P = 0.073; 5.9% vs. 2.6%, P = 0.154, respectively). We did not find differences in the resuscitation outcomes between those who received CPR with 100 CPM and those with 120 CPM. However, a large trial is warranted, with adequate power to confirm a statistically non-significant trend toward superiority of CPR with 100 CPM. (Clinical Trial Registration Information: www.cris.nih.go.kr, cris.nih.go.kr number, KCT0000231)

Neuroprotective Effects of Bone Marrow Stromal Cell Transplantation in Combination With Treadmill Exercise Following Traumatic Brain Injury / 대한배뇨장애요실금학회지

PURPOSE: Traumatic brain injury (TBI) causes cognitive impairments, motor deficits, and neuropsychiatric/behavioral deficits problems. Transplantation of bone marrow stromal cells (BMSCs) facilitates functional recovery from brain insults. Treadmill exercise increases neurogenesis and inhibits apoptosis. In this study, we investigated the effects of BMSC transplantation in combination with treadmill exercise on memory function, by evaluating its effect on neurogenesis and apoptosis in the hippocampus following TBI. METHODS: TBI was induced using an electromagnetic-controlled cortical impact device. BMSCs were transplanted into both sides of traumatic scar region 1 week after TBI induction. One week after transplantation of BMSCs, the rats in the exercise groups were trained to run on a treadmill for 30 minutes once daily for 28 days. Step-down avoidance task and radial 8-arm maze test were conducted. Levels of 5-bromo-2'-deoxyuridine and caspase-3 were evaluated using immunohistochemistry. Western blot was used to evaluate the expression of brain-derived neurotrophic factor (BDNF), tyrosine kinase B (TrkB), total-extracellular signal-regulated kinase 1 and 2 (t-ERK1/2), phosphorylated-ERK1/2 (p-ERK1/2), Bcl-2, and Bax. RESULTS: TBI deteriorated memory function, suppressed neurogenesis, and accelerated apoptosis in the hippocampus. Treadmill exercise and BMSC transplantation independently improved memory function by increasing neurogenesis with suppression of apoptosis through the BDNF-ERK pathway in the TBI-induced rats. Combination of BMSC transplantation with treadmill exercise showed additional enhancement of neurogenesis and suppression of apoptosis in the hippocampus. CONCLUSIONS: The present study shows that treadmill exercise may aid the therapeutic effect of BMSC transplantation on TBI in rats.

Near-complete optic nerve transection by high-pressure air

The use of high-pressure air instruments has become more common. Consequently, there have been a number of cases of orbital emphysema caused by contact with high-pressure air. In this case, a 62-year-old male patient visited an emergency medical center after his left eye was shot by an air compressor gun that was used to wash cars. Lacerations were observed in the upper and lower eyelids of his left eye. Radiological examinations revealed orbital emphysema, optic nerve transection, pneumocephalus, and subcutaneous emphysema in the face, neck, shoulder, and mediastinum. Canalicular injury repair was performed, and the emphysema resolved. However, there was near-complete vision loss in the patient's left eye. Because most optic nerve transections occur after a severe disruption in bone structure, pure optic nerve transections without any injury of the bone structure, as in the present case, is extremely rare.

Clinical Characteristics of Geriatric Patients with Digestive System Foreign Body in Emergency Center

BACKGROUND: In patients with foreign bodies in their digestive systems, old age is associated with higher rates of incidence and complications. Therefore, we compared the characteristics of geriatric patients with nongeriatric patients who were found to have with foreign bodies in their digestive systems. METHODS: We retrospectively analyzed 497 cases of foreign bodies in the digestive system over the period from 2010 through 2014. Patients were divided into two groups: nongeriatric (20-64 years, n=404) and geriatric (> or =65 years, n=93). RESULTS: The geriatric patients had more underlying diseases (12.0% vs. 3.0%), took longer to arrive at the hospital (8.92+/-21.31 hours vs. 4.50+/-14.76 hours, p<0.001), and had higher complication rates (4.3% vs. 0.2%, p<0.001), and longer hospital stays (4.88+/-4.26 days vs. 3.08+/-2.97 days, p<0.001). The following factors were significantly different between the geriatric and nongeriatric patients: type (p<0.001) and the locations (p=0.001) of the foreign bodies and their management (p=0.001). In the geriatric patients, the detected foreign bodies were more frequently located in the esophagus (46.0% vs. 17.4%), especially in the upper esophagus (30.0% vs. 14.5%). Smooth-shaped foreign bodies (18.0% vs. 5.0%) and food lumps (16.0% vs. 3.3%) were also frequently detected in the geriatric patients. CONCLUSION: In comparison with nongeriatric patients, the geriatric patients had more smooth-shaped shaped foreign bodies such as food lumps in their esophagi, and this patient group also showed higher rates of admission and complications. Thus, differences between geriatric and nongeriatric patients should be considered carefully in evaluating foreign bodies in the digestive system to prevent late diagnosis and further complications.

Diagnostic Characteristics of Geriatric Patients With Ureterolithiasis in Emergency Center

BACKGROUND: Incidence rate of ureterolithiasis has been increasing worldwide in general, with an especially rapid increase in the elderly, over 65 years of age. Therefore, the characteristics of geriatric patients diagnosed with uureterolithiasis in an Emergency Center were examined. METHODS: A total of 613 consecutive patients who were diagnosed with ureterolithiasis through computed tomography from January 2012 to March 2014 were analyzed retrospectively. The patients were divided in two groups: the geriatric group and nongeriatric group. RESULTS: Among the 613 patients, there were 64 geriatric patients (> or =65 years, 10.4%) and 549 nongeriatric patients (<65 years, 89.6%). In the geriatric patients, 13 patients (20.3%) appeared without any pain or with atypical types of pain, while 39 of the nongeriatric patients (7.1%) had no pain or atypical symptoms, presenting a statistically significant difference (p<0.001). Gastrointestinal symptoms such as nausea and vomiting were more common in geriatric patients than in nongeriatric patients (42.2% vs. 29.9%, p=0.044), while lower positive rate of microscopic hematuria was reported (78.1% vs. 90.5%, p=0.002). Furthermore, in geriatric patients, the positive rate of costovertebral angle tenderness was lower and distal ureter stones were found to be more common, while urine pH and serum creatinine levels were higher. CONCLUSION: In comparison to nongeriatric patients, geriatric patients with ureterolithiasis showed lower rates of renal colic and hematuria, while showing higher rates of having gastrointestinal symptoms such as nausea and vomiting. Thus, differences between these two groups should be considered in evaluating geriatric patients to prevent complications which may be caused from the late diagnosis of ureterolithiasis.

External Validation Study of San Francisco Syncope Rule Based on Standardized Reporting Guidelines for Emergency Department Syncope Risk Stratification Research

PURPOSE: We validated the performance of the San Francisco Syncope Rule (SFSR) for accurate identification of Korean emergency department (ED) syncope patients who will experience a short term serious outcome. METHODS: This retrospective study included patients over 16 years old who fulfilled the inclusion criteria according to the definition of syncope and visited the ED from January 2010 to June 2013. The authors excluded patients with alcohol or illicit drugs use seizure, stroke or transient ischemic attack, head trauma followed by loss of consciousness, or hypoglycemia. The patients were divided into two groups according to the SFSR for the purpose of performing a comparative analysis. The authors calculated sensitivity, specificity, positive predictive value, and negative predictive value of SFSR and analyzed other variables, except five predictor variables of SFSR. RESULTS: Of 1,235 visits screened, 409 were included. The average age of enrolled patients was 55.2+/-20.1 and male population accounted for 45.0%(n=184). A total of 93(27.7%) patients experienced serious outcomes; 41 of 287(14.3%) patients with a serious outcome were not identified as high risk according to the rule. The rule performed with a sensitivity of 55.9%, specificity of 77.8%, positive predictive value of 42.6%, and negative predictive value of 85.7%. CONCLUSION: In this retrospective validation study based on the standardized reporting guidelines for ED syncope risk stratification research, the SFSR performed with significantly lower sensitivity than previously reported. The results suggest that application of the original rule has limited generalizability and conduct of future studies will be needed in order to refine the SFSR.

External Validation Study of San Francisco Syncope Rule Based on Standardized Reporting Guidelines for Emergency Department Syncope Risk Stratification Research

PURPOSE: We validated the performance of the San Francisco Syncope Rule (SFSR) for accurate identification of Korean emergency department (ED) syncope patients who will experience a short term serious outcome. METHODS: This retrospective study included patients over 16 years old who fulfilled the inclusion criteria according to the definition of syncope and visited the ED from January 2010 to June 2013. The authors excluded patients with alcohol or illicit drugs use seizure, stroke or transient ischemic attack, head trauma followed by loss of consciousness, or hypoglycemia. The patients were divided into two groups according to the SFSR for the purpose of performing a comparative analysis. The authors calculated sensitivity, specificity, positive predictive value, and negative predictive value of SFSR and analyzed other variables, except five predictor variables of SFSR. RESULTS: Of 1,235 visits screened, 409 were included. The average age of enrolled patients was 55.2+/-20.1 and male population accounted for 45.0%(n=184). A total of 93(27.7%) patients experienced serious outcomes; 41 of 287(14.3%) patients with a serious outcome were not identified as high risk according to the rule. The rule performed with a sensitivity of 55.9%, specificity of 77.8%, positive predictive value of 42.6%, and negative predictive value of 85.7%. CONCLUSION: In this retrospective validation study based on the standardized reporting guidelines for ED syncope risk stratification research, the SFSR performed with significantly lower sensitivity than previously reported. The results suggest that application of the original rule has limited generalizability and conduct of future studies will be needed in order to refine the SFSR.

A Retrospective Study for Validity of the Denver Seizure Score in Emergency Medical Care Center for Differential Diagnosis of Seizure and Syncope

PURPOSE: The purpose of this study is to validate the Denver seizure score (DSS) compared with a questionnaire and scoring system for symptoms pertaining to loss of consciousness (QSLOC) in patients with loss of consciousness who visited the emergency department (ED). METHODS: This was an observational study. Patients with loss of consciousness who were admitted from January, 2011, to July, 2013 in an urban ED with approximately 30,000 annual visits were eligible. General characteristics, clinical manifestation, hemodynamic, and laboratory data were collected. DSS and QSLOC were calculated as originally described. The SPSS package with Mann-Whitney U test, Fisher's exact test, and logistic regression was used for analysis of the data. The area under the receiver operating characteristics curve (AUC) was used for discrimination of each score. RESULTS: Based on the historical feature, clinical manifestation, and final diagnosis, the patients were divided into 45 seizure and 52 syncope cases. In the seizure group, there were more males than females (p=0.015) and statistically significant findings were observed for serum bicarbonate (p<0.001), anion gap (p<0.001). AUCs were 0.954 and 0.998 for DSS and QSLOC, respectively. CONCLUSION: Compared to QSLOC, DSS did not show a noticeable difference in differentiating seizure disorder, and for patients who lost consciousness, it can be used in determining procedures and for prediction of both treatment method and prognosis in the emergency department.

The Characteristics and Factors Affecting Patients Diagnosed with Lower Limb Arteriosclerosis Obliterans in an Emergency Department

PURPOSE: This study investigated the relationship between the laboratory results of patients diagnosed with lower limb arteriosclerosis obliterans (LASO) in an emergency department (ED), general characteristics, clinical manifestation, hematological conditions, and clinical views of severity. Another purpose of the study was to determine the factors that could contribute to clinical severity to facilitate the prediction and diagnosis of LASO in the ED. METHODS: From January 2005 to December 2012 we conducted a retrospective study on patients diagnosed with LASO in the ED. Included in the study were 52 patients diagnosed with LASO through CT. The patients were divided into two groups according to the Fontaine classification-for comparative analysis: "less severe" (for stage II and below) and "more severe" (for stage III and above). Vital signs, clinical findings, laboratory data, and CT findings were analyzed in each patient. The SPSS package with the Mann-Whitney U test, Fisher's exact test, and logistic regression were used for data analysis. A p-value <0.05 was considered statistically significant. RESULTS: The average age of patients diagnosed with LASO was 73.1+/-10.1 and male saccounted for 76.9% of the population (n=40). Based upon the levels of severity by the Fontaine classification, patients were divided into 28 "more severe" and 24 "less severe" cases. The "more severe" LASO patients showed a high pulse rate (p=0.017) and a higher current smoking rate (p=0.04). The laboratory data from "more severe" LASO patients showed significant differences in total white blood cell count (p=0.040), erythrocyte sedimentation rate (p=0.000), and the levels of lactate dehydrogenase (p=0.002), creatine kinase (p=0.000), creatine kinase-MB (p=0.002), myoglobin (p=0.000), and C-reactive protein (p=0.000). The significant factors that could affect clinical severity were erythrocyte sedimentation rate (OR 1.066, 95% CI 1.010-1.125, p=0.021), and the levels of lactate dehydrogenase (OR 1.015, 95% CI 1.002-1.029, p=0.027), creatine kinase-MB (OR 1.229, 95% CI 1.028-1.468, p=0.023), and C-reactive protein (OR 1.533, 95% CI 1.074-2.188, p=0.019). CONCLUSION: The patients diagnosed with more severe LASO showed a high pulse rate, a higher current smoking rate, high levels of inflammation (erythrocyte sedimentation rate and C-reactive protein), and high levels of muscle enzymes (lactate dehydrogenase, creatine kinase, myogolobin, creatine kinase-MB). The factors that could influence clinical severity were erythrocyte sedimentation rate, and the levels of lactate dehydrogenase, creatine kinase-MB, and C-reactive protein.