Clinical significance of hemoglobin decrease in emergency department elderly hip fracture patients

Objective@#Decreases in the hemoglobin level compared to the pre-injury lab results are often observed in patients with elderly hip fractures visiting the emergency department (ED). This decrease could be the outcome of the fracture itself or a complication caused by comorbidities. This study examined whether significant hemoglobin decreases, as detected in the ED, are related to other-than-hip-fracture bleeding focus or clinical outcomes. @*Methods@#The electronic medical records were reviewed retrospectively at a single university ED from January 2012 to March 2019. ED diagnoses of hip fractures were screened and enrolled if the patient was 60 years or older and had hemoglobin levels recorded within the previous 6 months. A significant decrease in the hemoglobin level is defined as more than 2 g/dL. @*Results@#Three hundred patients were enrolled in this study. Significant hemoglobin decreases were apparent in 43 patients (14.3%). Only four patients (1.3%) had an other-than-hip-fracture bleeding focus. One of those had a significant hemoglobin decrease. In a “significant decrease” versus “non-significant decrease” intergroup comparison, length of hospital stays (median and interquartile range: 17.0 [15.0-21.5] vs. 17.0 [12.0-21.0], P=0.55), survival discharge (4.7% vs. 2.3%, P=0.72), and other-than-hip-fracture bleeding focus (2.3% vs. 1.2%, P>0.99) did not differ significantly. @*Conclusion@#A decrease in hemoglobin level is common among elderly hip fracture patients. On the other hand, the incidence of other-than-hip-fracture bleeding focus was rare and unrelated to a decrease in significant hemoglobin levels. Similarly, neither the hospital length of stay nor survival discharge was unrelated to the hemoglobin level decrease.

Clinical predictors of the positive brain magnetic resonance imaging finding in patients with acute altered mental status in the emergency department

Objective@#This study aimed to determine the clinical factors associated with positive brain magnetic resonance imaging (MRI) findings in patients presenting to the emergency department (ED) with acute altered mental status (AMS). @*Methods@#Patients with acute AMS who presented to the ED were retrospectively analyzed from September 2019 to March 2020. Non-traumatic patients with abnormal alert, verbal, pain, unresponsive (AVPU) scale scores and exhibiting acute change in mental status were included in the study. We evaluated the clinical characteristics of patients with acute AMS according to the results of their brain MRI. A multivariable logistic regression model was used to determine the clinical factors associated with positive brain MRI findings. @*Results@#During the study period, 138 patients underwent brain MRI in the ED, with 36 (26.1%) positive results. A majority of patients with positive brain MRI findings had underlying malignancies, cerebrovascular disease, higher serum total bicarbonate (TCO2) levels, TCO2≥22 mmol/L, lower blood urea nitrogen levels, abnormal findings on brain computed tomography and abnormal findings on neurologic examination. In the multivariable analysis, serum TCO2≥22 mmol/L (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.09-4.12) and the presence of cranial nerve abnormalities (OR, 3.88; 95% CI, 1.55-9.68) and extremity abnormalities (OR, 2.76; 95% CI, 1.11-6.88) were significantly associated with positive brain MRI results. @*Conclusion@#Serum TCO2 level and the presence of cranial nerve and extremity abnormalities in the neurologic examinations were significantly associated with positive brain MRI results in patients with acute AMS.

Magnetic resonance imaging as the first diagnostic imaging modality forpregnant women with suspected acute appendicitis

Objective@#The sensitivity of ultrasonography is poor in pregnant women with suspected appendicitis. Additional magnetic resonance imaging (MRI) is usually required, which can delay the diagnosis and surgical intervention. We hypothesized that the use of MRI as the first diagnostic tool could increase the detection rate and reduce the time for diagnosis. Therefore, we sought to investigate the diagnostic yield of ultrasonography vs. MRI and the emergency department length of stay (ED-LOS) of pregnant women with suspected appendicitis. @*Methods@#This was a retrospective, observational study in the ED of a single tertiary teaching hospital from January 2010 to December 2017. Patients who underwent ultrasonography or MRI or both were enrolled. The primary outcome was the diagnostic yield of acute appendicitis and the ED-LOS. The secondary outcome was the proportion of complicated appendicitis cases. @*Results@#A total of 145 pregnant women were enrolled (ultrasonography only, n=73; MRI only, n=26; both ultrasonography and MRI, n=46). The diagnostic yield was 23.5% (28/119) by ultrasonography and 79.2% (57/72) by MRI. The diagnostic yield of ultrasonography was significantly lower than that of MRI, especially in the second and third trimesters. The ED-LOS was significantly longer in the ultrasonography plus MRI group than that in the MRI-only group (9 hours vs. 6 hours, P=0.002). @*Conclusion@#In this study, MRI had a higher diagnostic yield than ultrasonography and can reduce the time to diagnosis. Thus, MRI should be considered as the first diagnostic tool for suspected acute appendicitis in pregnant women.

Magnetic resonance imaging as the first diagnostic imaging modality forpregnant women with suspected acute appendicitis

Objective@#The sensitivity of ultrasonography is poor in pregnant women with suspected appendicitis. Additional magnetic resonance imaging (MRI) is usually required, which can delay the diagnosis and surgical intervention. We hypothesized that the use of MRI as the first diagnostic tool could increase the detection rate and reduce the time for diagnosis. Therefore, we sought to investigate the diagnostic yield of ultrasonography vs. MRI and the emergency department length of stay (ED-LOS) of pregnant women with suspected appendicitis. @*Methods@#This was a retrospective, observational study in the ED of a single tertiary teaching hospital from January 2010 to December 2017. Patients who underwent ultrasonography or MRI or both were enrolled. The primary outcome was the diagnostic yield of acute appendicitis and the ED-LOS. The secondary outcome was the proportion of complicated appendicitis cases. @*Results@#A total of 145 pregnant women were enrolled (ultrasonography only, n=73; MRI only, n=26; both ultrasonography and MRI, n=46). The diagnostic yield was 23.5% (28/119) by ultrasonography and 79.2% (57/72) by MRI. The diagnostic yield of ultrasonography was significantly lower than that of MRI, especially in the second and third trimesters. The ED-LOS was significantly longer in the ultrasonography plus MRI group than that in the MRI-only group (9 hours vs. 6 hours, P=0.002). @*Conclusion@#In this study, MRI had a higher diagnostic yield than ultrasonography and can reduce the time to diagnosis. Thus, MRI should be considered as the first diagnostic tool for suspected acute appendicitis in pregnant women.

Assessment of clinical and laboratory parameters for the severity ofacute diverticulitis in a Korean emergency department

Objective@#Practice guidelines for diverticulitis have been developed in countries where left-colon diverticulitis is dominant,but there is limited information on right-colon diverticulitis. This study examined the clinical characteristics and riskfactors of clinically severe right-colon diverticulitis. @*Methods@#A retrospective chart review of patients diagnosed with diverticulitis in an emergency department in Koreabetween 2013 and 2017 was performed. Clinically severe diverticulitis was defined as any cause of death, intensive careunit admission, surgery, or invasive intervention due to diverticulitis, and admission for seven or more hospital days.Multivariable logistic regression was used to identify the risk factors for clinically severe diverticulitis. @*Results@#This study analyzed 302 patients. Patients with older age (odds ratio [OR], 1.044; 95% confidence interval [CI],1.009-1.080; P=0.013), complications observed on computed tomography (CT) (OR, 6.906; 95% CI, 2.514-18.968;P<0.001), rebound tenderness on a physical examination (OR, 2.542; 95% CI, 1.041-6.218; P=0.041), high alkalinephosphatase (ALP) levels (OR, 1.014; 95% CI, 1.002-1.026; P=0.026), and high C-reactive protein (CRP) levels (OR,1.095; 95% CI, 1.017-1.178; P=0.013) were at higher risk of clinically severe diverticulitis. @*Conclusion@#Among patients diagnosed with right-colon diverticulitis in the emergency department, those of older age,distinct complications on CT, rebound tenderness on physical examination, high ALP, and high CRP levels are related toclinically severe disease.

Clinical Factors Associated with Obstructive Coronary Artery Disease in Patients with Out-of-Hospital Cardiac Arrest: Data from the Korean Cardiac Arrest Research Consortium (KoCARC) Registry

BACKGROUND: Although coronary artery disease (CAD) is a major cause of out-of-hospital cardiac arrest (OHCA), there has been no convinced data on the necessity of routine invasive coronary angiography (ICA) in OHCA. We investigated clinical factors associated with obstructive CAD in OHCA. METHODS: Data from 516 OHCA patients (mean age 58 years, 83% men) who underwent ICA after resuscitation was obtained from a nation-wide OHCA registry. Obstructive CAD was defined as the lesions with diameter stenosis ≥ 50% on ICA. Independent clinical predictors for obstructive CAD were evaluated using multiple logistic regression analysis, and their prediction performance was compared using area under the receiver operating characteristic curve with 10,000 repeated random permutations. RESULTS: Among study patients, 254 (49%) had obstructive CAD. Those with obstructive CAD were older (61 vs. 55 years, P < 0.001) and had higher prevalence of hypertension (54% vs. 36%, P < 0.001), diabetes mellitus (29% vs. 21%, P = 0.032), positive cardiac enzyme (84% vs. 74%, P = 0.010) and initial shockable rhythm (70% vs. 61%, P = 0.033). In multiple logistic regression analysis, old age (≥ 60 years) (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.36–3.00; P = 0.001), hypertension (OR, 1.74; 95% CI, 1.18–2.57; P = 0.005), positive cardiac enzyme (OR, 1.72; 95% CI, 1.09–2.70; P = 0.019), and initial shockable rhythm (OR, 1.71; 95% CI, 1.16–2.54; P = 0.007) were associated with obstructive CAD. Prediction ability for obstructive CAD increased proportionally when these 4 factors were sequentially combined (P < 0.001). CONCLUSION: In patients with OHCA, those with old age, hypertension, positive cardiac enzyme and initial shockable rhythm were associated with obstructive CAD. Early ICA should be considered in these patients.

Predictors of abnormal brain computed tomography findings in patients with acute altered mental status in the emergency department

OBJECTIVE: Brain computed tomography (CT) is commonly performed to diagnose acute altered mental status (AMS), a critically important symptom in many serious diseases. However, negative CT results are common, which result in unnecessary CT use. Therefore, this study aimed to determine the clinical factors associated with positive CT findings. METHODS: Patients with acute AMS selected from an emergency department-based registry were retrospectively evaluated. Patients with non-traumatic and noncommunicable diseases on initial presentation and with Glasgow Comal Scale scores of < 15 were included in the study. RESULTS: Among the 367 brain CT results of patients with AMS during the study period, 146 (39.8%) were positive. In a multivariate analysis, the presence of focal neurologic deficit (odds ratio [OR], 132.6; 95% confidence interval [CI], 37.8 to 464.6), C-reactive protein level < 2 mg/dL (OR, 3.9; 95% CI, 1.4 to 10.6), and Glasgow Comal Scale score < 9 (OR, 2.4; 95% CI, 1.2 to 4.8) were significantly associated with positive brain CT results. CONCLUSION: The presence of focal neurologic deficit, initial Glasgow Comal Scale score of < 9, and initial C-reactive protein levels of < 2 mg/dL can facilitate the selection of brain CT to diagnose patients with acute AMS in the emergency department.

Time Interval from Intubation to Return of Spontaneous Circulation in Out-of-hospital Cardiac Arrest Patient with Brain Hemorrhage

PURPOSE: This study was conducted to investigate the relationship of time interval from intubation to return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients according to the presence or absence of intracranial hemorrhage (ICH). METHODS: This retrospective study used data from a prospectively collected OHCA registry for patients treated from January 2008 to December 2016. Non-traumatic adult OHCA patients who underwent brain computed tomography were included, while patients who achieved a prehospital ROSC or required advanced airway management were excluded. Utstein variables, initial blood gas analysis, electrolyte levels, and the time interval from intubation to ROSC were used to compare the ICH and non-ICH groups. RESULTS: A total of 448 patients were analyzed. The ICH group was younger and had more females than the non-ICH group. The time interval from intubation to ROSC was significantly shorter in the ICH group than the non-ICH group. The median time and interquartile range were 3 (2 to 7) minutes in the ICH group and 6 (3 to 10) minutes in the non-ICH group. The patient age, gender, potassium level, and time interval from intubation to ROSC were significant variables in the multivariable analysis. In a multivariable logistic regression model that included these variables, the area under the receiver operating characteristic curve was 0.838. CONCLUSION: OHCA patients with ICH achieve ROSC after intubation in a shorter amount of time than those without ICH.

Changes in Inflammatory Cytokines during Rewarming Period of Therapeutic Hypothermia for Post-Cardiac Arrest Patients

PURPOSE: Therapeutic hypothermia is an important treatment strategy for control of the overwhelming inflammatory reactions of cardiac arrest patients. Rapid rewarming is related to poor outcome, however the kinds of inflammatory processes that occur during the rewarming period are not well understood. Our aim in the current study was to evaluate the changes in inflammatory cytokine levels during cardiac arrest patients' rewarming period. METHODS: This study was conducted in an emergency intensive care unit of a tertiary referral hospital. Blood samples were collected on admission (0 h) and 24, 26, 28, and 32 h after return of spontaneous circulation. Eight inflammatory cytokines (E-selectin, soluble ICAM, interleukin-10, interleukin-1ra, interleukin-6, interleukin-8, monocyte chemotactic protein-1, and tumor necrosis factor-α) were measured. RESULTS: Twenty-eight patients were enrolled and completed a protocol of 24 h hypothermia and 8h rewarming. Eight patients were of the good cerebral performance category (CPC) and 20 of the bad. The IL-1Ra level in the good CPC group was statistically changed at 26 (p=0.039) and 28 (p=0.003) but not at 32 h (p=0.632) when compared with the 24 h level. The IL-10 levels of the bad CPC group were decreased at 26 (p=0.017) and 28h (p=0.013) but not at 32 h (p=0.074) when compared with 24 h. None of the other cytokines showed meaningful differences during the rewarming period. CONCLUSION: Change in inflammatory-cytokine-level change during the rewarming period is not significant.

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)

Clinical Insights for Early Screening of Pulmonary Tuberculosis in Homeless Patients Who Visited Emergency Department

PURPOSE: In 2014, Korea ranked as the first among the Organization for Economic Cooperation and Development countries on the prevalence, incidence, and mortality of pulmonary tuberculosis (TB). The prevalence of TB among the homeless was 6.4% in the United State and 7.1% in South Korea. The aim of this study is to develop predicting indicators of TB by analyzing homeless people who visit the public hospital emergency department (ED). METHODS: We analyzed 7,500 homeless individuals who visited a public hospital ED between January 1, 2001 and May 31, 2014. A total of 4,552 patients were included, and of these, 145 homeless patients were infected with TB. We conducted univariate and multivariate analysis of clinical variables obtained from the initial check list and later lab analysis, and made a scoring system by weighing each variable. Then applying this scoring system, the area under the receiver (AUC) operating characteristic curve (ROC) was calculated. RESULTS: The prevalence of TB was 3.2%. The initial meaningful predictor variables were as follows: Being homeless, abnormal heart rate, abnormal respiratory rate, no alcohol intake, hypoalbuminemia, and CRP elevation. The AUC of ROC curve from these predictor variables were 0.815. CONCLUSION: We developed a novel scoring system to screen TB patients in a vulnerable social group who visit the ED. We can detect potential TB patients early and effectively control TB, preventing the spread of TB. Prospective internal and external validation is necessary by using the scoring system of TB among the homeless.

Vitamin C Deficiency of Korean Homeless Patients Visiting to Emergency Department with Acute Alcohol Intoxication

Vitamins are essential micronutrients for maintenance of tissue functions. Vitamin deficiency is one of the most serious and common health problems among both chronic alcoholics and the homeless. However, the vitamin-level statuses of such people have been little studied. We evaluated the actual vitamin statuses of alcoholic homeless patients who visited an emergency department (ED). In this study the blood levels of vitamins B1, B12, B6, and C of 217 alcoholic homeless patients were evaluated retrospectively in a single urban teaching hospital ED. Vitamin C deficiency was observed in 84.3% of the patients. The vitamin B1, B12, and B6 deficiency rates, meanwhile, were 2.3%, 2.3%, and 23.5%, respectively. Comparing the admitted patients with those who were discharged, only the vitamin C level was lower. (P=0.003) In fact, the patients' vitamin C levels were markedly diminished, vitamin C replacement therapy for homeless patients should be considered in EDs.

External Validation of Scoring Systems for Pelvic Inflammatory Disease and Acute Appendicitis for Acute Abdominal Pain of Reproductive-aged Women in Emergency Department

PURPOSE: Differential diagnosis of acute abdominal pain of the childbearing age woman is a difficult challenge to the emergency physician. Clinical scoring systems for pelvic inflammatory disease (PID) and acute appendicitis have already been introduced. We want to validate these scoring systems externally. METHODS: This study was conducted at a single urban teaching hospital emergency department from May 2011 to September 2013. Retrospective analysis of a prospectively collected registry for reproductive-aged women was performed. RESULTS: A total of 1432 patients were registered. Among them, 322 patients diagnosed as PID (177 patients) or acute appendicitis (145 patients) were finally analyzed in this study. Among the PID and acute appendicitis scored, lower and higher cut-off points were 3 and 8 for PID risk score, and 6 and 10 for appendicitis risk score. PID risk score of PID patients was 7.0 (+/-1.9), acute appendicitis patients was 4.3 (+/-2.1), and other patients was 4.0 (+/-2.2) (p<0.001). Appendicitis risk score of PID patients was 5.7 (+/-1.9), acute appendicitis patients was 9.0 (+/-2.1), and other patients was 5 (+/-1.6) (p<0.001). The areas under the receiver operating characteristic curves were 0,832 and 0,950 for diagnosis of PID with PID risk score and acute appendicitis with appendicitis risk score, respectively. CONCLUSION: These scoring systems have appropriate diagnostic power for diagnosis of PID and acute appendicitis.

The Usefulness of Tablet Computer for Self-surveys of Child-bearing Aged Women Who Visit the Emergency Department with Abdominal Pain

PURPOSE: In the emergency department (ED), identification of the obstetrical and gynecologic history for diagnosis of child-bearing aged women who present with abdominal pain is very important. We compared the usefulness of self-registry using a tablet computer and a traditional paper registry for taking history of child-bearing aged women. METHODS: We reviewed the prospective registries of child-bearing aged women presenting with abdominal pain without underlying disease to the ED of the Seoul Metropolitan Boramae Medical Center. We used a paper version of this registry from April 2008 to April 2011. From May 2011 to October 2012, we used the Smart Medical Registry (SMR), where the patient used a tablet computer to record her own data. The registries of child-bearing aged women included information on the patient's basic information, medical history, gynecologic history, symptoms, physician's examination, and laboratory results. We performed statistical analysis of the difference between the paper registry and SMR. RESULTS: A total of 1193 patients were registered. Among them, 835 patients were registered using the SMR. There were no statistically significant differences in the patients' basic information and diagnostic classification. However, the SMR group reported more recent history of pelvic inflammatory disease (p<0.01), higher number of abortions (p<0.01), and higher number of sexual partners (p<0.01). CONCLUSION: Using the tablet computer based self-survey, patients had a more positive tendency toward answering privacy sensitive items. Therefore, it might be more useful and effective in obtaining sensitive, private information from patients.

Clinical Predictors for Reproductive-aged Gynecologic Emergency Surgery Candidates Presenting to the Emergency Department with Acute Abdominal Pain

PURPOSE: Differentiating gynecological emergency surgery indications among reproductive-age female patients presenting with acute abdominal pain is challenging for emergency department (ED) physicians. We evaluated the clinical demographics of female patients diagnosed with gynecological surgery indications in the ED and found clinical predictors associated with surgical indications overall and with each surgical indication. METHODS: We conducted a prospective review study of the hospital registries of reproductive-aged women who presented with abdominal pain but without underlying disease from April 2008 to October 2010. These registries included information concerning the patient's basic characteristics, medical history, gynecologic history, symptoms, physician's examination, and laboratory results. Using a multivariate logistic regression analysis, we found a number of statistically significant factors indicating a gynecological emergency necessitating surgery. RESULTS: A total of 1047 cases involving female patients of reproductive age were initially included. We found 89 patients(8.50%) who were diagnosed as having gynecological surgery indications: 50(4.78%) were diagnosed with hemorrhagic ovarian cyst rupture, 16(1.53%) with ectopic pregnancy, and 23(2.20%) with ovarian torsion. Pain of more than 14 days from the last menstrual period (OR, 2.332; 95% CI, 1.406-3.968; p=0.001), bilateral lower abdominal tenderness (OR, 0.467; 95% CI, 0.288-0.758; p=0.002), rebound tenderness (OR, 0.54; 95% CI, 0.329-0.887; p=0.015), normal C-reactive protein value (CRP) (OR, 3.286; 95% CI, 1.717-6.290; p<0.001), and positive human chorionic gonadotropin test (OR, 0.058; 95% CI, 0.024-0.142; p<0.001) were related to gynecologic emergency surgery indication in a patient with abdominal pain. CONCLUSION: Clinical findings of the last menstrual period, bilateral abdominal tenderness, rebound tenderness, CRP value, and urine hCG result can be helpful in exclusion of gynecologic emergency surgical indications.

The Usefulness of Tablet Computer for Self-surveys of Child-bearing Aged Women Who Visit the Emergency Department with Abdominal Pain

PURPOSE: In the emergency department (ED), identification of the obstetrical and gynecologic history for diagnosis of child-bearing aged women who present with abdominal pain is very important. We compared the usefulness of self-registry using a tablet computer and a traditional paper registry for taking history of child-bearing aged women. METHODS: We reviewed the prospective registries of child-bearing aged women presenting with abdominal pain without underlying disease to the ED of the Seoul Metropolitan Boramae Medical Center. We used a paper version of this registry from April 2008 to April 2011. From May 2011 to October 2012, we used the Smart Medical Registry (SMR), where the patient used a tablet computer to record her own data. The registries of child-bearing aged women included information on the patient's basic information, medical history, gynecologic history, symptoms, physician's examination, and laboratory results. We performed statistical analysis of the difference between the paper registry and SMR. RESULTS: A total of 1193 patients were registered. Among them, 835 patients were registered using the SMR. There were no statistically significant differences in the patients' basic information and diagnostic classification. However, the SMR group reported more recent history of pelvic inflammatory disease (p<0.01), higher number of abortions (p<0.01), and higher number of sexual partners (p<0.01). CONCLUSION: Using the tablet computer based self-survey, patients had a more positive tendency toward answering privacy sensitive items. Therefore, it might be more useful and effective in obtaining sensitive, private information from patients.

Clinical Predictors for Reproductive-aged Gynecologic Emergency Surgery Candidates Presenting to the Emergency Department with Acute Abdominal Pain

PURPOSE: Differentiating gynecological emergency surgery indications among reproductive-age female patients presenting with acute abdominal pain is challenging for emergency department (ED) physicians. We evaluated the clinical demographics of female patients diagnosed with gynecological surgery indications in the ED and found clinical predictors associated with surgical indications overall and with each surgical indication. METHODS: We conducted a prospective review study of the hospital registries of reproductive-aged women who presented with abdominal pain but without underlying disease from April 2008 to October 2010. These registries included information concerning the patient's basic characteristics, medical history, gynecologic history, symptoms, physician's examination, and laboratory results. Using a multivariate logistic regression analysis, we found a number of statistically significant factors indicating a gynecological emergency necessitating surgery. RESULTS: A total of 1047 cases involving female patients of reproductive age were initially included. We found 89 patients(8.50%) who were diagnosed as having gynecological surgery indications: 50(4.78%) were diagnosed with hemorrhagic ovarian cyst rupture, 16(1.53%) with ectopic pregnancy, and 23(2.20%) with ovarian torsion. Pain of more than 14 days from the last menstrual period (OR, 2.332; 95% CI, 1.406-3.968; p=0.001), bilateral lower abdominal tenderness (OR, 0.467; 95% CI, 0.288-0.758; p=0.002), rebound tenderness (OR, 0.54; 95% CI, 0.329-0.887; p=0.015), normal C-reactive protein value (CRP) (OR, 3.286; 95% CI, 1.717-6.290; p<0.001), and positive human chorionic gonadotropin test (OR, 0.058; 95% CI, 0.024-0.142; p<0.001) were related to gynecologic emergency surgery indication in a patient with abdominal pain. CONCLUSION: Clinical findings of the last menstrual period, bilateral abdominal tenderness, rebound tenderness, CRP value, and urine hCG result can be helpful in exclusion of gynecologic emergency surgical indications.

Optimal Dose of Antivenin for Asymptomatic or Minor Envenomation Patient with Korean Viperidae Injuries

PURPOSE: The aim of this study was to evaluate the feasibility and safety of our antivenin treatment protocol for patients with Korean Viperidae envenomation. METHODS: We developed an antivenin treatment protocol for Korean Viperidae envenomation, based on previous data, and applied this treatment to the enrolled patients. In brief, antivenin was not used for patients with grade 0. Patients with grade I and II received one vial of antivenin. Those with grade III and IV received two and three vials of antivenin, respectively. Adult patients who visited the emergency department (ED) after receiving a snakebite between July 2008 to August 2010 were included. Follow ups were performed at 24 hours, 7 days, and 28 days after the snakebite. RESULTS: A total of 62 patients were enrolled. At the initial evaluation, 6 patients (9.7%) were grade 0, 47 patients (75.8%) were grade I, and 9 patients (14.5%) were grade II. Upon the follow-up evaluation, 14 patients (29.8%) progressed from grade I to grade II and 2 patients (22.2%) progressed from grade II to III. Coagulopathy developed in 5 patients (8.0%) and rhabdomyolysis in 5 patients (8.0%). Urticaria developed in 2 patients (3.2%) and cellulitis in 3 patients (4.8%) as delayed complications. As an antivenin-related complication, serum sickness developed in only 1 patient (1.6%). There were no severe complications and all clinical and laboratory abnormalities disappeared within 28 days. CONCLUSION: Our antivenin treatment protocol was feasible and safe. To confirm our data, multicenter validation studies are needed.

Low Serum Selenium Level is Associated with Poor Prognosis of Cardiac Arrest Victims

PURPOSE: Selenium plays a major role in the intracellular antioxidant system. The aim of this study was to determine whether a low serum selenium level is associated with poor neurological outcome for victims of cardiac arrest. METHODS: We enrolled consecutive patients who were admitted to the emergency intensive care unit (ICU) of a tertiary referral center for post-resuscitation care after cardiac arrest from May 2008 to April 2010. Data were collected with respect to demographic information, variables of cardiac arrest and resuscitation, and application of therapeutic hypothermia. We examined neurologic findings and measured serum selenium level at admission to the ICU. In addition, we also calculated severity scores. The Glasgow-Pittsburgh cerebral performance categories (CPCs) were used for evaluation of neurological outcome. According to the six-month CPCs, patients were divided into two groups: the good prognosis (CPC 1-2) group and the poor prognosis (CPC 3-5) group. We then compared data between the two groups. RESULTS: Among 52 enrolled patients, 17 were classified as the good prognosis group and 35 as the poor prognosis group. Glasgow coma scale (odds ratio [OR]=0.343, 95% confidence intervals [CI], 0.124-0.947, p=0.039), intact pupilary reflex (OR=0.045, 95% CI, 0.004-0.561, p=0.016), and serum selenium level (OR=0.959, 95% CI, 0.921-0.999, p=0.045) showed an independent association with poor neurological outcome for victims of cardiac arrest. CONCLUSION: Low serum selenium level showed an association with poor neurological outcome for victims of cardiac arrest.

Heart-type Fatty Acid Binding Protein as an Adjunct to Cardiac Troponin-I for the Diagnosis of Myocardial Infarction

We hypothesized that when used in combination with cardiac troponins, heart-type fatty acid binding protein (H-FABP) would have greater diagnostic value than conventional markers for the early diagnosis of myocardial infarction (MI). Patients with typical chest pain at a single emergency department were consecutively enrolled. Initial blood samples were drawn for H-FABP, myoglobin, creatine kinase isoenzyme MB (CK-MB), and cardiac troponin-I (cTnI) measurements. MI was defined by serial cTnI measurements. To evaluate the adjunctive role of biochemical markers, we derived and compared logistic regression models predicting MI in terms of their discrimination (area under the receiver operating characteristics curve, AUC) and overall fit (Bayesian information criterion, BIC). Seventy-six of 170 patients were diagnosed as having MI. The AUC of cTnI, H-FABP, myoglobin, and CK-MB were 0.863, 0.827, 0.784, and 0.772, respectively. A logistic regression model using cTnI (P = 0.001) and H-FABP (P < 0.001) had the biggest AUC (0.900) and the best fit determined by BIC. Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of this model at 30% probability were 81.6%, 80.9%, 4.26, and 0.23, respectively. H-FABP has a better diagnostic value than both myoglobin and CK-MB as an adjunct to cTnI for the early diagnosis of MI.