Outcomes of Mechanical Thrombectomy in Patients with Large Diffusion-Weighted Imaging Lesions

Objective@#: Despite many advancements in endovascular treatment, the benefits of mechanical thrombectomy (MT) in patients with large infarctions remain uncertain due to hemorrhagic complications. Therefore, we aimed to investigate the efficacy and safety of recanalization via MT within 6 hours after stroke in patients with large cerebral infarction volumes (>70 mL). @*Methods@#: We retrospectively reviewed the medical data of 30 patients with large lesions on initial diffusion-weighted imaging (>70 mL) who underwent MT at our institution within 6 hours after stroke onset. Baseline data, recanalization rate, and 3-month clinical outcomes were analyzed. Successful recanalization was defined as a modified treatment in cerebral ischemia score of 2b or 3. @*Results@#: The recanalization rate was 63.3%, and symptomatic intracerebral hemorrhage occurred in six patients (20%). The proportion of patients with modified Rankin Scale (mRS) scores of 0–3 was significantly higher in the recanalization group than in the non-recanalization group (47.4% vs. 9.1%, p=0.049). The mortality rate was higher in the non-recanalization group, this difference was not significant (15.8% vs. 36.4%, p=0.372). In the analysis of 3-month clinical outcomes, only successful recanalization was significantly associated with mRS scores of 0–3 (90% vs. 50%, p=0.049). The odds ratio of recanalization for favorable outcomes (mRS 0–3) was 9.00 (95% confidence interval, 0.95–84.90; p=0.055). @*Conclusion@#: Despite the risk of symptomatic intracerebral hemorrhage, successful recanalization via MT 6 hours after stroke may improve clinical outcomes in patients with large vessel occlusion.

Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: A literature review

Thanks to new generation devices, mechanical thrombectomy (MT) has substantially evolved and become the standard treatment for patients with acute occlusion of the internal carotid artery or proximal middle cerebral artery (MCA) (M1 segment). However, the role and benefit of MT in patients with distal MCA (M2 segment) occlusion remain unclear. Therefore, there is a need for further studies. To evaluate the efficacy and safety of MT for M2 occlusion, this article reviews the natural course of M2 occlusion, the evidence regarding MT for M2 segment occlusion, clinical outcomes of MT for M2 occlusion, and treatment outcomes according to device type.

Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: A literature review

Thanks to new generation devices, mechanical thrombectomy (MT) has substantially evolved and become the standard treatment for patients with acute occlusion of the internal carotid artery or proximal middle cerebral artery (MCA) (M1 segment). However, the role and benefit of MT in patients with distal MCA (M2 segment) occlusion remain unclear. Therefore, there is a need for further studies. To evaluate the efficacy and safety of MT for M2 occlusion, this article reviews the natural course of M2 occlusion, the evidence regarding MT for M2 segment occlusion, clinical outcomes of MT for M2 occlusion, and treatment outcomes according to device type.

Quick Sequential Organ Failure Assessment (qSOFA) to predict clinical outcome in tsutsugamushi disease patients in emergency department

Objective@#Tsutsugamushi disease is a febrile illness caused by tick bites. Delay in making the diagnosis and treatment cause an increase of the frequency of complications and mortality. The aim of this study was to determine quick sequential organ failure assessment (qSOFA) to predict the clinical outcome of scrub typhus patients in emergency departments. @*Methods@#This was a retrospective, observational study of patients with tsutsugamushi disease and who presented to the emergency department of an urban hospital and a rural tertiary hospital between January 2013 and December 2018. The demographic and laboratory data was collected through a chart review. Statistical analysis was performed by dividing the patients into the general ward admission group (general ward) and the intensive care unit admission group (ICU). @*Results@#Age, Acute Physiology and Chronic Health Evaluation II (APACHE) II score and laboratory tests such as pH, leukocyte count, C-reactive protein, and procalcitonin also showed significant differences between the general ward and ICU groups on the univariable logistic regression analysis, but only the qSOFA score among the variables showed a significant difference on the multivariate logistic regression analysis (P=0.014). @*Conclusion@#The qSOFA score will be a prompt and useful tool for predicting the prognosis of patients with tsutsugamushi disease in the emergency department.

Utility of lactate measurement in the diagnosis of serious bacterial infection in young infants

Objective@#Serious bacterial infection (SBI) is a common disease among infants, and it is associated with high morbidity and mortality. Making the diagnosis of SBI is challenging and measurement of various biomarkers is useful. This study examined the utility of lactate at an emergency department for diagnosing SBI patients. @*Methods@#This was a retrospective, observational study of febrile infants less than 90 days old presenting to the emergency department of a tertiary hospital between September 2014 and August 2017. The demographic and laboratory data was collected through a chart review. @*Results@#Laboratory tests such as the white blood cell count, C-reactive protein (CRP), procalcitonin, and lactate showed significant differences on the Student-T test and the Mann Whitney-U test. Multivariabe logistic regression test was done using the variables with significant differences. CRP (P=0.037; odds ratio, 1.01), procalcitonin (P=0.011; odds ratio, 1.02) and lactate (P=0.001; odds ratio, 2.38) shows significant correlation. @*Conclusion@#For febrile infants at the emergency department, the measurement of lactate is expected to be a useful tool to diagnose serious bacterial infection.

Impact of Neurointensivist Co-Management in a Semiclosed Neurocritical-Care Unit

Background@#and Purpose: The importance of the specialized management of neurocritical patients is being increasingly recognized. We evaluated the impact of neurointensivist comanagement on the clinical outcomes (particularly the mortality rate) of neurocritical patients admitted to a semiclosed neurocritical-care unit (NCU). @*Methods@#We retrospectively included neurocritical patients admitted to the NCU between March 2015 and February 2018. We analyzed the clinical data and compared the outcomes between patients admitted before and after the initiation of neurointensivist co-management in March 2016. @*Results@#There were 1,785 patients admitted to the NCU during the study period. Patients younger than 18 years (n=28) or discharged within 48 hours (n=200) were excluded. The 1,557 remaining patients comprised 590 and 967 who were admitted to the NCU before and after the initiation of co-management, respectively. Patients admitted under neurointensivist co-management were older and had higher Acute Physiologic Assessment and Chronic Health Evaluation II scores. The 30-day mortality rate was significantly lower after neurointensivist co-management (p=0.042). A multivariate logistic regression analysis demonstrated that neurointensivist co-management significantly reduced mortality rates in the NCU and in the hospital overall [odds ratio=0.590 (p=0.002) and 0.585 (p=0.001), respectively]. @*Conclusions@#Despite the higher severity of the condition during neurointensivist co-management, co-management significantly improved clinical outcomes (including the mortality rate) in neurocritical patients.

Efficacy of Combining Proximal Balloon Guiding Catheter and Distal Access Catheter in Thrombectomy with Stent Retriever for Anterior Circulation Ischemic Stroke

OBJECTIVE: We evaluated efficacy of combining proximal balloon guiding catheter (antegrade flow arrest) and distal access catheter (aspiration at the site of occlusion) in thrombectomy for anterior circulation ischemic stroke. METHODS: We retrospectively analyzed 116 patients who underwent mechanical thrombectomy with stent retriever. The patients were divided by the techniques adopted, the combined technique (proximal balloon guiding catheter and large bore distal access catheter) group (n=57, 49.1%) and the conventional (guiding catheter with stent retriever) technique group (n=59, 50.9%). We evaluated baseline characteristics (epidemiologic data, clinical and imaging characteristics) and procedure details (the number of retrieval attempts, procedure time), as well as angiographic (thrombolysis in cerebral infarction (TICI) score, distal thrombus migration) and clinical outcome (National Institutes of Health Stroke Scale at discharge, modified Rankin Scale [mRS] at 3 months) of them. RESULTS: The number of retrieval attempts was lower (p=0.002) and the first-pass successful reperfusion rate was higher (56.1% vs. 28.8%; p=0.003) in the combined technique group. And the rate of final result of TICI score 3 was higher (68.4% vs. 28.8%; p<0.01) and distal thrombus migration rate was also lower (15.8% vs. 40.7%; p=0.021) in the combined technique group. Early strong neurologic improvement (improvement of National Institutes of Health Stroke Scale ≥11 or National Institutes of Health Stroke Scale ≤1 at discharge) rate (57.9% vs. 36.2%; p=0.02) and favorable clinical outcome (mRS at 3 months ≤2) rate (59.6% vs. 33.9%; p=0.005) were also better in the combined technique group. CONCLUSION: The combined technique needs lesser attempts, decreases distal migration, increases TICI 3 reperfusion and achieves better clinical outcomes.

Efficacy of Combining Proximal Balloon Guiding Catheter and Distal Access Catheter in Thrombectomy with Stent Retriever for Anterior Circulation Ischemic Stroke

OBJECTIVE: We evaluated efficacy of combining proximal balloon guiding catheter (antegrade flow arrest) and distal access catheter (aspiration at the site of occlusion) in thrombectomy for anterior circulation ischemic stroke.METHODS: We retrospectively analyzed 116 patients who underwent mechanical thrombectomy with stent retriever. The patients were divided by the techniques adopted, the combined technique (proximal balloon guiding catheter and large bore distal access catheter) group (n=57, 49.1%) and the conventional (guiding catheter with stent retriever) technique group (n=59, 50.9%). We evaluated baseline characteristics (epidemiologic data, clinical and imaging characteristics) and procedure details (the number of retrieval attempts, procedure time), as well as angiographic (thrombolysis in cerebral infarction (TICI) score, distal thrombus migration) and clinical outcome (National Institutes of Health Stroke Scale at discharge, modified Rankin Scale [mRS] at 3 months) of them.RESULTS: The number of retrieval attempts was lower (p=0.002) and the first-pass successful reperfusion rate was higher (56.1% vs. 28.8%; p=0.003) in the combined technique group. And the rate of final result of TICI score 3 was higher (68.4% vs. 28.8%; p<0.01) and distal thrombus migration rate was also lower (15.8% vs. 40.7%; p=0.021) in the combined technique group. Early strong neurologic improvement (improvement of National Institutes of Health Stroke Scale ≥11 or National Institutes of Health Stroke Scale ≤1 at discharge) rate (57.9% vs. 36.2%; p=0.02) and favorable clinical outcome (mRS at 3 months ≤2) rate (59.6% vs. 33.9%; p=0.005) were also better in the combined technique group.CONCLUSION: The combined technique needs lesser attempts, decreases distal migration, increases TICI 3 reperfusion and achieves better clinical outcomes.

Carotid Arterial Calcium Scoring Using Upper Airway Computed Tomography in Patients with Obstructive Sleep Apnea: Efficacy as a Clinical Predictor of Cerebrocardiovascular Disease

OBJECTIVE: To evaluate the value of airway computed tomography (CT) in patients with obstructive sleep apnea (OSA) as a predictor of cerebrocardiovascular disease (CCVD) clinically, by quantitatively analyzing carotid arterial calcification (CarAC). MATERIALS AND METHODS: This study included 287 patients aged 40–80 years, who had undergone both polysomnography (PSG) and airway CT between March 2011 and October 2015. The carotid arterial calcium score (CarACS) was quantified using the modified Agatston method on each upper airway CT. The OSA severity was categorized as normal, mild, moderate, and severe using the PSG results. Clinical characteristics, comorbid diseases, and lipid profiles of all patients were analyzed, and the prevalence of CCVDs was investigated during the follow up period (52.2 ± 16.0 months). RESULTS: CCVD occurred in 27 patients (9.3%) at the end of follow-up, and the CCVD-present groups showed a significantly older mean age (57.5 years vs. 54.2 years), higher prevalence of hypertension (59% vs. 34%) and CarAC (51.9% vs. 20.8%), whereas sex, other comorbid diseases, and severity of OSA were not significantly different from the CCVD-absent group. A univariate analysis showed that age, hypertension, incidence of CarAC, and CarACS were risk factors for the occurrence of CCVD events. In a multivariate analysis, the incidence of CarAC was the only independent risk factor for CCVD. CONCLUSION: CarAC is an independent risk factor for CCVD, whereas the severity of OSA is not a contributory risk factor in patients with OSA. Therefore, additional analysis of CarACS based on airway CT scans may be useful for predicting CCVD.

Correlation between Carotid Arterial Calcium Score and Silent Cerebrovascular Lesions in Obstructive Sleep Apnea Patients: by Using Upper Airway CT and Brain MRI

PURPOSE@#To investigate the relationship between carotid arterial calcium score (CarACS) and silent cerebrovascular lesions in patients with obstructive sleep apnea (OSA).@*MATERIALS AND METHODS@#This study involved retrospective evaluation of 60 OSA patients who underwent both upper airway CT and brain MRI. Using polysomnography, several indicators, including apnea index (AI), were used to evaluate the relationship between OSA and silent cerebrovascular lesions. The CarACS was quantified on CT imaging using the modified Agatston method. Silent cerebrovascular lesions were evaluated on brain MRI by grading periventricular hyperintensity (PVH). Various clinical characteristics, including age, were analyzed in each patient.@*RESULTS@#The number of patients per PVH grade 0, 1, 2, 3, and 4 was 26 (43.3%), 14 (23.3%), 14 (23.3%), 4 (6.7%), and 2 (3.3%), respectively. The mean age, hypertension, smoking status, AI, and CarACS were significantly different among PVH groups (Ps < 0.05). In univariate analysis, the presence of carotid arterial calcification (β = 0.483, p < 0.01), CarACS (β = 0.482, p < 0.01), and age (β = 0.360, p < 0.01) showed a significant association with PVH grade. The mean AI and lowest O₂ saturation had statistically weak associations with PVH grade (β = 0.267, p < 0.01; β = −0.219, p < 0.14, respectively). In multivariate analysis, CarACS was the only factor affecting PVH grade (p < 0.04).@*CONCLUSION@#CarACS is associated with the severity of silent cerebrovascular lesions. Therefore, additional analysis of CarACS in OSA patients may provide more information on their cerebrovascular status.

Predictors of intentional intoxication using decision tree modeling analysis: a retrospective study

OBJECTIVE: The suicide rate in South Korea is very high and is expected to increase in coming years. Intoxication is the most common suicide attempt method as well as one of the common reason for presenting to an emergency medical center. We used decision tree modeling analysis to identify predictors of risk for suicide by intentional intoxication. METHODS: A single-center, retrospective study was conducted at our hospital using a 4-year registry of the institute from January 1, 2013 to December 31, 2016. Demographic factors, such as sex, age, intentionality, therapeutic adherence, alcohol consumption, smoking status, physical disease, cancer, psychiatric disease, and toxicological factors, such as type of intoxicant and poisoning severity score were collected. Candidate risk factors based on the decision tree were used to select variables for multiple logistic regression analysis. RESULTS: In total, 4,023 patients with intoxication were enrolled as study participants, with 2,247 (55.9%) identified as cases of intentional intoxication. Reported annual percentages of intentional intoxication among patients were 628/937 (67.0%), 608/1,082 (56.2%), 536/1,017 (52.7), 475/987 (48.1%) from 2013 to 2016. Significant predictors identified based on decision tree analysis were alcohol consumption, old age, psychiatric disease, smoking, and male sex; those identified based on multiple regression analysis were alcohol consumption, smoking, male sex, psychiatric disease, old age, poor therapeutic adherence, and physical disease. CONCLUSION: We identified important predictors of suicide risk by intentional intoxication. A specific and realistic approach to analysis using the decision tree modeling technique is an effective method to determine those groups at risk of suicide by intentional intoxication.

Safety and Efficacy of Hypothermia (34°C) after Hemicraniectomy for Malignant MCA Infarction

OBJECTIVE: The beneficial effect of hypothermia after hemicraniectomy in malignant middle cerebral artery (MCA) infarction has been controversial. We aim to investigate the safety and clinical efficacy of hypothermia after hemicraniectomy in malignant MCA infarction. METHODS: From October 2012 to February 2016, 20 patients underwent hypothermia (Blanketrol III, Cincinnati Sub-Zero, Cincinnati, OH, USA) at 34°C after hemicraniectomy in malignant MCA infarction (hypothermia group). The indication of hypothermia included acute cerebral infarction >2/3 of MCA territory and a Glasgow coma scale (GCS) score 10 mm or transtentorial herniation sign (a fixed and dilated pupil). We retrospectively collected 27 patients, as the control group, who had undergone hemicraniectomy alone and simultaneously met the inclusion criteria of hypothermia between January 2010 and September 2012, before hypothermia was implemented as a treatment strategy in Dong-A University Hospital. We compared the mortality rate between the two groups and investigated hypothermia-related complications, such as postoperative bleeding, pneumonia, sepsis and arrhythmia. RESULTS: The age, preoperative infarct volume, GCS score, National institutes of Health Stroke Scale score, and degree of midline shift were not significantly different between the two groups. Of the 20 patients in the hypothermia group, 11 patients were induced with hypothermia immediately after hemicraniectomy and hypothermia was initiated in 9 patients after the decision of hypothermia during postoperative care. The duration of hypothermia was 4±2 days (range, 1 to 7 days). The side effects of hypothermia included two patients with arrhythmia, one with sepsis, one with pneumonia, and one with hypotension. Three cases of hypothermia were discontinued due to these side effects (one sepsis, one hypotension, and one bradycardia). The mortality rate of the hypothermia group was 15.0% and that of the control group was 40.7% (p=0.056). On the basis of the logistic regression analysis, hypothermia was considered to contribute to the decrease in mortality rate (odds ratio, 6.21; 95% confidence interval, 1.04 to 37.05; p=0.045). CONCLUSION: This study suggests that hypothermia after hemicraniectomy is a viable option when the progression of patients with malignant MCA infarction indicate poor prognosis.

Role of N-terminal Pro-brain Natriuretic Peptide in Differentiating Node-first Presentations of Kawasaki Disease and Bacterial Cervical Lymphadenitis

PURPOSE: Kawasaki disease (KD) is an acute, self-limited, febrile disease. For cases of KD in which the first symptom is cervical lymphadenopathy (node-first presentations of KD, NFKD), it is frequently misdiagnosed as bacterial cervical lymphadenitis (BCL). Therefore, we evaluated the usefulness of N-terminal pro-brain natriuretic peptide (NT-proBNP) to differentiate between NFKD and BCL. METHODS: This is a retrospective, observational study. Patients were divided into three groups, KD as 1st diagnosis, NFKD, and BCL. The laboratory and demographic data, intravenous immunoglobulin (IVIG) administration time and total febrile duration, length of hospital stay, and number of coronary artery complications were then compared for each group. RESULTS: A total of 451 patients were diagnosed as KD and 45 patients as BCL. Of the 451 KD patients, 417 (92.5%) were KD as 1st diagnosis, and 34 (7.5%) were NFKD. White blood cell count, absolute neutrophil count, C-reactive protein, erythrocyte sedimentation rate, and NT-proBNP differed significantly between NFKD and BCL. Variables that differed significantly were analyzed using a receiver operating characteristic curve, which revealed that NT-proBNP had the largest area under curve (0.944). Additionally, IVIG administration time, total febrile duration and length of hospital stay differed between KD as 1st diagnosis and NFKD. CONCLUSION: It is difficult to differentiate NFKD from BCL, so proper treatment and length of hospital stay were delayed. NT-proBNP is very useful for differentiating NFKD and BCL. Therefore, in cases of BCL with a long febrile period without reacting general treatments, the NT-proBNP test can be considered.

Safety and Efficacy of Hypothermia (34°C) after Hemicraniectomy for Malignant MCA Infarction

OBJECTIVE: The beneficial effect of hypothermia after hemicraniectomy in malignant middle cerebral artery (MCA) infarction has been controversial. We aim to investigate the safety and clinical efficacy of hypothermia after hemicraniectomy in malignant MCA infarction.METHODS: From October 2012 to February 2016, 20 patients underwent hypothermia (Blanketrol III, Cincinnati Sub-Zero, Cincinnati, OH, USA) at 34°C after hemicraniectomy in malignant MCA infarction (hypothermia group). The indication of hypothermia included acute cerebral infarction >2/3 of MCA territory and a Glasgow coma scale (GCS) score < 11 with a midline shift >10 mm or transtentorial herniation sign (a fixed and dilated pupil). We retrospectively collected 27 patients, as the control group, who had undergone hemicraniectomy alone and simultaneously met the inclusion criteria of hypothermia between January 2010 and September 2012, before hypothermia was implemented as a treatment strategy in Dong-A University Hospital. We compared the mortality rate between the two groups and investigated hypothermia-related complications, such as postoperative bleeding, pneumonia, sepsis and arrhythmia.RESULTS: The age, preoperative infarct volume, GCS score, National institutes of Health Stroke Scale score, and degree of midline shift were not significantly different between the two groups. Of the 20 patients in the hypothermia group, 11 patients were induced with hypothermia immediately after hemicraniectomy and hypothermia was initiated in 9 patients after the decision of hypothermia during postoperative care. The duration of hypothermia was 4±2 days (range, 1 to 7 days). The side effects of hypothermia included two patients with arrhythmia, one with sepsis, one with pneumonia, and one with hypotension. Three cases of hypothermia were discontinued due to these side effects (one sepsis, one hypotension, and one bradycardia). The mortality rate of the hypothermia group was 15.0% and that of the control group was 40.7% (p=0.056). On the basis of the logistic regression analysis, hypothermia was considered to contribute to the decrease in mortality rate (odds ratio, 6.21; 95% confidence interval, 1.04 to 37.05; p=0.045).CONCLUSION: This study suggests that hypothermia after hemicraniectomy is a viable option when the progression of patients with malignant MCA infarction indicate poor prognosis.

Evaluating the Quality of Basic Life Support Information for Primary Korean-Speaking Individuals on the Internet / 의료커뮤니케이션

PURPOSE: The aim of this study is to investigate the quality of basic life support (BLS) information for primary Korean-speaking individuals on the internet.METHODS: Using the Google © search engine, we searched for the terms ‘CPR’, ‘cardiopulmonary resuscitation (in Korean)’ and ‘cardiac arrest (in Korean)’. The accuracy, reliability and accessibility of web pages was evaluated based on the 2015 American heart association(AHA) guidelines for CPR & emergency cardiovascular care, the health on the net foundation code of conduct and Korean web content accessibility guidelines 2.1, respectively.RESULTS: Of the 178 web pages screened, 50 met criteria for inclusion. The overall quality of BLS information was not enough (median 5/7, IQR 4.75-6). 23(36%) pages were created in accordance with 2010 AHA guidelines. Only 24(48%) web pages educated on how to use the automated electrical defibrillator. The attribution and transparency of the reliability of pages was relatively low, 20(40%) and 16(32%). The web accessibility score was relatively high.CONCLUSION: A small of proportion of internet web pages searched by Google have high quality BLS information for a Korean-speaking population. Web pages based on past guideline were still being searched. The notation of the source of CPR information and the transparency of the author should be improved. The verification and evaluation of the quality of BLS information exposed to the Internet are continuously needed.

A Single-center, Prospective, Cross-over Study to Compare the Efficiency of Oxygen Supply between the OxyMask™ and Non-rebreather Mask in Healthy Adults

PURPOSE: In this single-center, prospective, randomized, cross-over study, we compared the efficiency of oxygen supply between OxyMask and non-rebreather mask (NRM), depending on the position of the mask. METHODS: Either OxyMask or NRM was applied to 33 healthy volunteers, in a random manner, on the upper (that 1 cm upper to it), lower (that 1 cm inferior to it) and lateral malposition (that 1 cm lateral to it). After a 3-minute oxygenation, at a flow rate of 15 L/min, we measured the fractional expired oxygen concentration (F(E)O₂), fractional expired carbon dioxide concentration (F(E)CO₂), and visual analogue scale (VAS) scores for the degree-of-wearing sensation. RESULTS: OxyMask showed a lower level of F(E)O₂ as compared with NRM in all positions. Moreover, OxyMask showed no significant difference between F(E)O₂ and the position of the mask. However, NRM showed a significantly lower F(E)O₂ in the upper and lateral malposition. F(E)CO₂ had no significant difference with the types and position of the mask. The mean VAS scores for the degree-of-wearing sensation were 2.2±1.5 in the OxyMask and 4.3±1.5 in the NRM (p<0.001). CONCLUSION: OxyMask may offer greater benefit in maintaining the concentration of supplied oxygen and provide greater comfort than NRM in patients with difficulty applying the mask on an adequate location and maintaining the seal.

Ileal epithelioid leiomyosarcoma with omental and peritoneal seeding / 영남의대학술지

Leiomyosarcoma (LMS) of the small intestine is a rare tumor, accounting for about 1% of all malignant mesenchymal lesions in the gastrointestinal tract. Since small bowel tumors are initially asymptomatic and nonspecific, delayed diagnosis and treatment are common. We found that a 44-year-old male patient who came in for lower abdominal pain had partial obstruction in the small bowel. Multiple ascites and ileal tumors involving peritoneal seeding were observed from his abdominal computed tomography. He was diagnosed as epithelioid LMS involving peritoneal transition after surgical resection, and the outpatient department has planned for a conservative therapy with observation. To the best of our knowledge, ileal epithelioid LMS accompanying a huge omental mass, with a size of 18 cm in dimension, and peritoneal seeding has not yet been reported in Korea. We report this rare case with literature review.

Discussion of Lumbar Puncture in Infants Aged Less than 3 Months Who Visited Emergency Department

PURPOSE: This study was conducted to confirm the necessity of lumbar puncture to identify the cause of fever in febrile infants aged less than 3 months who visited an emergency department. METHODS: This was a retrospective study conducted on 399 infants aged 31 days to 90 days who visited the emergency department with fever from March 2014 to February 2016. RESULTS: Of the 399 patients, 49 patients had serious bacterial infections (SBI), and were finally diagnosed with urinary tract infection (UTI), sepsis, and bacterial meningitis. Of these, only one case was diagnosed with bacterial meningitis, and this patient was accompanied by sepsis. UTIs were present in 47 patients, and only 1 case was diagnosed with sepsis without bacterial meningitis or UTI. The Boston criteria and Philadelphia criteria included the cerebrospinal fluid (CSF) results for predicting SBI. In this study, the modified Philadelphia criteria was used, which does not include the CSF results, and there was no factor that showed a significant correlation as a result of statistical analysis. Rather, a C-reactive protein ≥50 mg/L, procalcitonin ≥2 ng/mL, and fever over 39℃C showed statistical significance with SBI. In this study, the 1 patient diagnosed with bacterial meningitis also met all three factors (C-reactive protein, 106 mg/L; procalcitonin, 40.25 ng/mL; peak body temperature, >39℃). CONCLUSION: Because the incidence of bacterial meningitis has decreased recently, when an infant under 3 months of age visits the emergency room with fever, lumbar puncture should be performed selectively to identify the cause.

Efficacy of Initial Lactate and Lactate Clearance by Emergency Department Treatment in Diabetic Ketoacidosis Patients

PURPOSE: Diabetic ketoacidosis (DKA) is a fatal complication caused by unregulated diabetes. Lactate is used as a prognostic indicator for a range of serious illnesses and its level is higher in DKA patients. This study examined the utility of lactate and lactate clearance measurements at an emergency department for predicting the prognosis of DKA patients. METHODS: This was a retrospective, observational study of patients with DKA presenting to the emergency department of an urban and rural tertiary hospital between January, 2013 and December, 2016. The demographic and laboratory data were collected through a chart review. RESULTS: Seventy-six patients with DKA were included. Of these 76 patients, 46 (56.8%) had lactic acidosis (lactate >2.5 mmol/L) and 24 (29.6%) had a high lactate level (>4 mmol/L). Lactate and lactate clearance showed a significant difference in terms of the intensive care unit length of stay and mortality. CONCLUSION: Lactate and lactate clearance measurements in DKA patients are favorable and significant prognostic factors. In DKA patients, serial measurements of lactate should be considered.

Bacterial Contamination and Disinfection Status of Laryngoscopes Stored in Emergency Crash Carts / 예방의학회지

OBJECTIVES: To identify bacterial contamination rates of laryngoscope blades and handles stored in emergency crash carts by hospital and area according to the frequency of intubation attempts. METHODS: One hundred forty-eight handles and 71 blades deemed ready for patient use from two tertiary hospitals were sampled with sterile swabs using a standardized rolling technique. Samples were considered negative (not contaminated) if no colonies were present on the blood agar plate after an 18-hour incubation period. Samples were stratified by hospital and according to the frequency of intubation attempts (10 attempts per year) using the χ2-test and Fisher exact test. RESULTS: One or more species of bacteria were isolated from 4 (5.6%) handle tops, 20 (28.2%) handles with knurled surfaces, and 27 (18.2%) blades. No significant differences were found in microbial contamination levels on the handle tops and blades between the two hospitals and two areas according to the frequency of intubation attempts. However, significant differences were found between the two hospitals and two areas in the level of microbial contamination on the handles with knurled surfaces (p<0.05). CONCLUSIONS: Protocols and policies must be reviewed to standardize procedures to clean and disinfect laryngoscope blades and handles; handles should be re-designed to eliminate points of contact with the blade; and single-use, one-piece laryngoscopes should be introduced.