Characteristics of patients transferred from long-term care hospital to emergency department

Objective@#This study was undertaken to assess the appropriateness of transfer of patients from a long-term care hospital to the emergency department (ED). @*Methods@#We conducted a retrospective study in a Wide Regional Emergency Center in Gyeongsangnam-do between January 2019 and December 2019. The patients were divided into groups (direct visit, transferred from other hospitals, and transferred from long-term care hospitals [LTCHs]). The baseline characteristics, Korean Triage and Acuity Scale (KTAS), vital signs, length of stay, ED disposition, cost, clinical outcome, and instances of application of the “Act on decisions on life-sustaining treatment” were collected. @*Results@#A total of 30,142 patients were enrolled during the study period. Twenty-one thousand, nine hundred and sixty-five patients were in the direct visit group, 7,057 patients were transferred from other hospitals, and 1,120 patients were transferred from LTCHs. Hospital admission was higher in cases of transfer from other hospitals and LTCHs (LTCHs, 63.8%; transferred from other hospitals, 64.1%, direct visit, 30.1%; P<0.001). Re-transfer and mortality in the ED were much higher (re-transfer: LTCHs, 11.0%; transferred from other hospitals 3.8%, direct visit 1.9%; P<0.001 and mortality in ED: 2.9%, 0.8%, 1.4%; respectively P<0.001). In the LCTH group after admission, mortality was higher (mortality: 16.2%, 5.4%, 7.1% for LTCH transfers and direct respectively; P<0.001). The implementation rate of the “Act on decisions on life-sustaining treatment”, the well-dying law, was higher in the LTCHs (26.6%, 12.5%, and 11.4% LTCH transfers, and direct respectively; P<0.001). @*Conclusion@#In the LTCH group, re-transfer, mortality, and the implementation rate of the “Act on decisions on life-sustaining treatment” were higher than in the other groups.

Appropriateness of Korean Triage and Acuity Scale-based triage system for dizziness without neurologic symptoms

Objective@#This study aimed to identify the appropriateness of the Korean Triage and Acuity Scale (KTAS) for dizziness without neurological symptoms, which was level 3. @*Methods@#Using the registry of the National Emergency Department Information System (NEDIS), data regarding consecutive emergency patients from January 2016 to July 2018, who were aged 15 years and older, were reviewed retrospectively. The data were classified using KTAS and Dizziness KTAS level 3 were compared with non-dizziness KTAS level 3 including age, total admission rate, intensive care unit (ICU) admission rate, discharge rate, hospital cost, and length of stay in the emergency department (length of stay [LOS]). @*Results@#Of the 76,153 emergency patients, 345 (0.5%) had a KTAS level 1, 4,593 (6.0%) had a KTAS level 2, 21,561 (28.3%) had a KTAS level 3, 45,390 (59.6%) had a KTAS level 4, and 4,264 (5.6%) had a KTAS level 5. As the patient’s triage score decreased, the total admission rate, ICU admission rate, hospital cost, and LOS decreased. Patients discharged to home also had the same result. Dizziness KTAS level 3 had a significantly lower rate of total admission (23% vs. 56.2%, P<0.001) and ICU admission (0.9% vs. 6.2%, P<0.001) compared with non-dizziness KTAS level 3. On the other hand, the hospital cost and LOS were higher when patients were discharged to their home. The predictors of the admission rate of dizziness KTAS level 3 were the transportation method using a private ambulance service and older age, but older age was only slightly associated. @*Conclusion@#This study showed that KTAS level 3 for dizziness needs to be adjusted because of lower severity than other level 3. Old age and the transportation method should be considered factors.

Effect of vasopressin on prognosis in sepsis shock

Objective@#This study analyzed the relationship between the timing of vasopressin treatment and the prognosis ofpatients with septic shock. @*Methods@#Patients who were admitted to a university hospital for one year using vasopressin were studied retrospectively.All records were collected through the medical records; several factors were studied to determine the prognosis of thepatient. The 24-hour, 48-hour mortality, and hospital mortality were examined. The difference in the timing of vasopressinadministration between death and survival patients was analyzed to determine the effect of the vasopressor on the survivalrate using the receiver operating characteristic (ROC) curve. @*Results@#The general characteristics of the patients in the hospital and survivors were similar. Vasopressin infusion wasfaster in the surviving patients than in the death patients, but there was no significant difference (survival, 187.0 minutes;interquartile range [IQR], 95.0-548.0 minutes vs. death, 285.5 minutes; IQR, 92.7-739.2). To determine the effect of vasopressorinjection on the survival rate, the ROC curve was drawn, and the area under curve was not affected significantlyby norepinephrine (NE) 0.416 and vasopressin 0.529. In addition, the duration of the ventilator application was found toincrease with increasing NE injection period in survivors (period of application of ventilator: NE injection time, r=0.460,P=0.048; vasopressin, r=0.369, P=0.120). @*Conclusion@#The prognosis was similar regardless of the timing of vasopressin in patients with septic shock.

The influence of symptom to balloon time in ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVE@#The current guidelines for the treatment of ST-segment elevation myocardial infarction (STEMI) recommends early reperfusion with a door to balloon (DTB) time of 90 minutes or less in patients undergoing primary percutaneous coronary intervention (PPCI). Therefore, the focus of most studies has been the DTB time. On the other hand, the ischemic time is related to the symptom to balloon (STB) time rather than the DTB time. This study examined the clinical effects of the STB time as well as the social and clinical factors affecting the STB time in STEMI patients.@*METHODS@#This study analyzed 286 patients diagnosed with STEMI from December 2008 to December 2016. The STB time (≤4 hours and>4 hours, ≤12 hours, and >12 hours) in the groups was compared. The mortality and ejection fraction were investigated. In addition, the characteristics of patients and socioeconomic factors affecting STB were analyzed.@*RESULTS@#The SBT time is inversely associated with the ejection fraction (R=−0.126, P=0.033), and the ejection fraction of the ≤12 hours group was higher than that of the >12 hours group (54% vs. 50%, P=0.047). On the other hand, there was no significant difference in mortality between the two groups (3.26% vs. 4.84%, P=0.506). In multivariate analysis, the variable related to SBT was only typical chest pain (adjusted odd ratio, 1.931; 95% confidential interval, 1.014-3.792; P=0.045).@*CONCLUSION@#The results of the study support the prognostic value of SBT in STEMI undergoing PPCI. Therefore, efforts should be made to shorten the STB time.

Chronic Recurrent Methicillin Resistant Staphylococcus Hemolyticus Endophthalmitis after Cataract Surgery

PURPOSE: To report a case of recurrent endophthalmitis due to methicillin resistant Staphylococcus hemolyticus after phacoemulsification and posterior chamber intraocular lens (IOL) implantation. CASE SUMMARY: A 76-year-old female visited our outpatient clinic with decreased vision 40 days after uncomplicated cataract surgery in her right eye. At the visit, anterior chamber inflammation and cloudy fluid between the posterior capsule and IOL were observed. Uveitis due to residual cortex of lens or capsular block syndrome was suspected, so YAG laser capsulotomy and subconjunctival injection of dexamethasone were performed. Two days later, hypopyon and vitreous opacity were seen. The patient underwent an emergency vitrectomy and intravitreal antibiotic injection with suspicion of bacterial endophthalmitis. The culture was negative. Twenty days after the vitrectomy, anterior chamber inflammation and vitreous opacity developed. The recurrence of endophthalmitis was suspected due to infection by bacteria in the surrounding tissue of the IOL, so the patient underwent an IOL and lens capsule removal with intravitreal antibiotic injection. At this time, the culture revealed methicillin resistant staphylococcus hemolyticus. Systemic and topical vancomycin was then administered, resulting in decreased inflammation. Twenty days after the IOL removal, decreased vision, anterior chamber inflammation, and vitreous opacity developed. Endophthalmitis was decreased by intravitreal antibiotic injection and topical antibiotic treatment. CONCLUSIONS: Methicillin resistant staphylococcus hemolyticus should be considered in the differential diagnosis of chronic recurrent endophthalmitis after cataract surgery.

Etiology of Pleural Effusions in Cancer Patients

PURPOSE: The purpose of this study is to examine the causes of Pleural effusion (PE) in cancer patients and to compare the clinical characteristics between malignant PE (MPE) and non-MPE. METHODS: All consecutive cancer patients with PE who underwent diagnostic thoracentesis from January 1, 2008 to March 31, 2011 were analyzed retrospectively. RESULTS: A total of 719 patients were included; mean age was 58.4+/-13.6 years and 44.5% were female. The most common cause of PE was MPE (57.7%), followed by parapneumonic or empyema in 16.3%. However, the etiology was significantly different according to primary tumor origin and subtypes of lung cancer. While MPE was most common in lung, breast, and gynecologic cancer, hepatic hydrothorax was the main cause in Hepatocellular carcinoma (HCC). MPE accounted for 85.2% in adenocarcinoma, and 30.2% and 58.8% in squamous cell and small cell carcinomas, respectively. Patients with MPE were younger (57.0 vs. 60.2 years) and female-dominant (55.4% vs. 29.6%) compared to those with non-MPE. MPE had the large size (53.5% vs. 34.9%) and left location of PE (31.3% vs. 19.4%) more frequently than non-MPE, and fewer neutrophils (15.4% vs. 30.6%) and more lymphocytes (32.2% vs. 28.2%), higher levels of pH (7.33 vs. 7.29), and lower levels of glucose (111.5 vs. 129.7 mg/dL) than non-MPE (p<0.001 for all). CONCLUSION: Overall, MPE was the most common cause of PE in cancer patients. However the etiology of PE was significantly different according to primary tumor origin and subtypes of lung cancer. A difference in age, gender, size and location of PE, cell count, pH, and glucose was observed between MPE and non-MPE.

Clinical Features of Acute Aortic Dissection Patients Initially Diagnosed with ST-segment Elevation Myocardial Infarction

PURPOSE: Acute myocardial infarction (AMI) concomitant with acute aortic syndrome (AAS) is rare but prompt recognition of concomitant AAS is critical, particularly in patients with ST-segment elevation myocardial infarction (STEMI) because misdiagnosis with early thrombolytic or anticoagulant treatment may result in catastrophic consequences. This study examined the clinical features of patients of STEMI concomitant with AAS that may be a diagnostic clue. METHODS: Between January 1, 2010 and December 31, 2014, 22 patients who had the initial diagnosis of acute coronary syndrome (AMI and unstable angina) and AAS (aortic dissection, intramural hematoma, and ruptured thoracic aneurysm) in our emergency department were reviewed. Among them, 10 patients who were transferred from other hospitals and 4 patients with non-STEMI were excluded, leaving 8 patients of STEMI concomitant with AAS for analysis. RESULTS: The mean age of study patients was 57.5+/-16.31 years and five patients were Stanford type A and three patients were type B aortic dissection. Six patients had ST-segment elevation in anterior leads and 2 patients in inferior leads. Most patients had acute onset and severe chest pain, but none had dissecting nature chest pain. Serum troponin I was elevated in three patients but all patients had Ddimer elevation. Aortic regurgitation or regional wall motion abnormality was detected in four patients, and widened mediastinum was observed in all study patients. CONCLUSION: Concomitant AAS might be suspected in patients with STEMI who have elevated D-dimer and widened mediastinum.

A Case of Bilateral Acute Angle Closure Attack Induced by Common Cold Medication

PURPOSE: The authors report a case of bilateral simultaneous acute angle closure attack following administration of an over-the-counter common cold medication (ingredients: chlorpheniramine maleate, phenylephrine hydrochloride, and belladonna alkaloid). CASE SUMMARY: A 67-year-old man visited the emergency room with a sudden onset of bilateral blurred vision and ocular pain accompanied by headache, nausea, and vomiting. He had taken an over-the-counter common cold medication three times per day for three days before the visit. His visual acuity was 0.3 and 0.7 and intraocular pressure (IOP) was 50 mm Hg and 40 mm Hg in right and left eye, respectively. The refraction in manifest refractive test was +0.75 D sph = -0.75 D cyl x 100 in right eye and +1.25 D sph = -1.25 D cyl x 80 in left eye. The anterior chamber depth was three times the corneal thickness in center and less than 1/4 of the corneal thickness in periphery in both eyes on van Herick method. The angles of both eyes were closed on gonioscopy. He was treated with ocular hypotensive medication and miotics followed by withdrawal of common cold medications. After 10 days, bilateral neodymium-doped yttrium aluminium garnet (Nd:YAG) laser peripheral iridotomies were done. During four months of follow-up, there was no recurrence of angle closure attack, and normal IOP was maintained without glaucoma medications. CONCLUSIONS: Common cold medications which are easily accessible can induce acute angle closure attack in those who are predisposed to develop angle closure attacks, hence attention must be taken in those people when taking common cold medications.

Transscleral Fixation of Intraocular Lenses Using Modified Injector

PURPOSE: To evaluate the clinical stability and outcomes of 3-piece intraocular lens (IOL) transscleral fixation surgery using a modified injector. METHODS: We have modified and used the Sapphire unfolder injector system (Allergan(R), USA). This involved, cutting a slit longitudinally at the terminal part of the injector so that a thread could pass through it freely. After a conjunctival peritomy created at 2 and 8 o'clock, a long curved needle with double-armed 10-0 polypropylene is passed through the exposed sclera. Two pieces of suture are withdrawn through the 2.8 mm corneal incision and 1 suture (from 8 o'clock) is passed through the opening of the cartridge and then tied to the leading haptic. Next, the IOL was implanted with the cartridge and then inserted through the corneal incision site. The other suture (from 2 o'clock) is tied to the haptic on the opposite side and inserted. RESULTS: The study included 20 eyes of 20 patients with a mean age of 62.8 years at the initial visit. There were no complications, such as vitreous hemorrhage, retinal detachment, glaucoma, corneal edema, or iris injury. While the knot fixed to the leading haptic of IOL passed by the cartridge, there was no change of position. During the follow-up period, IOL dislocation did not occur and the corrected visual acuity and corneal astigmatism improved significantly. CONCLUSIONS: This technique is an effective procedure for minimizing entangled thread and corneal astigmatism.

Central Corneal Thickness Measured by Noncontact Specular Microscopy, Dual Rotating Scheimpflug Camera and Ultrasound Pachymetry

PURPOSE: To compare central corneal thickness (CCT) as measured using noncontact specular microscopy (NCSM), dual rotating Scheimpflug camera (Galilei(R)), and ultrasound pachymetry (USP). METHODS: The measurements of CCT using NCSM, dual rotating Scheimpflug camera and USP in 70 eyes of 70 healthy subjects were compared. RESULTS: The average measurements of CCT using NCSM, dual rotating Scheimpflug camera, and USP were 567.70 +/- 31.21 microm, 557.84 +/- 26.29 microm, and 553.31 +/- 29.69 microm, respectively. The CCT measurement using NCSM was statistically significantly thicker than when measured using USP (p 0.900, p < 0.001). CONCLUSIONS: The results of the 3 methods were significantly correlated but the measurement using NCSM was significantly thicker than when using USP. CCT measurements of healthy eyes using dual rotating Scheimpflug camera were more correlated with USP than NCSM. The CCT measurements using dual rotating Scheimpflug camera is a better alternative for USP than NCSM.

Association of Demographic and Socioeconomic Factors With Risk Factors for Chronic Kidney Disease / 예방의학회지

OBJECTIVES: The goal of this study was to examine the association of various demographic and socioeconomic factors with risk factors for chronic kidney disease (CKD). METHODS: We used nationally representative pooled data from the Korea National Health and Nutrition Examination Survey (KNHANES), 2007-2013. We estimated the glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease equation. We defined CKD as a GFR <60 mL/min/1.73 m2, and 1304 of the 45 208 individuals included in the KNHANES were found to have CKD by this definition. The outcome variable was whether individual subjects adhered to the CKD prevention and management guidelines recommended by the Korea Centers for Disease Control and Prevention. The guidelines suggest that individuals maintain a normal weight, abstain from alcohol consumption and smoking, manage diabetes and hypertension, and engage in regular exercise in order to prevent and manage CKD. RESULTS: This study found that individuals with CKD were more likely to be obese and have hypertension or diabetes than individuals without CKD. In particular, male and less-educated CKD patients were less likely to adhere to the guidelines. CONCLUSIONS: Although the prevalence of CKD, as indicated by the KNHANES data, decreased from 2007 to 2013, the prevalence of most risk factors associated with CKD fluctuated over the same time period. Since a variety of demographic and socioeconomic factors are related to the successful implementation of guidelines for preventing and managing CKD, individually tailored prevention activities should be developed.