Comparative and retrospective evaluation of the predictive performance of optic nerve sheath thickness and optic nerve sheath diameter for traumatic brain injury using facial computed tomography

Objective@#To evaluate the predictive performance of optic nerve sheath thickness (ONST) on the outcomes of traumatic brain injury (TBI) and to compare the inter-observer agreement To evaluate the predictive performance of optic nerve sheath thickness (ONST) for traumatic brain injury (TBI) and to compare the predictive performance and inter-observer agreement between ONST and optic nerve sheath diameter (ONSD) on facial computed tomography (CT). @*Methods@#We retrospectively enrolled patients with a history of facial trauma and who underwent both facial CT and brain CT. Two reviewers independently measured ONST and ONSD of each patient using facial CT images. Final brain CT with clinical outcome was used as the reference standard for TBI. Multivariate logistic regression analyses, receiver operating characteristic (ROC) curves, and intraclass correlation coefficients were used for statistical analyses. @*Results@#Both ONST (P=0.002) and ONSD (P=0.001) on facial CT were significantly independent factors to distinguish between TBI and healthy brains; an increase in ONST and ONSD values corresponded with an increase in the risk of TBI by 8.9- and 7.6-fold, respectively. The predictive performances of the ONST (sensitivity, 96.2%; specificity, 94.3%; area under the ROC curve, 0.968) and ONSD (sensitivity, 92.6%; specificity, 90.2%; area under the ROC curve, 0.955) were excellent and exhibited similar sensitivity, specificity, and area under the curve (P=0.18–0.99). Interobserver and intraobserver intraclass correlation coefficients for ONST were significantly higher than those for ONSD (all P<0.001). @*Conclusion@#ONST on facial CT is a feasible predictor of TBI and demonstrates similar performance and superior observer agreement than ONSD. We recommend using ONST measurements to assess the need for additional brain CT scans in TBI-suspected cases.

Clinical Manifestations of Contrast Media Extravasation in the Emergency Department and the Ward

PURPOSE@#Contrast media extravasation (CME) is an adverse reaction after administration of contrast media during CT examinations. The purpose of this study was to evaluate the frequency, management, and outcomes of extravasations and to assess the risk factors for CME in the emergency department (ED) and the ward.@*MATERIALS AND METHODS@#This retrospective study was conducted at a single academic urban hospital from January 2013 to December 2015. We analyzed the medical records of all patients who experienced CME after undergoing a CT scan. We compared the patients' age, sex, underlying disease, injection site, injection flow rate, time of CT examination, type of CT examination, and severity of injury between those in the ED and the ward.@*RESULTS@#CME occurred in 41 (0.36%) of 114767 patients, which included 16 (0.34%) in the ED and 25 (0.37%) in the ward. Both groups were more frequent in those aged older than 60 years and in female. Additionally, the abdominopelvic CT type and 2–3 mL/s as the injection rate were more common in both groups. However, CME was more frequent during the nighttime (10, 62.5%) in the ER, while it was more common in the daytime (14, 56.0%) in the ward. Severe complications were more frequent in the ER (9, 56.3%) compared with the ward (8, 32.8%). There were no significant differences in CME between the ED and the ward. When comparing the clinical manifestations in the mild and severe groups, the antecubital fossa (33.3% and 0%, respectively; p = 0.013) for the injection site and abdominopelvic CT (41.7% and 82.4%, respectively; p = 0.012) and CT angiography (41.7% and 5.87%, respectively; p = 0.014) for the CT examination showed significant differences between the mild and severe groups.@*CONCLUSION@#In this study, there were no significant clinical differences in CME between the ED and ward. Thus, prevention is more important than the place of admission. Radiologists and emergency physicians should pay attention to CME in the ED because it frequently occurs at night and results in more severe complications.

Risk factors for hospital admission in revisiting patients to the emergency department with abdominal pain

OBJECTIVE: The aim of this study was to identify the clinical characteristics and risk factors associated with the admission of patients in the emergency department (ED) within 30 days after discharge. METHODS: A retrospective, observational study was conducted on adult patients presenting with abdominal pain to the ED of a single, urban, university hospital, between January 2014 and December 2015, who revisited the ED within 30 days after discharge. Data was collected on the emergency severity index level, time to contact doctors, physical examination, laboratory tests, use of computed tomography (CT), and patient disposition on revisitation. The primary outcome was hospital admission following an ED revisit in the 30-day period after the first visit. RESULTS: During the study period, 19,480 patients visited the ED with the chief complaint of abdominal pain, and 13,577 were discharged. A total of 251 patients (1.29%) revisited the ED within 30 days, of which 89 were eligible for the study. The primary outcome was associated with not performing a CT scan on the initial visit and an increased C-reactive protein (CRP) value. Receiver operating characteristic curve analysis showed that a cut-off baseline CRP value of >0.35 mg/dL can predict the primary outcome with a sensitivity and specificity of 75% and 62.1%, respectively (area under the curve, 0.701; 95% confidence interval, 0.569–0.833; P=0.007). CONCLUSION: An increased CRP value and not performing abdominal CT were associated with a higher rate of admission following ED revisits of patients with abdominal pain. Future prospective studies on the role of abdominal CT imaging in patients presenting to the ED with abdominal pain will be needed.

Neutrophil-to-lymphocyte Ratio as A Predictor of Aspiration Pneumonia in Drug Intoxication Patients

PURPOSE: To evaluate the association between neutrophil-to-lymphocyte ratio (NLR) and occurrence of aspiration pneumonia in drug intoxication (DI) patients in the emergency department (ED) and to evaluate the relationship between NLR and length of hospital admission/intensive care unit (ICU) admission. METHODS: A total of 466 patients diagnosed with DI in the ED from January 2016 to December 2017 were included in the analysis. The clinical and laboratory results, including NLR, were evaluated as variables. NLR was calculated as the absolute neutrophil count/absolute lymphocyte count. To evaluate the prognosis of DI, data on the development of aspiration pneumonia were obtained. Also, we evaluated the relationship between NLR and length of hospital admission and between NLR and length of ICU admission. Statistically, multivariate logistic regression analyses, receiver-operating characteristic (ROC) curve analysis, and Pearson's correlation (ρ) were performed. RESULTS: Among the 466 DI patients, 86 (18.5%) developed aspiration pneumonia. Multivariate logistic regression analysis revealed NLR as an independent factor in predicting aspiration pneumonia (odds ratio, 1.7; p=0.001). NLR showed excellent predictive performance for aspiration pneumonia (areas under the ROC curves, 0.815; cut-off value, 3.47; p 3.47).

Cervical Spine Epidural Hematoma Disguised as Acute Ischemic Stroke: A Case Report

Cervical spine epidural hematoma is a rare disease, which can sometimes be misdiagnosed as acute ischemic stroke when a patient shows hemiparesis. A 68-year-old woman visited the emergency department with right side motor weakness without signs of facial palsy or cranial nerve deficit. She also complained of accompanying neck pain. Acute ischemic stroke was suspected initially and a non-contrast computed tomography of the brain was taken, which showed no cerebral hemorrhage. Brain and cervical spine magnetic resonance imaging (MRI) was performed for further evaluation. No evidence of cerebral infarction. However, an epidural hematoma was detected on cervical spine MRI. The patient was consulted to the neurosurgery department and decompressive laminectomy and hematoma evacuation was performed. Emergency physicians should consider cervical spine epidural hematoma in cases of sudden onset hemiparesis with accompanying neck pain.

Cervical Spine Epidural Hematoma Disguised as Acute Ischemic Stroke: A Case Report

Cervical spine epidural hematoma is a rare disease, which can sometimes be misdiagnosed as acute ischemic stroke when a patient shows hemiparesis. A 68-year-old woman visited the emergency department with right side motor weakness without signs of facial palsy or cranial nerve deficit. She also complained of accompanying neck pain. Acute ischemic stroke was suspected initially and a non-contrast computed tomography of the brain was taken, which showed no cerebral hemorrhage. Brain and cervical spine magnetic resonance imaging (MRI) was performed for further evaluation. No evidence of cerebral infarction. However, an epidural hematoma was detected on cervical spine MRI. The patient was consulted to the neurosurgery department and decompressive laminectomy and hematoma evacuation was performed. Emergency physicians should consider cervical spine epidural hematoma in cases of sudden onset hemiparesis with accompanying neck pain.

Leg Weakness After An Automobile Accident Due To Spinal Cord Ischemia: A Case Report

Anterior spinal artery syndrome, also known as Beck's syndrome, is defined as ischemia or infarction of the spinal cord. Beck's syndrome occurs from aortic thrombus, embolism, or dissection blocking the blood flow to the great radicular artery (GRA) of Adamkiewicz. Abdominal artery embolism due to trauma is relatively rare and urgent detection of vascular injury is substantial to fair clinical outcome of the patient, therefore, we report on a case of traumatic artery dissection presenting as lower leg weakness.

Spontaneous Uterine Perforation from Pyometra: A Case Report

Pyometra is the accumulation of pus in the uterine cavity. The incidence of pyometra in elderly patients is approximately 13.6%. Abdominal pain, fever, and vaginal discharge are the usual symptoms, but about half of the cases of uncomplicated pyometra have no specific symptoms. Spontaneous uterine rupture, resulting from complications of pyometra, is extremely rare. We report a case of spontaneous uterine rupture due to pyometra. A 77-year-old female patient who complained of nausea, abdominal pain, and poor oral intake (which started the day before) was transferred from the local hospital after having taken an abdominal CT. She had been bedridden for a year and had a history of hypertension, cerebral infarction, and colon cancer (for which she had a successful operation 12 years prior). Upon arrival, the patient was alert and her vital signs were: blood pressure of 113/78 mmHg, temperature of 36.9degrees C, respiratory rate of 22/min, and a pulse rate of 99/min. Her bowel sound was normal and physical examinations indicated a rigid abdomen with tenderness and rebound tenderness. Free air was observed in the abdominal CT and panperitonitis, due to uterine perforation resulting from pyometra, was also suggested. Hence, an emergency operation was undertaken. During the operation, the fundus of the uterus was found to be perforated with a 1 cmx1 cm-sized passage and a purulent discharge was apparent. Both the adnexa and bowel showed adhesion, but there was no bowel perforation or evident cancerous lesion. Entercoccus faecalis was cultured from both the cervical discharge and tissue obtained during operation. In summary, emergency physicians may consider uterine perforation due to pyometra in elderly woman with peritonitis.

Procalcitonin as a Prognosis Marker for the Severe Sepsis and Septic Shock Patients in Emergency Department / 대한구급학회지

BACKGROUND: Advance in sepsis management has increased the survival of patients with sepsis. However, severe sepsis and septic shock patients still have high mortality. We intend to verify the use of the procalcitonin (PCT) level as a prognosis marker in patients with severe sepsis or septic shock in the emergency department (ED). METHODS: ED Patients with severe sepsis or septic shock were enrolled in our study. We used mortality and Intensive Care Unit (ICU) days as a prognosis index, and compared the PCT level in survivors and non-survivors. We introduced the simplified acute physiology score 3(SAPS3) to assess the severity of the patients and analyzed whether or not the PCT level correlated with the severity index. RESULTS: The PCT level in septic shock patients [7.36 (0.92-33.69, IQR)] was higher than that in severe sepsis patients [3.24 (0.36-10.53, IQR)] (p = 0.04). However, there was no significant PCT level difference between survivors [median (IQR), 6.59 (0.60-29.25)] and non-survivors [median (IQR), 3.49 (0.40-20.41)] (p = 0.293). The SAPS3 score was higher in the non-survivor group [median (IQR), 64 (59.0-71.5)] than in the survivor group [median (IQR), 77 (68.5-82.0)] (p = 0.001). The PCT level did not correlate with either ICU days or hospital days. CONCLUSIONS: Using the PCT level as a prognosis factor in severe sepsis and septic shock patients in ED has little value.

A Case Arthritis After Intravesical BCG Instillation for Bladder Cancer / 대한류마티스학회지

Intravesical instillation of BCG(Calmette-Guerin Bacillus) is the most widely used treatment of superficial transitional cell carcinoma of the bladder. While the exact mechanisms are not yet known, it is assumed that the recognition of tumor antigen is enhanced by immunologic response of the urothelium of mycobacterium. Various complications have been reported after BCG treatment and arthritis is observed in 0.5 to% of treated patients. This from of arthritis may be attributed to an antigen of mycobacterium sharing a cross reactive epitope with an antigen in articular cartilage. A 40-year-old male had transurethral resection and intravesical instillation of BCG for transitional cell carcinoma of bladder. Within few days of the fourth instillation, he developed arthritis on right knee and right metatarsal joint. Laboratory findings showed nonspecific inflammatory sign, positive HLA B27, negative rheumatoid facor and negative antinuclear antibody. The joint effusion was aseptic. He was treated with nonsteroidal antiinflammatory drugs (indomethacin 200rag/day) with resolution of arthritis symptom. We report a patient who developed an inflammatory oligoarthritis following intravesica] instillation of BCG for the treatment oof bladder cancer.