Evaluating the Utility of Rapid Point-of-Care Potassium Testing for the Early Identification of Hyperkalemia in Patients with Chronic Kidney Disease in the Emergency Department

PURPOSE: Severe hyperkalemia leads to significant morbidity and mortality if it is not immediately recognized and treated. The concentration of potassium (K+) in the serum increases along with deteriorating renal function. The use of point-of-care K+ (POC-K+) in chronic kidney disease (CKD) could reduce the time for an accurate diagnosis and treatment, saving lives. We hypothesized that POC-K+ would accurately report K+ serum level without significant differences compared to reference testing, regardless of the renal function of the patient. MATERIALS AND METHODS: The retrospective study was performed between January 2008 and September 2011 at an urban hospital in Seoul. The screening program using POC was conducted as a critical pathway for rapid evaluation and treatment of hyperkalemia since 2008. When a patient with CKD had at least one warning symptom or sign of hyperkalemia, both POC-K+ and routine laboratory tests were simultaneously ordered. The reliability of the two assays for serum-creatinine was assessed by intra-class correlation coefficient (ICC) analysis using absolute agreement of two-way mixed model. RESULTS: High levels of reliability were found between POC and the laboratory reference tests for K+ (ICC=0.913, 95% CI 0.903-0.922) and between two tests for K+ according to changes in the serum-creatinine levels in CKD patients. CONCLUSION: The results of POC-K+ correlate well with values obtained from reference laboratory tests and coincide with changes in serum-creatinine of patients with CKD.

Exposure to Music and Noise During Pregnancy Influences Neurogenesis and Thickness in Motor and Somatosensory Cortex of Rat Pups / 대한배뇨장애요실금학회지

PURPOSE: Prenatal environmental conditions affect the development of the fetus. In the present study, we investigated the effects of exposure to music and noise during pregnancy on neurogenesis and thickness in the motor and somatosensory cortex of rat pups. METHODS: The pregnant rats in the music-applied group were exposed to 65 dB of comfortable music for 1 hour, once per day, from the 15th day of pregnancy until delivery. The pregnant rats in the noise-applied group were exposed to 95 dB of sound from a supersonic sound machine for 1 hour, once per day, from the 15th day of pregnancy until delivery. After birth, the offspring were left undisturbed together with their mother. The rat pups were sacrificed at 21 days after birth. RESULTS: Exposure to music during pregnancy increased neurogenesis in the motor and somatosensory cortex of rat pups. In contrast, rat pups exposed to noise during pregnancy showed decreased neurogenesis and thickness in the motor and somatosensory cortex. CONCLUSIONS: Our study suggests that music and noise during the developmental period are important factors influencing brain development and urogenital disorders.

The Clinical Utility of Blood Cultures by Pneumonia Severity Index for Patients with Community-Acquired Pneumonia in the Emergency Department

PURPOSE: Community-Acquired Pneumonia (CAP) is a common cause of mortality and serious morbidity. Regardless of the condition of the patients, almost all are hospitalized. And it seems to be a standard procedure to obtain blood cultures before the administration of antibiotics in suspected pneumonic patients. Recent studies show that the blood cultures don't affect the treatment of the patients with CAP. Accordingly, this study was designed to examine the usefulness of the blood cultures routinely performed and to evaluate the stratification of the patients with CAP by Pneumonia Severity Index (PSI) in the Emergency Department (ED). METHODS: Research subjects were patients over 16 years old who had been diagnosed with CAP in a general hospital between January and December 2008 and were admitted by way of the ED. We evaluated their records retrospectively. RESULTS: A total of 261 patients were diagnosed with CAP. According to the PSI, 155 (59%) of the 261 were classified as being in the low risk group and 106 (41%) in the high risk group. Blood cultures were positive in 13 of 261 (5%). Three of 13 patients belonged to the low risk group, and 10 to the high risk group. Antibiotics were changed in 43 of 261 patients. Nineteen of those belonged to the low risk group and 24 to the high risk group. Of the 13 bacteremic patients, blood cultures results altered therapy for 4 patients. CONCLUSION: Most often, blood cultures performed in the ED do not alter the therapy of patients with CAP. But we do recommend blood cultures for the high risk group.

The Effectiveness of a Repeatedly Checked Alvarado Score as a Screening Tool for Acute Appendicitis

PURPOSE: Acute appendicitis is one of the more challenging disease entities to diagnose. Early and correct diagnosis is necessary to decrease morbidity and mortality. The diagnosis of acute appendicitis does not depend on a single modality because it is often difficult and the symptoms of appendicitis can change with time. The Alvarado score is a sensitive and specific tool for diagnosis of appendicitis. But the effectiveness of a single Alvarado score for diagnosis of acute appendicitis can be less meaningful due to diagnostic difficulties. The purpose of this study was to evaluate the usefulness of repeatedly checked Alvarado scores in acute abdomen patients as a diagnostic tool for acute appendicitis. METHODS: A total of 196 patents who visited our ER with acute abdominal pain between March 2008 and February 2009 were enrolled. Emergency physicians checked the initial Alvarado score and re-checked that score after 3 hours of observation. We prospectively compared the results between (a) the initial and the 3 hours Alvarado scores and (b) the final pathology. RESULTS: We measured diagnostic for the initial Alvarado score and the 3 hours Alvarado score groups. The sensitivities of the two groups for detecting appendcitis were 85.1% and 92.0%, respectively; specificities were 81.6% and 89.0%; positive predictive values were 78.7% and 87.0%; negative predictive values were 87.3% and 93.3%; accuracy scores were 83.2% and 90.3%. All diagnostic values of the 3 hours Alvarado score group were superior to those of the initial Alvarado score group. CONCLUSION: Repeatedly checked Alvarado scores provides a superior diagnostic accuracy to the initial Alvarado score alone. Thus, we can say that repeatedly checked 3 hours Alvarado scores are more useful for diagnosing acute appendicitis than an initial, one-time checking of the Alvarado score. This new scoring system will be particularly useful to physicians who are working in health care facilities where computerized tomography or ultra-sonography is not available.

The Effect of an Alerting Call with a Cellular Phone on Emergency Care for Critically Ill Patients

PURPOSE: The overcrowding of the ECC (Emergency Care Center) is a significant problem for most general hospitals. This overcrowding can be a potential cause of undesirable outcomes in critically ill patients. The purpose of this study was to evaluate the effect of an alerting call, with a cellular phone, before the presentation of critically ill patients in overcrowded emergency care centers. METHODS: One hundred and two patients with cardiac arrest, altered mental status, dyspnea, and chest pain were brought to the emergency care center by 119 EMS (Emergency Medical Transport System) from July 2007 to August 2007 and March 2008 to April 2008 and were enrolled in this study. The EMS made 39 alerting calls with a cellular phone before arrival to the ECC. Each alerting call was answered by the senior resident emergency physician over a 24 hour period. We prospectively reviewed the data and compared the cases with an alerting call to those without such a call. RESULTS: Thirty-nine (38%) patients arrived at the ECC with an alerting call and 63 (62%) without one. The general characteristics between the two groups were not different. The mean duration for the initiation of care for the patients with a cardiac arrest, with an alerting call, was faster than for those who arrived without an alerting call; the difference in the start of compressions was significant (p=0.006). For patients with altered mental status, all variables studied showed a significant statistical difference (p<0.001) between the two study groups. For acute dyspnea and chest pain, the first set of vital signs (p=0.004) and the ABG (p=0.001) were significantly different between the two groups. The mean time to the initiation of care was faster for the patients with an alerting call than for those without an alerting call. CONCLUSION: The initiation of care in critically ill patients was significantly faster with a cellular phone alerting call before the patient's arrival to the ECC. Therefore, an alerting call from the 119 EMS to the ECC appears to improve the time to initiating emergency care of critically ill patients in the ECC.

Do You Follow The ACLS Guideline?

PURPOSE: In 2000, the American Heart Association and International Liaison Committee on Resuscitation published guidelines for CPR (Cardiopulmonary Resuscitation), and these guidelines were revised in 2005. Many physicians perform CPR differently than suggested by these guidelines. We investigated guideline conformation rates for CPR by non-emergency physicians. METHODS: From January 1st, 2005, to December 31st, 2005, and from January 1st, 2007, to September 30th, 2007, 103 in-hospital CPR cases were enrolled. We separated the 103 cases into two groups: 2005 patients and 2007 patients. Fifty-two cases in the 2005 group and 51 cases in the 2007 group were enrolled. The defibrillation method, defibrillation energy, epinephrine use, and atropine use were analyzed. RESULTS: Nineteen cases (82.6%) in the 2005 group and three cases (21.4%) in the 2007 group were performed using the appropriate defibrillation method (p=0.0002). Seventeen cases (73.9%) in the 2005 group and four cases (28.6%) in the 2007 group received the appropriate defibrillation energy (p=0.0069). Seven cases (14.0%) in the 2005 group and 16 cases (32.0%) in the 2007 group used the appropriate epinephrine dose (p=0.0325). Fourteen cases (28.0%) in the 2005 patient group and 14 cases (29.2%) in the 2007 patient group used the appropriate atropine dose (p=0.8983). CONCLUSION: Although CPR guidelines were renewed in 2005, many physicians do not follow these guidelines. We suggest that adequate information, education, feedback, and further study are needed for guideline conformation.

Correlation between High Resolution Dynamic MR Features and Prognostic Factors in Breast Cancer

OBJECTIVE: To correlate high resolution dynamic MR features with prognostic factors in breast cancer. MATERIALS AND METHODS: One hundred and ninety-four women with invasive ductal carcinomas underwent dynamic MR imaging using T1-weighted three-dimensional fast low-angle shot (3D-FLASH) sequence within two weeks prior to surgery. Morphological and kinetic MR features were determined based on the breast imaging and reporting data system (BI-RADS) MR imaging lexicon. Histological specimens were analyzed for tumor size, axillary lymph node status, histological grade, expression of estrogen receptor (ER), expression of progesterone receptor (PR), and expression of p53, c-erbB-2, and Ki-67. Correlations between the MR features and prognostic factors were determined using the Pearson chi-square test, linear-by-linear association, and logistic regression analysis. RESULTS: By multivariate analysis, a spiculated margin was a significant, independent predictor of a lower histological grade (p < 0.001), and lower expression of Ki-67 (p = 0.007). Rim enhancement was significant, independent predictor of a higher histological grade (p < 0.001), negative expression of ER (p = 0.001), negative expression of PR (p < 0.001) and a larger tumor size (p = 0.006). A washout curve may predict a higher level of Ki-67 (p = 0.05). Most of the parameters of the initial enhancement phase cannot predict the status of the prognostic factors. Only the enhancement ratio may predict a larger tumor size (p = 0.05). CONCLUSION: Of the BI-RADS-MR features, a spiculated margin may predict favorable prognosis, whereas rim enhancement or washout may predict unfavorable prognosis of breast cancer.

Factors in Delayed Arrival at the Emergency Department in Patients with Suspected Acute Stroke

PURPOSE: Acute stroke is a leading cause of serious, longterm disability and mortality in Korea. Two major refractory problems limiting effective stroke management are patient delays in recognizing stroke symptoms and reluctance to take action. The purpose of this study was to evaluate the actors influencing delayed arrival at the hospital in patients with suspected acute stroke. METHODS: One hundred and seventy-one patients with symptoms of acute stroke who presented to the emergency department (ED) between November 2004 and April 2005 were enrolled in the study. A questionnaire prospectively surveyed by emergency medicine residents was used in evaluating patients for inclusion. RESULTS: Fifty-eight patients (34% of the total) arrived at the hospital within 3 hours of symptom onset. As suggested by univariate analysis, initial symptoms (mental change and speech disturbance), presence or absence of bystanders at the time of symptom onset, utilization of an emergency medical service (EMS) system and inter-hospital transfer all seemed to be associated with the time interval between detection and ED arrival. Further evaluation using multiple linear regression indicated that severity of initial neurologic symptoms, use of EMS transport, the necessity of interhospital transfer, and score on the abnormal Los Angeles Prehospital Stroke Scale (LAPSS) were statistically significant factors affecting arrival time. CONCLUSION: Factors that were associated with earlier ED arrival were severe initial symptoms, utilization of the EMS system, direct arrival from the site of symptom onset, and abnormal LAPSS. Therefore, continuous public education and paramedic training is required to promote early detection and delivery of patients with acute stroke to an appropriate facility.

Pattern of Regional Emergency Medical Service Utilization and Its Determinants

PURPOSE: This study was performed to analyze the existing patterns of regional emergency medical service utilization and to identify their determinants. METHODS: The original data consisted of the Electronic Data Interchange (EDI) claims of the National Health Insurance about the utilization of emergency medical services in 2002. The relevance index and commitment index were calculated; Then, those indices were analyzed, by using clustering analysis, to categorize the regions. A multiple-regression test identified the determinants for the relevance index and the commitment index. RESULTS: Regional relevance indices were 91.8% for Jeonju-si, 91.4% for Seoul, 91.0% for Ulsan, and 90.9% for Gumi-si, while the commitment indices were 28.0% for Guri-si, 42.9% for Masan-si, 44.0% for Gangneung-si, and 45.3% for Uijeongbu-si. Regions were categorized into inflow-type (e.g., Seoul), mixed-type (e.g., Uijeongbu-si), and outflow-type (e.g., Pyeongtaek-si) by their relevance indices and commitment indices. The determinants for the relevance index and the commitment index were analyzed, and the significant variables affecting the relevance index were the number of emergency medical doctors per 100,000 population, the proportion of general hospitals, the proportion of local and regional emergency medical centers, and administrative districts while those affecting the commitment index were the number of emergency medical doctors per 100,000 population and the proportion of general hospitals. CONCLUSION: This study is the first trial to analyze nationwide data on the utilization of emergency medical services in Korea and to identify its determinants, and it can provide a practical evidence for policy planning for the allocation of emergency medical service resources.

Breast MR Imaging: Correlation of High Resolution Dynamic MR Findings with Prognostic Factors

PURPOSE: We wanted to correlate the kinetic and morphologic MR findings of invasive breast cancer with the classical and molecular prognostic factors. MATERIALS AND METHODS: Eighty-seven patients with invasive ductal carcinoma NOS underwent dynamic MR imaging at 1.5 T, and with using the T1-weighted 3D FLASH technique. The morphologic findings (shape, margin, internal enhancement of the mass or the enhancement distribution and the internal enhancement of any non-mass lesion) and the kinetic findings (the initial phase and the delayed phase of the time-signal Intensity curve) were interpreted using a ACR BI-RADS(R)174;-MRI lexicon. We correlate MR findings with histopathologic prognostic factors (tumor size, lymph node status and tumor grade) and the immunohistochemically detected biomarkers (ER, PR, p53, c-erbB-2, EGFR and Ki-67). Univariate and multivariate statistical analyses were then performed. RESULTS: Among the MR findings, a spiculated margin, rim enhancement and washout were significantly correlated with the prognostic factors. A spiculated margin was independently associated with the established predictors of a good prognosis (a lower histologic and nuclear grade, positive ER and PR) and rim enhancement was associated with a poor prognosis (a higher histologic and nuclear grade, negative ER and PR). Wash out was a independent predictor of Ki-67 activity. CONCLUSION: Some of the findings of high resolution dynamic MR imaging were associated with the prognostic factors, and these findings may predict the prognosis of breast cancer.

Plain Chest Radiographic Findings of Smoke Inhalation

PURPOSE: To evaluate the plain chest radiographic findings of smoke inhalation. MATERIALS AND METHODS:Our study included 72 burn patients who had suffered smoke inhalation. On admis-sion,all underwent serial portable chest AP radiography. We retrospectively reviewed the plain chest radi-ographs taken between admission and pootburn day five, evaluating the pattern, distribution, and time onset of direct injury to the respiratory system by smoke inhalation. The lesions were also assessed for change. RESULTS: In 16 of 72 patients (22%), abnormal findings of direct injury to the respiratory system by smoke in-halation were revealed by the radiographs. Abnormal findings were 15 pulmonary lesions and one subglottic tracheal narrowing. Findings of pulmonary lesions were multiple small patchy consolidations (10/15), peri-bronchial cuffing (8/15), and perivascular fuzziness (6/15). Patterns of pulmonary lesions were mixed alveolar and interstitial lesion (n=9), interstitial lesion (n=5), and alveolar lesion (n=1). No interlobular septal thicken-ing was observed. Pulmonary edema was distributed predominantly in the upper lung zone and perihilar re-gion, with asymmetricity. Its time of onset was within 24 hours in 13 cases, 24 -48 hours in two cases, and 48 -72 hours in one. Five of 16 patients progressed to ARDS. CONCLUSION: Chest radiographs showed that pulmonary lesions caused by inhalation injury were due to pul-monary edema, which the pattern of which was commonly mixed alveolar and interstitial.

MRI and CT Findings of Intracranial Neurosyphilis

PURPOSE: To evaluate the CT and MRI findings of neurosyphilis. MATERIALS AND METHODS: We retrospectivelyreviewed the CT and MR imaging findings in five patients with intracranial neurosyphilis confirmed by CSF, VDRL,TPHA, and clinical follow-up. MR imaging was performed in all five cases, and CT in two. RESULTS: The MRI and CTfindings of intracranial neurosyphilis included infarction (n=3), focal inflammation (n=1) and encephalopathy(n=1). There was a total of ten infaretions : three of the basal ganglia, two each of the frontal lobe, watershedzone, and cerebellum, and one of the occipital lobe. Intaretion was most common in MCA territory (n=9; 50%),followed by the watershed zone (16.6%), posterior cerebral artery territory (16.6%), and posterior inferiorcerebellar artery territory (11.1%), The size of the lesion varied from 1cm to larger than one lobe. One patientshowed diffuse high signal intensity in the left temporal lobe, but on follow-up MRI, this had resolved. CONCLUSION: The most common finding of neurosyphilis, as seen on MRI and CT, was infarction in middle cerebralarterial territory.

Foreignbody Removal Using Goose Neck Snare

PURPOSE: To valuate the value of goose neck snare in removal of foreignbody in endovascular system. METHODS & MATERIAL: Foreignbody removal in endovascular system using goose neck snare were done in 4 cases. In one case, a broken guide-wire was located in left subclaviar vein and in three cases, guide-wires were located in vena cava. RESULTS: Technical success was achieved in all four cases. CONCLUSION: Goose neck snare technique is safe and effective in removal of Foreignbody in endovascular system.

Bone and Joint changes following Electrical Burn: Plain Radiographic findings

PURPOSE: To evaluate the plain radiographic findings of bone and joint changes following electrical burn. MATERIALS AND METHODS: This study involved 19 patients with 27 bone and joints regions which had sufferedelectrical injury. The most common input and output sites were, respectively, the hand(7/14) and foot (6/10).Three other sites were involved. Four cases involved osteomyelitis, and in four, amputation was performed. Weobserved bone and joint changes, changes following osteomyelitis and changes in the amputation stump. We analyzedthe difference between input and output changes, and when this was interesting, the average time of onset wasassessed. RESULTS: In bone and joint changes following electrical burn, the most frequent radiographic findingwas joint contracture (n=16). Other findings included osteolysis (n=8), articular abnormalites (n=6), periostitis(n=5), fracture (n=5), acro-osteolysis (n=2), and heterotopic bone formation (n=2). In cases involvingosteomyelitis(n=4), aggravation of underlying bone changes was noted. CONCLUSION: In electrical burn, variouschanges were noted in bone and joints, and input injury was more severe than that of output.

The Effects of Handgrip and Cold Pressor Test on Mitral Flow in Patients with Left Ventricular Hypertrophy

BACKGROUND: Handgrip and cold pressor test may increase the afterload of the heart. And in left ventricular hypertrophy, it is known that mitral flow pattern is affected by decreased left ventricular compliance. We investigated the effects of handgrip and cold pressor test on mitral flow pattern in patients with left ventricular hypertrophy. METHODS: Handgrip and cold pressor test were performed in 12 subjects with left ventricular hypertrophy and in 14 healthy normal subjects. In supine position, blood pressure, heart rate and Doppler echocardiographic parameters(early peak flow velocity : E, atrial peak flow velocity : A) were obtained at rest, 1 and 3 minutes after the onset of tests respectively. RESULTS: In both groups, handgrip and cold pressor test increased blood pressure slightly without a statistical significance. In left ventricular hypertrophy group, there were significant increments in heart rates at 1 minute of handgrip (78+/-12min-1, p<0.001) and cold pressor test(77+/-7min-1, p<0.05) as compared to that at rest (73+/-12min-1). Mitral flow velocities did not show significant change after the tests in control group. A waves after 1 minute of handgrip(85.2+/-18.4cm/sec, p<0.05) and cold pressor test (87.3+/-17.8cm/sec, p<0.001) showed significant increases as compared to that at rest (79.1+/-14.9cm/sec) in left ventricular hypertrophy group whereas E waves did not. CONCLUSION: Although handgrip and cold pressor tests did not affect the mitral flow significantly in control group, each test raised A waves in left ventricular hypertrophy group. These results suggest that increased A waves may be due to a rise in afterload and decreased left ventricular compliance caused by handgrip and cold pressor test in left ventricular hypertrophy group.

Clinical study on urinary tract infections after renal transplantation / 대한신장학회잡지

No abstract available.