A prospective study about the discrepancy between postmortem inspections conducted by emergency physicians and forensic pathologists.

BACKGROUND: In South Korea, most postmortem examination certificates (death certificates) are issued by attending physicians working in the emergency department (ED). However, ED overcrowding has made continuous education and quality control of the postmortem examination certificate difficult. In this context, the National Forensic Service (NFS) is conducting an on-site postmortem inspection (OPI) project. AIMS: In this study, we analyzed the discrepancy between postmortem inspection conducted by emergency physicians and forensic pathologists and identified the effects of the OPI project. METHOD: The study examined cases where OPIs were conducted by NFS medical examiners (forensic pathologists) on patients who died on arrival or died in the ED where the OPI project is being conducted. The case reports written by emergency physicians were compared with the postmortem examination certificates written by medical examiners to analyze the discrepancy in cause and manner of death between the two groups. RESULT: A total of 75 field examinations were conducted during the study period, with a 56% agreement rate between the two groups regarding cause of death. Manner of death was consistent at 73.3% and the most common reason for requesting an OPI was that the cause of death was presumed to be natural, but what that cause may be was unclear. CONCLUSION: The discrepancy in postmortem examinations between emergency physicians and medical examiners is attributed to various factors. To ensure more reliable postmortem examinations, emphasis should be placed on improving the death investigation system and quality control activities for physicians.

Validation and proposal for cut-off values of an abbreviated version of the Alcohol Use Disorder Identification Test using the Korean National Health and Nutrition Examination Survey.

OBJECTIVE: Several abbreviated versions of the Alcohol Use Disorder Identification Test (AUDIT) have been developed and are widely used in clinical settings. In this study, we provide evidence supporting the use of abbreviated versions of AUDIT by comparing the utility of various abbreviated versions and determining cut-off values for the population of South Korea. METHODS: Data were obtained from the 4th to 6th Korean National Health and Nutrition Examination Surveys. After calculating the whole AUDIT score, we applied the cut-off value of at-risk drinking proposed by the World Health Organization and divided the study sample into normal and at-risk drinking groups. Receiver operating characteristic curves were drawn for AUDIT-3rd question (Q3) alone, AUDIT-quantity and frequency (QF), AUDIT-consumption (C), AUDIT-4, and AUDIT-primary clinic (PC), and optimal cut-off values were obtained for each group. RESULTS: A total of 46,450 subjects were analyzed. The at-risk drinking group comprised 29.2% of all subjects. The area under receiver operating characteristic curve (AUROC) of the abbreviated versions of AUDIT increased from 0.954 to 0.991 as the number of questions increased from one to four. The differences in AUROC between the abbreviated versions of AUDIT were statistically significant. The most appropriate cut-off values for AUDIT-Q3 alone, AUDIT-QF, AUDIT-C, AUDIT-4, and AUDIT-PC for adults over age 19 were 2, 4, 5, 6, and 4 points, respectively. CONCLUSION: As the number of items analyzed increased from one to four items, the AUROC increased to a statistically significant level. Cut-off values for abbreviated versions of AUDIT are similar in South Korea to other countries.

Screening Test for At-Risk Drinking: Development of New Abbreviated Version of Alcohol Use Disorder Identification Test for Young and Middle-Aged Adults.

Several abbreviated versions of the Alcohol Use Disorders Identification Test (AUDIT) have been developed for use in high-volume clinical situations such as emergency departments. In this study, we developed a new abbreviated version of AUDIT called the Screening Tool for At-risk Drinking (STAD) for young and middle-aged adults, consisting of two questions that reflect the structure of the AUDIT questionnaire using data from the Korea National Health and Nutrition Examination Survey (KNHANES). To derive the abbreviated test considering AUDIT item structure, we performed confirmatory factor analysis on the 10 AUDIT questions in the Korea National Health and Nutrition Examination Survey (KNHANES) IV. To validate the new abbreviated test, we analyzed the sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) on the KNHANES V-VI except for the KNHANES VI-2. Based on the two-factor structure of AUDIT, question (Q) 3 and Q7 were finally selected for STAD. In validation, AUROC was significantly wider for STAD than for AUDIT-QF, which has the same number of questions. There was no significant difference between AUDIT-C, consisting of three questions, and STAD. It can be used as a simple and reliable screening test in clinical settings.

Body mass index as a prognostic factor in organophosphate-poisoned patients.

Organophosphate poisoning is a serious clinical entity and considerable morbidity and mortality. Several factors have been identified to predict outcomes of organophosphate poisoning. Organophosphates are lipophilic and therefore predicted to have a large volume of distribution and to rapidly distribute into tissue and fat. Thus, toxic effects of organophosphate would be expected to last longer in obese patients. We investigated the relationship between obesity and clinical course in 112 acute organophosphate-poisoned patients from an initial medical record review of 234 patients. One hundred twenty-two patients were excluded: 6 were children, 14 had an uncertain history of exposure and of uncertain agent, 10 were transferred to another hospital, 67 were discharged from the emergency department because their toxicity was mild, 21 had carbamate poisoning, and 4 did not have height or weight checked. Clinical features, body mass index, Glasgow Coma Scale, laboratory findings, serum cholinesterase activity, electrocardiogram finding, management, and outcomes were examined. The lipid solubility of the implicated organophosphate was characterized by its octanol/water coefficient. Forty of 112 patients were obese. Obese patients who were poisoned by high lipophilicity organophosphate compounds had a need for longer use of mechanical ventilation, intensive care unit care, and total length of admission. Body mass index can provide a guide to physicians in predicting clinical course and management in organophosphate-poisoned patients.

Characteristics of intentional fall injuries in the ED.

INTRODUCTION: This study was conducted to examine the characteristics of intentional fall injuries and the factors associated with their prognosis. METHODS: The study included 8992 patients with unintentional falls from a height (nonintentional group) and 144 patients with intentional falls from a height (intentional group). General and clinical characteristics were compared between the 2 groups. Intentional fall cases were divided into severe and nonsevere groups, and the factors associated with severe injury were evaluated by comparing these groups. RESULTS: The most common age group was younger than 14 years in the nonintentional group and between 30 and 44 years old in the intentional group. For the nonintentional group, 65% of the patients were male, and 48% were male in the intentional group. Fall heights of more than 4 m were most common in the intentional group. Discharge was the most common result in the nonintentional group; however, death before arrival at the emergency department (ED) or during ED treatment occurred in 54.9% of patients in the intentional group. In the severe injury group within the intentional group, patients were older, and the height of the fall was higher. Factors associated with severe injury in the intentional group included being a high school graduate rather than a college graduate and greater fall height. CONCLUSION: The risk of severe injury increased with fall height in the intentional group, and a high school level of education rather than a college level of education was associated with more severe injury.

Characteristics of patients who visit the emergency department with self-inflicted injury.

During visits to emergency medical facilities, the primary care of and risk identification for individuals who have attempted suicide is considered an important element in suicide prevention. With the ultimate goal of helping to prevent suicide, the aim of the present study was to determine the characteristics of patients with self-inflicted injuries who presented in the emergency department. Patients with self-inflicted injuries who visited 1 of 3 sentinel emergency medical centers from 2007 through 2009 were included in the study. The characteristics, methods, and reasons for suicide attempts were evaluated. Moreover, predictors of severe outcomes were evaluated. A total of 2,996 patients with self-inflicted injuries visited the three centers during a period of 3 yr. The male-to-female suicide ratio was 1:1.38 (P < 0.001). The mean age was 41 yr. Poisoning was the most common method of self-inflicted injury (68.7%) among all age groups. Medication was the primary means of injury in the < 50 age group, and the use of agricultural chemicals was the primary means in the ≥ 50 age group. The reasons for attempting suicide varied among the age groups. The predictors of severe outcome are male gender, older age, and not having consumed alcohol.

Emergency cricothyrotomy for trismus caused by instantaneous rigor in cardiac arrest patients.

Instantaneous rigor as muscle stiffening occurring in the moment of death (or cardiac arrest) can be confused with rigor mortis. If trismus is caused by instantaneous rigor, orotracheal intubation is impossible and a surgical airway should be secured. Here, we report 2 patients who had emergency cricothyrotomy for trismus caused by instantaneous rigor. This case report aims to help physicians understand instantaneous rigor and to emphasize the importance of securing a surgical airway quickly on the occurrence of trismus.

Characteristics of alcohol-related injuries in adolescents visiting the emergency department.

Alcohol is frequently a factor affecting emergency department patients, and alcohol consumption is more common among those who are injured. In Korea, the socioeconomic impact of alcohol has been enormous because of traditional permissive attitudes toward alcohol. Juvenile drinking has increased recently; consequently, an increase in alcohol-related injuries is likely in this population. Therefore, we compared the characteristics and severity of alcohol-related injuries in adolescents and adults. All injured patients seen at six EDs throughout 2007 were included. We obtained data from the 'Development of a model for an in-depth injury surveillance system based on the emergency department' surveillance. The proportion of adolescents who drank was 5.0%. No significant alcohol-related difference in injuries was found between male and female adolescents (P = 0.14), whereas in adults, being male was strongly related to alcohol consumption (P < 0.001). Among traffic accidents, motorcycle-related injuries were strongly associated with alcohol use in adolescents (odds ratio [OR] 2.52, 95% confidence interval [CI] 1.09-5.83). Results also indicated that alcohol-related injuries in adolescents showed poor outcomes (OR 2.36, 95% CI 1.47-3.81) as compared with those in adults (OR 1.42, 95% CI 1.26-1.59). Preventive strategy on alcohol-related injuries in adolescents should focus on reducing motorcycle accidents.

Use of maximal sterile barrier precautions and/or antimicrobial-coated catheters to reduce the risk of central venous catheter-related bloodstream infection.

Central venous catheter-related bloodstream infection is clinically important because of its high mortality rate. This prospective study shows by multivariate analysis that the use of maximal sterile barrier precautions (odds ratio, 5.205 [95% confidence interval, 0.015-1.136]; P=.023) and the use of antimicrobial-coated catheters (odds ratio, 5.269 [95% confidence interval, 0.073-0.814]; P=.022) are independent factors associated with a lowered risk of acquiring a central venous catheter-related bloodstream infection.

Utility of the international classification of diseases injury severity score: detecting preventable deaths and comparing the performance of emergency medical centers.

OBJECTIVE: The purpose of this study was to assess the ability of the International Classification of Diseases-based Injury Severity Score (ICISS) to detect preventable deaths, and to compare the performance of trauma care facilities. METHODS: For 2 years, from 1997 to 1998, 131 trauma deaths and 1,087 blunt trauma inpatients from 6 emergency medical centers (EMCs) in Korea were reviewed. Trauma deaths were reviewed and the preventability of those deaths was judged by two professional panels. For both trauma deaths and trauma inpatients, the survival probability of each trauma patient was assessed using the ICISS full model. The degree of agreement in the preventability of trauma death between survival probability on the basis of the ICISS and judgment rendered by professional panels was determined, and the correlation between the W-score and the preventable death rate in each EMC was also assessed. RESULTS: The overall agreement rate between ICISS survival probability and preventable deaths judged by professional panels was 66.4% (kappa statistic, 0.36), and the positive predictive value of the ICISS in detecting preventable trauma deaths was 54.1% and the negative predictive value was 84.8%. The Spearman correlation coefficient between the W-score and the preventable death rate by each EMC was -0.77 (p = 0.07). CONCLUSION: The degree of agreement in the preventability of trauma death derived from the ICISS with a professional judgment on preventability was similar to that derived from the Trauma and Injury Severity Score. The W-scores of EMCs correlated well with their preventable death rates, with marginal statistical significance. This study has demonstrated that the ICISS is useful in detecting preventable deaths and in comparing the performance of trauma care facilities.