Predicting acute aortic syndrome using aortic dissection detection risk score, D-dimer, and X-ray.

Objective: Acute aortic syndrome (AAS) is a fatal disease with high mortality. There were previous studies using aortic dissection detection risk score (ADD-RS) and D-dimer (DD) to screen AAS. There were screening failures in previous studies, suggesting the need for a more accurate tool. This study investigated the effect of combining ADD-RS and age adjusted D-dimer (DDage-adj) with abnormal findings on chest radiographs on the diagnosis of AAS in patients admitted to emergency department (ED). Methods: This single-center retrospective case-control study included 93 patients with AAS and 465 with chest pain (CP), diagnosis other than AAS. We attempted to compare the initial clinical presentation and laboratory examination findings. Results: Age-adjusted DD (DDage-adj), defined as age x 0.01 mg/L in patients ≥50 years, showed sensitivity of 92.5% and specificity of 76.3% for patients with AAS (p < 0.001). Positive chest radiography findings were significant with AAS group; sensitivity was 89.2% with a specificity of 80.9% (p < 0.001). Multivariate logistic regression analysis was used; widened mediastinum, widening of aortic contour and aortic kinking indicates the probability of AAS in patients with CP (p < 0.05).ADD-RS was used to evaluate the risk of AAS. For low risk group, ADD-RS ≤1, combined use of chest radiography and DDage-adj showed meaningful result. Sensitivity and specificity were 100% and 67.1% with failure rate of 0% (p < 0.001). Multivariate logistic regression analysis were made; widening of the mediastinum (p = 0.035), widening of the aortic contour (p < 0.001) and aortic kinking (p < 0.001) showed significant p-value. Combining DDage-adj and these three chest radiography findings in ADD-RS≤1 patients resulted 0% failure rate with 67.8% specificity (p < 0.001). Conclusions: The combination of ADD-RS, DDage-adj and chest radiography could lower the failure rate of AAS exclusion strategy. This combination strategy satisfies low failure rate (<3%) and yields relatively high specificity of 67.8%.

A case of paragonimiasis inducing bilateral pneumothorax with lung and liver involvement.

Pulmonary paragonimiasis can occasionally induce bilateral pneumothorax and cause lesions in ectopic organs such as the liver. We report the case of a 26-year-old man who had been treated for bilateral hydropneumothorax one month earlier and returned to the emergency center complaining of epigastric pain that had persisted for four months. After being diagnosed with pulmonary and hepatic paragonimiasis, he was treated with praziquantel and his condition improved without complications.

Clinical differentiation between acute renal infarction and acute ureteral stone in the emergency department: A single-center retrospective case-control study.

BACKGROUND: Few studies have compared renal infarction (RI) and ureteral stone (US), so there is insufficient evidence for emergency clinicians (ECs) to quickly suspect RI during the first assessment. Therefore, we compared the initial clinical presentation and laboratory findings of these diseases in the emergency department (ED) to determine a factor that may indicate RI. METHODS: This single-center retrospective case-control study included 42 patients with acute RI and 210 with US who visited the ED from 2014 to 2020. Medical record data from first ED arrival were investigated, and clinical presentations, blood and urine test results obtained in the ED were compared and analyzed using logistic regression analysis. RESULTS: ECs never suspected the initial diagnosis of RI as RI. The most common initial diagnosis was US (40.5%). Among patients with US, 150 patients (71.4%) were suspected of having US (p < 0.001). Abdominal pain (61.9%) was the most common chief complaint in the RI group, and flank pain (73.8%) was the most common in the US group (p < 0.001). 27 factors showed significant differences between the groups. Among those, age ≥ 70 years (odds ratio [OR]: 311.2, 95% confidence interval [CI]: 2.0-47,833.1), history of A-fib (OR: 149872.8, 95% CI: 289.4-7.8E+07), fever ≥37.5 °C (OR: 297.3, 95% CI: 3.3-27,117.8), Cl- ≤ 103 mEq/L (OR: 9.0, 95% CI: 1.0-80.1), albumin ≤4.3 g/dL (OR: 26.6, 95% CI: 2.1-330.3), LDH ≥500 IU/L (OR: 17.9, 95% CI: 1.8-182.5), and CRP ≥0.23 mg/dL (OR: 7.5, 95% CI: 1.1-52.3) showed significantly high ORs, whereas urine RBCs (OR: 0, 95% CI: 0-0.02) showed a low OR (p < 0.05). The regression model showed good calibration (chi-square: 6.531, p = 0.588) and good discrimination (area under the curve = 0.9913). CONCLUSIONS: When differentiating acute RI from US in the ED, age ≥ 70 years, history of A-fib, fever ≥37.5 °C, LDH ≥500 IU/L, Cl- ≤ 103 mEq/L, albumin ≤4.3 g/dL, CRP ≥0.23 mg/dL and negative urine RBC result suggest the possibility of RI.

Poisoning due to consumption of horse chestnut seed.

Horse chestnut (Aesculus hippocastanum) is a common tree found on roads and parks. The shape of the fruit is very similar to that of the edible Korean chestnut (Castanea crenata); thus, people can eat it by mistake. However, reports of the side effects and toxicity from ingestion are very rare. A 46-year-old male who had no unusual findings in the past had eaten horse chestnut seed which he had mistaken to be Korean chestnut. He visited the emergency department (ED) with complaints of epigastric pain, nausea, and sweating. Blood tests showed a slight increase in the levels of liver enzymes, serum amylase, and pancreatic amylase. During the monitoring, he complained of palpitations, and electrocardiogram showed atrial fibrillation. On the following day after conservative treatment, blood testing and electrocardiogram showed normal findings. He was discharged from the ED as he did not complain of any further symptoms. When a patient who has eaten horse chestnut visits the ED, blood examination and electrocardiogram monitoring are needed, and conservative treatment is required.

Indoor environmental quality, occupant satisfaction, and acute building-related health symptoms in Green Mark-certified compared with non-certified office buildings.

Indoor environmental quality (IEQ) has become an important component of green building certification schemes. While green buildings are expected to provide enhanced IEQ, higher occupant satisfaction, and less risks of occupant health when compared with non-green buildings, the literature suggests inconsistent evidence due to diverse research design, small sample size, and weak statistical analysis. This study compared several outcomes pertinent to IEQ performance in green and non-green office buildings in Singapore. Adopting a cross-sectional study design, objective measurements were taken in eight green and six non-green buildings, and satisfaction and acute health symptom risks of 367 occupants were obtained. Green buildings exhibited lower concentration of PM2.5, bacteria, and fungi and maintained temperature and humidity more consistently compared to non-green counterparts. The mean ratings for satisfaction with temperature, humidity, lighting level, air quality, and indoor environment were higher in green buildings (with statistical significance P < 0.05). There was statistically significant reduction in risk of occupants having headache, unusual fatigue, and irritated skin in green buildings. Although matching of buildings and occupant characteristics, survey participation bias, and sampling duration (a 1-week snapshot) of IEQ monitoring remain as limitations, this study offered positive association of green buildings with qualitatively and quantitatively measured performance of IEQ.

Changes in medical care due to the absence of internal medicine physicians in emergency departments.

OBJECTIVE: Especially in emergency departments (EDs), a lack of internal medicine (IM) residents in charge causes difficulties in medical care and ED overcrowding. Thus, protocols without IM residents in EDs is needed. This study aimed to investigate changes in medical care when emergency medicine residents replaced the roles of IM residents. METHODS: This study was conducted at a single-site ED of a university medical center. The study group contained patients admitted to the IM department between September and December 2015, during which IM residents were absent in the ED. The control group contained patients admitted to the IM department between September and December 2014, during which IM residents were present in the ED. Changes in medical care between the presence and absence of IM residents in the ED were studied by comparing admission rates from the ED, length of ED stay, duration of hospitalization, and concordance of diagnoses between admission and discharge by the IM department. RESULTS: The study group contained 2,341 patients; the control group contained 2,215 patients. Admission rates from the ED increased by 53.4% (95% confidence interval [CI], P<0.001); lengths of stay decreased by 15.1% (95% CI, P<0.001); and durations of hospitalization in the pulmonology department decreased by 38.4% (95% CI, P=0.001). Concordance of diagnoses between admission and discharge decreased by 14.2% in the cardiology department (95% CI, P=0.021). CONCLUSION: Lengths of stay were reduced without critical declines in diagnostic concordance rates when emergency medicine physicians, instead of IM residents in the ED, decided upon admissions of IM patients.

Ingestion of Portland Cement.

BACKGROUND: The common toxicities of cement are allergic dermatitis, abrasions, and chemical burns, but reports of cement ingestion are rare. In this study, we report a case of successful treatment of cement ingestion using emergency gastrointestinal endoscopy. CASE REPORT: An 83-year-old female was admitted to the emergency department with altered mental state and abdominal pain. We assumed that she ingested cement based on her medical history and radiologic examination. A previous report recommended surgical removal with gastric lavage. However, we thought that wet cement is highly alkaline, and gastric lavage is contraindicated. We performed emergency gastrointestinal endoscopy, instead of gastric lavage. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: If a patient ingests cement, the recommendation is to check the status of the upper gastrointestinal tract and remove the cement by emergency gastrointestinal endoscopy as soon as possible.

Comparison of the therapeutic effect between sodium bicarbonate and insulin on acute propafenone toxicity.

PURPOSE: Unlike other sodium-channel-blocking antiarrhythmic agents, propafenone has ß-blocking effects and calcium-channel-blocking effects. Yi et al recently studied insulin's treatment effect on acute propafenone toxicity in rats. However, because the degree of effectiveness of insulin compared to the previously known antidote sodium bicarbonate (NaHCO3) was not studied, the 2 treatment methods were compared for propafenone intoxication in rats. METHODS: Rats received intravenous propafenone (36 mg/[kg h]) for 12 minutes. After the induction of toxicity, rats (n = 10 per group) received normal saline solution (NSS), NaHCO3, or insulin with glucose as treatment. Animals in the NSS, NaHCO3, and Insulin groups received an intravenous infusion of 36 mg/(kg h) propafenone until death occurred. For each animal, the mean arterial pressure (MAP, heart rate, PR interval, QRS duration, total hemoglobin, sodium, potassium, potential of hydrogen, bicarbonate, glucose, lactate, and central venous oxygen saturation (Scvo2) were measured and compared among the groups. RESULTS: Survival of the Insulin group was greater than that of the NSS group by log-rank test (P = .021). Sodium bicarbonate prevented the decline of MAP for 55 minutes. In comparison, insulin prevented the decline of MAP and heart rate, and the elongation of the PR interval and QRS duration for 55 minutes (P < .05). Propafenone toxicity led to decreased Ca(2+), potential of hydrogen, and Scvo2 and increased lactate levels. Insulin prevented the decrease of Ca(2+) and Scvo2, whereas NaHCO3 prevented the increase in lactate. CONCLUSION: Insulin treatment was more effective than NaHCO3 on acute propafenone toxicity in rat. Therefore, when propafenone-induced cardiotoxicity occurs, which is unresponsive to current treatment methods, glucose-insulin infusion may be considered.

Naproxen-induced methemoglobinemia in an alcohol-dependent patient.

The authors report a case of acute methemoglobinemia in a patient treated with naproxen for the common cold. A 42-year-old Asian woman began taking naproxen sodium and methocarbamol formylagia, chills, and coughing. On the day prior to her emergency department (ED) admission,the patient was taking lorazepam, trazodon, and paroxetine in addition to the naproxen and methocarbamol prescribed for the cold symptoms, and she also ingested approximately 300 mL of 20% alcohol. Upon awakening the next morning, the patient experienced dyspnea and dizziness. At the hospital, she was diagnosed with severe methemoglobinemia. After initiation of methylene blue therapy, the patient's symptoms improved substantially and her serum methemoglobin levels decreased. After 10 days in the hospital, the patient was discharged without any complications.Naproxen is known to cause oxidative stress. Alcohol is known to reduce G6PD activity, and thus it is hypothesized that the administration of naproxen in an alcohol-dependent patient caused methemoglobinemia.

Cardioprotective effect of glucose-insulin on acute propafenone toxicity in rat.

OBJECTIVE: We recently observed a case of propafenone self-poisoning in which the patient was initially unresponsive to conventional therapies such as sodium bicarbonate, dopamine, and norepinephrine but recovered with intravenous glucose-insulin infusion. We raised the hypothesis that insulin may have a cardioprotective effect in acute propafenone toxicity. METHODS: We evaluated the effect of glucose-insulin infusion on mortality and electrocardiographic abnormalities during acute propafenone toxicity in rats. After measurements of basal mean arterial pressure, heart rate, PR interval, and QRS duration, rats received intravenous propafenone (36 mg/kg per hour) for 12 minutes. Two minutes after the induction of toxicity, the rats (n=10 per group) received either normal saline solution (NSS) or insulin with glucose. Rats in the insulin-treated (Insulin group) and the NSS-treated (NSS group) groups received an intravenous infusion of 36 mg/kg per hour of propafenone until death occurred. Rats receiving only NSS intravenously without propafenone toxicity served as control (Control group, n=10). RESULTS: Insulin treatment improved survival and delayed the hemodynamic and electrocardiographic consequences of propafenone toxicity. Survival was significantly greater in the insulin group than that in the NSS group (P<.001). Insulin prevented the decline in mean arterial pressure and heart rate (P<.05). Insulin also prevented the increase of the PR interval and the QRS duration (P<.05). CONCLUSION: Glucose-insulin infusion delayed the abnormalities in cardiac conduction and improved rat survival after acute propafenone toxicity. These results suggest a cardioprotective effect of glucose-insulin in acute propafenone toxicity.

Identification of Soybean mosaic virus Strains by RT-PCR/RFLP Analysis of Cylindrical Inclusion Coding Region.

A reverse-transcriptase polymerase chain reaction/restriction fragment length polymorphism (RT-PCR/RFLP) was employed successfully for detection and identification of Soybean mosaic virus (SMV) strains. A primer pair amplifying a 1,385-bp fragment of the cylindrical inclusion (CI) coding region was used for RT-PCR and the RFLP profiles of the RT-PCR products were compared after restriction digestion with RsaI, EcoRI, or AccI restriction endonucleases. These enzymes were chosen based on the nucleotide sequences of SMV strains G2, G5, G5H, G7, and G7H in the CI coding region. These five strains, as well as seedborne SMV isolates from local soybean cultivars, could be differentiated by RT-PCR/RFLP analysis. The results correlated well with strain identification by symptom phenotypes produced on differential cultivars inoculated with strains and isolates. The sensitivity of RT-PCR enabled detection of SMV from plants with necrotic symptoms in which the number of virus particles was too low to be detected by enzyme-linked immunosorbent assay.