Seokyong Ryu

Use of S-100B, NSE, CRP and ESR to predict neurological outcomes in patients with return of spontaneous circulation and treated with hypothermia

Background With the introduction of therapeutic hypothermia (TH), the prediction of neurological outcomes in cardiac arrest (CA) survivors is challenging. Early, accurate determination of prognosis by emergency physicians is important to avoid unnecessarily prolonged critical care with a likely poor neurological outcome. Methods This prospective observational study included patients with non-traumatic CA and return of spontaneous circulation (ROSC) between March 2009 and May 2012 at a tertiary academic hospital. Unconscious patients with ROSC were treated with mild TH (32°C–34°C) for 24 hours. Blood samples were collected for S-100B, neuron-specific enolase (NSE), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) at 0, 24 and 48 hours post-ROSC. Neurological outcomes were evaluated at hospital discharge and dichotomised as good (cerebral performance category (CPC) 1 or 2) or poor (CPC 3, 4 or 5). Results Of the 119 patients (68.1% male, 53±15.6 years old) who underwent TH, 46 patients had a good outcome (38.9%). Poor neurological outcomes were predicted using receiver operating characteristic analyses at cut-off values of 0.12 g/L for S-100B at 24 hours post-ROSC (sensitivity, 95.0%; specificity, 75.6%; area under the curve (AUC) 0.916; 95% CI of AUC: 0.846 to 0.961), 31.03 ng/mL for NSE at 48 hours post-ROSC (sensitivity, 83.9%; specificity, 96.9%; AUC 0.929; 95% CI of AUC: 0.836 to 0.979) and 11.2 mg/dL for CRP at 48 hours post-ROSC (sensitivity, 69.4%; specificity, 75.0%; AUC 0.731; 95% CI of AUC: 0.617 to 0.827). ESR was not significant. Conclusions Among the biomarkers, S-100B at 24 hours and NSE at 48 hours post-ROSC were highly predictive of neurological outcomes in patients treated with TH after CA.

Brain Computed Tomography Compared with Facial 3-Dimensional Computed Tomography for Diagnosis of Facial Fractures

Objectives To compare the detection of facial fractures and radiation dose between brain computed tomography (CT) and facial 3‐dimensional (3D) CT in pediatric patients who have experienced a trauma. Study design Four hundred pediatric patients who experienced a trauma and underwent immediate brain CT and facial 3D CT between January 2016 and June 2016 were included in this retrospective study. Two reviewers independently analyzed and determined the presence of the facial fractures of 8 anatomic regions based on brain CT and facial 3D CT over a 1‐week interval. Suggested treatment decisions for facial fractures seen on brain CT and facial 3D CT were evaluated by one physician. The facial 3D CT scans, interpreted by a senior radiologist, were considered as the reference standard. Diagnostic performance, radiation dose, and interobserver agreement of the CT scans were evaluated. Results Brain CT showed a high sensitivity (94.1%‐96.5%), high specificity (99.7%‐100%), and high accuracy (98.8%‐99.0%) in both reviewers, and performed as well as did facial 3D CT (P ≥ .25). The suggested treatment decision was not different between the brain CT and facial 3D CT findings. The agreements between the reference standard and the reviewers, and between reviewers 1 and 2 were excellent (k = 0.946‐0.993). The mean effective radiation doses used in brain CT (3.6 mSv) were significantly lower than those in brain CT with facial 3D CT (5.5 mSv) (P < .001). Conclusions Brain CT showed acceptable diagnostic performance and can be used as the first‐line imaging tool in the workup of pediatric patients with suspected facial fractures.

Acute abdominal pain due to spontaneous rupture of the right gastric artery

Abdominal apoplexy was reported by Barber in 1909, and the occurrence rate of the apoplexy is known to be quite rare, but the mortality is high if untreated. We report an unusual case of abdominal apoplexy due to spontaneous rupture of gastric artery. A male patient in his fifth decade with recently diagnosed liver cirrhosis history arrived to the emergency department with severe abdominal pain, which led to abdominal computer tomography indicating spontaneous rupture of gastric artery. Celiac angiogram and embolization were conducted, and exploratory laparotomy was followed. The outcome of the patient was poor, and he died on the second day of admission. As in our case, the mortality can be high, so prompt restoration of circulation volume and early diagnosis should be made in similar cases.

Neutrophil-to-lymphocyte ratio as a feasible prognostic marker for pyogenic liver abscess in the emergency department

PurposeThe neutrophil-to-lymphocyte ratio (NLR) is an effective predictor of mortality in patients with for various conditions. To date, there are no previous studies on NLR as a prognostic marker for pyogenic liver abscess (PLA), especially on admission to the emergency department (ED).MethodsFrom January 2013 to December 2015, 102 patients diagnosed with PLA in the ED were included. Clinico-radiological and laboratory results, including NLR, were evaluated as variables. NLR was calculated as absolute neutrophil count/absolute lymphocyte count. To evaluate the prognosis of PLA, data on hospital mortality, intensive care unit (ICU) admission, and development of septic shock were obtained. Multivariate logistic regression analyses and receiver-operating characteristic (ROC) curve analysis were performed.ResultsAmong 102 patients, 10 (9.8%) died, 14 (13.7%) were admitted to the ICU, and 15 (14.7%) developed septic shock during hospitalization. Multivariate logistic regression analysis revealed NLR as an independent factor in predicting death [odds ratio (OR), 1.4; p = 0.020], ICU admission (OR, 1.4; p = 0.021), and development of septic shock (OR, 1.6; p = 0.041). NLR showed an excellent predictive performance for death (areas under the ROC curves [AUC], 0.941; cut-off value, 19.7; p < 0.001), ICU admission (AUC, 0.946; cut-off value, 16.9; p < 0.001), and development of septic shock (AUC, 0.927; cut-off value, 16.9; p < 0.001).ConclusionNLR was positively associated with poor prognosis of PLA; elevated NLR could predictor of high risk of death, ICU admission, and development of septic shock. Emergency physicians should consider NLR for the prognosis of PLA and early aggressive treatment, especially in patients with NLR > 16.9.

Air pollutants and atmospheric pressure increased risk of ED visit for spontaneous pneumothorax

Objective: To investigate the impact of short‐term exposure to air pollutants and meteorological variation on ED visits for primary spontaneous pneumothorax (PSP). Material and methods: We retrospectively identified PSP cases that presented at the ED of our tertiary center between January 2015 and September 2016. We classified the days into three types: no PSP day (0 case/day), sporadic days (1–2 cases/day), and cluster days (PSP, ≥3 cases/day). Association between the daily incidence of PSP with air pollutants and meteorological data were determined using Poisson generalized‐linear‐model to calculate incidence rate ratio (IRRs) and the use of time‐series (lag‐1 [the cumulative air pollution level on the previous day of PSP], lag‐2 [two days ago], and lag‐3 [three days ago]). Results: Using multivariate logistic regression analysis, O3 (p = 0.010), NO2 (p = 0.047), particulate matters (PM)10 (p = 0.021), and PM2.5 (p = 0.008) were significant factors of PSP occurrence. When the concentration of O3, NO2, PM10, and PM2.5 were increased, PSP IRRs increased approximately 15, 16, 3, and 5‐fold, respectively. With the time‐series analyses, atmospheric pressure in lag‐3 was significantly lower and in lag‐2, was significantly higher in PSP days compared with no PSP days. Among air pollutant concentrations, O3 in lag‐1 (p = 0.017) and lag‐2 (p = 0.038), NO2 in lag‐1 (p = 0.015) and lag‐2 (p = 0.009), PM10 in lag‐1 (p = 0.012), and PM2.5 in lag‐1 (p = 0.021) and lag‐2 (p = 0.032) were significantly different between no PSP and PSP days. Conclusion: Increased concentrations of air pollutants and abrupt change in atmospheric pressure were significantly associated with increased IRR of PSP.

Intentional cyanoacrylate ingestion: A rare cause of delayed gastric perforation requiring gastric wedge resection

Cyanoacrylate (LOCTITE® 401™) is a fast-acting adhesive available nationwide, with medical and household uses. Most cases of cyanoacrylate exposure are accidental and occur in children less than 5years old. Various routes of exposure have been reported including the dermal, oral, ocular, otic, nasal, and urethral routes; however, very few result in serious complication and mortality. Although a few cases of airway obstruction related to cyanoacrylate ingestion have been reported, intentional cyanoacrylate ingestion-induced gastrointestinal tract injury has scarcely been reported. In addition, there have been no reports of serious complications following intentional cyanoacrylate ingestion requiring surgical intervention. Herein, we report a case of intentional ingestion of cyanoacrylate in a 70-year-old man who required gastric wedge resection due to delayed gastric perforation.

Rectal free perforation after stapled hemorrhoidopexy: A case report of laparoscopic peritoneal lavage and repair without stoma

Highlights • Stapled hemorrhoidopexy (SH) is common treatment for prolapsed hemorrhoid.• Unexpected abdominal pain following SH may related rectal perforation.• Laparoscopic repair of rectal perforation is feasible in selective patients.• A transanal rectal tube keep in several days may substitute diverting stoma.

Taking varenicline for smoking cessation: A rare cause of pulmonary thromboembolism with infarction

Varenicline (Champix®, Chantix®) is a partial agonist of the α4β2 nicotinic acetylcholine receptor (nAChR) and a full agonist of the α7 nAChR. It has been used for smoking cessation since 2006. Varenicline has been associated with adverse cardiovascular (CV) events, including myocardial infarction, which may be caused by activation of the α7 nAChR receptor that in turn stimulates parasympathetic output from the brainstem to the heart, release of catecholamines, and has a prothrombotic effect. However, among the adverse CV events, the issue related to the varenicline-induced pulmonary thromboembolism (PTE) has not being addressed. We report a case of PTE with pulmonary infarction presenting as right flank pain that resulted from the use of varenicline (the total score of adverse drug reaction probability scale, 6; probable association between varenicline and pulmonary PTE) in a patient without underlying CV disease and in whom low probability of PTE (Wells score was zero) was identified.

Do we need a change in ED diagnostic strategy for adult acute epiglottitis

Objectives: To retrospectively evaluate the diagnostic performance of qualitative and quantitative radiographic parameters for diagnosing adult acute epiglottitis, and identify the prevalence and risk factors of false‐negative neck radiography‐based diagnosis of acute epiglottitis. Methods: An emergency physician and a radiologist independently reviewed neck radiographs of 91 patients with laryngoscopy‐confirmed acute epiglottitis and 91 control subjects between March 2010 and June 2016 for qualitative and quantitative radiographic parameters of acute epiglottitis, and concluded a diagnosis. Receiver operating characteristic (ROC) curves were constructed to assess the diagnostic performance of radiographic parameters, while independent risk factors of false‐negative diagnosis were determined by multivariate logistic regression analysis. Inter‐observer agreement was also calculated. Results: All radiographic parameters showed good diagnostic performance with sensitivities and specificities of 33.0–80.2% and 64.8–100%, respectively. Epiglottis width (EW) > 6.3 mm showed the highest diagnostic performance (area under the ROC curve [AUC]: 0.867, sensitivity: 75.8%, specificity: 97.8%). Interobserver agreement for all radiographic parameters was excellent (range: 0.893–0.991). The lateral neck radiography‐based false‐negative diagnosis rate was 31.9%, and previous oral antibiotic usage was an independent risk factor of false‐negative results. Conclusion: EW > 6.3 mm showed the best diagnostic accuracy, facilitating a neck radiograph‐based diagnosis of acute epiglottitis. However, false‐negative results on neck radiograph are quite common and previous oral antibiotic usage is a risk factor. Based on the knowledge of the usefulness and risk factors of false‐negative results of neck radiography, diagnostic process for acute epiglottitis using neck radiography need to be changed.