Usefulness of contrast-enhanced multi-detector computed tomography in identifying upper gastrointestinal bleeding: A retrospective study of patients admitted to the emergency department

Upper gastrointestinal bleeding (UGIB) is a major cause of clinical deterioration worldwide. A large number of patients with UGIB cannot be diagnosed through endoscopy, which is normally the diagnostic method of choice. Therefore, this study aimed to investigate the diagnostic value of multi-detector computed tomography (MDCT) for patients with suspected UGIB. In this retrospective observational study of 386 patients, we compared contrast-enhanced abdominopelvic MDCT to endoscopy to analyze the performance of MDCT in identifying the status, location of origin, and etiology of UGIB. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were examined. In the assessment of bleeding status, MDCT was able to accurately identify 32.9% (21.9-43.9, 95% confidence interval [CI]) of patients with active bleeding, 27.4% (18.9-35.9, 95% CI) of patients with recent bleeding, and 94.8% (91.8-97.8, 95% CI) of patients without bleeding evidence (P<0.001). MDCT showed an accuracy of 60.9%, 60.6%, and 50.9% in identifying bleeding in the esophagus, stomach, and duodenum, respectively (P = 0.4028). The accuracy in differentiating ulcerative, cancerous, and variceal bleeding was 58.3%, 65.9%, and 56.6%, respectively (P = 0.6193). MDCT has limited use as a supportive screening method to identify the presence of gastrointestinal bleeding.ope

Effects of Paraquat Ban on Herbicide Poisoning-Related Mortality.

PURPOSE: In Korea, registration of paraquat-containing herbicides was canceled in November 2011, and sales thereof were completely banned in November 2012. We evaluated the effect of the paraquat ban on the epidemiology and mortality of herbicide-induced poisoning. MATERIALS AND METHODS: This retrospective study analyzed patients treated for herbicide poisoning at 17 emergency departments in South Korea between January 2010 and December 2014. The overall and paraquat mortality rates were compared pre- and post-ban. Factors associated with herbicide mortality were evaluated using logistic analysis. To determine if there were any changes in the mortality rates before and after the paraquat sales ban and the time point of any such significant changes in mortality, R software, version 3.0.3 (package, bcp) was used to perform a Bayesian change point analysis. RESULTS: We enrolled 2257 patients treated for herbicide poisoning (paraquat=46.8%). The overall and paraquat poisoning mortality rates were 40.6% and 73.0%, respectively. The decreased paraquat poisoning mortality rate (before, 75% vs. after, 67%, p=0.014) might be associated with increased intentionality. The multivariable logistic analysis revealed the paraquat ban as an independent predictor that decreased herbicide poisoning mortality (p=0.035). There were two major change points in herbicide mortality rates, approximately 3 months after the initial paraquat ban and 1 year after complete sales ban. CONCLUSION: This study suggests that the paraquat ban decreased intentional herbicide ingestion and contributed to lowering herbicide poisoning-associated mortality. The change point analysis suggests a certain timeframe was required for the manifestation of regulatory measures outcomes.ope

The effect of lecturing about communication skill with standardized patient for medical students

Background : Effective communication between doctors and patients is very important not only for diagnosis and treatment but also for building trust. Although teaching communication skills is very important in medical schools, there are limitations such as the number of students and the uncertainty of the patient population. Therefore, this study evaluates the effect of Fishbowl method to teach communication skills to medical students, which involves the medical students communicating with standardized patients in front of a large classroom and being observed by rest of the students. Methods : This study involves 10 weeks of educating 126 fourth grade medical students and graduates. During this period, total 8 classes were taken by subjects, where each class lasts 2 hours and is conducted by observing treatments of the standardized patients on 14 clinical topics by randomly selected medical students and giving feedback on the communication skills of the selected medical students. The educational effect was evaluated based on the scores of the clinical performance examination before and after the classes. Results : The scores assessed for medical history taking before and after the training are increased by 2.45 (p<0.001) and the scores for patient-doctor relationship is increased by 7.56 (p<0.001). Conclusions : It is expected to improve the communication skills of medical students by large scale lectures with standardized patients.ope

Effect of Electromagnetic Interference on Automated External Defibrillator: Simulation Study with Literature Review.

Purpose: Automated external defibrillators (AEDs) could not recommend shock for ventricular fibrillation in the presence of electromagnetic interference. The purpose of this study was to examine the effect of an induced electromagnetic field on performance of AED. Methods: The intensity of magnetic waves from commercial electric mats was measured. Three AEDs were attached to the resuscitation manikin and the question of whether shock would be recommended for simulated electrocardiogram of VF or normal sinus rhythm was tested. The simulation was repeated 10 times under the influence of 0, 5, and 18 μT magnetic field or electric mat. Relevant literature studies on electromagnetic interference on AED were reviewed. Results: The magnetic flux density from the electric mat was measured to 5.67-6.1 μT in warming phase, and 2.25-2.84 μT in maintenance phase. There was no false positive or false negative recommendation of shock under the influence of 0, 5, and 18 μT magnetic field or electric mat. However, one AED detected motion even in the stationary state. Among 11 studies from the literature search, five studies reported misinterpretation of AED. Minor errors including delayed analysis, motion artefact, and noise in speakers were reported from 6 studies. Conclusion: Although we could not reproduce false negative interpretation, AED made a mistake in confusing electromagnetic interference with motion artefact. Therefore, emergency providers should be cautious not to use AED close to household appliances or medical equipment inducing electromagnetic interference.ope

Extracorporeal Life Support in Treatment of Poisoning Patient: Systematic Review

Purpose: Extracorporeal life support (ECLS) is a term used to describe a number of modalities including extracorporeal membrane oxygenation (ECMO) to support cardiac and/or pulmonary systems. The purpose of this study is to review the available evidence regarding the effect of ECLS in patients with acute poisoning. Methods: Electronic literature searches with PubMed, Embase, Cochrane library, and KoreaMed were conducted for identification of relevant studies addressing ECLS in treatment of acute poisoning. The literature search was conducted by two investigators in March, 2016 with publication language restricted to English and Korean. The toxic substance, technique of ECLS, and final outcome of each case were analyzed. Results: The final analysis included 64 articles including 55 case reports. There were no articles classified according to a high level of evidence such as randomized trial and prospective cohort study. ECLS treatment was used in the management of patients poisoned with 36 unique substances. Venovenous ECMO was performed in 4 cases. Among the reported cases, 10 patients died despite treatment with ECLS. Conclusion: Evidence supporting ECLS for patients with acute poisoning is inadequate. However, many case reports suggest that early consideration of ECLS in poisoned patients with refractory cardiac arrest or hemodynamic compromise refractory to standard therapies may be beneficial.ope

Causative Substance and Time of Mortality Presented to Emergency Department Following Acute Poisoning: 2014-2018 National Emergency Department Information System (NEDIS)

Purpose: The purpose of this study was to investigate the cause of acute fatal poisoning and the time of death by analyzing the National Emergency Department Information System (NEDIS) of South Korea. Methods: The NEDIS data from 2014 to 2018 excluding non-medical visits were used for this study. The patients with acute poisoning were extracted using diagnostic codes. The toxic substances were classified into pharmaceuticals, pesticides, gases, artificial poisonous substances, and natural toxic substances. Patients were classified according to the time of death, place of death, and region. In each case, the most causative substances of poisoning were identified. Results: There were 380,531 patients including poisoning-related diagnoses, of which 4,148 (1.1%) died, and the WHO age-standardized mortality rate was 4.8 per 100,000. Analysis of 2,702 death patients whose primary diagnosis was acute poisoning, the most common cause of poisoning death was pesticides (62%), followed by therapeutic drugs, gas, and artificial toxic substances. Herbicides were the most common pesticides at 64.5%. The proportion of mortality by time, hyperacute (7 d) were 9.8%. Conclusion: This study suggests that the most common cause of poisoning death was pesticides, and 60% of deaths occurred within 24 hours. The 71% of mortality from pesticides occurred within 6-24 hours, but mortality from gas was mostly within 6 hours. According to the geographic region, the primary cause of poisoning death was varied to pesticides or pharmaceuticals.ope

The effect of time target on overcrowding and clinical quality in the ED: a systematic review and meta-analysis

Objective: Many studies have reported the effectiveness of the ‘time target’ on reducing emergency department (ED) overcrowding and improving clinical quality. This study examined the effects of introducing the time target on ED overcrowding and clinical quality using meta-analysis. Methods: The electronic databases including PubMed (Medline), Cochrane Library, and Embase until June 2017 were searched. The search keywords were ‘time target,’ ‘national emergency access target,’ ‘four-hour rule,’ and ‘shorter stays in ED’. Two investigators selected and reviewed articles according to the predefined inclusion and exclusion criteria. The quality of the articles was evaluated using the RoBANS checklist. The data were abstracted by predetermined criteria and meta-analysis was performed using RevMan software. Results: Of 721 articles, 16 studies were included in the final analysis. A meta-analysis of four studies on the ED length of stay (LOS) showed that the mean EDLOS was reduced by 0.64 hours (95% confidence interval [CI], 0.34-0.94) since the introduction of the time target. Other studies also showed that the EDLOS was reduced. There was no definite trend in the hospital admission rate. Meta-analysis of nine studies on the clinical quality revealed a total odds ratio of 1.02 (95% CI, 0.74-1.32). Time taken until the visitation of a doctor and the initiation of treatment were both reduced. The rate of “left without being seen” was decreased. Conclusion: EDLOS was reduced and no significant association was observed between mortality and the application of a time target since the introduction of time target. ‘Rate of revisiting,’ ‘time to clinician,’ ‘time to treatment,’ and ‘rate of left without being seen’ was reduced.ope

Effect of Intravenous Lipid Emulsion in the Patient with Acute Poisoning : A Systematic Review

Purpose: The purpose of this study was to evaluate the usefulness of intravenous lipid emulsion as well as adverse events in acute poisoning patients. Methods: Literature was accessed through PubMed, EMBASE, Cochrane library, Web of science, and KoreaMed. All forms of literatures relevant to human use of intravenous lipid emulsion for acute poisoning were included. Cases reports or letters without description of clinical outcomes for each case were excluded. The literature search was conducted by two investigators in March, 2015, with publication language restricted to English and Korean. The effect, onset time, and adverse event of lipid emulsion and final outcome of each case were analyzed. Results: Eighty-one published articles were included, excluding articles whose title and abstract were not relevant to this study. No articles were classified as high level of evidence. Sixty-eight case reports were identified, consisting of 25 local anesthetics and 43 other drugs, such as tricyclic antidepressants and calcium channel blockers. Although most cases described significant clinical improvements, some of them showed no beneficial effect or worsening of clinical course. Several adverse events including hyperamylasemia and laboratory interference were reported. Conclusion: Although there were many case reports illustrating successful use of lipid for various drug poisonings, the effect cannot be estimated due to significant possibility of publication bias. Therefore, lipids might be considered in severe hemodynamic instability resulting from lipophilic drug poisoning, however further studies should follow to establish the use of lipid as the standard of care.ope

Usefulness of Predictors for Hepatotoxicity in Acetaminophen Poisoning Patient

Purpose: The purpose of this study was to determine whether hepatotoxicity could be predicted early using biochemical markers in patients with acetaminophen (AAP) poisoning and to assess the usefulness of predictive factors for acute liver injury or hepatotoxicity. Methods: This study was a retrospective observational study involving a medical records review. The participants were patients who were admitted to the emergency department (ED) with AAP overdose at two hospitals over a 10- year period. Demographic data, age, time from ingestion to visit, initial AAP level, initial hepatic aminotransferases, and initial prothrombin time were recorded. Acute liver injury was defined as a peak serum ALT >50 U/L or double the admission value, and hepatotoxicity was defined as a peak ALT >1,000 U/L. Receiver operating characteristic curve analyses were performed to compare the prognostic performance among variables. Results: A total of 97 patients were admitted to the ED with AAP overdose, of whom 26 had acute liver injury and 6 had hepatotoxicity. Acute liver injury was associated with the time interval after taking the drug, and hepatotoxicity was associated with the initial PT and the ALT level. The scoring system proposed by the authors has a significant ability to predict both acute liver injury and hepatotoxicity. Conclusion: To predict the prognosis of AAP poisoning patients, the time interval after taking AAP was important, and initial prothrombin time and ALT level were useful tests. Also a scoring system combining variables may be useful.ope

Effect of fast track on prognosis in patients with common bile duct obstruction with cholangitis in emergency department

Objective: Biliary decompression through bile drainage is a key treatment for common bile duct obstruction with cholangitis. However, the effectiveness of early interventions has not been studied sufficiently in Korea. This study investigated the effectiveness of fast-track biliary decompression. Methods: A group of patients diagnosed with common bile duct obstruction with cholangitis between January 1, 2014, and December 31, 2019, was reviewed retrospectively. We divided them into two groups: before and after the implementation of fast-track biliary decompression. The following items were analyzed in the two groups: time to intervention, number of hospital days, length of stay in the emergency department, and intensive care unit (ICU) admission. Results: Between January 1, 2014, and December 31, 2019, 418 patients were admitted for common bile duct obstruction, and a total of 369 patients were included in this study. Of these, 168 patients visited the hospital prior to implementation of the treatment, and 201 patients visited after implementation. The time to intervention was 6.1 (4.2-11.0) hours in the fast-track group, which was about 9 hours shorter than the other group (P<0.001). There was no statistical difference in the number of hospital days, emergency department length of stay, and ICU admissions (P=0.535, P=0.034, P=0.322). Conclusion: The time to intervention was shortened significantly in the fast-track group. However, we did not observe a significant improvement in patient prognosis. It may be possible that the procedure time may need to be shortened for a better prognosis. This should be investigated in future studies.ope