Ethylene glycol (EG) poisoning is highly lethal and difficult to diagnose. EG is metabolized through enzymatic reactions, producing glycolic acid, leading to high anion gap acidosis. The authors report a case wherein EG poisoning produced a large lactate gap between the two measuring methods. A 33-year-old male presented to the emergency department with an altered level of consciousness. The lactate levels measured using a point-of-care test (POCT) revealed severe lactic acidosis. The POCT lactate level corresponded to the amount of anion gap. Follow-up tests in the intensive care unit revealed a serum lactate level of 1.91 mmol/L, while the arterial POCT test yielded 28.1 mmol/L. Based on the lactate gap observed between the two methods, the possibility of EG poisoning was re-considered. EG poisoning was later confirmed by detecting EG in the patient’s system. Thus, EG poisoning should be considered when there is a severe lactate gap between the measuring methods.

Black spot of sweet persimmon, caused by Alternaria alternata, occurred in an orchard in Gyeongnam province, Korea in 2012. The symptom was appearance of 0.5 to 4 cm black spots on the surface of fruit. The pathogen was isolated from flesh of disease lesions. The causal agent was identified as A. alternata by morphological characteristics and sequencers of the internal transcribed spacer (ITS) 1 and ITS4 regions of rRNA. Artificial inoculation of the pathogen resulted in development of disease symptoms and the re-isolated pathogen showed characteristics of A. alternata.
Alternaria* ; Diospyros* ; Fruit* ; Korea

Restoring lost teeth is very important in terms of both function and aesthetics. If tooth loss occurs in the posterior region and the loss of support is persistent, it may cause a gradual shift in the position of the mandible and a change in occlusion. This clinical case attempted to restore support for the posterior teeth with a fixed prosthesis using implants in a patient whose opposing teeth were erupted and the occlusal plane collapsed due to long-term loss of the maxillary left posterior teeth and mandibular right first molars. To correct the occlusal plane of remaining dentition, wax-up of maxillary left posterior teeth was duplicated with acrylic resin and placed on maxilla. Surgical template for implant placement were fabricated using digital technology. After the support of the posterior teeth was restored with the placement of the implant, stable occlusion with temporary restorations was observed for a sufficient time. Afterwards, monolithic zirconia prosthesis was placed on the patient to ensure functional and aesthetic improvement.

BACKGROUND: Acute respiratory distress syndrome (ARDS) remains a life-threatening disease. Many patients with ARDS do not recover fully, and progress to terminal lung fibrosis. Angiotensin-converting enzyme (ACE) inhibitor is known to modulate the neurohormonal system to reduce inflammation and to prevent tissue fibrosis. However, the role of ACE inhibitor in the lungs is not well understood. We therefore conducted this study to elucidate the effect of renin-angiotensin system (RAS) blockage on the prognosis of patients with ARDS. METHODS: We analyzed medical records of patients who were admitted to the medical intensive care unit (ICU) at a tertiary care hospital from January 2005 to December 2010. ARDS was determined using the Berlin definition. The primary outcome was the mortality rate of ICU. Survival analysis was performed after adjustment using propensity score matching. RESULTS: A total of 182 patients were included in the study. Thirty-seven patients (20.3%) took ACE inhibitor or angiotensin receptor blocker (ARB) during ICU admission, and 145 (79.7%) did not; both groups showed similar severity scores. In the ICU, mortality was 45.9% in the RAS inhibitor group and 58.6% in the non-RAS inhibitor group (P = 0.166). The RAS inhibitor group required a longer duration of mechanical ventilation (29.5 vs. 19.5, P = 0.013) and longer ICU stay (32.1 vs. 20.2 days, P < 0.001). In survival analysis, the RAS inhibitor group showed better survival rates than the non-RAS group (P < 0.001). CONCLUSIONS: ACE inhibitor or ARB may have beneficial effect on ARDS patients.
Angiotensin Receptor Antagonists ; Angiotensin-Converting Enzyme Inhibitors ; Angiotensins ; Berlin ; Case-Control Studies* ; Fibrosis ; Humans ; Inflammation ; Intensive Care Units ; Lung ; Medical Records ; Mortality ; Prognosis ; Propensity Score ; Renin-Angiotensin System* ; Respiration, Artificial ; Respiratory Distress Syndrome, Adult* ; Retrospective Studies* ; Survival Rate ; Tertiary Healthcare

Objective: This study investigates the characteristics of patients who were re-transferred from other hospitals to regional or local emergency medical centers. Methods: Data from 2016 to 2017 was obtained from the National Emergency Department Information System (NEDIS). The study population was classified as ‘transferred group’ and ‘direct visit group.’ The transferred group was further subdivided into the ‘re-transfer group’ (patients transferred out to another hospital) and ‘single transfer group’ (patients not transferred out). Multiple logistic regression analysis was performed to identify factors associated with re-transfer. Results: The re-transfer rate (3.7%) of the ‘transferred group’ was higher than the transfer rate (1.3%) of the ‘direct visit group’. Multiple regression analysis revealed that older age, male (adjusted odds ratio [aOR], 1.082; 95% confidence interval [CI], 1.606-1.105), medical aid (aOR, 1.231; 95% CI, 1.191-1.105), injury origin (aOR, 1.063; 95% CI, 1.006-1.122), and Korean Triage and Acuity Scale level 1 or 2 (aOR, 1.214; 95% CI, 1.182-1.247), are associated with re-transfer. The Korean Standard Classification of Diseases group having the highest re-transfer rate was determined to be the neoplasm disease group. Conclusion Data from the current study reveals that factors associated with an increased likelihood of re-transfer were high severity, old age, medical aid, and neoplasm diagnosis. Considering these characteristics of re-transferred patients, it is necessary to improve the transfer system to reduce re-transfers. However, further research is required, including the reasons for the transfer.

Objective: The purpose of this study was to analyze the effects of emergency department length of stay (ED LOS) on the prognosis of patients classified in 28 severe illness diagnosis code groups. Methods: We used data from the National Emergency Department Information System (NEDIS) from 2016 to 2017. Patients with severe illness diagnosis codes as per the discharge diagnosis reports of the emergency department were included and classified into 28 diagnosis code groups. We used multiple logistic regression analysis on the various diagnosis groups to determine whether 6 hours of ED LOS was a factor influencing mortality. Results: Of the 18,217,034 patients in the NEDIS data, 553,918 patients were hospitalized with a severe illness code at regional or local emergency medical centers. The average ED LOS was 389 minutes in the non-survivor group and 420 minutes in the survivor group. After adjusting for confounders, ED LOS >6 hours was associated with lower mortality (odds ratio, 0.737; 95% confidence interval, 0.715-0.759). The association of ED LOS >6 hours with lower mortality was found in the diagnosis groups for acute myocardial infarction, intracranial hemorrhage, major trauma, aortic dissection, gastrointestinal bleeding/foreign bodies, intoxication, acute kidney injury, and post-resuscitation status. Conclusion In the analysis for the 28 severe disease illness code groups, ED LOS of more than 6 hours was not a factor that adversely affects the in-hospital mortality.

Discharge against medical advice remains a problematic issue worldwide because it may not only lead to adverse medical outcomes for the patients but also medicolegal problems for emergency physicians. Recently, there have been cases in Korea in which a patient in the emergency room, who had been discharged from hospital without following medical instructions, filed a lawsuit against the hospital and emergency medical staff for their responsibility for their worsening disease since discharge. The court acknowledged the responsibility of the medical staff. To minimize the legal risk and reach the optimal ethical standard for these patients, this paper suggests the best practice guideline for the emergency physicians for patients who request discharge against medical advice from the emergency department in Korea.

Early removal of a percutaneous transhepatic biliary drainage (PTBD) tube commonly causes pneumoperitoneum. However, we encountered a patient who developed pneumoperitoneum even with an indwelling PTBD tube. An 84-year-old man was admitted with type III combined duodenal and biliary obstruction secondary to metastatic bladder cancer. A biliary stent was placed using a percutaneous approach, and a duodenal stent was placed endoscopically. A large amount of subphrenic free air was detected after the procedures. Laboratory tests indicated intestinal perforation; however, peritoneal signs were absent. The patient was treated conservatively using an indwelling Levin tube. Seven days later, the massive amount of subphrenic free air disappeared. Follow-up tubography revealed unrestricted bile flow into the small intestine, and the PTBD tube was removed. Prolonged endoscopic procedures in patients with a PTBD tract communicating with the gastrointestinal tract can precipitate pneumoperitoneum. Clinicians should be careful to avoid misdiagnosing this condition as intestinal perforation.
Aged, 80 and over ; Bile ; Drainage ; Follow-Up Studies ; Gastrointestinal Tract ; Humans ; Intestinal Perforation ; Intestine, Small ; Pneumoperitoneum ; Stents ; Urinary Bladder Neoplasms

In Korea, the national evaluation program for emergency medical centers (EMCs) was introduced in 2003. EMCs in Korea have three levels of emergency centers including regional emergency centers, local emergency centers, and local emergency rooms. The evaluation system assesses the performance of EMCs at all three levels. The role of both regional emergency centers and local emergency centers administer the final treatment for severe emergency patients, although the definition of severe emergency patients is unclear. These factors may aggravate crowding at the emergency department. The national evaluation system aims to reduce the length of stay in the emergency department. However, reduction of the length of stay at emergency department may cause a conflict with the administration of final treatment for critically ill emergency patients owing to a lack of in-hospital beds. Crowding of the emergency department is not a problem of EMCs but that of the health system. In 2019, the Korean Society of Emergency Medicine performed a study to improve the national evaluation program for EMC and the performance of EMC. Here, we have summarized the results.

PURPOSE: A tension pneumothorax is a fatal condition that requires immediate intervention. Although a definitive treatment for a tension pneumothorax is a tube thoracostomy, needle decompression can provide temporary relief, that is lifesaving. The traditional procedure for needle decompression involves inserting a needle or catheter at the second intercostal space, the midclavicular line. Recent evidence suggests that the commonly used catheters do not have sufficiently penetrate the chest wall. There are also claims that a lateral approach to needle decompression is easier and safer than the traditional anterior approach. The purpose of this study is to evaluate the optimal approach for needle decompression for the Korean population by measuring chest wall thicknesses at the points used for both the anterior and the lateral approaches. METHODS: The chest wall thickness (CWT) of trauma victims who visited the Emergency Center of Pusan National University Hospital was measured by computed tomography (CT) images. The CWT was measured at the points used for the anterior and the lateral methods and was compared with the length of commonly used catheters, which is 45 mm. RESULTS: The mean CWT at the second intercostal space, the midclavicular line, was shorter than the CWT at the 5th intercostal space, the anterior axillary line. However, the percentage of patients whose CWT was greater than 45 mm was larger when measured anteriorly (8.2%) that when measure laterally (5.7%). Female patients and those older than 60 were more likely to have an anterior CWT greater than 45 mm (28.2% for females and 15.5% for those older than 60). CONCLUSION: The percentage of trauma victims in Korea whose CWT is greater than 45 mm is lower than the values previously reported by other countries. However, females and older patients tend to have thicker chest walls, so the lateral approach would be suggested when performing needle decompression for such patients with suspected tension pneumothoraces.
Catheters ; Decompression ; Emergencies ; Female ; Humans ; Korea ; Needles ; Pneumothorax ; Thoracic Injuries ; Thoracic Wall ; Thoracostomy ; Thorax