Objective: With the increase in the elderly population worldwide, there has been a corresponding increase in the proportion of elderly patients who visit the emergency department (ED). Therefore, research on the elderly not only aids in the treatment of diseases but also assists in the efficient utilization of limited medical resources. Respiratory symptoms are one of the most common and sometimes life-threatening symptoms in elderly patients. Knowing the factors that can predict the prognosis in advance can help with rapid diagnosis and immediate treatment. Methods: A retrospective study was conducted from September 2019 to March 2020 at an ED in an urban area. Patients with respiratory symptoms who were treated in the critical care area of the ED were reviewed. The ED clinical data were compared with the outcomes in the ED. Results: A total of 750 patients were screened, of which 703 were elderly patients. Many clinical factors showed variations between the elderly and non-elderly patients. Oxygen volume, elevated lactate level, elevated troponin level, hypocalcemia, and hypothermia were related with ED death or ICU admission among the elderly. Conclusion We identified several clinical factors with respect to elderly ED patients with respiratory symptoms that were related to the clinical outcomes and can be used for decision-making and prediction of poor outcomes.

Objective: This study aimed to determine the clinical factors associated with positive brain magnetic resonance imaging (MRI) findings in patients presenting to the emergency department (ED) with acute altered mental status (AMS). Methods: Patients with acute AMS who presented to the ED were retrospectively analyzed from September 2019 to March 2020. Non-traumatic patients with abnormal alert, verbal, pain, unresponsive (AVPU) scale scores and exhibiting acute change in mental status were included in the study. We evaluated the clinical characteristics of patients with acute AMS according to the results of their brain MRI. A multivariable logistic regression model was used to determine the clinical factors associated with positive brain MRI findings. Results: During the study period, 138 patients underwent brain MRI in the ED, with 36 (26.1%) positive results. A majority of patients with positive brain MRI findings had underlying malignancies, cerebrovascular disease, higher serum total bicarbonate (TCO2) levels, TCO2≥22 mmol/L, lower blood urea nitrogen levels, abnormal findings on brain computed tomography and abnormal findings on neurologic examination. In the multivariable analysis, serum TCO2≥22 mmol/L (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.09-4.12) and the presence of cranial nerve abnormalities (OR, 3.88; 95% CI, 1.55-9.68) and extremity abnormalities (OR, 2.76; 95% CI, 1.11-6.88) were significantly associated with positive brain MRI results. Conclusion Serum TCO2 level and the presence of cranial nerve and extremity abnormalities in the neurologic examinations were significantly associated with positive brain MRI results in patients with acute AMS.

Objective: Decreases in the hemoglobin level compared to the pre-injury lab results are often observed in patients with elderly hip fractures visiting the emergency department (ED). This decrease could be the outcome of the fracture itself or a complication caused by comorbidities. This study examined whether significant hemoglobin decreases, as detected in the ED, are related to other-than-hip-fracture bleeding focus or clinical outcomes. Methods: The electronic medical records were reviewed retrospectively at a single university ED from January 2012 to March 2019. ED diagnoses of hip fractures were screened and enrolled if the patient was 60 years or older and had hemoglobin levels recorded within the previous 6 months. A significant decrease in the hemoglobin level is defined as more than 2 g/dL. Results: Three hundred patients were enrolled in this study. Significant hemoglobin decreases were apparent in 43 patients (14.3%). Only four patients (1.3%) had an other-than-hip-fracture bleeding focus. One of those had a significant hemoglobin decrease. In a “significant decrease” versus “non-significant decrease” intergroup comparison, length of hospital stays (median and interquartile range: 17.0 [15.0-21.5] vs. 17.0 [12.0-21.0], P=0.55), survival discharge (4.7% vs. 2.3%, P=0.72), and other-than-hip-fracture bleeding focus (2.3% vs. 1.2%, P>0.99) did not differ significantly. Conclusion A decrease in hemoglobin level is common among elderly hip fracture patients. On the other hand, the incidence of other-than-hip-fracture bleeding focus was rare and unrelated to a decrease in significant hemoglobin levels. Similarly, neither the hospital length of stay nor survival discharge was unrelated to the hemoglobin level decrease.

Background: There is a need to update the cardiovascular (CV) Sequential Organ Failure Assessment (SOFA) score to reflect the current practice in sepsis. We previously proposed the modified CV SOFA score from data on blood pressure, norepinephrine equivalent dose, and lactate as gathered from emergency departments. In this study, we externally validated the modified CV SOFA score in multicenter intensive care unit (ICU) patients. Methods: A multicenter retrospective observational study was conducted on ICU patients at six hospitals in Korea. We included adult patients with sepsis who were admitted to ICUs. We compared the prognostic performance of the modified CV/total SOFA score and the original CV/total SOFA score in predicting 28-day mortality. Discrimination and calibration were evaluated using the area under the receiver operating characteristic curve (AUROC) and the calibration curve, respectively. Results: We analyzed 1,015 ICU patients with sepsis. In overall patients, the 28-day mortality rate was 31.2%. The predictive validity of the modified CV SOFA (AUROC, 0.712; 95% confidence interval [CI], 0.677–0.746; P < 0.001) was significantly higher than that of the original CV SOFA (AUROC, 0.644; 95% CI, 0.611–0.677). The predictive validity of modified total SOFA score for 28-day mortality was significantly higher than that of the original total SOFA (AUROC, 0.747 vs. 0.730; 95% CI, 0.715–0.779; P = 0.002). The calibration curve of the original CV SOFA for 28-day mortality showed poor calibration. In contrast, the calibration curve of the modified CV SOFA for 28-day mortality showed good calibration. Conclusion In patients with sepsis in the ICU, the modified SOFA score performed better than the original SOFA score in predicting 28-day mortality.

Objective: We investigated the factors that affect the time from the onset of acute stroke symptoms to arrival at the emergency department (ED). Methods: Between July 2019 and February 2020, patients with acute stroke symptoms who visited a public hospital were evaluated by retrospective analysis using a prospective survey. The data for this study was gathered from baseline interviews with patients enrolled in stroke surveys. The primary outcome was time to arrival at the ED, evaluated as a binary variable with a value of 4.5 hours. Results: Overall, 205 patients were included in the final analysis. Among them, 47% (n=96) of patients with acute stroke symptoms arrived at the ED later than 4.5 hours from the time of onset of acute stroke symptoms. After multivariable logistic regression analyses, it was found that patients with higher National Institutes of Health Stroke Scale (NIHSS) scores, patients who did not live with their family members, and patients who were found by a passerby were associated with early ED arrival post onset of acute stroke symptoms. Among patients diagnosed with acute stroke, those with higher NIHSS scores or underlying malignant diseases were found to present earlier at the ED. Conclusion Approximately half of the patients (47%) with acute stroke symptoms presented to the ED within 4.5 hours. Higher NIHSS scores and the presence of underlying malignancy were identified as the key factors that were associated with an early presentation at the ED from the time of onset of acute stroke.

Objective: The sensitivity of ultrasonography is poor in pregnant women with suspected appendicitis. Additional magnetic resonance imaging (MRI) is usually required, which can delay the diagnosis and surgical intervention. We hypothesized that the use of MRI as the first diagnostic tool could increase the detection rate and reduce the time for diagnosis. Therefore, we sought to investigate the diagnostic yield of ultrasonography vs. MRI and the emergency department length of stay (ED-LOS) of pregnant women with suspected appendicitis. Methods: This was a retrospective, observational study in the ED of a single tertiary teaching hospital from January 2010 to December 2017. Patients who underwent ultrasonography or MRI or both were enrolled. The primary outcome was the diagnostic yield of acute appendicitis and the ED-LOS. The secondary outcome was the proportion of complicated appendicitis cases. Results: A total of 145 pregnant women were enrolled (ultrasonography only, n=73; MRI only, n=26; both ultrasonography and MRI, n=46). The diagnostic yield was 23.5% (28/119) by ultrasonography and 79.2% (57/72) by MRI. The diagnostic yield of ultrasonography was significantly lower than that of MRI, especially in the second and third trimesters. The ED-LOS was significantly longer in the ultrasonography plus MRI group than that in the MRI-only group (9 hours vs. 6 hours, P=0.002). Conclusion In this study, MRI had a higher diagnostic yield than ultrasonography and can reduce the time to diagnosis. Thus, MRI should be considered as the first diagnostic tool for suspected acute appendicitis in pregnant women.

Background and Objectives: Prior studies have shown that stroke patients treated with percutaneous left atrial appendage occlusion (LAAO) for non-valvular atrial fibrillation (NVAF) experience better outcomes than similar patients treated with warfarin. We investigated the impact of percutaneous left atrial appendage closure on post-stroke neurological outcomes in NVAF patients, compared with non-vitamin K antagonist oral anticoagulant (NOAC) therapy. Methods: Medical records for 1,427 patients in multiple registries and for 1,792 consecutive patients at 6 Korean hospitals were reviewed with respect to LAAO or NOAC treatment.Stroke severity in patients who experienced ischemic stroke or transient ischemic attack after either treatment was assessed with modified Rankin Scale (mRS) scoring at hospital discharge and at 3 and 12 months post-stroke. Results: mRS scores were significantly lower in LAAO patients at 3 (p<0.01) and 12 months (p<0.01) post-stroke, despite no significant differences in scores before the ischemic cerebrovascular event (p=0.22). The occurrences of disabling ischemic stroke in the LAAO and NOAC groups were 36.7% and 44.2% at discharge (p=0.47), 23.3% and 44.2% at 3 months post-stroke (p=0.04), and 13.3% and 43.0% at 12 months post-stroke (p=0.01), respectively.Recovery rates for disabling ischemic stroke at discharge to 12 months post-stroke were significantly higher for LAAO patients (50.0%) than for NOAC patients (5.6%) (p<0.01). Conclusions Percutaneous LAAO was associated with more favorable neurological outcomes after ischemic cerebrovascular event than NOAC treatment.

Objective: The sensitivity of ultrasonography is poor in pregnant women with suspected appendicitis. Additional magnetic resonance imaging (MRI) is usually required, which can delay the diagnosis and surgical intervention. We hypothesized that the use of MRI as the first diagnostic tool could increase the detection rate and reduce the time for diagnosis. Therefore, we sought to investigate the diagnostic yield of ultrasonography vs. MRI and the emergency department length of stay (ED-LOS) of pregnant women with suspected appendicitis. Methods: This was a retrospective, observational study in the ED of a single tertiary teaching hospital from January 2010 to December 2017. Patients who underwent ultrasonography or MRI or both were enrolled. The primary outcome was the diagnostic yield of acute appendicitis and the ED-LOS. The secondary outcome was the proportion of complicated appendicitis cases. Results: A total of 145 pregnant women were enrolled (ultrasonography only, n=73; MRI only, n=26; both ultrasonography and MRI, n=46). The diagnostic yield was 23.5% (28/119) by ultrasonography and 79.2% (57/72) by MRI. The diagnostic yield of ultrasonography was significantly lower than that of MRI, especially in the second and third trimesters. The ED-LOS was significantly longer in the ultrasonography plus MRI group than that in the MRI-only group (9 hours vs. 6 hours, P=0.002). Conclusion In this study, MRI had a higher diagnostic yield than ultrasonography and can reduce the time to diagnosis. Thus, MRI should be considered as the first diagnostic tool for suspected acute appendicitis in pregnant women.

Background and Objectives: Prior studies have shown that stroke patients treated with percutaneous left atrial appendage occlusion (LAAO) for non-valvular atrial fibrillation (NVAF) experience better outcomes than similar patients treated with warfarin. We investigated the impact of percutaneous left atrial appendage closure on post-stroke neurological outcomes in NVAF patients, compared with non-vitamin K antagonist oral anticoagulant (NOAC) therapy. Methods: Medical records for 1,427 patients in multiple registries and for 1,792 consecutive patients at 6 Korean hospitals were reviewed with respect to LAAO or NOAC treatment.Stroke severity in patients who experienced ischemic stroke or transient ischemic attack after either treatment was assessed with modified Rankin Scale (mRS) scoring at hospital discharge and at 3 and 12 months post-stroke. Results: mRS scores were significantly lower in LAAO patients at 3 (p<0.01) and 12 months (p<0.01) post-stroke, despite no significant differences in scores before the ischemic cerebrovascular event (p=0.22). The occurrences of disabling ischemic stroke in the LAAO and NOAC groups were 36.7% and 44.2% at discharge (p=0.47), 23.3% and 44.2% at 3 months post-stroke (p=0.04), and 13.3% and 43.0% at 12 months post-stroke (p=0.01), respectively.Recovery rates for disabling ischemic stroke at discharge to 12 months post-stroke were significantly higher for LAAO patients (50.0%) than for NOAC patients (5.6%) (p<0.01). Conclusions Percutaneous LAAO was associated with more favorable neurological outcomes after ischemic cerebrovascular event than NOAC treatment.

Objective: Practice guidelines for diverticulitis have been developed in countries where left-colon diverticulitis is dominant,but there is limited information on right-colon diverticulitis. This study examined the clinical characteristics and riskfactors of clinically severe right-colon diverticulitis. Methods: A retrospective chart review of patients diagnosed with diverticulitis in an emergency department in Koreabetween 2013 and 2017 was performed. Clinically severe diverticulitis was defined as any cause of death, intensive careunit admission, surgery, or invasive intervention due to diverticulitis, and admission for seven or more hospital days.Multivariable logistic regression was used to identify the risk factors for clinically severe diverticulitis. Results: This study analyzed 302 patients. Patients with older age (odds ratio [OR], 1.044; 95% confidence interval [CI],1.009-1.080; P=0.013), complications observed on computed tomography (CT) (OR, 6.906; 95% CI, 2.514-18.968;P<0.001), rebound tenderness on a physical examination (OR, 2.542; 95% CI, 1.041-6.218; P=0.041), high alkalinephosphatase (ALP) levels (OR, 1.014; 95% CI, 1.002-1.026; P=0.026), and high C-reactive protein (CRP) levels (OR,1.095; 95% CI, 1.017-1.178; P=0.013) were at higher risk of clinically severe diverticulitis. Conclusion Among patients diagnosed with right-colon diverticulitis in the emergency department, those of older age,distinct complications on CT, rebound tenderness on physical examination, high ALP, and high CRP levels are related toclinically severe disease.