Objective: Many studies have examined the July effect. However, little is known about the July effect in sepsis. We hypothesized that the July effect would result in worse outcomes for patients with sepsis. Methods: Data from patients with sepsis, collected prospectively between January 2018 and December 2021, were analyzed. In Korea, the new academic year starts on March 1, so the “July effect” appears in March. The primary outcome was 30-day mortality. Secondary outcomes included adherence to the Surviving Sepsis Campaign bundle. Outcomes in March were compared to other months. A multivariate Cox proportional hazard regression was performed to adjust for confounders. Results: We included 843 patients. There were no significant differences in sepsis severity. The 30-day mortality in March was higher (49.0% vs. 28.5%, P<0.001). However, there was no difference in bundle adherence in March (42.2% vs. 48.0%, P=0.264). The multivariate Cox proportional hazard regression showed that the July effect was associated with 30-day mortality in patients with sepsis (adjusted hazard ratio, 1.925; 95% confidence interval, 1.405–2.638; P<0.001). Conclusion The July effect was associated with 30-day mortality in patients with sepsis. However, bundle adherence did not differ. These results suggest that the increase in mortality during the turnover period might be related to unmeasured in-hospital management. Intensive supervision and education of residents caring for patients with sepsis is needed in the beginning of training.

Background: Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. Methods: This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016–2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. Results: We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). Conclusion The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the firsttransfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.

Background: Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. Methods: This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016–2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. Results: We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). Conclusion The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the firsttransfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.

Objective: The Surviving Sepsis Campaign (SSC) guidelines have been associated with reduced mortality in sepsis patients. On the other hand, previous studies were performed using the Sepsis-2 definitions and past guidelines. This study assessed the association between compliance with the 2016 SSC guidelines and the outcomes of patients with sepsis and septic shock in accordance with the latest Sepsis-3 definitions. Methods: Three hundred and fifteen patients with sepsis and septic shock were enrolled in this study. The patients were stratified according to their compliance with the SSC guidelines bundle. The characteristics and outcomes of the compliance and non-compliance groups were compared. In the overall patients, the risk factors for all-cause mortality were assessed using Cox proportional hazards models. Results: Among the patients, 172 and 143 patients were in the compliance group and non-compliance group, respectively. The baseline characteristics and disease severity were similar in the two groups. The all-cause mortality rates were 27.3% and 38.5% in the compliance group and non-compliance group, respectively (P=0.035). The all-cause mortality was significantly lower in the compliance group than in the non-compliance group (log-rank test, P=0.025). The risk factors for the all-cause mortality were age (adjusted hazard ratio [aHR], 1.025; 95% confidence interval [CI], 1.008-1.042; P=0.004), septic shock (aHR, 3.14; 95% CI, 1.98-4.98; P<0.001), and lactate levels (aHR, 1.08; 95% CI, 1.03-1.14; P=0.002). The overall compliance with the guidelines protected against all-cause mortality (aHR, 0.66; 95% CI, 0.45-0.98; P=0.040). Conclusion Compliance with the SSC guidelines bundle was associated with a lower all-cause mortality among patients with sepsis and septic shock

OBJECTIVE: We evaluated the effect of rapid influenza diagnostic tests (RIDTs) on patient management in an emergency department for 3 years after 2009, and also identified factors associated with the choice of treatment for patients with influenza-like illnesses.METHODS: The study period consisted of three influenza epidemic seasons. Patients older than 15 years who underwent RIDTs in the emergency department and were then discharged without admission were included.RESULTS: A total of 453 patients were enrolled, 114 of whom had positive RIDT results and 339 had negative results. Antiviral medication was prescribed to 103 patients (90.4%) who had positive RIDT results, while 1 patient (0.3%) who tested negative was treated with antivirals (P<0.001). Conservative care was administered to 11 RIDT-positive patients (9.6%) and 244 RIDT-negative patients (72.0%) (P<0.001). Symptom onset in less than 48 hours, being older than 65 years, and the presence of comorbidities were not associated with the administration of antiviral therapy.CONCLUSION: RIDT results had a critical effect on physician decision-making regarding antiviral treatment for patients with influenza-like illnesses in the emergency department. However, symptom onset in less than 48 hours, old age, and comorbidities, which are all indications for antiviral therapy, were not found to influence the administration of antiviral treatment.
Antiviral Agents ; Comorbidity ; Diagnostic Tests, Routine ; Emergencies ; Emergency Service, Hospital ; Humans ; Influenza, Human ; Seasons

PURPOSE: The present study developed formulas for estimation of standard liver volume (SLV) with high accuracy for the Korean population. MATERIALS AND METHODS: SLV estimation formulas were established using gender-balanced and gender-unbalanced measurements of anthropometric variables, body composition variables, and abdominal geometry of healthy Koreans (n=790). Total liver volume excluding blood volume, was measured based on CT volumetry. RESULTS: SLV estimation formulas as preferred in various conditions of data availability were suggested in the present study. The suggested SLV estimation formulas in the present study were found superior to existing formulas, with an increased accuracy of 4.0–217.5 mL for absolute error and 0.2–18.7% for percentage of absolute error. CONCLUSION: SLV estimation formulas using gender-balanced measurements showed better performance than those using gender-unbalanced measurements. Inclusion of body composition and abdominal geometry variables contributed to improved performance of SLV estimation.
Blood Volume ; Body Composition* ; Liver*

PURPOSE: This study aims to review the appropriateness of the issued death certificates and autopsy reports and to evaluate the improvement points of these documents in accordance with the guidelines of the Korean Medical Association and the National Statistical Office. Moreover, this study also examines why the guideline is necessary for the credibility of these documents. METHODS: The death certificates and autopsy reports written by a training hospital were analyzed for a 12-month period, between December 2014 and November 2015. The reference to analysis was the “guidelines to medical certificate 2015” written by the Korean Medical Association, “World Health Organization (WHO) death certificate principle”, and “guideline leaflet,” as provided by the National Statistical Office. Two researchers analyzed the documents that were against the guidelines, and suggested improvement points. The analyzed variables were age, sex, issued date, direct cause of death, manner of death, location of death, and types of accident. The primary goal was to see the rate of issued documents written correctly according to the guidelines and to suggest possible improvement points. The secondary goal was to analyze the reason for accordance and discordance between researchers. RESULTS: There were a total of 603 death certificates and autopsy reports issued during the research period; 562 (93.2%) and 41 (6.8%) cases, respectively. As for the manner of death, 521 cases were “death from disease,” 64 were “external causes,” and 18 were “others or unknown” (86.4%, 10.6%, and 3.0%, respectively). As for the issued department, internal medicine and emergency medicine issued 301 (49.9%) and 126 (20.9%) documents, respectively. Of these, 139 (23.1%) cases were regarded to be in accordance with the guidelines, while 304 (50.4%) were considered to be discordant cases. Among the discordant cases, there were 177 (29.4%) cases that were the mode of death directly written to cause of death. As for the records of “period of occurrence to death” were recorded only 70 (11.7%) cases (including “unknown” 65 cases) and the others were blank. The Kappa number of analysis regarding the evaluation correspondence of the two researchers was 0.44 (95% confidence interval, 0.38 to 0.51). CONCLUSION: The most frequent error was ‘the condition of death to direct cause of death’ with the ratio of 29.4%. This may have been because the rate of concordance between the researchers based on the guidelines was not high enough. There is a need to provide specific guidelines for each case, and also promote and educate regarding significant errors.
Autopsy ; Cause of Death ; Death Certificates* ; Emergency Medicine ; Internal Medicine ; Medical Errors ; Observational Study*

PURPOSE: Xp11.2 translocation renal cell carcinoma (RCC) is characterized by various translocations of the TFE3 transcription factor gene. These rare cancers occur predominantly in children and young adults. Here, we review the clinicopathological features of Xp11.2 translocation RCC. MATERIALS AND METHODS: We identified 21 patients with Xp11.2 translocation RCC. We retrospectively analyzed patient characteristics, clinical manifestations, and specific pathological features to assess definitive diagnosis, surgical and systemic treatments, and clinical outcomes. RESULTS: The mean age at diagnosis was 43.4+/-20.0 years (range, 8-80 years; 8 males and 13 females). Eleven patients were incidentally diagnosed, nine patients presented with local symptoms, and one patient presented with systemic symptoms. The mean tumor size was 6.2+/-3.8 cm (range, 1.9-14 cm). At the time of diagnosis, 11, 1, and 5 patients showed stage I, II, and III, respectively. Four patients showed distant metastasis. At analysis, 15 patients were disease-free after a median follow-up period of 30.0 months. Four patients received target therapy but not effectively. CONCLUSIONS: Xp11 translocation RCC tends to develop in young patients with lymph node metastasis. Targeted therapy did not effectively treat our patients. Surgery is the only effective therapy for Xp11 translocation RCC, and further studies are needed to assess systemic therapy and long-term prognosis.
Adolescent ; Adult ; Aged ; Aged, 80 and over ; Basic Helix-Loop-Helix Leucine Zipper Transcription Factors/*genetics ; Biomarkers ; Carcinoma, Renal Cell/diagnosis/*genetics ; Child ; Chromosomes, Human, X/*chemistry ; Female ; Humans ; Kidney Neoplasms/diagnosis/*genetics ; Lymphatic Metastasis ; Male ; Middle Aged ; Prognosis ; Retrospective Studies ; Translocation, Genetic ; Young Adult

PURPOSE: Primary prostate sarcomas are a rare type of prostate cancer that account for less than 0.1% of primary prostate malignancies. We analyzed the experience of a single institution with prostate sarcoma over 20 years. MATERIALS AND METHODS: In this case series, the medical records of 20 patients with prostate sarcoma were reviewed from June 1990 to December 2013 to identify symptoms at presentation, diagnostic procedures, metastasis presence and development, histologic subtype, French Federation Nationale des Centres de Lutte Contre le Cancer grade, primary tumor grade and size, and treatment sequence, including surgery and preoperative and postoperative therapies. The average follow-up period was 23.6 months (range, 1.4-83.3 months). RESULTS: The average patient age was 46.3+/-16.7 years. Most patients presented with lower urinary tract symptoms (55%). The histologic subtype was spindle cell sarcoma in five patients (25%), rhabdomyosarcoma in three patients (15%), synovial sarcoma in three patients (15%), liposarcoma in three patients (15%), stromal sarcoma in three patients (15%), and Ewing sarcoma, nerve sheath tumor, and adenocarcinoma with sarcomatoid component (5% each). For liposarcoma, two patients were alive after complete surgical resection and had a good prognosis. At last follow-up, 15 patients had died of sarcoma. The 2- and 5-year actuarial survival rates for all 20 patients were 53% and 12%, respectively (medial survival, 20 months). CONCLUSIONS: The disease-specific survival rate of prostate sarcoma is poor. However, sarcoma that is detected early shows a better result with proper management including surgical intervention with radio-chemotherapy than with no treatment. Early diagnosis and complete surgical resection offer patients the best curative chance.
Adult ; Aged ; Humans ; Kaplan-Meier Estimate ; Male ; Middle Aged ; Prognosis ; Prostatectomy/methods ; Prostatic Neoplasms/diagnosis/*pathology/therapy ; Retrospective Studies ; Sarcoma/diagnosis/*pathology/secondary/therapy ; Treatment Outcome ; Young Adult

There are concerns whether megestrol acetate (MA) stimulates the growth of prostate cancer in castration-resistant prostate cancer (CRPC). We evaluated the effect of cumulative doses of MA on the disease-specific survival (DSS) in patients with CRPC who were receiving Docetaxel-based chemotherapy. From July 2003 through June 2009, we identified 109 consecutive patients with CRPC and who had received docetaxel-based chemotherapy. Of these patients, 68 (62.4%) have not received MA, whereas 21 patients (19.3%) and 20 patients (18.3%) had received low dose MA (total < or = 18,400 mg) and high dose MA (total > 18,400 mg), respectively. We assessed the effect of several variables on DSS. None of the clinicopathological variables differed among the three groups. When comparing DSS using Kaplan-Meier analysis, there was no statistically significant survival differences among the three groups (P = 0.546). Using multivariate Cox proportional analyses with backward elimination, the number of docetaxel cycles was only significant factor predicting DSS (HR: 0.578, 95% CI: 0.318-0.923, P = 0.016). Cumulative doses of MA as adjuvant treatment for patients with CRPC and who are receiving docetaxel-based chemotherapy, did not affect their DSS. Therefore, MA can be safely administered in cachexic patients with CRPC.
Aged ; Aged, 80 and over ; Anorexia/complications/*drug therapy ; Antineoplastic Agents/therapeutic use ; Antineoplastic Agents, Hormonal/*therapeutic use ; Cachexia/complications/*drug therapy ; Castration ; Humans ; Kaplan-Meier Estimate ; Male ; Megestrol Acetate/*therapeutic use ; Middle Aged ; Proportional Hazards Models ; Prostatic Neoplasms/complications/*drug therapy/mortality ; Taxoids/therapeutic use