Background: There has been no comparison of the determinants of admission route between acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We examined whether factors associated with direct versus transferred-in admission to regional cardiocerebrovascular centers (RCVCs) differed between AIS and AMI. Methods: Using a nationwide RCVC registry, we identified consecutive patients presenting with AMI and AIS between July 2016 and December 2018. We explored factors associated with direct admission to RCVCs in patients with AIS and AMI and examined whether those associations differed between AIS and AMI, including interaction terms between each factor and disease type in multivariable models. To explore the influence of emergency medical service (EMS) paramedics on hospital selection, stratified analyses according to use of EMS were also performed. Results: Among the 17,897 and 8,927 AIS and AMI patients, 66.6% and 48.2% were directly admitted to RCVCs, respectively. Multivariable analysis showed that previous coronary heart disease, prehospital awareness, higher education level, and EMS use increased the odds of direct admission to RCVCs, but the odds ratio (OR) was different between AIS and AMI (for the first 3 factors, AMI > AIS; for EMS use, AMI < AIS). EMS use was the single most important factor for both AIS and AMI (OR, 4.72 vs. 3.90). Hypertension and hyperlipidemia increased, while living alone decreased the odds of direct admission only in AMI;additionally, age (65–74 years), previous stroke, and presentation during non-working hours increased the odds only in AIS. EMS use weakened the associations between direct admission and most factors in both AIS and AMI. Conclusions Various patient factors were differentially associated with direct admission to RCVCs between AIS and AMI. Public education for symptom awareness and use of EMS is essential in optimizing the transportation and hospitalization of patients with AMI and AIS.

Objective: Arterial blood gas analysis (ABGA) is routinely performed in hyperventilation syndrome (HVS) patients in the emergency department (ED). We tried to substitute end-tidal carbon dioxide (ETCO2) for arterial partial pressure of carbon dioxide (PaCO2) in HVS patients in ED. Methods: It was a prospective observational cohort study of HVS patients from May 2019 to March 2020. Data of age, sex, vital sign, ETCO2 and ABGA were collected. We compared the Pearson correlation between ETCO2 and PaCO2. Results: A total of 135 HVS patients were included in the study. The average value for ETCO2 was 24.9±7.2. It showed a significant linear between ETCO2 and PaCO2. The Pearson correlation coefficient was 0.893 (P<0.001). The linear correlation coefficients of ETCO2 <20 mmHg and ETCO2 20-35 mmHg groups were 0.513 and 0.827, respectively (P<0.001). Conclusion We suggest that ABGA can be replaced by ETCO2 in HVS patients in ED.

Objective: A retrospective study was performed to evaluate the usefulness of the delta neutrophil index as a prognosticfactor for mortality in intensive care unit patients admitted via the emergency department. Methods: Patients, who presented to the emergency department and were admitted to the intensive care unit fromJanuary 2018 to August 2018, were reviewed retrospectively. The clinical features, inflammatory marker levels, such asC-reactive protein, lactate, simplified acute physiology score 3, length of stay, and in-hospital mortality were obtainedfrom the medical records. Patients, who visited the emergency department because of trauma or suicidal attempts,arrived after out-hospital cardiac arrest, or were diagnosed with cerebrovascular disease, were excluded. Results: Of the 310 patients included, 65 died during their admission, and 245 patients were discharged after treatment.The receiver operating characteristic curve showed that the delta neutrophil index (area under curve [AUC], 0.72), Creactiveprotein (AUC, 0.70), lactate (AUC, 0.64), and simplified acute physiology score 3 (AUC, 0.79) indicated a lowpredictive power for in-hospital mortality. Whole patients were divided into four subgroups (infectious diseases, cardiovasculardiseases, gastrointestinal bleeding diseases, and others). The receiver operating curve of delta neutrophil indexrevealed infectious diseases (AUC, 0.65), in cardiovascular diseases (AUC, 0.70), and gastrointestinal bleeding diseases(AUC, 0.79). Conclusion The role of the delta neutrophil index for predicting the prognosis of in-hospital mortality showed equally lowpredictive power for critically ill patients with the C-reactive protein and lactate.

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.
Abdomen ; Budgets ; Chest Pain ; Critical Care ; Dyspnea ; Emergencies ; Heart ; Heart Arrest ; Insurance Coverage ; Insurance ; Insurance, Health ; Korea ; Medical Records ; National Health Programs ; Patient Care ; Point-of-Care Systems ; Prescriptions ; Shock ; Thorax ; Ultrasonography

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

OBJECTIVE: The aim of this study was to validate the Glasgow-Blatchford score (GBS), Pre-Rockall score (PRS), and AIMS65 score to predict active bleeding in patients with normotension and upper gastrointestinal bleeding (UGIB), and analyze the variables that can predict active bleeding to help develop new predictive factors. METHODS: Data were collected retrospectively from January 2015 to December 2017. A systolic blood pressure ≥90 mmHg were defined as normotension, and the patients were divided into active bleeding and not-active bleeding groups based on an esophagogastroduodenoscopy and levin-tube irrigation. The GBS, PRS, and AIMS65 of each group were calculated. The receiver operator characteristic (ROC) curve and area under the curve (AUC) were also calculated to obtain the predictive power for active bleeding. Furthermore, the factors that can predict active bleeding were analyzed by multivariate logistic regression. The ROC curve and AUC were calculated using the variables that were adopted as useful factors. RESULTS: Of the 250 patients included, 85 were active bleeding and 165 were not-active bleeding. The ROC curve showed GBS (AUC, 0.54; 95% confidence interval [CI], 0.47–0.61), PRS (AUC, 0.58; 95% CI, 0.50–0.65), and AIMS65 (AUC, 0.51; 95% CI, 0.43–0.59) to have low predictive power for active bleeding. Multivariate logistic regression revealed the lactate (odds ratio [OR], 1.10; 95% CI, 1.01–1.20) and shock indices (OR, 4.15; 95% CI, 1.12–15.40) to be significant predictors of active bleeding. When calculating the probability of predicting active bleeding through these variables, AUC 0.64 (95% CI, 0.57–0.71) showed higher prediction power than the previous scores. CONCLUSION: The conventional scoring systems that predict the prognosis of UGIB showed low predictability in predicting active bleeding in UGIB patients with a systolic blood pressure ≥90 mmHg. Further study suggests the development of new score using factors, such as the lactate and shock indices.
Area Under Curve ; Blood Pressure ; Emergency Medicine ; Endoscopy, Digestive System ; Gastrointestinal Hemorrhage ; Hemorrhage ; Humans ; Lactic Acid ; Logistic Models ; Prognosis ; Retrospective Studies ; ROC Curve ; Shock

OBJECTIVE: Adult appendicitis (AA) with equivocal computed tomography (CT) findings remains a diagnostic challenge for physicians. Herein we evaluated the diagnostic performance of several clinical scoring systems in adult patients with suspected appendicitis and equivocal CT findings. METHODS: We retrospectively evaluated 189 adult patients with equivocal CT findings. Alvarado, Eskelinen, appendicitis inflammatory response, Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA), and adult appendicitis score (AAS) scores were evaluated, receiver operating characteristic analysis was conducted, and the optimal, low, and high cut-off values were determined for patient classification into three groups: low, intermediate, or high. RESULTS: In total, 61 patients were included in the appendicitis group and 128 in the non-appendicitis group. There were no significant differences between the area under the curve of the clinical scoring systems in the final diagnosis of AA for equivocal appendicitis on CT (Alvarado, 0.698; Eskelinen, 0.710; appendicitis inflammatory response, 0.668; RIPASA, 0.653; AAS, 0.726). A RIPASA score greater than 7.5 had a high positive predictive value (90.9) and an AAS score less than or equal to 5 had a high negative predictive value (91.7) in the diagnosis of AA. CONCLUSION: The accuracy of clinical scoring systems in the diagnosis of AA with equivocal CT findings was moderate. Therefore, a high RIPASA score may assist in the diagnosis of AA in patients with equivocal CT findings, and a low AAS score may be used as a criterion for patient discharge. Most patients presented with intermediate scores. The patients with equivocal CT findings may be considered as a third diagnostic category of AA.
Adult* ; Appendicitis* ; Classification ; Clinical Decision-Making ; Diagnosis ; Diagnostic Tests, Routine ; Humans ; Multidetector Computed Tomography ; Patient Discharge ; Retrospective Studies ; ROC Curve ; Skates (Fish)

PURPOSE: The present study is to investigate the significance of CD44 variant 9 (CD44v9) expression as a biomarker in primary gastric cancer. MATERIALS AND METHODS: With various gastric tissues, we performed immunohistochemical staining for CD44v9. RESULTS: The positive expression rates for CD44v9 in tumor, including adenoma, early gastric cancer (EGC), and advanced gastric cancer (AGC), were higher than those in non-tumor tissues (p=0.003). In addition, the higher expression for CD44v9 was observed as the tissue becomes malignant. In the analysis of 333 gastric cancer tissues, we found that positive expression rates for CD44v9 were higher in the intestinal type or well differentiated gastric cancer than in the diffuse type or poorly differentiated gastric cancer. Interestingly, the positive expression indicated poor prognosis in EGC (5-year survival rate [5-YSR] in stage I, 81.7% vs. 95.2%; p=0.013), but not in AGC (5-YSR in stage II, 66.9% vs. 62.2%; p=0.821; 5-YSR in stage III, 34.5% vs. 32.0%; p=0.929). Moreover, strong positive expression (3+) showed a trend suggesting worse prognosis only in EGC, and it appeared to be associated with lymph node metastasis. CONCLUSION: This study suggests that CD44v9 may be a good biomarker for prognosis prediction and for chemoprevention or biomarker-driven therapies only for EGC.
Adenoma ; Biological Markers ; Chemoprevention ; Lymph Nodes ; Neoplasm Metastasis ; Prognosis ; Stomach Neoplasms* ; Survival Rate

OBJECTIVE: The aim of this study was to evaluate the effect of adding bedside ultrasonography to the diagnostic algorithm for nephrolithiasis on emergency department (ED) length of stay. METHODS: A prospective, randomized, controlled pilot study was conducted from October 2014 to December 2014 with patients with acute flank pain. In the non-ultrasonography group (NUSG), non-contrast computed tomography was selected based on clinical features and hematuria in the urinalysis. In the ultrasonography group (USG), non-contrast computed tomography was selected based on clinical features and hydronephrosis on bedside ultrasonography. The primary outcome was ED length of stay. The secondary outcomes were radiation exposure, amount of analgesics, proportion of patients with diseases other than ureteral calculus, and proportion of patients with unexpected ED revisits within 7 days from the index visit. RESULTS: A total of 103 patients were enrolled (NUSG, 51; USG, 52). The ED length of stay for the USG (89.0 minutes) was significantly shorter than that for the NUSG (163.0 minutes, P<0.001). There were no significant differences between the two groups in the radiation exposure dose (5.29 and 5.08 mSv, respectively; P=0.392), amount of analgesics (P=0.341), proportion of patients with diseases other than ureteral calculus (13.0% and 6.8%, respectively; P=0.486), and proportion of patients with unexpected ED revisits within 7 days from the index visit (7.8% and 9.6%, respectively; P=1.000). CONCLUSION: The use of early bedside ultrasonography for patients with acute flank pain could reduce the ED length of stay without increasing unexpected ED revisits.
Analgesics ; Emergencies* ; Emergency Service, Hospital* ; Flank Pain ; Hematuria ; Humans ; Hydronephrosis ; Length of Stay* ; Nephrolithiasis ; Pilot Projects* ; Prospective Studies ; Radiation Exposure ; Renal Colic* ; Ultrasonography* ; Ureteral Calculi ; Ureterolithiasis ; Urinalysis

PURPOSE: Central venous catheterization (CVC) plays important roles in treatment of critically ill patients. Although use of ultrasound has led to a decrease in CVC related complications, adverse events still occur. Therefore, we usually check the chest x-ray for confirmation. The purpose of this study was to evaluate the usefulness of point of care ultrasound during catheterization of the internal jugular vein (IJV). METHODS: The authors conducted a prospective study of emergency department (ED) patients undergoing CVC via IJV. Among the enrolled patients, 97 underwent SAVE, which consisted of 1) pre-CVC lung ultrasound, 2) ultrasound guided puncture of central vein, 3) sonographic detection of the guide wire before dilation, and 4) post-CVC lung ultrasonography. The primary outcome was the success rate of each stage. The secondary outcome was an estimated time of the SAVE exam. The entire process of patients' care was recorded by video for the purpose of time analysis. Physicians described anatomical site, reason for catheterization, and acute mechanical complications. RESULTS: In all subjects, the guide wire was visible within the lumen of the IJV. Median access time, from insertion to detection of the guide wire in IJV via ultrasound, was 20 seconds. After the CVC was inserted, post-CVC lung ultrasonography was completed within a median time of 68 seconds. Identification of the chest x-ray image took more than 5 minutes. Acute mechanical complications - which occurred in three patients - were detected immediately by SAVE. CONCLUSION: SAVE may provide greater safety during CVC by detection of CVC related complication more properly, without delay.
Catheterization* ; Catheterization, Central Venous ; Catheters* ; Central Venous Catheters ; Critical Illness ; Emergency Service, Hospital ; Humans ; Jugular Veins* ; Lung ; Patient Safety ; Prospective Studies ; Punctures ; Thorax ; Ultrasonography* ; Veins