We report a case of a ruptured triple hormone-secreting adrenal mass with hyperaldosteronism, hypercortisolism, and elevated normetanephrine levels, diagnosed as adrenal cortical carcinoma (ACC) by histology. A 53-year-old male patient who initially presented with abdominal pain was referred to our hospital for angiocoagulation of an adrenal mass rupture. Abdominal computed tomography revealed a heterogeneous 19×11×15 cm right adrenal mass with invasion into the right lobe of the liver, inferior vena cava, retrocaval lymph nodes, and aortocaval lymph nodes. Angiocoagulation was performed. Laboratory evaluation revealed excess cortisol via a positive 1-mg overnight dexamethasone suppression test, primary hyperaldosteronism via a positive saline infusion test, and plasma normetanephrine levels three times higher than normal. An adrenal mass biopsy was performed for pathological confirmation to commence palliative chemotherapy because surgical management was not deemed appropriate considering the extent of the tumor. Pathological examination revealed stage T4N1M1 ACC. The patient started the first cycle of adjuvant mitotane therapy along with adjuvant treatment with doxorubicin, cisplatin, and etoposide, and was discharged. Clinical cases of dual cortisol- and aldosterone-secreting ACCs or ACCs presenting as pheochromocytomas have occasionally been reported; however, both are rare. Moreover, to the best of our knowledge, a triple hormone-secreting ACC has not yet been reported. Here, we report a rare case and its management. This case report underscores the necessity of performing comprehensive clinical and biochemical hormone evaluations in patients with adrenal masses because ACC can present with multiple hormone elevations.

Objective: This study aimed to determine the factors that affect successful esophageal foreign body (FB) removal using a Foley catheter and to identify methods to increase the success rate. Methods: In this retrospective, cross-sectional study, we included pediatric patients who presented with esophageal FB impaction that was removed using a Foley catheter in the emergency departments of tertiary care and academic hospitals. We analyzed the effect of the patients’ age, sex, and symptoms; FB type, size, and location; Foley catheter size; complications during FB removal; duration between FB ingestion and removal; operator’s years of training; sedation; success rate of FB removal; endoscopy; and patient’s posture during FB removal on the success of Foley catheter-based FB removal. Results: Of the 43 patients we enrolled, Foley catheter-based FB removal was successful in 81.4% (35/43) but failed in 18.6% (8/43) of patients; no FB-removal-related complications were reported. There was no significant association between the success rate of Foley catheter-based FB removal and any study variable. A higher number of years in training tended to increase the success rate of Foley catheter-based FB removal, although statistical significance was not achieved. Conclusion Children’s esophageal FB removal is a practical challenge in the emergency rooms, and using a Foley catheter is associated with a high success rate of the removal and low occurrence of complications. In this study, no single variable was found correlated with the success rate of Foley catheter-based esophageal FB removal in pediatric patients, which may indicate multiple variables interacting with one another to affect the success rate.

Background/Aims: There have been few multicenter studies on colonic polyps conducted by primary medical institutions. This study examined the detection rate of colonic polyps in primary health care institutions and the related factors while following the guidelines. Methods: The medical records of 14,029 patients who underwent colonoscopy between January-June 2020 at 40 primary medical institutions in Korea were analyzed. High-risk adenoma was defined as advanced adenoma, carcinoma, or ≥3 adenomas. Results: Most patients (71.2%) aged ≥50 years underwent re-colonoscopy within 5 years (51.3%) for diagnostic purposes (61.3%) in Korean primary medical institutions. The detection rates of colon polyps, adenoma, advanced adenoma, high-risk adenoma, and carcinoma was 59.9%, 38.9%, 5.9%, 11.4%, and 0.3% in all subjects and 59.8%, 37.5%, 8.5%, 12.9%, and 0.3% in average-risk patients, respectively. The incidences of adenoma in average-risk patients increased significantly with age (30s/40s/50s: 20.1%/29.4%/43% for adenoma, 4.4%/6.7%/10.3% for advanced adenoma, and 5.6%/9.5%/14.6% for high-risk adenoma; p<0.05). Before 50 years of age, high-risk adenoma was detected in 9.1% of patients in the first-time screening group, and the significant risk factors were being male and ≥40 years of age. The detection rate of high-risk adenoma in the normal index colonoscopy group within 5 years was 9.0%. The significant risk factors included older age, male sex, positive fecal occult blood test, stool form changes, and nonspecific symptoms (gas and indigestion). Conclusions More colonic adenoma studies targeting real-world clinical practice will be needed to revise the Korean guidelines for colorectal cancer screening and surveillance.

Objective: This study aimed to determine the factors that affect successful esophageal foreign body (FB) removal using a Foley catheter and to identify methods to increase the success rate. Methods: In this retrospective, cross-sectional study, we included pediatric patients who presented with esophageal FB impaction that was removed using a Foley catheter in the emergency departments of tertiary care and academic hospitals. We analyzed the effect of the patients’ age, sex, and symptoms; FB type, size, and location; Foley catheter size; complications during FB removal; duration between FB ingestion and removal; operator’s years of training; sedation; success rate of FB removal; endoscopy; and patient’s posture during FB removal on the success of Foley catheter-based FB removal. Results: Of the 43 patients we enrolled, Foley catheter-based FB removal was successful in 81.4% (35/43) but failed in 18.6% (8/43) of patients; no FB-removal-related complications were reported. There was no significant association between the success rate of Foley catheter-based FB removal and any study variable. A higher number of years in training tended to increase the success rate of Foley catheter-based FB removal, although statistical significance was not achieved. Conclusion Children’s esophageal FB removal is a practical challenge in the emergency rooms, and using a Foley catheter is associated with a high success rate of the removal and low occurrence of complications. In this study, no single variable was found correlated with the success rate of Foley catheter-based esophageal FB removal in pediatric patients, which may indicate multiple variables interacting with one another to affect the success rate.

OBJECTIVE: Massive intracerebral hemorrhage (ICH) and major infarction (MI) are devastating cerebral vascular diseases. Decompression craniectomy (DC) is a common treatment approach for these diseases and acceptable clinical results have been reported. Author experienced the postoperative intracranaial pressure (ICP) trend is somewhat different between the ICH and MI patients. In this study, we compare the ICP trend following DC and evaluate the clinical significance.METHODS: One hundred forty-three patients who underwent DC following massive ICH (81 cases) or MI (62 cases) were analyzed retrospectively. The mean age was 56.3±14.3 (median=57, male : female=89 : 54). DC was applied using consistent criteria in both diseases patients; Glasgow coma scale (GCS) score less than 8 and a midline shift more than 6 mm on brain computed tomography. In all patients, ventricular puncture was done before the DC and ICP trends were monitored during and after the surgery. Outcome comparisons included the ictus to operation time (OP-time), postoperative ICP trend, favorable outcomes and mortality.RESULTS: Initial GCS (p=0.364) and initial ventricular ICP (p=0.783) were similar among the ICH and MI patients. The postoperative ICP of ICH patients were drop rapidly and maintained within physiological range if greater than 80% of the hematoma was removed. While in MI patients, the postoperative ICP were not drop rapidly and maintained above the physiologic range (MI=18.8 vs. ICH=13.6 mmHg, p=0.000). The OP-times were faster in ICH patients (ICH=7.3 vs. MI=40.9 hours, p=0.000) and the mortality rate was higher in MI patients (MI=37.1% vs. ICH=17.3%, p=0.007).CONCLUSION: The results of this study suggest that if greater than 80% of the hematoma was removed in ICH patients, the postoperative ICP rarely over the physiologic range. But in MI patients, the postoperative ICP was above the physiologic range for several days after the DC. Authors propose that DC is no need for the massive ICH patient if a significant portion of their hematoma is removed. But DC might be essential to improve the MI patients’ outcome and timely treatment decision.
Brain ; Cerebral Hemorrhage ; Cerebral Infarction ; Decompression ; Decompressive Craniectomy ; Glasgow Coma Scale ; Hematoma ; Humans ; Infarction ; Intracranial Hemorrhages ; Intracranial Pressure ; Male ; Mortality ; Punctures ; Retrospective Studies ; Stroke ; Vascular Diseases

The daily insertion of endotracheal tubes, laryngeal mask airways, oral/nasal airways, gastric tubes, transesophageal echocardiogram probes, esophageal dilators and emergency airways all involve the risk of airway structure damage. In the closed claims analysis of the American Society of Anesthesiologists, 6% of all claims concerned airway injury. Among the airway injury claims, the most common cause was difficult intubation. Among many other causes, esophageal stethoscope is a relatively noninvasive monitor that provides extremely useful information. Relatively not many side effects that hardly is ratable. Some of that was from tracheal insertion, bronchial insertion resulting in hypoxia, hoarseness due to post cricoids inflammation, misguided surgical dissection of esophagus. Also oropharyngeal bleeding and subsequent anemia probably are possible and rarely pharyngeal/esophageal perforations are also possible because of this device. Careful and gentle procedure is necessary when inserting esophageal stethoscope and observations for injury and bleeding are needed after insertion.
Anemia ; Anoxia ; Emergencies ; Esophagus ; Hemorrhage* ; Hoarseness ; Inflammation ; Insurance Claim Review ; Intubation ; Laryngeal Masks ; Stethoscopes*

PURPOSE: For the differential diagnosis of acute abdomen, abdominal computed tomography (CT) is commonly performed in the emergency department (ED). Rapid and accurate interpretation after CT is essential; however, final interpretation of the images by a board-certified radiologist for 24 hours a day is nearly impossible. Therefore, a preliminary interpretation is mainly made by emergency physicians in the ED, which may result in some discrepancy with the interpretations of board-certified radiologists. This study was conducted to determine the discrepancy rate of emergency medicine (EM) residents' preliminary interpretation and any reduction in discrepancy through feedback imaging education programs by attending radiologists. METHODS: This was a before-and-after study, including 540 cases of abdominal CT scans performed in the ED between November 1, 2014 and April 30, 2015. Residents first documented their preliminary interpretation of 300 cases for 3 months. Board-certified radiologists then provided feedback image education to EM residents for these cases for 1 month. After feedback education, preliminary interpretations of 240 cases were documented for 2 months. Discrepancy rates before and after feedback education were then analyzed. RESULTS: Total and major discrepancy rates before feedback image education were 28% and 11.7%, respectively, which declined to 14.6% and 4.6%, respectively, after feedback image education (p<0.05). CONCLUSION: Feedback image education was effective in reducing the discrepancy rate of the interpretation of abdominal CT scans by EM residents.
Abdomen, Acute ; Diagnosis, Differential ; Education* ; Emergencies* ; Emergency Medicine* ; Emergency Service, Hospital ; Tomography, X-Ray Computed*

BACKGROUND: Postoperative pain is the most common complaint of patients following laparoscopic cholecystectomy (LC). Intravenous lidocaine has analgesic, anti-hyperalgesic, and anti-inflammatory effects, and dexmedetomidine has anti-nociceptive and analgesic sparing effects. We evaluated the effects of perioperative intravenous infusion of lidocaine and dexmedetomidine on postoperative pain control and analgesic consumption after LC. METHODS: Eighty-four patients, aged 20-60 years, who were undergoing elective LC were assigned randomly to three groups (n = 28 in each). The patients in group L received an intravenous lidocaine bolus of 1.5 mg/kg and then continuous infusion of 2 mg/kg/hr. The group D received an intravenous dexmedetomidine bolus of 1 microg/kg, followed by continuous infusion of 0.4 microg/kg/hr. The group N received saline as described for group L. Bolus doses were given during the 10 minutes before the induction of anesthesia, followed by continuous infusion until end of the surgery. Visual analogue scale (VAS) score and postoperative analgesics consumption were evaluated during 24 hours after the surgery. RESULTS: No significant difference was observed in VAS score among the groups during the first 24 hr after LC. The amount of fentanyl consumption in the post-anesthesia care unit was significantly less in groups L and D compared to group N. CONCLUSIONS: Both perioperative intravenous infusion of dexmedetomidine and lidocaine reduced postoperative requirements of fentanyl in the early post-operative period after LC. However, there was no significant difference between dexmedetomidine and lidocaine in the analgesic sparing effect.
Analgesics* ; Anesthesia ; Cholecystectomy, Laparoscopic* ; Dexmedetomidine* ; Fentanyl ; Humans ; Infusions, Intravenous ; Lidocaine* ; Pain, Postoperative

BACKGROUND: Melanocytes are present in both basal epidermis and hair follicles. Melanocyte stem cells have been found in hair follicle bulge. During embryogenesis, the outer cells of the bulge differentiate into the sebaceous gland (SG) and proliferate. OBJECTIVE: To identify and determine the distribution and morphological characteristics of melanocytes in human SGs. METHODS: A total of 171 biopsy specimens of face and scalp were studied. Of these specimens, 103 samples contained SGs. We conducted a retrospective review of slides stained with H&E, F-M, anti-S100, anti-c-kit, anti-HMB-45, anti-CD1a, anti-MITF, and anti-tyrosinase. The presence and distribution of melanocytes in human SGs was also evaluated by electron microscopy. In addition, melanocytes were isolated from SGs for primary culture. RESULTS: S-100-positive cells were observed mainly at the periphery of SGs in 34 of 54 specimens. We did not find F-M-positive and HMB-45-positive cells in SGs. CD1a-positve cells were identified in two specimens. We also found c-kit-, MITF-, and tyrosinase-positive cells in SGs. Electron micrograph showed the presence of melanocytes in the suprabasal portion of SGs. These melanocytes showed fewer melanin-containing granules than the melanocytes of basal epidermis. However, the individually distributed melanosomes in suprabasal melanocytes were larger than those in epidermal melanocytes. Primary culture of melanocytes derived from SGs showed morphologically homogeneous, slender cell bodies with few dendrites. CONCLUSION: Our study confirms the presence of non-melanogenic melanocytes and Langerhans cells in human SGs. In addition, the characteristics of the melanocytes in SGs were found to be different from those of the epidermal melanocytes.
Biopsy ; Dendrites ; Embryonic Development ; Epidermis ; Female ; Hair Follicle ; Humans ; Langerhans Cells ; Melanocytes* ; Melanosomes ; Microscopy, Electron ; Pregnancy ; Retrospective Studies ; Scalp ; Sebaceous Glands* ; Stem Cells

PURPOSE: The aim of this study was to compare the difference in acute stroke management between urban and rural areas, to investigate the factors affecting these differences, and to acquire basic information for establishing an efficient regional hub and spoke system for stroke patients. METHODS: This retrospective study was based on adult patients diagnosed with acute ischemic stroke from January 2012 to December 2012 at a regional cerebrovascular center. The term "acute" was defined as 24 hours from symptom recognized. The term "urban" was defined as the region within the boundary of a metropolitan area. The distance from the symptom onset location to the stroke center was calculated using a global positioning system. RESULTS: The rate of arriving at a stroke center within 3 hours after stroke recognition for acute ischemic stroke patients was much higher in urban areas compared to rural areas (27.5 vs. 19.2%, respectively; p-value=0.011). In stroke cases in rural areas, the distance from symptom onset location to a stroke center was determined as statistically significant through multivariate logistic regression analysis (Odds ratio (OR), 0.982; 95% Confidence interval (CI) 0.969-0.995). In contrast, the use of a public ambulance (OR, 4.258; 95% CI 2.233-8.118) and inter-hospital transfer (OR, 0.416; 95% CI 0.216-0.800) were the main prehospital delay factors in urban areas. CONCLUSION: For stroke cases in urban areas, it was important to directly visit a stroke center without transfer using a public ambulance. For rural areas, a new hub hospital and policies are necessary for reducing prehospital delay.
Adult ; Ambulances ; Emergency Medical Services ; Geographic Information Systems ; Humans ; Logistic Models ; Retrospective Studies ; Stroke*