Objective: We investigated the effects of a quick Sequential Organ Failure Assessment (qSOFA)–negative result (qSOFA score <2 points) at triage on the compliance with sepsis bundles among patients with sepsis who presented to the emergency department (ED). Methods: Prospective sepsis registry data from 11 urban tertiary hospital EDs between October 2015 and April 2018 were retrospectively reviewed. Patients who met the Third International Consensus Definitions for Sepsis and Septic Shock criteria were included. Primary exposure was defined as a qSOFA score ≥2 points at ED triage. The primary outcome was defined as 3-hour bundle compliance, including lactate measurement, blood culture, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration. Multivariate logistic regression analysis to predict 3-hour bundle compliance was performed. Results: Among the 2,250 patients enrolled in the registry, 2,087 fulfilled the sepsis criteria. Only 31.4% (656/2,087) of the sepsis patients had qSOFA scores ≥2 points at triage. Patients with qSOFA scores <2 points had lower lactate levels, lower SOFA scores, and a lower 28-day mortality rate. Rates of compliance with lactate measurement (adjusted odds ratio [aOR], 0.47; 95% confidence interval [CI], 0.29–0.75), antibiotics administration (aOR, 0.64; 95% CI, 0.52–0.78), and 30 mL/kg crystalloid administration (aOR, 0.62; 95% CI, 0.49–0.77) within 3 hours from triage were significantly lower in patients with qSOFA scores <2 points. However, the rate of compliance with blood culture within 3 hours from triage (aOR, 1.66; 95% CI, 1.33–2.08) was higher in patients with qSOFA scores <2 points. Conclusion A qSOFA-negative result at ED triage is associated with low compliance with lactate measurement, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration within 3 hours in sepsis patients.

Background/Aims: The objective of this study was to determine the more appropriate wound-closure method by comparing the effectiveness of two methods in a group of patients who underwent ileostomy repair. Methods: The study conducted after obtaining the approval of the Institutional Review Board (IRB) included 58 patients ≥19 years of age who underwent ileostomy at the Department of Surgery at the Presbyterian Medical Center. This was a retrospective, single-center trial. Patients who underwent ileostomy closure between January 2011 and September 2017 were assigned to the primary wound-closure (PC, n=25) group and the purse-string wound-closure (PSC, n=33) group. Post-repair complications, such as wound infection, delayed healing, and patient satisfaction related to wound management, were investigated and compared according to the wound-closure method. Results: The PSC group had a significantly lower surgical site infection rate than the PC group (0% vs. 44%, p<0.001). The wound-healing period was also significantly different between the PC and PSC groups (mean 27.18 days vs. 20.96 days, p=0.023). However, the postoperative wound-healing delay of >30 days was not significantly different (39% vs. 20%, p=0.114). In addition, there were no significant differences in the response to questionnaires on patient satisfaction between the two groups. Conclusions PSC has a lower surgical site infection rate and the wound-healing delay was not very different from that of PC. Therefore, if patients are at risk of wound infection, such as in severe wound contamination, long operating time, and immunocompromised conditions, we should consider PSC as a wound closure method of choice.

Background: Reconstruction of congenital microtia remains challenging, particularly in patients with a history of ear canaloplasty due to insufficient regional soft tissue. The insertion of a tissue expander prior to implantation of the cartilage framework has traditionally been employed. However, this procedure could induce additional morbidity. Herein, we present a method using V-Y advancement of a temporal triangular flap to gain additional soft tissue in these challenging cases. Methods: Congenital microtia patients with a history of ear canaloplasty who underwent auricular reconstruction using the Nagata technique between 2016 and 2020 were reviewed. To obtain additional soft tissue, V-Y advancement of a temporal triangular flap was performed concurrently with implantation of the costal cartilage framework, without prior insertion of a tissue expander. The outcomes of these patients with respect to postoperative complications and esthetics were evaluated. Results: Eight patients with bilateral lesions were included. No specific complications developed after the first-stage surgery. However, one patient experienced complications after the second stage (auricular elevation). An analysis of the esthetic results showed most patients had excellent outcomes, achieving a satisfactory convolution. The median number of operations needed to complete reconstruction was 2, which was fewer than required using the conventional method with prior insertion of a tissue expander. Conclusions In patients with a history of previous canaloplasty, V-Y advancement of a temporal triangular flap could serve as an alternative to tissue expansion for microtia reconstruction. This technique provided reliable and satisfactory results with a reduced number of surgical stages.

Objective: Prior studies have explored the relationship between initial body temperature (BT) and mortality in patients with sepsis in the emergency department (ED). However, there has been no study on whether or not changes in BT are associated with prognosis in these patients. We hypothesize that BT measured upon ED arrival and septic shock registry enroll time are related to the prognosis of patients with septic shock. Methods: We conducted a prospective, observational, registry-based study. Each patient was assigned to 1 of 4 groups according to BT upon ED arrival and registry enrollment. Odds ratios for 28-day mortality according to the patient group were estimated using multivariable logistic regression. We also conducted logistic regression sensitivity analysis, except for patients whose time interval between arrival and enrollment was less than 1 hour. Results: A total of 2,138 patients with septic shock were included. The 28-day mortalities were 13.7%, 11.2%, 13.0%, and 25.8% in groups 1, 2, 3, and 4, respectively (P<0.001). After adjusting for age, sex, mean atrial pressure, respiratory rate, Sequential Organ Failure Assessment score, lactate concentration, comorbidity, and suspicious infection focus, the risk of mortality was significantly low in patients from group 1 (adjusted odds ratio [aOR], 0.433; 95% confidence interval [CI], 0.310-0.604) and group 2 (aOR, 0.540; 95% CI, 0.336-0.868) compared with group 4. In the sensitivity analysis, group based on BT measured upon ED arrival and registry enrollment also remained an independent predictor of mortality. Conclusion Afebrile status upon ED arrival and registry enrollment were strongly associated with higher 28-day mortality in patients with septic shock.

Purpose: The aim of this study is to review our experience in treating indirect inguinal hernia in pediatric patients. Methods: We retrospectively studied a total of 43 patients who underwent percutaneous internal ring suturing (PIRS) for indirect inguinal hernia from January 2016 to September 2018. The participants included 29 boys and 14 girls. There were cases of bilateral internal inguinal hernia (n=12), right indirect inguinal hernia (n=16), and left indirect inguinal hernia (n=15). Their mean age was 3.8±2.9 years, and mean body weight was 16 kg. Clinical features and surgical outcomes were analyzed. Results: Mean operating time was 35 min for unilateral inguinal hernia and 40 min for bilateral inguinal hernia. There were five cases of intraoperative bleeding (12%) during needle insertion. In two cases, stress test resulted in escape of gas into the hernial sac and a second suture was inserted. The contralateral patent processus vaginalis was present in six (14% of cases) and closed. Follow-up was 6~30 months. Mean postoperative hospital stay was 1.2 days. No recurrence hernia and postoperative complications were reported. Conclusion Although this study investigated a small number of cases and the surgical experience was rather limited, the PIRS technique was shown to have advantages such as a short learning curve and its aid in detecting contralateral hernias. In this study, there were no reports of recurrence, metachronous inguinal hernias, and postoperative complications.

OBJECTIVE: Endotracheal intubation (ETI) is the most reliable way to manage the airway. Stepwise deliberate practice and mastery training is essential in maintaining and promoting the skill of intubation. This study was conducted to identify differences in examiners' expectations regarding competent skill performance and to develop learner-adjusted assessment tools with appropriate levels according to student and resident learners based on the expectations and limited observation of performance by examiners. METHODS: This was an exploratory, psychometric study using a simple airway part task trainer. The draft ETI assessment tool from the literatures, previous tools, and the preliminary learner-adjusted assessment tool for students and residents were developed and analyzed. Knowledge-based and competence-based items for each learner group were identified based on experts' expectations. The final learner-adjusted tools were refined through analyzing the content validity, internal consistency, and interrater reliability based on assessing the observed performance of 14 students and 12 residents by ten experts. RESULTS: The preliminary student-adjusted assessment tool and resident-adjusted assessment tool had 12 items on the checklist with a ternary scoring system and a ternary scoring checklist including 15 items, and an overall Global Rating Scale. The final student-adjusted assessment tool was composed of a ternary scoring checklist including 9 items (total CVI, 86.6%; Cronbach's α, 0.83; interrater reliability, 0.64). The resident-adjusted assessment, on the other hand, was also composed of a ternary scoring checklist including 12 items (total CVI, 86.4%; Cronbach's α, 0.7; interrater reliability, 0.78), in addition to global rating scale including ‘rating of the overall process’. CONCLUSION: The experts had different expectations regarding the level of competence in each step according to learner groups with different levels of difficulty. Understanding the factors influencing assessments can provide a guide for teaching and objectively assessing to the examiner.
Checklist ; Hand ; Humans ; Intubation ; Intubation, Intratracheal ; Mental Competency ; Psychometrics

PURPOSE: This study compared the oncologic impact of postoperative chemotherapy and chemoradiotherapy on patients with rectal cancer without preoperative chemoradiation. METHODS: This retrospective study analyzed 713 patients with a mean follow-up of 58 months who had undergone radical resection for stage II/III rectal cancer without preoperative treatment in nine hospitals from January 2004 to December 2009. The study population was categorized a chemotherapy group (CG, n = 460) and a chemoradiotherapy group (CRG, n = 253). Five-year overall survival (OS) and disease-free survival (DFS) were analyzed, and independent factors predicting survival were identified. RESULTS: The patients in the CRG were significantly younger (P < 0.001) and had greater incidences of low rectal cancer (P < 0.001) and stage III disease (P < 0.001). Five-year OS (P = 0.024) and DFS (P = 0.012) were significantly higher in the CG for stage II disease; however, they were not significantly different for stage III disease. In the multivariate analysis, independent predictive factors were male sex, low rectal cancer and stage III disease for OS and male sex, abdominoperineal resection, stage III disease and tumor-positive circumferential margin for DFS. However, adjuvant therapy type did not independently affect OS (hazard ratio [HR], 1.243; 95% confidence interval [CI], 0.794–1.945; P = 0.341) and DFS (HR, 1.091; 95% CI, 0.810–1.470; P = 0.566). CONCLUSION: Adjuvant therapy type did not affect survival of stage II/III rectal cancer patients without neoadjuvant chemoradiotherapy. These results suggest that adjuvant therapy can be chosen based on the patient’s condition and the policies of the surgeons and hospital facilities.
Chemoradiotherapy ; Disease-Free Survival ; Drug Therapy ; Follow-Up Studies ; Humans ; Incidence ; Male ; Multivariate Analysis ; Rectal Neoplasms* ; Retrospective Studies* ; Surgeons

We experienced a case of 1 patient who died from rhabdomyolysis-related complications after colonoscopy. A 60-year-old man had undergone an ‘uncomplicated’ colonoscopic polypectomy. Approximately 10 hours following this procedure, the patient complained of increasing left abdominal pain. His computed tomography image showed free gas, but his operative findings revealed no macroscopic perforation or abscess formation. Eight hours after the operation, the patient presented with myoglobulinuria, and we diagnosed the condition to be rhabdomyolysis. Based on this case, we recommend that rhabdomyolysis be added to the list of complications following a colonoscopic procedure. Moreover, for prevention and early treatment, endoscopists should be attentive to the risk factors and signs/symptoms of rhabdomyolysis.
Abdominal Pain ; Abscess ; Colonoscopy ; Humans ; Middle Aged ; Rhabdomyolysis ; Risk Factors

OBJECTIVE: We evaluated the clinical characteristics and prognoses of patients with septic shock who transferred to the emergency department (ED) in a tertiary referral center. METHODS: This study was performed using a prospective, multi-center registry of septic shock, with the participation of 11 tertiary referral centers in the Korean Shock Society between October 2015 and February 2017. We classified the patients as a transferred group who transferred from other hospitals after meeting the inclusion criteria upon ED arrival and a non-transferred group who presented directly to the ED. Primary outcome was hospital mortality. We conducted multiple logistic regression analysis to assess variables related to in-hospital mortality. RESULTS: A total of 2,098 patients were included, and we assigned 717 patients to the transferred group and 1,381 patients to the non-transferred group. The initial Sequential Organ Failure Assessment score was higher in the transferred group than the non-transferred group (6; interquartile range [IQR], 4–9 vs. 6; IQR, 4–8; P < 0.001). Mechanical ventilator (29% vs. 21%, P < 0.001) and renal replacement therapy (12% vs. 9%, P=0.034) within 24 hours after ED arrival were more frequently applied in the transferred group than the non-transferred group. Overall hospital mortality was 22% and there was no significant difference between transferred and non-transferred groups (23% vs. 22%, P=0.820). Multivariable analysis showed an odds ratio for in-hospital mortality of 1.00 (95% confidence interval, 0.78–1.28; P=0.999) for the transferred group compared with the non-transferred group. CONCLUSION: The transferred group showed higher severity and needed more organ support procedures than the nontransferred group. However, inter-hospital transfer did not affect in-hospital mortality.
Emergencies* ; Emergency Service, Hospital* ; Hospital Mortality ; Humans ; Logistic Models ; Mortality ; Observational Study* ; Odds Ratio ; Prognosis ; Prospective Studies ; Renal Replacement Therapy ; Retrospective Studies* ; Sepsis ; Shock ; Shock, Septic* ; Tertiary Care Centers* ; Ventilators, Mechanical

OBJECTIVE: To evaluate the clinical characteristics, therapeutic interventions, and outcomes of patients with septic shock admitted to the emergency department (ED). METHODS: This study was a preliminary, descriptive analysis of a prospective, multi-center, observational registry of the EDs of 10 hospitals participating in the Korean Shock Society. Patients aged 19 years or older who had a suspected or confirmed infection and evidence of refractory hypotension or hypoperfusion were included. RESULTS: A total of 468 patients were enrolled (median age, 71.3 years; male, 55.1%; refractory hypotension, 82.9%; hyperlactatemia without hypotension, 17.1%). Respiratory infection was the most common source of infection (31.0%). The median Sepsis-related Organ Failure Assessment score was 7.5. The sepsis bundle compliance was 91.2% for lactate measurement, 70.3% for blood culture, 68.4% for antibiotic administration, 80.3% for fluid resuscitation, 97.8% for vasopressor application, 68.0% for central venous pressure measurement, 22.0% for central venous oxygen saturation measurement, and 59.2% for repeated lactate measurement. Among patients who underwent interventions for source control (n=117, 25.1%), 43 (36.8%) received interventions within 12 hours of ED arrival. The in-hospital, 28-day, and 90-day mortality rates were 22.9%, 21.8%, and 27.1%, respectively. The median ED and hospital lengths of stay were 6.8 hours and 12 days, respectively. CONCLUSION: This preliminary report revealed a mortality of over 20% in patients with septic shock, which suggests that there are areas for improvement in terms of the quality of initial resuscitation and outcomes of septic shock patients in the ED.
Central Venous Pressure ; Compliance ; Emergency Service, Hospital ; Humans ; Hyperlactatemia ; Hypotension ; Lactic Acid ; Male ; Mortality ; Oxygen ; Patient Care Bundles ; Prospective Studies ; Resuscitation ; Sepsis ; Shock* ; Shock, Septic*