Background: We explored the utility of a small multi-gene DNA panel for assessing molecular profiles of thyroid nodules and influencing clinical decisions by comparing outcomes between tested and untested nodules. Methods: Between April 2022 and May 2023, we prospectively performed fine-needle aspiration (FNA) with gene testing via DNA panel of 11 genes (BRAF, RAS [NRAS, HRAS, KRAS], EZH1, DICER1, EIF1AX, PTEN, TP53, PIK3CA, TERT promoter) in 278 consecutive nodules (panel group). Propensity score-matching (1:1) was performed with 475 nodules that consecutively underwent FNA without gene testing between January 2021 and December 2021 (control group). Results: In the panel group, positive call rate for mutations was 41.7% (BRAF 16.2%, RAS 12.6%, others 11.5%, double mutation 1.4%) for all nodules, and 40.0% (BRAF 4.3%, RAS 19.1%, others 15.7%, double mutation 0.9%) for indeterminate nodules. Benign call rate was 69.8% for all nodules, and 75.7% for indeterminate nodules. In four nodules, additional TP53 (in addition to BRAF or EZH1) or PIK3CA (in addition to BRAF or TERT) mutations were co-detected. Sensitivity, specificity, positive predictive value, and negative predictive value were 80.0%, 53.3%, 88.1%, 38.1% for all nodules, and 78.6%, 45.5%, 64.7%, 62.5% for indeterminate nodules, respectively. Panel group exhibited lower surgical resection rates than the control group for all nodules (27.0% vs. 52.5%, P<0.001), and indeterminate nodules (23.5% vs. 68.2%, P<0.001). Malignancy risk was significantly different between the panel and control groups (81.5% vs. 63.9%, P=0.008) for all nodules. Conclusion Our panel aids in managing thyroid nodules by providing information on malignancy risk based on mutations, potentially reducing unnecessary surgery in benign nodules or patients with less aggressive malignancies.

Purpose: Advances in chemotherapeutic and targeted agents have increased pathologic complete response (pCR) rates after neoadjuvant systemic therapy (NST). Vacuum-assisted biopsy (VAB) has been suggested to accurately evaluate pCR. This study aims to confirm the non-inferiority of the 5-year disease-free survival of patients who omitted breast surgery when predicted to have a pCR based on breast magnetic resonance imaging (MRI) and VAB after NST, compared with patients with a pCR who had undergone breast surgery in previous studies. Methods The Omission of breast surgery for PredicTed pCR patients wIth MRI and vacuumassisted bIopsy in breaST cancer after neoadjuvant systemic therapy (OPTIMIST) trial is a prospective, multicenter, single-arm, non-inferiority study enrolling in 17 tertiary care hospitals in the Republic of Korea. Eligible patients must have a clip marker placed in the tumor and meet the MRI criteria suggesting complete clinical response (post-NST MRI size ≤ 1 cm and lesion-to-background signal enhancement ratio ≤ 1.6) after NST. Patients will undergo VAB, and breast surgery will be omitted for those with no residual tumor. Axillary surgery can also be omitted if the patient was clinically node-negative before and after NST and met the stringent criteria of MRI size ≤ 0.5 cm. Survival and efficacy outcomes are evaluated over five years.Discussion: This study seeks to establish evidence for the safe omission of breast surgery in exceptional responders to NST while minimizing patient burden. The trial will address concerns about potential undertreatment due to false-negative results and recurrence as well as improved patient-reported quality of life issues from the omission of surgery. Successful completion of this trial may reshape clinical practice for certain breast cancer subtypes and lead to a safe and less invasive approach for selected patients.

Objective: RapidRhino is widely used in emergency departments (EDs) to treat epistaxis, and we have used RapidRhino plus epinephrine empirically. In this study, we evaluated the effectiveness of RapidRhino plus epinephrine compared to RapidRhino with saline. Methods: This prospective randomized study was performed on patients with epistaxis who visited our ED between October 2021 and January 2023. Patients were randomized to RapidRhino plus epinephrine or RapidRhino groups by drawing numbers. Subgroup analyses were performed on patients who received or did not receive anticoagulants or antiplatelets. Results: The overall success rates for RapidRhino with saline and RapidRhino with epinephrine were both high (92% and 94%, respectively), but the 10-minute success rates of RapidRhino with saline and RapidRhino with epinephrine were 57.4% and 78%.0%, respectively, which was a significant difference (P=0.001). In patients administered anticoagulants, initial success rate of RapidRhino with epinephrine was higher than that of RapidRhino with saline (83.3% and 62.9%, respectively, P=0.046), and these results were confirmed by adjusted logistic regression analyses-for all patients (adjusted odds ratio [aOR]=2.42; 95% confidence interval [CI], 1.28-4.58) and for patients treated with anticoagulants (aOR=6.31; 95% CI, 1.17-34.17). Conclusion RapidRhino with epinephrine may be more effective at controlling hemorrhage than RapidRhino. The combined administration of RapidRhino and epinephrine might reduce the time spent in emergency departments by epistaxis patients.

Objective: The purpose of this study was to develop a machine learning-based model (eXtreme Gradient boost [XGBoost]) that can accurately predict the severity of acute cholangitis in patients. The model was designed to simplify the classification process compared to conventional methods. Methods: We retrospectively collected data from patients with cholangitis who visited the emergency department of a secondary medical institution in Seongnam, Korea from January 1, 2015 to December 31, 2019. The patients were divided into three groups (Grade I, II, III) based on severity according to the Tokyo Guidelines 2018/2013 (TG18/13) severity assessment criteria for cholangitis. We used algorithms to select variables of high relevance associated with the grade of severity. For the XGBoost models, data were divided into a train set and a validation set by the random split method. The train set was trained in XGBoost models using only the top seven variables. The area under the receiver operating characteristic (AUROC) and the area under the precision-recall curve (AUPRC) were obtained from the validation set. Results: 796 patients were enrolled. The top 7 variables associated with the grade of severity were albumin, white blood cells, blood urea nitrogen, troponin T, platelets, creatinine, prothrombin time, and international normalized ratio. The AUROC values were 0.881 (Grade I), 0.836 (Grade II), and 0.932 (Grade III). The AUPRC values were 0.457 (Grade I), 0.820 (Grade II), and 0.880 (Grade III). Conclusion We believe that the developed XGBoost model is a useful tool for predicting the severity of acute cholangitis with high accuracy and fewer variables than the conventional severity classification method.

Objective: This study examined the predictive factors to decide the surgical treatment for clinically suspected pediatric acute appendicitis with equivocal imaging findings. Methods: This study was conducted retrospectively on children who visited local emergency medical centers and outpatients from January 2018 to February 2021. The electronic medical records were reviewed from 811 pediatric patients younger than 16 years of age with the chief complaint of abdominal pain and who underwent an imaging test for the clinical suspicion of appendicitis. Ninety-two patients who showed ambiguous findings on imaging tests but were still suspected of having appendicitis were analyzed. Recursive partitioning analysis and multivariable logistic regression were used to identify the variables associated with appendicitis. Results: Of the 92 enrolled patients, 23 patients were confirmed to have appendicitis, and 69 did not. Patients with the clinical suspicion who had an elevated white blood cell (WBC) count, polymorphonuclear leukocyte differential count (PMN), absolute neutrophil count (ANC), and leukocytosis were more likely to have appendicitis. The PMN (odds ratio=1.175; 95% confidence interval, 1.092-1.265) and ANC (odds ratio=1.00050; 95% confidence interval, 1.00025-1.00075) remained significant after multivariable logistic analysis. Conclusion Elevated PMN and ANC are clinical predictors of pediatric appendicitis when the imaging findings are nondiagnostic, and the clinical suspicion is continuous.

Objective: A drowsy mentality is a common chief complaint at emergency departments (EDs), but it is difficult to evaluate the reason for drowsy mentality. Serum biomarkers are an alternative way to discover the reason for drowsy mentalities. This study examined the values of four biomarkers for a differential diagnosis of ED patients with drowsy mentality: Creactive protein (CRP), delta neutrophil index (DNI), lactic acid and ammonia. Methods: Adult patients who presented to the ED from April 2018 to March 2019 were reviewed retrospectively. Among the 369 patients with a drowsy mentality, 122 patients with acute trauma, dementia, epilepsy, seizure, alcohol abuse, syncope, psychological problems, and anaphylaxis were excluded. The four biomarkers of each patient were then measured. The clinical records were reviewed to analyze the usefulness of the four biomarkers as a differential diagnosis tool for ED patients. Results: Of the 247 included patients, 64 were diagnosed with a stroke, and 183 were not. CRP, DNI, lactic acid and ammonia were analyzed statistically, and the elevation of each biomarker level was related to a diagnosis of non-stroke disease. Conclusion Elevations of CRP, DNI, lactic acid and ammonia suggest non-stroke disease in patients with drowsy mentality in ED. There might be metabolic causes other than stroke in ED patients with a drowsy mentality when the CRP, DNI, lactic acid and ammonia levels are highly elevated. A future study will be needed to confirm this.

Objective: This study analyzed the urine cultures of emergency department patients diagnosed with acute uncomplicated cystitis and determined the antimicrobial resistance and appropriate treatment for our region. Methods: Results of urine analysis and urine culture of acute uncomplicated cystitis patients diagnosed in our emergency department between January 2019 and December 2020 were examined and analyzed. Results: In our study, 256 out of 340 urine culture samples (75.3%) were positive for cystitis. The most common microorganism was reported to be Escherichia coli (93.0%). The resistance rates of E. coli to the following antimicrobial agents were as follows: amikacin (0.0%), ampicillin (63.5%), amoxicillin/clavulanate (15.6%), aztreonam (7.1%), ceftazidime (3.4%), cefotaxime (16.4%), cefoxitin (5.5%), cefazolin (19.9%), ciprofloxacin (29.4%), cefepime (1.7%), ertapenem (0.0%), gentamicin (18.1%), piperacillin/tazobactam (2.1%), trimethoprim/sulfamethoxazole (36.1%), and tigecycline (0.4%). The prevalence of extended-spectrum beta-lactamase producing E. coli strains was 17.8%. Conclusion To determine the proper empirical antimicrobial treatment for acute uncomplicated cystitis, it is essential to examine the antimicrobial resistance. For our region, fosfomycin, nitrofurantoin, and 2nd and 3rd generation cephalosporin should be considered the first-line empirical treatment for acute uncomplicated cystitis.

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.

Purpose: Breast-conserving surgery (BCS) is a surgical method designed to minimize intraoperative tissue injury. Although this technique is minimally invasive, it can cause significant postoperative pain and may be a risk factor for persistent pain.Erector spinae plane block (ESPB) is an easy interfascial plane block for analgesia in patients undergoing breast surgery. The primary outcome was the numeric rating scale scores measured separately on the breast and axilla. Secondary outcomes included correlation between pain score and skin sensitivity test. Methods: Forty patients were divided into 2 groups (ESPB group and control group). Patients in the ESPB group received an ESPB 30 minutes before the induction of general anesthesia, whereas patients in the control group did not receive any regional analgesia during the perioperative period. Results: Median pain scores of the breast were significantly lower in the ESPB group than that in the control group at 12, 24, and 48 hours after surgery. However, the median pain scores of the axilla were not significantly different between the groups, and the pain score was unrelated to skin sensitivity. Conclusion ESPB can effectively alleviate acute postoperative pain with an opioid-sparing analgesic technique in patients undergoing BCS, and a strong correlation is lacking between pain scores and skin sensitivity test.

OBJECTIVES: Biliary tract cancers (BTCs) are rare but highly fatal. Although the etiology of BTC is poorly understood, gallstones are proposed to be a major risk factor. We conducted a systematic review and meta-analysis to examine the associations between gallstone characteristics and BTC risk. METHODS: We searched the MEDLINE, Embase, and Cochrane Central databases and systematically reviewed cohort and case-control studies published before April 9, 2018. All the included studies reported appropriate risk estimates and confidence intervals (CIs) for associations between the presence, size, number, or duration of gallstones and the risk of BTC, including gallbladder cancer (GBC), extrahepatic bile duct cancer (EBDC), and ampulla of Vater cancer (AOVC). Summary odds ratios (ORs) and their 95% CIs were calculated using a random-effects model in the meta-analysis. Subgroup analyses were conducted to inspect sources of potential heterogeneity, and the Egger test was performed to assess publication bias. RESULTS: Seven cohort studies and 23 case-control studies in Asian, European, and American populations were included. The presence of gallstones was associated with an increased risk of BTC (OR, 4.38; 95% CI, 3.23 to 5.93; I2=91.2%), GBC (OR, 7.26; 95% CI, 4.33 to 12.18), EBDC (OR, 3.17; 95% CI, 2.24 to 4.50), and AOVC (OR, 3.28; 95% CI, 1.33 to 8.11). Gallstone size (>1 vs. <1 cm; OR, 1.88; 95% CI, 1.10 to 3.22) was significantly associated with the risk of GBC. CONCLUSIONS Gallstone characteristics, such as presence, size, and number, are associated with an increased risk of BTC. However, significantly high heterogeneity in the meta-analyses is a limitation of this study.