Factors affecting patients who attempted suicide in the emergency department due to the prolonged pandemic of COVID-19.

OBJECTIVE: This study examined the characteristics of patients who attempted suicide in the emergency department before and during the COVID-19 pandemic. METHODS: We compared data from patients in the emergency department following suicide attempts between January 2018 and December 2021. The patients were categorized into two groups: "pre-COVID-19" and "during COVID-19" pandemic. RESULTS: The findings revealed an increasing trend of suicide attempts during the study period. Suicide attempts were reported at 1,107 before the COVID-19 pandemic and 1,356 during the COVID-19 pandemic. Patients who attempted suicide during the COVID-19 pandemic were younger (38.0±18.5 years vs. 40.7±18.4 years, P<0.01), had a smaller proportion of men (36% vs. 44%, P<0.01), and had fewer medical comorbidities (20.2% vs. 23.6%, P<0.05). The group during the COVID-19 pandemic reported better hygiene conditions (50.5% vs. 40.8%, P<0.01) and lower alcohol consumption (27.7% vs. 37.6%, P<0.01). Patients who attempted suicide during the COVID-19 pandemic had higher rates of use of psychiatric medications and previous suicide attempts. The most common reasons for the suicide attempt were unstable psychiatric disorders (38.8%), poor interpersonal relationships (20.5%), and economic difficulties (14.0%). Drug poisoning (44.1%) was the most common method of suicide attempts. Subgroup analysis with patients who attributed their suicide attempts to COVID-19 revealed a higher level of education (30.8%) and employment status (69.2%), with economic difficulties (61.6%) being the primary cause of suicide attempts. CONCLUSION: These findings suggest that the prolonged duration of the COVID-19 pandemic and its effects on social and economic factors have influenced suicide attempts.

Machine learning model for predicting ciprofloxacin resistance and presence of ESBL in patients with UTI in the ED.

Increasing antimicrobial resistance in uropathogens is a clinical challenge to emergency physicians as antibiotics should be selected before an infecting pathogen or its antibiotic resistance profile is confirmed. We created a predictive model for antibiotic resistance of uropathogens, using machine learning (ML) algorithms. This single-center retrospective study evaluated patients diagnosed with urinary tract infection (UTI) in the emergency department (ED) between January 2020 and June 2021. Thirty-nine variables were used to train the model to predict resistance to ciprofloxacin and the presence of urinary pathogens' extended-spectrum beta-lactamases. The model was built with Gradient-Boosted Decision Tree (GBDT) with performance evaluation. Also, we visualized feature importance using SHapely Additive exPlanations. After two-step customization of threshold adjustment and feature selection, the final model was compared with that of the original prescribers in the emergency department (ED) according to the ineffectiveness of the antibiotic selected. The probability of using ineffective antibiotics in the ED was significantly lowered by 20% in our GBDT model through customization of the decision threshold. Moreover, we could narrow the number of predictors down to twenty and five variables with high importance while maintaining similar model performance. An ML model is potentially useful for predicting antibiotic resistance improving the effectiveness of empirical antimicrobial treatment in patients with UTI in the ED. The model could be a point-of-care decision support tool to guide clinicians toward individualized antibiotic prescriptions.

Predictive factors for acute brain lesions on magnetic resonance imaging in acute carbon monoxide poisoning.

BACKGROUND: Acute brain lesions on diffusion-weighted-magnetic resonance imaging (MRI) after acute carbon monoxide (CO) poisoning were associated with delayed neurological sequelae. This study was conducted to identify the risk factors associated with acute brain lesions on MRI after acute CO poisoning and to help select patients who need acute-phase brain MRI after acute CO poisoning in the emergency department (ED). METHODS: This retrospective observational study included 103 adult patients who were hospitalized at a tertiary-care hospital between November 2016 and September 2019 and underwent brain MRI because of acute CO poisoning. Multivariable logistic regression analysis was applied to identify predictive factors for acute brain lesions on MRI after acute CO poisoning. RESULTS: Multivariable logistic regression analysis showed that Glasgow Coma Scale (GCS) score of <9 at ED presentation (odds ratio [OR] 17.749, 95% confidence interval [CI] 3.098-101.690, P = 0.001) and the initial troponin-I level at presentation in the ED (OR 13.657, 95% CI 1.415-131.834, P = 0.024) were predictive factors for acute brain lesions on MRI in acute CO poisoning. The receiver operating characteristics curve for initial troponin-I showed an area under the curve of 0.761 (95% CI 0.638-0.883, P < 0.001) and the optimal cutoff value was 0.105 ng/mL. CONCLUSIONS: Acute-phase brain MRI in acute CO poisoning can be considered for patients who present at the ED with a GCS score <9 or troponin-I level >0.105 ng/mL.

Geographic distribution of Tick-borne encephalitis virus complex.

A comprehensive understanding of the geographic distribution of the tick-borne encephalitis virus (TBEV) complex is necessary due to increasing transboundary movement and cross-reactivity of serological tests. This review was conducted to identify the geographic distribution of the TBEV complex, including TBE virus, Alkhurma haemorrhagic fever virus, Kyasanur forest disease virus, louping-ill virus, Omsk haemorrhagic fever virus, and Powassan virus. Published reports were identified using PubMed, EMBASE, and the Cochrane library. In addition to TBEV complex case-related studies, seroprevalence studies were also retrieved to assess the risk of TBEV complex infection. Among 1406 search results, 314 articles met the inclusion criteria. The following countries, which are known to TBEV epidemic region, had conducted national surveillance studies: Austria, China, Czech, Denmark, Estonia, Finland, Germany, Hungary, Italy, Latvia, Norway, Poland, Romania, Russia, Switzerland, Sweden, Slovenia, and Slovakia. There were also studies/reports on human TBEV infection from Belarus, Bulgaria, Croatia, France, Japan, Kyrgyzstan, Netherland, and Turkey. Seroprevalence studies were found in some areas far from the TBEV belt, specifically Malaysia, Comoros, Djibouti, and Kenya. Kyasanur forest disease virus was reported in southwestern India and Yunnan of China, the Powassan virus in the United States, Canada, and east Siberia, Alkhurma haemorrhagic fever virus in Saudi Arabia and east Egypt, and Louping-ill virus in the United Kingdom, Ireland, and east Siberia. In some areas, the distribution of the TBEV complex overlaps with that of other viruses, and caution is recommended during serologic diagnosis. The geographic distribution of the TBEV complex appears to be wide and overlap of the TBE virus complex with other viruses was observed in some areas. Knowledge of the geographical distribution of the TBEV complex could help avoid cross-reactivity during the serologic diagnosis of these viruses. Surveillance studies can implement effective control measures according to the distribution pattern of these viruses.

Subcapsular Splenic Hemorrhage in Vivax Malaria.

In malaria, splenic rupture is a serious complication potentially leading to death. Subcapsular hemorrhage of spleen is thought to be an impending sign of splenic rupture; however, the characteristics of subcapsular hemorrhage are not well known. We report 3 cases of subcapsular hemorrhage of the spleen in vivax malaria, with varying degrees of severity. Case 1 showed subcapsular hemorrhage without splenic rupture, was treated by antimalarial drug without any procedure. The healing process of the patient's spleen was monitored through 6 computed tomography follow-up examinations, over 118 days. Case 2 presented subcapsular hemorrhage with splenic rupture, treated only with an antimalarial drug. Case 3 showed subcapsular hemorrhage with splenic rupture and hypotension, treated using splenic artery embolization. They all recovered from subcapsular hemorrhage without any other complications. These 3 cases reveal the process of subcapsular hemorrhage leading to rupture and a potentially fatal outcome. The treatment plan of subcapsular hemorrhage should be determined carefully considering the vital signs, changes in hemoglobin, and bleeding tendency.

Splenic Infarction in Plasmodium vivax Infection in South Korea.

Splenic infarction caused by malaria can be fatal, but its incidence and clinical presentation are not well-known. Thus, we investigated the prevalence and characteristics of splenic complications in patients with vivax malaria from 2005 to 2017 in a university hospital. Among 273 patients who were diagnosed with Plasmodium vivax infection by blood smear, 92 underwent abdominal computed tomography or ultrasonography. Twelve patients had splenic infarction. All patients with splenic infarction recovered after treatment with antimalarial drugs, without surgery and intervention. Although anemia and prolonged fever may be risk factors for splenic infarction, the incidence of these events was insufficient for a detailed analysis.

Tracheal Rupture Related to Endotracheal Intubation during Cardiopulmonary Resuscitation.

Postintubation tracheal rupture is rare, but serious. Emergency intubation is often conducted during cardiopulmonary resuscitation (CPR), and the risk of postintubation tracheal rupture can be increased during CPR. We describe here a case of postintubation tracheal rupture in a 65-year-old female who was transferred from another hospital after CPR. Postintubation tracheal rupture in this case is thought to have been related to malposition of the endotracheal tube (ETT), elevation of the intratrachea pressure due to chest compression, and an overinflated cuff. However, the most important factor is considered to be the overinflated cuff, which is often caused by manual palpation. Therefore, emergency physicians should consider using a manometer to check the cuff pressure of the ETT, even during CPR. When spontaneous circulation is restored, the pressure of the cuff must be measured with a manometer.

Current Status of Tick-Borne Diseases in South Korea.

BACKGROUND: Bites with tick-borne pathogens can cause various bacterial, viral, or parasitic diseases in humans. Tick-transmitted diseases are known as contributing factors to the increasing incidence and burden of diseases. The present article investigated the epidemiology of tick-borne diseases in South Korea. METHODS: The incidence and distribution of common tick-borne diseases in Korea (Lyme disease, Q fever, and severe fever with thrombocytopenia syndrome [SFTS]) were investigated and analyzed, using data from the Korea Centers for Disease Control and Prevention (KCDC) infectious disease reporting system. A literature review was compiled on the current status of uncommon tick-borne diseases (Rickettsia, anaplasmosis, ehrlichiosis, bartonellosis, tularemia, tick-borne encephalitis, and babesiosis). RESULTS AND CONCLUSIONS: In South Korea, SFTS is an emerging disease, showing a rapid increase in reports since 2012, with high mortality. Likewise, reports of Lyme disease and Q fever cases have also been rapidly increasing during 2012-2017, although caution should be taken when interpreting these results, considering the likely influence of increased physician awareness and reporting of these diseases. Other tick-borne diseases reported in South Korea included spotted fever group rickettsiae, anaplasmosis, ehrlichiosis, tularemia, Bartonella, and babesiosis. Evidences on human infection with tick-borne encephalitis virus and Crimean-Congo hemorrhagic fever were recently unavailable, but both need constant monitoring.

Thrombophlebitis of superior mesenteric vein with bacteremia of Gemella sanguinis and Streptococcus gordonii.

Pylephlebitis is a condition with thrombophlebitis of the portal mesenteric venous system. Herein, we report a patient suggesting odontogenic bacteremia as a risk factor of pylephlebitis. He was diagnosed as superior mesenteric vein thrombophlebitis, and blood cultures grew Gemella sanguinis and Streptococcus gordonii.

Prognostic Factors Predicting Poor Outcome in Cancer Patients with Febrile Neutropenia in the Emergency Department: Usefulness of qSOFA.

BACKGROUND/AIMS: Febrile neutropenia is considered as one of the most important and potentially life-threatening oncologic emergencies, which requires prompt medical assessment and treatment with antibiotics. This was a single-center retrospective study that investigated the prognostic factors predicting poor outcome in patients with cancer who presented with febrile neutropenia at the emergency department (ED). METHODS: The medical records of patients diagnosed with febrile neutropenia in the ED from January 2014 to December 2017 were reviewed. Patients aged >18 years who were diagnosed with a malignancy were included in the analysis. Febrile neutropenia was defined as an absolute neutrophil count < 1,000/mm3 with a temperature greater than 38°C. Patients were divided into two groups: those who were admitted at the intensive care unit (ICU) or those who died in the hospital (case group) and those who were admitted at general wards and were discharged (control group). The two groups were compared to determine the factors associated with poor prognosis. RESULTS: We identified 104 patients (25 and 79 from the case and control groups, respectively) with cancer who presented with febrile neutropenia at the ED during the study period. Lower blood pressure, platelet count, and HCO3 - level, higher CRP and creatinine level, and the presence of bacteremia were more commonly observed in the case group than in the control group. In the multiple logistic regression analysis, the following independent predictors significantly correlated with ICU admission and in-hospital mortality: quick sequential (sepsis-related) organ failure assessment (qSOFA) score (odds ratio [OR]: 4.62; 95% confidence interval [CI]: 1.17-18.22; p=0.285), hemoglobin level (OR: 0.51; 95% CI: 0.33-0.78; p=0.002), total bilirubin level (OR: 7.69; 95% CI: 1.29-45.8; p=0.025), and respiratory tract infection (OR: 29.65; 95% CI: 3.81-230.7; p=0.0012). CONCLUSIONS: The qSOFA can be a useful bedside tool for patients with cancer who present with febrile neutropenia at the ED. Moreover, it can help emergency physicians in identifying patients at risk of poor prognosis and in initiating prompt empirical antimicrobial therapy. Further studies must be conducted to validate the efficacy of the qSOFA in these patients in the ED.

Fatal Pulmonary Edema in a Child After Jellyfish Stings in Korea.

Jellyfish have been increasing at a global scale in recent years. These blooms not only have deleterious effects on marine ecosystems, they also increase the risk of jellyfish stings and accompanying envenomation. Here, we report a fatal case of pulmonary edema caused by jellyfish envenomation in a child in Korea. The patient died 4 h after envenomation despite cardiopulmonary resuscitation. Nemopilema nomurai was the suspected species of jellyfish encountered by the patient, although we are unable to confirm this. With this case report, we aim to inform on the serious issue of toxicity associated with jellyfish species that bloom mainly along Korean, east Chinese, and Japanese shores and to discuss appropriate first aid methods in case of jellyfish stings.

Clinical Predictors of Pseudomonas aeruginosa Bacteremia in Emergency Department.

OBJECTIVES: Pseudomonas aeruginosa shows higher mortality rate compared to other bacterial infections and is susceptible to a limited number of antimicrobial agents. Considering inadequate empirical treatment of Pseudomonas bacteremia has been associated with increased mortality, it is important for emergency physicians to identify infections by P. aeruginosa. METHODS: This was a single-center retrospective case-control study to investigate the clinical predictors of patients diagnosed as Pseudomonas bacteremia in the emergency department (ED) from June 2012 to December 2016. Patients with blood culture positive for Escherichia coli in the same period were chosen as the control group, and type of infection was matched for each patient. RESULTS: A total of 54 cases with Pseudomonas bacteremia and 108 controls with E. coli bacteremia were included. In the case group, 76% was community-acquired infection, 44% received inappropriate empirical treatment in the ED, and in-hospital mortality was 30%. Multiple logistic regression showed that respiratory tract infection was an independent risk factor for Pseudomonas bacteremia (OR 6.56, 95% CI 1.78-23.06; p = 0.004), whereas underlying diabetes mellitus (OR 0.22, 95% CI 0.07-0.61; p = 0.004) and presentation as urinary tract infection (OR 0.06, 95% CI 0.02-0.18; p < 0.001) were negative clinical predictors. CONCLUSIONS: We suggest that antipseudomonal antibiotics should be considered beyond simple coverage of Gram-negative bacteria in the ED, especially if the patient is likely to have pneumonia. Having diabetes or presenting with urinary tract infection could be clinical factors unfavorable to use of antipseudomonal antibiotics.

Symptomatic bradycardia due to nicotine intoxication. / Bradicardia sintomática causada por intoxicação por nicotina.

Nicotine is a dangerous substance extracted from tobacco leaves. When nicotine is absorbed in excessive amounts, it can lead to respiratory failure and cardiac arrest. The commercialization of electronic cigarettes (e-cigarettes) has allowed users to directly handle e-cigarette liquid. Consequently, the risk of liquid nicotine exposure has increased. We describe our experience of managing the case of a patient who orally ingested a high concentration of liquid nicotine from e-cigarette liquid. The patient presented with bradycardia and hypotension, which are symptoms of parasympathetic stimulation, together with impaired consciousness. He recovered following treatment with atropine and a vasopressor.

A Case of Scrub Typhus complicated with a Splenic Infarction.

We present a patient with scrub typhus complicated with a splenic infarction. A 40-year-old man visited the emergency medical center complaining of fever for the previous week. He had no past medical history, but reported engaging in outdoor activities. Examination revealed a maculopapular rash on his trunk and an eschar on his epigastrium. Abdominal computed tomography was performed to examine the cause of the tenderness on the left upper quadrant of his abdomen, which revealed a splenic infarct. The patient was diagnosed with scrub typhus based on the results of blood polymerase chain reaction testing, and genetic sequencing confirmed the presence of Orientia tsutsugamushi Boryong. His symptoms improved following doxycycline treatment.

Serologic Study of Bartonella henselae in Patients with Acute Undifferentiated Febrile Illness in Korea.

BACKGROUND: Bartonella infection is an emerging cause of acute febrile illness; however, its significance has not been thoroughly investigated. We studied the antibody specific to Bartonella henselae in patients with various febrile diseases in Korea. MATERIALS AND METHODS: A total of 177 patients with acute febrile illness who were managed at the Inha University Hospital from February 2012 to January 2013 were evaluated with an in-house immunofluorescent antibody test to detect B. henselae immunoglobulin G (IgG) antibody. The clinical features of the patients included fever of undetermined origin (n = 88 patients), lymphadenopathy (n = 28), febrile rash (n = 17), respiratory infection (n = 12), aseptic meningitis (n = 7), intra-abdominal infection (n = 5), arthritis (n = 4), and other conditions (n = 16). We reviewed the medical records of these patients and collected demographic data, clinical features, and their histories of animal exposure. RESULTS: Among the 177 patients with acute febrile illness, 23.7% (42/177) had elevated levels of IgG antibodies to B. henselae (≥1:160). Of these seropositive patients, 32.4% (12/37) had contact with animals and had developed arthralgia (29.5%), headache (25%), or lymphadenopathy (15.9%). Seven (16.7%) of the 42 patients had higher IgG titers (≥1:640). Among them, four patients presented fourfold increase/decrease of IgG in convalescent serum. According to the clinical diagnosis, the antibody positivity rates were as follows: 24/88 with undifferentiated fever, 8/28 with lymphadenopathy, 4/17 with febrile rash, 2/12 with respiratory infection, 2/7 with aseptic meningitis, and 2/16 with other illnesses. CONCLUSIONS: There was high prevalence of B. henselae in patients with undifferentiated fever in Korea, for which further research is needed.

Bradicardia sintomática causada por intoxicação por nicotina / Symptomatic bradycardia due to nicotine intoxication

RESUMO A nicotina é uma substância perigosa, extraída das folhas de fumo. Quando absorvida em quantidade excessiva, ela pode levar à insuficiência respiratória e à parada cardíaca. A comercialização de cigarros eletrônicos (e-cigarros) permite que os usuários manuseiem diretamente o líquido, com consequente aumento do risco de exposição à nicotina líquida. Descrevemos nossa experiência no tratamento do caso de um paciente que ingeriu elevada concentração de nicotina líquida contida em líquido para e-cigarros. O paciente apresentava bradicardia e hipotensão, que são sintomas de estimulação parassimpática, além de comprometimento da consciência. O paciente teve recuperação após tratamento com atropina e vasopressor.

ABSTRACT Nicotine is a dangerous substance extracted from tobacco leaves. When nicotine is absorbed in excessive amounts, it can lead to respiratory failure and cardiac arrest. The commercialization of electronic cigarettes (e-cigarettes) has allowed users to directly handle e-cigarette liquid. Consequently, the risk of liquid nicotine exposure has increased. We describe our experience of managing the case of a patient who orally ingested a high concentration of liquid nicotine from e-cigarette liquid. The patient presented with bradycardia and hypotension, which are symptoms of parasympathetic stimulation, together with impaired consciousness. He recovered following treatment with atropine and a vasopressor.

Risk factors of urinary tract infection caused by extended spectrum ß-lactamase-producing Escherichia coli in emergency department.

OBJECTIVES: The incidence of urinary tract infection (UTI) due to extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli has increased over recent years. Initial empirical therapy is often ineffective for these resistant isolates resulting in prolonged hospitalization and increased mortality. This study was conducted to determine the risk factors of UTI caused by ESBL E. coli in the emergency department (ED). METHODS: This is a retrospective case-control study at a university hospital in Korea with UTI patients who visited ED between June 2015 and December 2016. We compared case patients with ESBL E. coli UTI (n = 50) to control patients with non-ESBL-producing E. coli UTI (n = 100), which were matched for age and sex. Multivariate logistic regression analysis was used to explore risk factors. RESULTS: Our study showed that hospital-acquired infection (OR = 3.86; 95% CI = 1.26-11.8; p = .017), prior UTI within 1 year (OR = 3.26; 95% CI = 1.32-8.05; p = .010), and underlying cerebrovascular disease (OR = 3.24; 95% CI = 1.45-7.25; p = .004) were independent risk factors for acquisition of ESBL-producing E. coli. Notably, 35 (70%) out of 50 case patients had community-acquired infection, and 68% and 54% of ESBL E. coli were resistance to ciprofloxacin and trimethoprim-sulfamethoxazole, respectively. On the contrary, 98% of ESBL E. coli was susceptible to amikacin. CONCLUSION: The main risk factors identified in our study should be considered when treating UTI patients in ED. Amikacin may improve the outcome of empirical treatment without increasing carbapenem utilization.

Two Imported Cases of Babesiosis with Complication or Co-Infection with Lyme Disease in Republic of Korea.

Babesiosis, caused by Babesia microti and B. divergens, is transmitted by Ixodid ticks. Symptoms of babesiosis vary from a mild flu-like illness to acute, severe, and sometimes fatal and fulminant disease. In Korea, 7 imported babesiosis cases and 1 endemic case have been reported. We report 2 cases of severe babesiosis initially mistaken as malaria. The first patient was complicated by shock and splenic infarction, the other co-infected with Lyme disease. As the population traveling abroad increases every year, physicians should be aware of babesiosis which mimics malaria, co-infection with other diseases, and its complications.

Hemodynamic changes after propacetamol administration in patients with febrile UTI in the ED.

OBJECTIVES: Clinical studies have indicated that transient hypotension can occur after propacetamol administration. This study aimed to analyze the hemodynamic changes after propacetamol administration in patients visiting the ED due to febrile UTI. We also examined the incidence of propacetamol-induced hypotension and compared the clinical characteristics of patients with persistent hypotension, defined as requiring additional fluids or vasopressors, to those with transient hypotension. METHODS: A retrospective analysis of the electronic medical records of patients who visited the ED between June 2015 and May 2016, were diagnosed with febrile UTI, and treated with propacetamol, was conducted. RESULTS: We included 195 patients in this study; of these, 87 (44.6%) showed hypotension. In all patients, significant decreases in systolic blood pressure (SBP; 135.06±20.45mmHg vs 117.70±16.41mmHg), diastolic blood pressure (DBP; 79.74±12.17mmHg vs 69.69±10.96mmHg), and heart rate (97.46±17.14mmHg vs 90.72±14.90mmHg) were observed after propacetamol administration. The basal SBP and DBP were higher in the hypotension than in the non-hypotension group (basal SBP: 144.4±22.3mmHg vs 127.6±15.3mmHg; basal DBP: 83.3±12.6mmHg vs 76.9±11.0mmHg). Patients with persistent hypotension had a lower baseline BP, which was not elevated despite fever, and a higher rate of bacteremia than those with transient hypotension. CONCLUSIONS: Although febrile UTI patients treated with propacetamol in the ED showed hemodynamic changes, these changes did not have a large effect on their prognosis. However, in patients who showed bacteremia or a normal initial BP despite fever, the possibility of developing persistent hypotension should be considered.