Epidemiology and Clinical Characteristics of Older Patients Transferred from Long-Term-Care Hospitals (LTCHs) to Emergency Departments by a Comparison with Non-LTCHs in South Korea: A Cross-Sectional Observational Study.

The South Korean population is rapidly aging, and the number of older patients in long-term-care hospitals (LTCHs) continues to increase. This study aims to investigate the epidemiologic data, characteristics, and clinical outcomes of patients aged 65 years and older transferred from LTCHs to emergency departments (EDs). This is a retrospective study based on National Emergency Department Information System data from 2014 to 2019. Of the 6,209,695 older patients visiting EDs for disease treatment, 211,141 (3.4%) were transferred from LTCHs. Among patients from LTCHs (211,141), 24.2% were discharged from EDs, 43.0% were admitted to general wards, 20.7% were hospitalized in intensive care units, 3.1% were transferred to another hospital, 6.1% returned to LTCHs, and 2.1% died in EDs. ED stays were the longest for those returning to LTCHs (710.49 ± 1127.43 min). Foley catheterization (40.3%) was most frequently performed in preventable ED visits. In South Korea, older patients being discharged from the ED or returning to LTCHs, after being transferred from LTCHs to EDs, increased. ED stays among older LTCH patients were longer than among non-LTCH older patients, contributing to congestion. To reduce avoidable transfer to EDs from LTCHs, it is necessary to discuss policies, such as expanding appropriate medical personnel and transitional treatment.

Comparison of the selection of nasotracheal tube diameter based on the patient's sex or size of the nasal airway: A prospective observational study.

When selecting the nasotracheal tube diameter for nasotracheal intubation, atraumatic introduction of the tube through the nasal passage and a safe location of the tube's cuff and tip should be ensured simultaneously. To maintain safety margin for the tube's cuff and tip from the vocal cords and carina (2 cm and 3 cm, respectively), the maximum allowable proximal-cuff-to-tip distance was calculated as 5 cm less than the measured vocal cords-to-carina distance. The primary aim of this study was to find a single predictive preoperative factor of the nostril size and maximum allowable proximal-cuff-to-tip distance of nasotracheal tubes. The secondary aim was to compare the difference in the safety margin between the maximum allowable proximal-cuff-to-tip distance based on the patient's airway and the actual proximal-cuff-to-tip distance of the selected tube. We used fiberoptic bronchoscope to measure the distance from the vocal cords to the carina for the calculation of the maximum allowable proximal-cuff-to-tip distance. We analyzed the association of preoperative characteristics such as age, sex, height, and weight with the nostril size and maximum allowable proximal-cuff-to-tip distance. The proportion of patients with appropriate locations of both the cuff and tip was evaluated. Sex and height were significant predictive factors of the nostril size and maximum allowable proximal-cuff-to-tip distance, respectively (p = 0.0001 and p = 0.0048). The difference in the safety margin was significantly decreased when the tube diameter was selected based on the nostril size rather than by sex (p<0.0001). The proportion of patients who had the appropriate cuff/tip location was significantly larger (75.2%) when the tube diameter was selected by sex compared to when it was selected by the nostril size (65%) (p<0.0001). It is more suitable to select the nasotracheal tube diameter based on sex rather than by nostril size to ensure the safe location of the tube's cuff and tip simultaneously.

Accuracy and Efficacy of Impedance Cardiography as a Non-Invasive Cardiac Function Monitor.

PURPOSE: The most common method of monitoring cardiac output (CO) is thermodilution using pulmonary artery catheter (PAC), but this method is associated with complications. Impedance cardiography (ICG) is a non-invasive CO monitoring technique. This study compared the accuracy and efficacy of ICG as a non-invasive cardiac function monitoring technique to those of thermodilution and arterial pressure contour. MATERIALS AND METHODS: Sixteen patients undergoing liver transplantation were included. Cardiac index (CI) was measured by thermodilution using PAC, arterial waveform analysis, and ICG simultaneously in each patient. Statistical analysis was performed using intraclass correlation coefficient (ICC) and Bland-Altman analysis to assess the degree of agreement. RESULTS: The difference by thermodilution and ICG was 1.13 L/min/m², and the limits of agreement were -0.93 and 3.20 L/min/m². The difference by thermodilution and arterial pressure contour was 0.62 L/min/m², and the limits of agreement were -1.43 and 2.67 L/min/m². The difference by arterial pressure contour and ICG was 0.50 L/min/m², and the limits of agreement were -1.32 and 2.32 L/min/m². All three percentage errors exceeded the 30% limit of acceptance. Substantial agreement was observed between CI of thermodilution with PAC and ICG at preanhepatic and anhepatic phases, as well as between CI of thermodilution and arterial waveform analysis at preanhepatic phase. Others showed moderate agreement. CONCLUSION: Although neither method was clinically equivalent to thermodilution, ICG showed more substantial correlation with thermodilution method than with arterial waveform analysis. As a non-invasive cardiac function monitor, ICG would likely require further studies in other settings.

Insertion depth of nasotracheal tubes sized to fit the nostril: an observational study.

OBJECTIVE: Nasotracheal (NT) intubation is commonly applied during head and neck surgery. However, improper tube size and depth may cause complications. In the current study, we investigated whether NT tubes are being appropriately used in terms of size and depth in adult patients. METHODS: Nares were sized in 40 patients using standard nasopharyngeal airways (6.0-8.0) before elective surgery under general anesthesia. The largest sized airway that passed easily into the nasopharynx without resistance was considered as a proper size. Using a fiberoptic scope, the distances from the nares to the vocal cords and the nares to the carina were measured. Rates of proper NT tube positioning were calculated with regard to the cuff and distal tip. RESULTS: The most frequent sizes of properly fitted NT tubes were 6.5 and 6.0 in male and female patients, respectively. Positioning of the cuff and distal tip was only appropriate when using a properly sized tube in 26% and 47% of male and female patients, respectively. CONCLUSION: Care should be taken to determine the insertion depth after placing an NT tube that has been sized to fit the nostril. Moreover, NT tubes of the same diameter may be required in various lengths. Trial registration: Registered at ClinicalTrial.gov; https://clinicaltrials.gov/ct2/show/NCT02876913 ; Registration number NCT02876913.

Clinical insomnia and associated factors in failed back surgery syndrome: a retrospective cross-sectional study.

Background Insomnia frequently occurs to patients with persistent back pain. By worsening pain, mood, and physical functioning, insomnia could lead to the negative clinical consequences of patients with failed back surgery syndrome (FBSS). This retrospective and cross-sectional study aims to identify the risk factors associated with clinical insomnia in FBSS patients. Methods A total of 194 patients with FBSS, who met the study inclusion criteria, were included in this analysis. The Insomnia Severity Index (ISI) was utilized to ascertain the presence of clinical insomnia (ISI score ≥ 15). Logistic regression analysis evaluates patient demographic factors, clinical factors including prior surgical factors, and psychological factors to identify the risk factors of clinical insomnia in FBSS patients. Results After the persistent pain following lumbar spine surgery worsened, 63.4% of patients reported a change from mild to severe insomnia. In addition, 26.2% of patients met the criteria for clinically significant insomnia. In a multivariate logistic regression analysis, high pain intensity (odds ratio (OR) =2.742, 95% confidence interval (CI): 1.022 - 7.353, P=0.045), high pain catastrophizing (OR=4.185, 95% CI: 1.697 - 10.324, P=0.002), greater level of depression (OR =3.330, 95% CI: 1.127 - 9.837, P=0.030) were significantly associated with clinical insomnia. However, patient demographic factors and clinical factors including prior surgical factors were not significantly associated with clinical insomnia. Conclusions Insomnia should be addressed as a critical part of pain management in FBSS patients with these risk factors, especially in patients with high pain catastrophizing.

The Effect of Skin Pressure on Needle Entry Point Accuracy During Fluoroscopically Guided Lumbar Transforaminal Epidural Injections: A Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to investigate the effect of skin pressure on needle entry point accuracy during fluoroscopically guided lumbar transforaminal epidural injection. DESIGN: This study is a prospective randomized clinical trial; 64 patients with a body mass index of 25 kg/m or greater were enrolled. For patients in the pressing group, the operator marked the needle entry point on the patient's back while pressing the patient's skin with the tip of an indicator. For patients in the nonpressing group, the tip of the indicator was gently positioned on the patient's skin. The data related to technical performance and radiation exposure during the procedure were compared. RESULTS: Sixty patients (nonpressing group, n = 30; pressing group, n = 30) were analyzed. There were more attempts to reposition the needle (n) and increased procedure time (in seconds) in the pressing group (median, 5 vs. 4 [P = 0.019]; 400.0 vs. 358.5 [P = 0.033]). The fluoroscopy time (in seconds) and the kerma-area product (in cGy cm) were also significantly longer and greater in the pressing group, respectively (median, 63.5 vs. 50.5 [P = 0.038]; 416.3 vs. 318.6 [P = 0.014]). CONCLUSIONS: This study shows that practitioners should not press the skin with a radiopaque indicator when determining the needle entry point by fluoroscopy during lumbar transforaminal epidural injection.

Role of Self-Directed Learning in Communication Competence and Self-Efficacy.

BACKGROUND: Although effective self-directed learning (SDL) has been shown to improve clinical performance, little is known about its role between communication competence and communication self-efficacy in nursing students. This study aimed to identify whether SDL mediates the relationship between communication competence and communication self-efficacy. METHOD: A cross-sectional survey was conducted with a sample of 213 nursing students taking a basic fundamentals of nursing course. A path diagram, using structural equation modeling, was used to estimate the direct and indirect effects of communication competence on communication self-efficacy, controlling for SDL as a mediator. RESULTS: A structural equation model confirmed direct and indirect effects of communication competence on communication self-efficacy when SDL was controlled as a mediator. An appropriate fit to the data was identified in this mediation model of SDL. CONCLUSIONS: For enhancing self-efficacy regarding communication skill, the specified SDL program based on the level of communication competence will yield more effective results.

The effect of warmed inspired gases on body temperature during arthroscopic shoulder surgery under general anesthesia.

BACKGROUND: Perioperative hypothermia can develop easily during shoulder arthroscopy, because cold irrigation can directly influence core body temperature. The authors investigated whether active warming and humidification of inspired gases reduces falls in core body temperature and allows redistribution of body heat in patients undergoing arthroscopic shoulder surgery under general anesthesia. METHODS: Patients scheduled for arthroscopic shoulder surgery were randomly assigned to receive either room temperature inspired gases using a conventional respiratory circuit (the control group, n = 20) or inspired gases humidified and heated using a humidified and electrically heated circuit (HHC) (the heated group, n = 20). RESULTS: Core temperatures were significantly lower in both groups from 30 min after anesthesia induction, but were significantly higher in the heated group than in the control group from 75 to 120 min after anesthesia induction. CONCLUSIONS: In this study the use of a humidified and electrically heated circuit did not prevent core temperature falling during arthroscopic shoulder surgery, but it was found to decrease reductions in core temperature from 75 min after anesthesia induction.

Profound hypotension after an intradermal injection of indigo carmine for sentinel node mapping.

Intradermal injections of indigo carmine for sentinel node mapping are considered safe and no report of an adverse reaction has been published. The authors described two cases of profound hypotension in women that underwent breast-conserving surgery after an intradermal injection of indigo carmine into the periareolar area for sentinel node mapping.

A case of rectus sheath hematoma due to Foley catheterization after acute urinary retention.

Rectus sheath hematoma (RSH) is generally not considered a reason for abdominal pain and its incidence as a cause of abdominal pain is unknown. RSH is a rarely seen but nonetheless an important disease causing abdominal pain. During contractions of the rectus abdominis muscle, the inferior epigastric artery must glide with the muscle to avoid tearing. When the inferior epigastric artery is torn, blood dissects along the rectus sheath leading to hematoma formation. We report a case of spontaneous rectus sheath hematoma due to Foley catheterization after acute urinary retention. In the current case, the rectus abdominis muscle stretched because of overdistended bladder. After the patient was catheterized to drain urinary retention, the rectus abdominis muscle contracted abruptly, and vessels were injured by rapid muscle contraction caused by Foley catheterization.

Delayed postpartum hemorrhage resulting from uterine artery pseudoaneurysm rupture.

BACKGROUND: Rupture of a uterine artery pseudoaneurysm is an uncommon, but life-threatening, cause of postpartum hemorrhage. Cesarean delivery is the most common cause. OBJECTIVES: Prompt recognition and management are critical in severe vaginal bleeding. A diagnosis of pseudoaneurysm of the uterine artery can be established radiologically, such as with color Doppler ultrasonography and computed tomography. Angiography confirms the diagnosis. This condition can be treated with selective arterial embolization. CASE REPORTS: We describe three cases of postpartum hemorrhage caused by rupture of pseudoaneurysms of the uterine artery after cesarean section. CONCLUSION: Uterine arterial pseudoaneurysm rupture is an infrequent, life-threatening cause of delayed postpartum hemorrhage requiring prompt diagnosis and treatment. Early crystalloid infusion and blood transfusion are essential. The initial management and stabilization of uterine artery pseudoaneurysm postpartum hemorrhage requires aggressive resuscitation. Arterial embolization should be considered the definitive treatment.