Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Recurrent hemoptysis in a 26-year-old woman with a ground-glass opacity lesion of the lung / 영남의대학술지

Hemoptysis is a major reason for emergency department (ED) visits. Catamenial hemoptysis (CH), a rare condition of thoracic endometriosis, can cause recurrent hemoptysis but is difficult to diagnose in the ED due to the scarcity of cases and nonspecific clinical findings. We report a case of a 26-year-old woman who presented to the ED with recurrent hemoptysis since 2 years without a definite cause. Her vital signs and blood test findings were unremarkable. Chest computed tomography (CT) did not show any specific lesions other than a non-specific ground-glass opacity pattern in her right lung. She was on day 4 of her menstrual cycle and her hemoptysis frequently occurred during menstruation. Although there was no histological confirmation, based on her history of hemoptysis during menstruation and no other cause of the hemoptysis, the patient was tentatively diagnosed with CH and was administered gonadotropin-releasing hormone. She had no recurrence of hemoptysis for 3 months. While CH is difficult to diagnose in the ED, the patient’s recurrent hemoptysis related to menstruation was a clue to the presence of CH. Therefore, physicians should determine the relationship between hemoptysis and menstruation for women of childbearing age presenting with repeated hemoptysis without a definite cause.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Acute Pancreatitis after Additional Trauma in Chronic Traumatic Pancreatic Diaphragmatic Hernia

Traumatic diaphragmatic injuries (TDIs) are a rare complication in thoraco-abdominal trauma. The diagnosis is difficult and if left untreated, TDI can cause traumatic diaphragmatic hernia (TDH). Through an injured diaphragm, the liver, spleen, stomach, small intestine, and large intestine can be herniated to the thoracic cavity, but pancreatic herniation and pancreatitis are quite rare in TDH. This paper reports a case of pancreatitis developed by additional trauma in a patient with asymptomatic chronic TDH. A 58-year-old male visited the emergency department with a left abdominal injury after a fall 6 hours earlier. The vital signs were stable, but the amylase and lipase levels were elevated to 558 U/L and 1,664 U/L, respectively. Abdominal computed tomography (CT) revealed a left diaphragmatic hernia and an incarceration of the stomach, pancreatic ductal dilatation, and peripancreatic fatty infiltration. Additional history taking showed that he had suffered a fall approximately 20 years ago and had an accidentally diaphragmatic hernia through a chest CT 6 months earlier. A comparison with the previous CT revealed the pancreatitis to be caused by secondary pancreatic ductal obstruction due to the incarcerated stomach. For pancreatitis, gastrointestinal decompression was performed, and after 3 days, the pancreatic enzyme was normalized; hence, a thoracotomy was performed. A small ruptured diaphragm was found and reposition of the organs was performed. This paper reports the experience of successfully treating pancreatitis and pancreatic hernia developed after trauma without complications through a thoracotomy following gastrointestinal decompression.

Scorecard for early recognition of patients at high risk of delirium in emergency department

OBJECTIVE: This study was conducted to evaluate scorecards for early recognition of high-risk patients of delirium in the emergency department (ED). METHODS: Data from 399 consecutive patients aged 65 years or older between January 1, 2015 and December 31, 2015 were retrospectively analyzed. Delirium was identified by reviewing medical records and was confirmed by a psychiatrist. The study population was divided into a training and validation group. Predisposing factors were evaluated and validated by multivariate logistic regression analysis and a calibration plot, after which a scorecard was constructed using these factors and applying points to double odds to each regression coefficient. RESULTS: Dementia, transfer from a long-term care facility, acute acid-base imbalance, moderate pain, and stroke were independent predisposing factors for delirium in ED, with assigned scores in the scorecard of 3, 2, 2, 2, and 2, respectively. The total score of the scorecard for delirious patients was significantly higher than that for non-delirious patients in both the training and validation groups. The coefficient of determination (R²) of the calibration plot was 0.74 and 0.68 in the training and validation group, respectively. In the receiver operation characteristic curve, the cut-off point of the scorecard for delirium was 2.5 and the sensitivity, specificity, and accuracy were 75.0%, 87.8%, and 86.7% in training group, while they were 76.9%, 85.1%, and 84.2% in the validation group, respectively. CONCLUSION: The scorecard was a useful screening tool for early recognition of patients with a high-risk of developing delirium in the ED.

Ultrasonographic findings in Fitz-Hugh-Curtis syndrome: a thickened or three-layer hepatic capsule / 영남의대학술지

Fitz-Hugh-Curtis syndrome (FHCS) is characterized by inflammation of the perihepatic capsules associated with the pelvic inflammatory disease (PID). FHCS is not a serious disease, but if not treated properly, it can result in increased medical costs, prolonged treatment, and dissatisfaction with treatment. However, early recognition of FHCS in the emergency department can be difficult because its symptoms or physical findings may mimic many other diseases. Although contrast-enhanced computed tomography (CECT) is the useful imaging modality for recognition of FHCS, it is available only when a high suspicion is established. We performed point-of-care ultrasonography in an 18-year-old woman who had a sharp right upper quadrant (RUQ) abdominal pain without PID symptoms and found a thickened or three-layer hepatic capsule. These findings coincided with areas showing increased hepatic capsular enhancement in the arterial phase of CECT. These results show that if the thickened or three-layer hepatic capsule without evidence of a common cause of RUQ pain is observed on ultrasonography in women of childbearing age with RUQ abdominal pain, the physician can consider the possibility of FHCS.

Ultrasonographic findings in Fitz-Hugh-Curtis syndrome: a thickened or three-layer hepatic capsule / 영남의대학술지

Fitz-Hugh-Curtis syndrome (FHCS) is characterized by inflammation of the perihepatic capsules associated with the pelvic inflammatory disease (PID). FHCS is not a serious disease, but if not treated properly, it can result in increased medical costs, prolonged treatment, and dissatisfaction with treatment. However, early recognition of FHCS in the emergency department can be difficult because its symptoms or physical findings may mimic many other diseases. Although contrast-enhanced computed tomography (CECT) is the useful imaging modality for recognition of FHCS, it is available only when a high suspicion is established. We performed point-of-care ultrasonography in an 18-year-old woman who had a sharp right upper quadrant (RUQ) abdominal pain without PID symptoms and found a thickened or three-layer hepatic capsule. These findings coincided with areas showing increased hepatic capsular enhancement in the arterial phase of CECT. These results show that if the thickened or three-layer hepatic capsule without evidence of a common cause of RUQ pain is observed on ultrasonography in women of childbearing age with RUQ abdominal pain, the physician can consider the possibility of FHCS.

Splenic artery aneurysm with the double-rupture phenomenon

Splenic artery aneurysm is the third most common type of intra-abdominal aneurysm, with a prevalence rate of 0.01% to 10.4% in the general population. Splenic artery aneurysm is usually asymptomatic and is typically detected by chance and does not require surgical management; however, if rupture occurs, although rare, the patient's situation can become critical. We report our experience with a man who presented with left flank and left shoulder pain. His symptoms were caused by multiple hematomas confined to the spleen, but 2 days after admission, he developed delayed hemoperitoneum and required surgical management. We believe that his condition was due to delayed intraperitoneal bleeding called the double-rupture phenomenon; emergency physicians must consider this phenomenon when taking care of splenic artery aneurysm patients.

A Case of Unknown Cause of Subcutaneous Emphysema Presented by Generalized Edema

Subcutaneous emphysema and pneumomediastinum are commonly derived from trauma or injury of respiratory or gastrointestinal tracts, but occasionally the origin of air was not determined at evaluation. We report on a case of severe subcutaneous emphysema detected using simple X-ray films in the emergency department, which extended to almost all of the bodies, with a review of the literature.

Nephropathy related to computed tomography in emergency department patients with serum creatinine <1.5 mg/dL / 영남의대학술지

BACKGROUND: Contrast-induced nephropathy (CIN) can cause serious adverse effects. To reduce the occurrence of CIN related computed tomography (CT) in emergency patients, we assessed the respective roles of serum creatinine (SCr) alone and estimated glomerular filtration rate (eGFR) as an early predictor for CIN related CT. METHODS: For patients with SCr <1.5 mg/dL who underwent CT in emergency department (ED) between September 2012 and October 2013, we assessed the prevalence of CIN and its adverse effects. The Modification of Diet in Renal Disease Study (MDRD) and Cockcroft-Gault (CG) formula was used for the calculation of eGFR. Practical calculation was performed by electronic medical record (EMR) system for MDRD and internet calculating service for CG. And we investigated the prevalence of CIN in eGFR <60 mL/min/1.73 m2 before CT. RESULTS: A total of 1,555 patients were enrolled. The prevalence of CIN after CT was 4.6% and it showed correlation with renal deterioration, increased in-hospital mortality, and prolonged hospitalization. Despite baseline SCr <1.5 mg/dL, among enrolled patients, 11.3% as MDRD equation and 29.5% as CG formula were <60 mL/min/1.73 m2 and in this condition, the prevalence of CIN was significantly high (odds ratio was 2.87 [1.64-5.02] as MDRD equation and 2.03 [1.26-3.29] as CG formula). CONCLUSION: Just SCr <1.5mg/dL was not appropriate to recognize preexisting renal insufficiency, but eGFR using MDRD equation was useful in predicting the risk of CIN related CT in ED. Using EMR, calculation of eGFR can be easier and more convenient.

Comparison of the Clinical Characteristics of the Patients Visited in Emergency Department with Pandemic 2009 Influenza A (H1N1) Virus Infection during the First Three Years; An Observational Study at a Single Emergency Department

PURPOSE: Daegu, Korea was severely affected by pandemic and post-pandemic H1N1 infection during August 2009 to March 2012. The aim of this study was to analyze various clinical characteristics of patients who visited the emergency department with H1N1 infection during the first three years, and to compare the results for each year. We then performed an evaluation of the differences. METHODS: The medical records of patients who visited our emergency department and conformed to H1N1 virus infection by conventional rRT-PCR during the pandemic wave from August 2009 to March 2010(wave 1) and post-pandemic waves from August 2010 to March 2011(wave 2) and from August 2011 to March 2012(wave 3) were reviewed. A total of 986 patients (wave 1; 840, wave 2; 144, wave 3; 2) were included in this study. We analyzed the clinical characteristics, proportions of pneumonia, admission rate, relationships with underlying medical conditions, and requirement for mechanical ventilation of the infected patients, and then performed a statistical evaluation of the differences between wave 1 and wave 2 that was severely affected. RESULTS: During wave 1,840 patients, during wave 2, 144 patients, and during wave 3, two patients were diagnosed as novel influenza. Age 18-39 showed a significantly higher rate(78.7%) in the wave 1 patients group. Main clinical symptoms were cough and febrile sense in both waves. Patients with underlying medical conditions in wave 2(97 cases, 67.4%) showed a higher rate than those of wave 1(101 cases, 12.0%). Chronic obstructive pulmonary disorder was the most closely related underlying disorder in wave 2(18.8%). Patients requiring admission(37.5%) and ventilatory care(6.9%) due to severe pneumonic symptoms showed a significantly higher rate in wave 2. Only two young patients were diagnosed as novel influenza. Both complained of mild fever and cough, which recovered spontaneously. CONCLUSION: Most cases of influenza A (H1N1) infection were uncomplicated, characterized by influenza-like symptoms and spontaneous recovery. The number of patients showed a marked decreased year by year, however, the severity of clinical presentations increased in wave 2. Young adults who did not have cross-reactive antibodies to novel influenza A (H1N1) from previous infection or immunization were dominant in wave 1. Older patients with underlying medical conditions were more likely to admitted and present fatal progress in wave 1 and wave 2. Because influenza viruses are unpredictable, continued national preparedness, flexible response, and careful monitoring are essential.

Comparison of the Clinical Characteristics of the Patients Visited in Emergency Department with Pandemic 2009 Influenza A (H1N1) Virus Infection during the First Three Years; An Observational Study at a Single Emergency Department

PURPOSE: Daegu, Korea was severely affected by pandemic and post-pandemic H1N1 infection during August 2009 to March 2012. The aim of this study was to analyze various clinical characteristics of patients who visited the emergency department with H1N1 infection during the first three years, and to compare the results for each year. We then performed an evaluation of the differences. METHODS: The medical records of patients who visited our emergency department and conformed to H1N1 virus infection by conventional rRT-PCR during the pandemic wave from August 2009 to March 2010(wave 1) and post-pandemic waves from August 2010 to March 2011(wave 2) and from August 2011 to March 2012(wave 3) were reviewed. A total of 986 patients (wave 1; 840, wave 2; 144, wave 3; 2) were included in this study. We analyzed the clinical characteristics, proportions of pneumonia, admission rate, relationships with underlying medical conditions, and requirement for mechanical ventilation of the infected patients, and then performed a statistical evaluation of the differences between wave 1 and wave 2 that was severely affected. RESULTS: During wave 1,840 patients, during wave 2, 144 patients, and during wave 3, two patients were diagnosed as novel influenza. Age 18-39 showed a significantly higher rate(78.7%) in the wave 1 patients group. Main clinical symptoms were cough and febrile sense in both waves. Patients with underlying medical conditions in wave 2(97 cases, 67.4%) showed a higher rate than those of wave 1(101 cases, 12.0%). Chronic obstructive pulmonary disorder was the most closely related underlying disorder in wave 2(18.8%). Patients requiring admission(37.5%) and ventilatory care(6.9%) due to severe pneumonic symptoms showed a significantly higher rate in wave 2. Only two young patients were diagnosed as novel influenza. Both complained of mild fever and cough, which recovered spontaneously. CONCLUSION: Most cases of influenza A (H1N1) infection were uncomplicated, characterized by influenza-like symptoms and spontaneous recovery. The number of patients showed a marked decreased year by year, however, the severity of clinical presentations increased in wave 2. Young adults who did not have cross-reactive antibodies to novel influenza A (H1N1) from previous infection or immunization were dominant in wave 1. Older patients with underlying medical conditions were more likely to admitted and present fatal progress in wave 1 and wave 2. Because influenza viruses are unpredictable, continued national preparedness, flexible response, and careful monitoring are essential.

High-dose Vitamin C therapy in Methemoglobinemia

Methylene blue is the first choice antidote for management of methemoglobinemia, however, some patients are refractory to methylene blue and in most cases, methylene blue cannot be available instantly in Korean emergency departments because of import suspension. A 69-year-old woman visited our emergency department for tachypnea and cyanosis after ingesting 30 tablets of dapsone. Because methylene blue was not available, we intravenously administrated 10 g of vitamin C for symptomatic methemoglobinemia. Repeated i.v. administrations of 10 g of vitamin C in patient without preexisting renal insufficiency successfully treated dapsone-induced methemoglobinemia without causing renal complications. Thus, we recommend that if methylene blue is unavailable or methemoglobinemia is refractory to methylene blue, repeated administrations of 10 g of vitamin C may be considered for the treatment of methemoglobinemia in patients without renal insufficiency.

Work-related Fatigue, Stress and Depression of the Emergency Department Interns

PURPOSE: An internship is a very generally a stressful period during medical training in general. Working in the Emergency Department (ED) is especially difficult and stressful because of its unique clinical environment. Our goal was to determine the level of the depression, fatigue, sleep disorders and stress of interns in the ED. METHODS: A questionnaire was distributed to 430 interns who are working or had worked in the ED. The questionnaire included questions about general characteristics and scales relating to symptoms of depression, fatigue, sleep disorder and stress. RESULTS: Of the 430 questionnaires given out, 178(41.4%) were returned. The mean age of the participants was 28.4+/-2.9, and 123(69.5%) were male. Also, 112(63.3%) participants were working at an alumni-affiliated hospital or at related hospital. The interns at an unrelated hospital experienced more discrimination than those working at an alumni-related hospital (21.5% vs. 9.8%, respectively, p=0.031). Also, female interns experienced more sexual harassment than male interns (16.7% vs. 2.4%, respectively, p=0.001). The average score for medical outcomes study MOS sleep scale, Beck Depression Inventory, Fatigue Severity Scale and Cohen Perceived Stress Scale were 16.2+/-4.0, 8.0+/-7.8, 4.3+/-1.2 and 19.4+/-5.4, respectively. The degree of participation in treating patients first hand (OR 2.33, 95% CI=1.19-4.57), experiencing discrimination (OR 3.17, 95% CI=1.15-8.73) and long working hours (OR 2.02, 95% CI=1.05-3.86) had a significant effect on stress and depression. CONCLUSION: The interns who worked at an ED had higher fatigue and stress scores compared to ordinary person. Also, participation, discrimination and working hours may be good to mention. Therefore, more research and effort is required to improve the factors that cause fatigue, stress and depression of the interns in ED.

Risk Factors for Delirium in Elderly Patients Visiting an Emergency Department

PURPOSE: Delirium is a common and worrisome problem among elder hospitalized patients. Many studies have sought to evaluate the risk factors of delirium. Most of these studies have dealt with the intensive care unit, with virtually nothing known about the emergency room. Our study was designated to evaluate the risk factors in an emergency department. METHODS: We retrospectively reviewed 414 cases of elder patients admitted to the general ward of internal medicine via the emergency room between January 2009 and December 2009. We divided these patients into a delirium group and non-delirium group. We statistically evaluated 31 known risk factors of delirium in these two groups. RESULTS: Using chi-square test, 14 of 31 known risk factors of delirium were proven as risk factors of delirium in an emergency room. Using logistic regression, three of the 14 proven risk factors were revealed as prior factors. CONCLUSION: A variety of factors of delirium are risk factors of delirium in an emergency room. A few important known risk factors are failed to pass statistically evaluation. These results are influenced by cultural pecularities of South Korea. Also, the small sample size limited conclusive evaluation. Nonetheless, the importance of patients' past medical history, laboratory results, and choice of medication when treating elder hospitalized patients to prevent delirium is likely important in reducing mortality and morbidity.

The Validation of the Admission Systemic Inflammatory Response Syndrome Score as the Trauma Score

PURPOSE: Multiple trauma is one of the major causes of deaths and physical disabilities of the young. Thus, a trauma scoring system which is easy, fast, and accurate is the most important factor for reducing the mortality due to multiple trauma. As studies have shows the systemic inflammatory response syndrome (SIRS) score is useful in estimating the severity of and determining the prognosis of the disease, so we investigated the usefulness of the SIRS score as a trauma score. METHODS: This study was a retrospective analysis of data collected from January 2002 to December 2002. Three hundred sixity nine trauma patients who were admitted to the emergency department were included. Patients who were transferred from other hospitals, children under the age of 15 years and patients transferred to other hospitals for ICU care and emergency operations were excluded. The SIRS score was defined according to the criteria of the American College of Chest Physicians and the Society of Critical Care Medicine (ACCP/SCCM). Patients were grouped by using the SIRS score(0 to 4) calculated at admission. RESULTS: Among the 369 trauma patients, 174 patients (47.2%) had a SIRS score > or =2 at admission, and 30 of the 369 patients expired. The admission SIRS score was significantly correlated with the injury severity score (ISS). The mortality rate and the length of stay (LOS) significantly increased as the admission SIRS score increased. Analysis of the variance, adjusting for age and ISS, should that are SIRS score> or =2 was a significant predictor of mortality and LOS. CONCLUSION: The admission SIRS score has been shown to be useful in estimating the severity of and the prognosis for a trauma. If we apply it to the trauma patients who visit ED, it should provide a more useful means for determining the severity of the trauma and the prognosis for the patient.

A Clinical Review of Acute Mountain Sickness

PURPOSE: Rapid ascent from low to high altitude (above 2500 m) often causes acute mountain sickness (AMS), a symptom-complex characterized by headache and other systemic symptoms (gastrointestinal upset, weakness, dizziness, and difficulty sleeping). In this study, we observed the vital signs and AMS symptoms. 13 participants in a mountain climb in order to determine correlation between AMS and risk factors such as obesity, smoking, and a previous history of AMS. METHODS: We studied 13 participants who climbed Mt.Cholatse (6440 m), and measured their vital signs and symptoms during the trekking. Standard Lake Louise questionnaires were filled out at five times during the trek: at the sea level, 2700 m, 3440 m, 4040 m, and 4700 m. With AMS scores and severity grades, we evaluate the severity of symptoms and the physical status. RESULTS: The overall AMS score was 3.7+/-.5, and headache was the most frequent symptom. As the altitude increased, oxygen saturation decreased whereas other vital signs (blood pressure, respiratory rate, and pulse rate) increased. The average AMS scores and severity grades increased more rapidly for obese men than for non-obese men (p<0.001). Smoking and previous history of AMS were also associated with the development of AMS (p<0.001). CONCLUSION: Persons who are obese or have a history of a smoking or AMS, are more likely to develop AMS symptoms. Further understanding of the natural and evolution of AMS and of the risk factors associated with AMS will educate the general population and physicians and help in its prevention and treatment.