Impact of discharge against medical advice on emergency department revisits and prognosis among pneumonia patients recommended to be hospitalized in a general ward

Objective@#This study examined the clinical consequences of a discharge against medical advice (DAMA) among pneumonia patients recommended to be hospitalized in a general ward and identified the risk factors related to a revisit after DAMA. @*Methods@#This retrospective observational study included pneumonia patients who presented at a university hospital emergency department (ED) and were recommended to be hospitalized in a general ward between January 2017 and December 2019. A multivariate logistic regression analysis was performed to identify the risk factors related to a revisit after DAMA and mortality. @*Results@#In the ‘revisit after DAMA’ group, the mortality rate was higher than the ‘no DAMA admission’ group (6.9% vs. 2.1%, P=0.009). Among all admitted patients, DAMA was a risk factor for mortality (odds ratio [OR], 6.185; P=0.023). In the ‘revisit after DAMA’ group, sex (OR, 6.590; P=0.005), C-reactive protein (CRP) score (OR, 1.149; P=0.022), febrile symptoms (OR, 6.569; P=0.004), and dyspnea (OR, 5.480; P=0.002) were risk factors of revisit. Furthermore, in the ‘revisit after DAMA’ group, the CRP score of the 2nd ED visit was higher than that of the 1st ED visit (6.55±6.27 vs. 8.20±7.31, P=0.014). @*Conclusion@#This study shows that DAMA is one of the risk factors for mortality. When DAMA patients revisit, the severity of their pneumonia was observed to have increased.

The impact of the COVID-19 pandemic on emergency department length of stay and outcomes of pneumonia patients

Objective@#This study aimed to investigate the impact of the coronavirus disease 2019 (COVID-19) outbreak on the emergency department length of stay (ED-LOS) and outcomes of patients admitted with pneumonia. @*Methods@#This was a retrospective observational study that included adult pneumonia patients admitted to the emergency department during the period from February to July 2019 and the corresponding period in 2020. After the COVID-19 outbreak, many changes occurred in medical systems, causing prolonged ED-LOS. We divided ED-LOS into pre-, mid-, and post-ED-LOS and compared ED-LOS, hospital LOS and in-hospital mortality rates of pneumonia patients during the above-mentioned periods. In addition, a multivariable logistic regression analysis was performed to identify the risk factors leading to in-hospital mortality in 2020. @*Results@#A total of 365 patients were included in the study. Pre-ED-LOS, mid-ED-LOS, post-ED-LOS, and in-hospital mortality in the 2020 group were significantly higher than those of the 2019 group (P<0.05). Mid-ED-LOS (odds ratio [OR], 1.474; P=0.001) and post-ED-LOS (OR, 1.098; P=0.024) were identified as being independently associated with an increased risk of in-hospital mortality in 2020. @*Conclusion@#Our study shows that ED-LOS and in-hospital mortality increased after the COVID-19 pandemic. Mid-ED-LOS and post-ED-LOS were independently associated with an increased risk of in-hospital mortality in patients with pneumonia in 2020.

Impact of decreased intensive care unit bed capacity on the emergency department length of stay and clinical outcomes of critically ill patients

Objective@#This study aimed to investigate the impact of reduced bed capacity in the intensive care unit (ICU) on emergency department (ED) length of stay (LOS) and prognosis of critically ill patients. @*Methods@#This retrospective observational study included patients who presented to a university hospital ED and were admitted to the ICU between August 2017 and July 2019. In our center, the number of beds in the traumatic ICU was maintained, while the number of beds in the non-traumatic ICU was reduced. We comparatively assessed ED LOS and the mortality rate between traumatic and non-traumatic patients over 2 years (1 year before and after the reduced number of beds in the non-traumatic ICU) to determine the impact of reduced ICU bed capacity. Also, a multivariate logistic regression analysis was performed to identify the risk factors related to in-hospital mortality. @*Results@#A total of 2,945 patients were included in this study. In the traumatic ICU patient group, the ED LOS did not change (2.62 [1.95-3.72] hours vs. 2.78 [2.01-3.92] hours, P=0.079) after reducing the number of ICU beds; and no significant difference in mortality rate was noted (19.5% vs. 17.6%, P=0.417). In the non-traumatic ICU patient group, both ED LOS (prolonged by 1.69 hours, 3.46 [2.17-5.66] hours vs. 5.15 [3.43-8.37] hours, P<0.001) and mortality rate (21.6% vs. 25.8%, P=0.003) were significantly increased after reducing the number of ICU beds. In the multivariate logistic regression analysis, ED LOS was identified as a risk factor for in-hospital mortality (odds ratio, 1.035; P<0.001). @*Conclusion@#In this study, the reduced ICU bed capacity resulted in prolonged ED LOS of critically ill patients, which consequently contributed to increased in-hospital mortality.

Impact of decreased intensive care unit bed capacity on the emergency department length of stay and clinical outcomes of critically ill patients

Objective@#This study aimed to investigate the impact of reduced bed capacity in the intensive care unit (ICU) on emergency department (ED) length of stay (LOS) and prognosis of critically ill patients. @*Methods@#This retrospective observational study included patients who presented to a university hospital ED and were admitted to the ICU between August 2017 and July 2019. In our center, the number of beds in the traumatic ICU was maintained, while the number of beds in the non-traumatic ICU was reduced. We comparatively assessed ED LOS and the mortality rate between traumatic and non-traumatic patients over 2 years (1 year before and after the reduced number of beds in the non-traumatic ICU) to determine the impact of reduced ICU bed capacity. Also, a multivariate logistic regression analysis was performed to identify the risk factors related to in-hospital mortality. @*Results@#A total of 2,945 patients were included in this study. In the traumatic ICU patient group, the ED LOS did not change (2.62 [1.95-3.72] hours vs. 2.78 [2.01-3.92] hours, P=0.079) after reducing the number of ICU beds; and no significant difference in mortality rate was noted (19.5% vs. 17.6%, P=0.417). In the non-traumatic ICU patient group, both ED LOS (prolonged by 1.69 hours, 3.46 [2.17-5.66] hours vs. 5.15 [3.43-8.37] hours, P<0.001) and mortality rate (21.6% vs. 25.8%, P=0.003) were significantly increased after reducing the number of ICU beds. In the multivariate logistic regression analysis, ED LOS was identified as a risk factor for in-hospital mortality (odds ratio, 1.035; P<0.001). @*Conclusion@#In this study, the reduced ICU bed capacity resulted in prolonged ED LOS of critically ill patients, which consequently contributed to increased in-hospital mortality.

Axon Guidance Molecules Guiding Neuroinflammation

Axon guidance molecules (AGMs), such as Netrins, Semaphorins, and Ephrins, have long been known to regulate axonal growth in the developing nervous system. Interestingly, the chemotactic properties of AGMs are also important in the postnatal period, such as in the regulation of immune and inflammatory responses. In particular, AGMs play pivotal roles in inflammation of the nervous system, by either stimulating or inhibiting inflammatory responses, depending on specific ligand-receptor combinations. Understanding such regulatory functions of AGMs in neuroinflammation may allow finding new molecular targets to treat neurodegenerative diseases, in which neuroinflammation underlies aetiology and progression.

The effect of change in medical care protocol for primary headache patients visiting the emergency medical center

OBJECTIVE@#University hospitals nationwide are experiencing a shortage of neurology residents and excessive workloads; new measures are required because a lack of neurologists in the emergency department (ED) leads to ED overcrowding. This study examined the effects of emergency medicine doctors taking over the role of neurologists in the treatment of primary headache patients visiting the ED.@*METHODS@#A study group of primary headache patients, who visited a single university hospital ED between 1 June and 31 October 2017 and were treated by an emergency medical doctor, was selected. The control group consisted of patients who met the same conditions as the study group and visited the ED during the same period in 2016 but were treated by a neurologist. The following variables between the two groups were compared: length of stay in the ED, medical expenses in the ED, and the time taken to decide on neuroimaging tests.@*RESULTS@#This study was conducted on 300 patients in the control group and 94 patients in the study group. The study group showed a shorter time to decide on neuroimaging tests (64.4%, 95% confidence interval [CI], P<0.001), shorter length of stay in the ED (15.2%, 95% CI, P<0.001), and lower medical expenses (12.8%, 95% CI, P=0.011).@*CONCLUSION@#When emergency medicine doctors take over the neurologic medical care of primary headache patients in ED, it can be expected to reduce ED overcrowding and medical expenses.

Changes in arterial blood gas analysis results according to body mass index in patients with acute dyspnea admitted through emergency department, and usefulness for predicting prognosis

OBJECTIVE@#This study examined the change tendency in the arterial blood gas analysis (ABGA) results according to the body mass index (BMI) of patients admitted through the emergency department (ED) with dyspnea, as well as the risk factors for intensive care unit (ICU) admission and in-hospital mortality in obese patients.@*METHODS@#A retrospective study was conducted on 768 patients, who were admitted to the ED for dyspnea during 2017 and underwent ABGA. The patients were divided into four groups according to their BMI. Multivariate logistic regression analysis was used to determine the risk factors of ICU admission and in-hospital mortality in obese patients using the ABGA results.@*RESULTS@#A higher BMI was associated with a lower pH (P<0.001) and higher arterial carbon dioxide pressure (PaCO2, P=0.001), hematocrit (P=0.009), and lactate concentration (P=0.012). In the obese group, low pH (odds ratio [OR], 5.780; P<0.001 and OR, 16.393; P=0.013), high PaCO2 (OR, 1.123; P=0.005), high lactate concentration (OR, 1.886; P=0.015), and base excess reduction (OR, 1.267; P=0.001) were the risk factors for ICU admission, whereas pH<7.33 (OR, 14.493; P=0.014) and high lactate concentration (OR, 1.462; P=0.008) were the risk factors for in-hospital mortality. The pH (area under the curve [AUC], 0.817; AUC, 0.890) and lactate concentration (AUC, 0.762; AUC, 0.728) were useful for predicting the ICU admission and in-hospital mortality.@*CONCLUSION@#A higher BMI in the subjects was associated with a lower pH and higher lactate concentration. In addition, pH and lactate concentration were significant risk factors for ICU admission and in-hospital mortality.

Effective method for reconstruction of remaining lower lip vermilion defect after a mental V-Y advancement flap

BACKGROUND: The mental V-Y advancement flap method is useful for reconstruction of lower lip defect because of its many advantages. However, it is not easy to select the optimal reconstructive method for the vermilion defect that remains after application of the mental V-Y advancement flap. In choosing the representative surgical method for vermilion mucosal reconstruction including mucosal V-Y advancement flap, buccal mucosal flap, and buccal mucosal graft. We describe an efficient technique to large lower lip defects combining mental V-Y advancement flap and buccal mucosal graft METHODS: This study included 16 patients who underwent reconstructive surgery for full-thickness and large defect (> half the entire width) of the lower lip from October 2006 to September 2017. The operation was conducted using mental V-Y advancement flap with various vermilion mucosal reconstruction methods considering the location of the defect and the amount of residual tissue of the lip coloboma after excision. RESULTS: All patients underwent mental V-Y advancement flap. In vermilion mucosal reconstruction, five patients underwent mucosal V-Y advancement flap, three underwent buccal mucosal flap, and eight underwent buccal mucosal graft. There were good aesthetic and functional results in all patients who underwent buccal mucosal graft. However, two patients who underwent mucosal V-Y advancement flap complained of oral incompetence, and all patients who underwent buccal mucosal flap had oral commissure deformity. CONCLUSION: Buccal mucosal graft combined with mental V-Y advancement flap can produce suitable functional and aesthetic outcomes in near total lower lip reconstruction in patient with large mucosal defect including vermilion portion.

A Case of Zaltoprofen Induced Kounis Syndrome

Kounis syndrome is defined as the occurrence of acute coronary syndrome associated with vasoactive mediators, such as histamines in the setting of hypersensitivity and allergic reactions or anaphylactic insults. The condition can be caused by various drugs, foods, or environmental factors that cause allergic reactions. A 35-year-old male visited the emergency room with anaphylaxis accompanied by chest pain approximately 20 minutes after taking zaltoprofen, a nonsteroidal anti-inflammatory drug. After acute treatment for the anaphylaxis, the patient was stabilized and all symptoms disappeared, but the ischemic changes in the electrocardiogram and elevation of the cardiac enzymes were observed. The emergency cardiac angiography and echocardiography were all normal. The allergic reaction of this patient to zaltoprofen was believed to cause a temporary coronary arterial vasospasm, inducing Type 1 Kounis syndrome. Thus far, there have been case reports of Kounis syndrome caused by a range of nonsteroidal anti-inflammatory drugs, but there are no reports of the condition being caused by zaltoprofen. According to the pathophysiology, both cardiac and allergic symptoms must be solved simultaneously, so rapid treatment and diagnosis are needed. Doctors treating acute allergic reactions and anaphylaxis patients must check the cardiovascular symptoms thoroughly and consider the possibility of Kounis syndrome.

Usefulness of combined chest and abdominal computed tomography for identification of infection sources in febrile patients without clinical clue

OBJECTIVE: This study examined the utility of combined chest and abdominal computed tomography (CT) for the identification of infection sources in acute febrile patients without clinical clues. The groups for whom combined CT was helpful and not were compared. In addition, the factors that affected the positive infection sources and predictors of the presence of infection sources when performing combined CT was investigated. METHODS: Acute febrile patients without clinical clues from a basic examination and the confirmation procedure were investigated prospectively for 6 months. A range of factors, such as demographic factors, duration of fever, vital signs, presence of prior medical treatment, inflammatory markers, and several sepsis prediction tools, were analyzed. RESULTS: Of the 87 patients, 32 (36.8%) tested positive for infection sources on combined CT, whereas 55 (63.2%) tested negative. The mean age, heart rate, procalcitonin (PCT) level, and proportion of the patients aged ≥65 years showed significant differences between the infection source-positive group and infection source-negative group (P=0.027, P=0.008, P=0.035, and P=0.026, respectively). The factors that affected the positive results for infection sources on combined CT included age (odds ratio [OR], 1.047; P=0.011), absence of chronic disease (OR, 0.157; P=0.045), and heart rate (OR, 1.056; P=0.030). Analysis of the receiver-operating characteristic curve showed that age (area under the curve [AUC], 0.630; P=0.041) and heart rate (AUC, 0.659; P=0.008) were significant predictive factors of positive results for infection sources. On the other hand, their predictive powers were poor, and PCT did not show a significant result (AUC, 0.565; P=0.351). CONCLUSION: In patients with underlying chronic disease, older age, increased heart rate due to fever, or a high PCT level, combined CT can be used to identify infection sources when its possible clinical benefits are considered to be high.

Caffeic acid phenethyl ester protects against photothrombotic cortical ischemic injury in mice

In this study, we aimed to investigate the neuroprotective effects of caffeic acid phenethyl ester (CAPE), an active component of propolis purified from honeybee hives, on photothrombotic cortical ischemic injury in mice. Permanent focal ischemia was achieved in the medial frontal and somatosensory cortices of anesthetized male C57BL/6 mice by irradiation of the skull with cold light laser in combination with systemic administration of rose bengal. The animals were treated with CAPE (0.5–5 mg/kg, i.p.) twice 1 and 6 h after ischemic insult. CAPE significantly reduced the infarct size as well as the expression of tumor necrosis factor-α, hypoxiainducible factor-1α, monocyte chemoattractant protein-1, interleukin-1α, and indoleamine 2,3-dioxygenase in the cerebral cortex ipsilateral to the photothrombosis. Moreover, it induced an increase in heme oxygenase-1 immunoreactivity and interleukin-10 expression. These results suggest that CAPE exerts a remarkable neuroprotective effect on ischemic brain injury via its anti-inflammatory properties, thereby providing a benefit to the therapy of cerebral infarction.

Long-term oncologic outcomes in pathologic tumor response after neoadjuvant chemoradiation for locally advanced rectal cancer

PURPOSE: The status of tumor regression in rectal cancer after neoadjuvant concurrent chemoradiotherapy (CCRT) has significant effect on tumor recurrence and patient survival. The aim of this study was to evaluate the long-term oncologic outcomes of rectal cancer patients presenting complete response or down-staging of rectal cancer compared to patients with non-response after neoadjuvant therapy in advanced mid-to-lower rectal cancer.METHODS: We retrospectively reviewed 79 patients with stage II/III mid-to-lower rectal cancer following neoadjuvant CCRT between March 2003 and April 2012. Patients were classified into three groups according to down-staging tumor response after neoadjuvant CCRT: complete response group (CRG), partial response group (PRG), and non-response group (NRG).RESULTS: Of the 79 patients in the study, eight (10.1%), 31 (39.2%), and 40 (50.7%) were classified as CRG, PRG, and NRG, respectively. Median follow-up period was 57 months. There was significant difference in local recurrence (P=0.012) between the three groups, yet there was no significant difference in overall survival (CRG, 100%; PRG, 82.5%; NRG, 74.0%; P=0.244). There was a significant difference in disease-free survival (CRG, 100%; PRG, 90.1%; NRG, 57.7%; P=0.006).CONCLUSION: Tumor response with complete response or down-staging provided better oncologic outcomes in terms of disease-free survival and local recurrence in locally advanced rectal cancer patients.

Clinicopathologic characteristics and survival rate in patients with synchronous or metachronous double primary colorectal and gastric cancer

PURPOSE: Double primary colorectal cancer (CRC) and gastric cancer (GC) represent the most common multiple primary malignant tumors (MPMT) in Korea. The recognition and screening of hidden malignancies other than the primary cancer are critical. This study aimed to investigate the clinicopathologic characteristics and survival rates in patients with synchronous or metachronous double primary CRC and GC.METHODS: Between January 1994 and May 2018, 11,050 patients were diagnosed with CRC (n=5,454) or GC (n=5,596) at Gil Medical Center. MPMT and metastatic malignant tumors were excluded from this study. A total of 103 patients with double primary CRC and GC were divided into two groups: the synchronous group (n=40) and the metachronous group (n=63). The incidence, clinicopathologic characteristics, and survival rate of the two groups were analyzed.RESULTS: The incidence of synchronous and metachronous double primary CRC and GC was 0.93%. Double primary CRC and GC commonly occurred in male patients aged over 60 years with low comorbidities and minimal previous cancer history. There were significant differences between the synchronous and metachronous groups in terms of age, morbidity, and overall survival. Metachronous group patients were 6 years younger on average (P=0.009), had low comorbidities (P=0.008), and showed a higher 5-year overall survival rate (94.8% and 61.3%, P < 0.001) in contrast to synchronous group.CONCLUSION: When primary cancer (CRC or GC) is detected, it is important to be aware of the possibility of the second primary cancer (GC or CRC) development at that time or during follow-up to achieve early detection and better prognosis.

Comparison of Outcomes of Hybrid and Surgical Correction for De Novo Arteriovenous Graft Occlusion

PURPOSE: This study aimed to compare surgical revisions and balloon angioplasty after surgical thrombectomy on thrombosed dialysis access as a first event. MATERIALS AND METHODS: Records of patients undergoing creation of arteriovenous grafts (AVGs) at the Gachon University Gil Medical Center between March 2008 and February 2016 were reviewed. Among them, patients who underwent treatment on first-time thrombotic occlusion after AVG creation were identified. Outcomes were primary, primary-assisted, and secondary patency. The patency was generated using the Kaplan-Meier method, and patency rates were compared by log-rank test. RESULTS: A total of 59 de novo interventions (n=26, hybrid interventions; n=33, surgical revisions) for occlusive AVGs were identified. The estimated 1-year primary patency rates were 47% and 30% in the surgery and hybrid groups, respectively. The estimated primary patency rates were not different between the two groups (log-rank test, P=0.73). The Kaplan-Meier estimates of 6 and 12 months for primary-assisted patency rates were 68% and 57% in the surgery group and 56% and 56% in the hybrid group. The Kaplan-Meier estimates of 12 and 24 months secondary patency rates were 90% and 71% in the surgery group and 79% and 62% in the hybrid group. There were no differences in the estimated primary-assisted and secondary patency rates between the two groups. CONCLUSION: Our results showed no significant difference between the two groups in terms of primary patency (P=0.73), primary-assisted patency (P=0.85), and secondary patency (P=0.78). However, percutaneous transluminal angioplasty can give more therapeutic options for both surgeons and patients.

Changes in medical care due to the absence of internal medicine physicians in emergency departments

OBJECTIVE: Especially in emergency departments (EDs), a lack of internal medicine (IM) residents in charge causes difficulties in medical care and ED overcrowding. Thus, protocols without IM residents in EDs is needed. This study aimed to investigate changes in medical care when emergency medicine residents replaced the roles of IM residents. METHODS: This study was conducted at a single-site ED of a university medical center. The study group contained patients admitted to the IM department between September and December 2015, during which IM residents were absent in the ED. The control group contained patients admitted to the IM department between September and December 2014, during which IM residents were present in the ED. Changes in medical care between the presence and absence of IM residents in the ED were studied by comparing admission rates from the ED, length of ED stay, duration of hospitalization, and concordance of diagnoses between admission and discharge by the IM department. RESULTS: The study group contained 2,341 patients; the control group contained 2,215 patients. Admission rates from the ED increased by 53.4% (95% confidence interval [CI], P < 0.001); lengths of stay decreased by 15.1% (95% CI, P < 0.001); and durations of hospitalization in the pulmonology department decreased by 38.4% (95% CI, P=0.001). Concordance of diagnoses between admission and discharge decreased by 14.2% in the cardiology department (95% CI, P=0.021). CONCLUSION: Lengths of stay were reduced without critical declines in diagnostic concordance rates when emergency medicine physicians, instead of IM residents in the ED, decided upon admissions of IM patients.

Two Cases of Tetramine Intoxication from Neptunea contricta

Even though Neptunea contricta appears similar to Batilus cornutus and Rapana venosa, they are different in tetramine content which inhibits the neuronal calcium channel. Therefore, mistaking Neptunea contricta for Batilus cornutus or Rapana venosa, can result in the occurrence of toxic symptoms. Three patients developed nausea, epigastric pain, chest pain, dizziness, blurred vision, dyspnea, hypertension and tachycardia after eating Neptunea contricta. Moreover, consumption of one only piece was sufficient to cause symptoms because each Neptunea contricta has 17.3 mg of tetramine. Accordingly, care should be taken when patients are consuming more than 5 pieces because toxic symptoms such as dyspnea can occur. Moreover, correct species identification is important because the quantity of tetramine varies among sea snail species. Finally, it is important to educate people to remove the salivary glands completely before consuming Neptunea contricta.

Acute Kidney Injury after Intravenous Injection of an Organophosphate Compound

Poisoning may result from self-injection. Previous reports have described acute cholinergic crisis, intermediate syndrome, and delayed toxicity resulting from parenteral organophosphate administration. These complications have been managed with antidotal and conservative treatment. Acute kidney injury was not listed among the complications. We report a case of acute kidney injury after intravenous injection with an unknown liquid. After chemical composition analysis, organophosphate dichlorvos has been identified as the injected liquid substance. A 50-year-old man injected this into his left arm. He visited the emergency department with a mental change accompanied by seizure. During admission, there were no typical cholinergic symptoms or intermediate syndrome; however, there was a development of acute oliguric kidney injury. The patient was treated successfully with a combination of hemodialysis, hemoperfusion, and conservative management. The manifested seizure, altered mental state, and acute kidney injury could have been caused by several types of poisoning. Based on patient history, which was obtained during the early treatment period, there was no information of what the injected material may have been, and there were no signs of a typical organophosphate toxidrome. However, the patient was successfully treated with rapid initiation of renal replacement treatment, without the use of antidotes. Poisoning by unknown causative substances poses a diagnostic challenge to emergency physicians. In many cases, treatment may be delayed while the physician tries to identify the toxin. However, the basic toxicology principle of focusing on the patient treatment rather than the poisonous substance should not be forgotten.

Comparison of long-term oncologic outcomes of stage III colorectal cancer following laparoscopic versus open surgery

PURPOSE: The oncologic outcomes after performing laparoscopic surgery (LS) compared to open surgery (OS) are still under debate and a concern when treating patients with colon cancer. The aim of this study was to compare the long-term oncologic outcomes of LS and OS as treatment for stage III colorectal cancer patients. METHODS: From January 2001 to December 2007, 230 patients with stage III colorectal cancer who had undergone LS or OS in this single center were assessed. Data were analyzed according to intention-to-treat. The primary endpoints were disease-free survival and overall survival. RESULTS: A total of 230 patients were entered into the study (114 patients had colon cancer-33 underwent LS and 81 underwent OS; 116 patients had rectal cancer-44 underwent LS and 72 underwent OS). The median follow-up periods for the colon and rectal cancer groups were 54 and 53 months, respectively. The overall conversion rate was 12.1% (n = 4) for colon cancer, and 4.5% (n = 2) for rectal cancer. Disease-free 5-year survival of colon cancer was 84.3% and 90% in LS group (LG) and OS group (OG), respectively, and that of rectal cancer was 83% and 74.6%, respectively (P > 0.05). Overall 5-year survival for colon cancer was 72.2% and 71.3% for LG and OG, respectively, and that for rectal cancer was 67.6% and 59.2%, respectively (P > 0.05). CONCLUSION: The long-term analyses for oncologic aspects of our study may confirm the safety of LS compared to OS in stage III colorectal cancer patients.

Multivariate Analysis of Risk Factors Associated With the Nonreversal Ileostomy Following Sphincter-Preserving Surgery for Rectal Cancer

PURPOSE: A loop ileostomy is used to protect an anastomosis after anal sphincter-preserving surgery, especially in patients with low rectal cancer, but little information is available concerning risk factors associated with a nonreversal ileostomy. The purpose of this study was to identify risk factors of ileostomy nonreversibility after a sphincter-saving resection for rectal cancer. METHODS: Six hundred seventy-nine (679) patients with rectal cancer who underwent sphincter-preserving surgery between January 2004 and December 2011 were evaluated retrospectively. Of the 679, 135 (19.9%) underwent a defunctioning loop ileostomy of temporary intent, and these patients were divided into two groups, that is, a reversal group (RG, 112 patients) and a nonreversal group (NRG, 23 patients) according to the reversibility of the ileostomy. RESULTS: In 23 of the 135 rectal cancer patients (17.0%) that underwent a diverting ileostomy, stoma reversal was not possible for the following reasons; stage IV rectal cancer (11, 47.8%), poor tone of the anal sphincter (4, 17.4%), local recurrence (2, 8.7%), anastomotic leakage (1, 4.3%), radiation proctitis (1, 4.3%), and patient refusal (4, 17.4%). The independent risk factors of the nonreversal group were anastomotic leakage or fistula, stage IV cancer, local recurrence, and comorbidity. CONCLUSION: Postoperative complications such as anastomotic leakage or fistula, advanced primary disease (stage IV), local recurrence and comorbidity were identified as risk factors of a nonreversal ileostomy. These factors should be considered when drafting prudential guidelines for ileostomy closure.

Comparison between Classical Lumbar Puncture and Ultrasonography-Assisted Lumbar Puncture in the Pediatric Patients

PURPOSE: We would like to study the effectiveness and safety during lumbar puncture by classic lumbar puncture and ultrasonography-assisted lumbar puncture in pediatric patients. METHODS: This was a prospective randomized controlled trial. We included under 14-year-old pediatric patients who needed to undergo lumbar puncture from May 2010 to August 2011. Patients were divided according to classic lumbar puncture (group A) and ultrasonography-assisted lumbar puncture (group B). Data were collected, including the patient's age, sex, height, underlying disease of vertebrate, weight, frequency of attempting procedure, procedure time, and failure of lumbar puncture. RESULTS: Group A and group B included 31 patients and 33 patients each, with average ages of 9.65+/-8.53 and 7.38+/-4.45(p=0.19), average heights of 126.65+/-29.81 cm and 122.39+/-30.01 cm (p=0.57), and average weights of 32.84 +/-20.68 kg and 29.17+/-16.96 kg (p=0.44), without statistically significant differences. Of the distribution of residencies who underwent lumbar puncture between the two groups, no statistically significant differences were observed (p=0.30). Lumbar puncture time in group A was 6.72+/-9.16 minutes and 3.88+/-1.51 minutes in group B, but without significant differences (p=0.098). The number of lumbar puncture attempts was 1.68+/-0.95 in group A and 1.45+/-0.56 in group B, without significant statistical difference (p=0.253). The number of patients who failed lumbar puncture was 11 in group A and 3 in group B, showing a statistically significant difference (p=0.015). CONCLUSION: Compared to the classic lumbar puncture, lumbar puncture using ultrasonography in pediatric patients did not reduce the number of proceduresand the time for the procedure, but reduced the failure rate. Therefore, we recommend the methods of lumbar puncture assisted by ultrasonography in pediatric patients as an effective method for use in the emergency department.