Use of ratio of D-dimer to C-reactive protein as an adjunctive method to differentiate between pulmonary embolism and pneumonia in elderly patients

Objective@#Discriminating between pulmonary embolism (PE) and pneumonia in the emergency department (ED) is one of the fastidious tasks. Elderly patients are at more risk of PE and pneumonia than younger patients. This study aimed to determine whether the ratio of D-dimer to C-reactive protein (CRP) could be used as an adjunctive method to differentiate between PE and pneumonia in elderly patients. @*Methods@#Medical records of patients visiting the ED diagnosed with PE and pneumonia were examined. Cutoff values of D-dimer (μg/mL) and the ratio of D-dimer to CRP ([μg/mL]/[mg/dL]) of subjects with PE or pneumonia were analyzed. @*Results@#There were a total of 60 patients with PE and 152 patients with pneumonia. In addition, 15 patients had both PE and pneumonia. The cutoff value of D-dimer to differentiate between PE and pneumonia was 4.26 μg/mL (4,260 ng/mL) (area under curve [AUC], 0.861; sensitivity, 80.0%; specificity, 80.3%; 95% confidence interval [CI], 0.805-0.917). The cutoff value of the ratio of D-dimer to CRP to differentiate between PE and pneumonia was 1.24 ([μg/mL]/[mg/dL]) (AUC, 0.919; sensitivity, 84.4%; specificity, 84.2%; 95% CI, 0.878-0.960). @*Conclusion@#The ratio of D-dimer to CRP can be used as an adjunctive method to determine whether a computed tomography pulmonary angiography or a ventilation-perfusion scan can be performed to differentiate between PE and pneumonia in elderly patients.

Revisiting the Bacterial Phylum Composition in Metabolic Diseases Focused on Host Energy Metabolism

Over a hundred billion bacteria are found in human intestines. This has emerged as an environmental factor in metabolic diseases, such as obesity and related diseases. The majority of these bacteria belong to two dominant phyla, Bacteroidetes and Firmicutes.Since the ratio of Firmicutes to Bacteroidetes increases in people with obesity and in various animal models, it has been assumed that phylum composition causes the increase in occurrence of metabolic diseases over the past decade. However, this assumption has been challenged by recent studies that have found even an opposite association of phylum composition within metabolic diseases. Moreover, the gut microbiota affects host energy metabolism in various ways including production of metabolites and interaction with host intestinal cells to regulate signaling pathways that affect energy metabolism. However, the direct effect of gut bacteria on host energy intake, such as energy consumption by the bacteria itself and its effects on intestinal energy absorption, has been underestimated. This review aims to discuss whether increased ratio of Firmicutes to Bacteroidetes is associated with the development of metabolic diseases, and whether energy competition between the bacteria and host is a missing part of the mechanism linking gut microbiota to metabolic diseases.

Comparative analysis of suicide attempt deaths and suicide survivors at one university hospital

Objective@#This study analyzed the characteristics of people who attempted suicide that resulted in deaths as compared to that of the suicide survivors. @*Methods@#This study included 799 suicide attempts that occurred from March 1, 2015, to March 31, 2019 at the emergency department of the university hospital in a city of around 300,000 people. Suicide attempts were classified into the survivor and death groups, and the characteristics of each group were compared. The suicide deaths due to re-attempts were also analyzed. @*Results@#There were more males than females in the death groups. There was a high proportion of people aged 50 or older in the death groups. Hanging, carbon monoxide poisoning, and jumping from great heights were the most commonly used methods of suicide in the death groups. In the selected death group, psychiatric symptom, physical illness, and economic problem among the suicidal causes and depressive disorder among the psychiatric diagnoses were factors that increase the risk of suicide death. Sixty-three point four percent of the survival groups and 52.5% of the selected deaths had not received psychiatric care. On the analysis of suicide deaths due to re-attempts, the average number of suicide attempts was 2.45±0.9. The time from the first suicide attempt to the last suicide attempt was 13.8±10.4 months. @*Conclusion@#If it is necessary to make a treatment decision for a suicide attempt in a limited time, such as the case of treating a suicide attempter who visits an emergency department, it is necessary to consider the characteristic factors of the death attempts of suicidal people.

The pre-hospital analysis of intentional taking poison in Gangwon-do

Objective@#This study examined the characteristics of the patients taking poison intentionally at the pre-hospital stage to prevent it at the community level. @*Methods@#We retrospectively reviewed the data that had been reported to fire stations from January 2017 to December 2018. This data included sex, age, occupation, the season of the year, time, place, methods, alcohol ingestion, transferred to the hospital or not, and we examined how taking poison had an effect on the suicide success rate. @*Results@#The subjects were a total of 1,356 patients who had been reported to fire stations due to intentionally taking poison. Forty-five point five percent of them were male, and 54.5% were female. The most common method of intentional taking poison was sedatives (58.3%), followed by pesticides (24.6%), antidepressants (19.0%), and other methods (12.6%). The home place was preferred more than any other places. The suicide success rate was 2.1% in males and 1.4% in females. For the age groups, those patients 40-64 years old tried taking poison much more than the other age groups. In the aspect of the season of the year, summer was the highest season for taking poison, at 30.3%. The daytime was more preferred than the night time. @*Conclusion@#In this study, we analyzed the characteristics of the pre-hospital intentional poisoning cases according to gender, age, occupation, season of the year, time, and between the transferred and the untransferred groups. Efforts should be made in cooperation with the community to prevent suicide attempts by intentionally taking poison.

Revisiting the Bacterial Phylum Composition in Metabolic Diseases Focused on Host Energy Metabolism

Over a hundred billion bacteria are found in human intestines. This has emerged as an environmental factor in metabolic diseases, such as obesity and related diseases. The majority of these bacteria belong to two dominant phyla, Bacteroidetes and Firmicutes. Since the ratio of Firmicutes to Bacteroidetes increases in people with obesity and in various animal models, it has been assumed that phylum composition causes the increase in occurrence of metabolic diseases over the past decade. However, this assumption has been challenged by recent studies that have found even an opposite association of phylum composition within metabolic diseases. Moreover, the gut microbiota affects host energy metabolism in various ways including production of metabolites and interaction with host intestinal cells to regulate signaling pathways that affect energy metabolism. However, the direct effect of gut bacteria on host energy intake, such as energy consumption by the bacteria itself and its effects on intestinal energy absorption, has been underestimated. This review aims to discuss whether increased ratio of Firmicutes to Bacteroidetes is associated with the development of metabolic diseases, and whether energy competition between the bacteria and host is a missing part of the mechanism linking gut microbiota to metabolic diseases.

Plasma CRABP2 as a Novel Biomarker in Patients with Non-Small Cell Lung Cancer

BACKGROUND: Lung cancer is the most common cause of cancer-related mortality worldwide. We previously reported the identification of a new genetic marker, cellular retinoic acid binding protein 2 (CRABP2), in lung cancer tissues. The aim of this study was to assess plasma levels of CRABP2 from patients with non-small cell lung cancer (NSCLC). METHODS: Blood samples that were collected from 122 patients with NSCLC between September 2009 and September 2013 were selected for the analysis, along with samples from age- (± 5 years), sex-, and cigarette smoking history (± 10 pack-years [PY])-matched controls from the Korea Biobank Network. The control specimens were from patients who were without malignancies or pulmonary diseases. We measured plasma levels of CRABP2 using commercially available enzyme-linked immunosorbent assay kits. RESULTS: The mean age of the NSCLC patients was 71.8 ± 8.9 years, and the median cigarette smoking history was 32 PY (range, 0–150 PY). Plasma CRABP2 levels were significantly higher in patients with NSCLC than in the matched controls (37.63 ± 28.71 ng/mL vs. 24.09 ± 21.09 ng/mL, P < 0.001). Higher plasma CRABP2 levels were also correlated with lower survival rates in NSCLC patients (P = 0.014). CONCLUSION: Plasma CRABP2 levels might be a novel diagnostic and prognostic marker in NSCLC.

Primary Aortoesophageal Fistula Presented as Massive Upper Gastrointestinal Bleeding

An aortoesophageal fistula is one of the very few causes of upper gastrointestinal bleeding but can be fatal if the diagnosis is delayed. This usually occurs secondary to esophageal or aortic surgery. A primary aortoesophageal fistula is rare and less likely to be suspected. Here, we present a case of a primary aortoesophageal fistula that presented as massive upper gastrointestinal bleeding. An 81-year-old man with a history of aortic aneurysm had syncope and bright color hematemesis. The aortoesophageal fistula was not diagnosed early enough and the patient died. Therefore, emergency physicians should consider aortoesophageal fistula as a potential cause when encountering upper gastrointestinal bleeding.

What factors determine the need for lumbar puncture in patients with fever and headache?

<p><b>INTRODUCTION</b>We performed this study to find clinical features and laboratory parameters that could facilitate the process of selecting patients who should receive lumbar punctures from among those who present with headache and fever.</p><p><b>METHODS</b>We selected patients aged ≥ 16 years who presented to and received lumbar puncture in the emergency department of Kangwon National University Hospital, South Korea, between 2011 and 2013. Patients who received lumbar punctures were divided into two groups - those who were diagnosed with viral meningitis and those who were not. We compared the clinical features and laboratory data between the two groups. Key indices were then used to develop a scoring system to diagnose viral meningitis in patients and identify those who should receive lumbar punctures.</p><p><b>RESULTS</b>Among the patients who were included in the study, 42 had viral meningitis and 96 did not. The variables of C-reactive protein level ≤ 1.291 mg/dL, neck stiffness and vomiting were assigned 3 points, 2 points and 1 point, respectively, in the scoring system. Overall scores ≥ 4 yielded a positive likelihood ratio of 7.79 (sensitivity 0.600, specificity 0.923), while negative likelihood ratio decreased to less than 0.1 (0.072) for overall scores < 3.</p><p><b>CONCLUSION</b>Using the proposed scoring system, we were able to determine the likelihood of viral meningitis in patients presenting with fever and headache, and to successfully identify those who should receive lumbar punctures.</p>

Cerebral and Coronary Air Embolism after Percutaneous Needle Aspiration Biopsy of Lung

Percutaneous needle aspiration biopsy is a relatively simple and safe procedure for the diagnosis of lung and mediastinal lesions. Systemic air embolism during and after percutaneous needle aspiration biopsy of the lung is very rare; however, it is still a complication that can cause fatal outcomes, such as cerebral infarction and myocardial infarction. Here, we report a 72-year-old woman who suffered a change in consciousness immediately after receiving a percutaneous needle aspiration biopsy for the pathologic examination of pulmonary nodules found during a routine health medical examination. She had left side weakness and ST segment elevation on an electrocardiogram. After a high concentration of oxygen, she recovered from neurological symptoms and electrocardiographic abnormalities. The authors report a case of air embolism occurring simultaneously in the brain and coronary arteries after percutaneous needle aspiration biopsy.

A Case of Primary Palmoplantar Kaposi Sarcoma: An Unusual Presentation

No abstract available.

The efficacy of low-dose transdermal fentanyl in opioid-naive cancer patients with moderate-to-severe pain

BACKGROUND/AIMS: Little is known about the efficacy of low-dose transdermal fentanyl (TDF) patches in opioid-naive patients with moderate-to-severe cancer pain. METHODS: This study had an open-label, prospective design, and was conducted between April 2007 and February 2009 in seven tertiary cancer hospitals; 98 patients were enrolled. TDF was started using a low-dose formulation (12.5 microg/hr), and the dose was adjusted according to the clinical situation of individual patients. Pain intensity, the TDF doses used, and adverse events (AEs) were monitored over 4 weeks. Data were analyzed using the intent-to-treat and per-protocol principles. RESULTS: Of the 98 patients enrolled, 64 (65%) completed the study. The median pain intensity decreased from 6.0 to 3.0 (p < 0.001) at the follow-up visit. The efficacy of low-dose TDF on pain relief was consistent across groups separated according to gender (p < 0.001), age (p < 0.001), metastasis (p < 0.001), previous treatment (p < 0.001), and baseline pain intensity (p < 0.001). The decrease in pain intensity was significantly greater in the severe group compared with the moderate group (mean +/- SD, 5.10 +/- 2.48 vs. 2.48 +/- 1.56; p < 0.001). TDF dose (27.8 microg/hr vs. 24.8 microg/hr, p = 0.423) and the mean treatment time (7.5 days vs. 7.9 days, p = 0.740) required for pain control were not different between the two pain-intensity groups. Patients had AEs of only mild or moderate intensity; among these, nausea (38%) was the most common, followed by vomiting (22%) and somnolence (22%). CONCLUSIONS: Low-dose TDF was an effective treatment for patients with cancer pain of moderate-to-severe intensity. Further randomized trials assessing the efficacy of TDF for severe pain and/or optimal starting doses are warranted.

The potential mechanism of the detrimental effect of defibrillation prior to cardiopulmonary resuscitation in prolonged cardiac arrest model / 한국실험동물학회지

Defibrillation is no longer universally recommended as initial intervention for the reversal of ventricular fibrillation (VF) after a prolonged and untreated cardiac arrest. We sought to examine this issue in an animal model where a prolonged untreated VF was induced. The aim of this study was to investigate the potential mechanism of the detrimental effect of defibrillation prior to cardiopulmonary resuscitation (CPR) in prolonged cardiac arrest model. VF was electrically induced in 32 domestic male swine weighing 40+/-3 kg and remained untreated for 15 minutes. The animals were then randomly allocated to either the initial defibrillation group or the chest compression group. Mean aortic pressure, right atrial pressure and coronary perfusion pressure (CPP) were continuously measured during the performance. The dimensions of the left ventricle (LV) were assessed by echocardiographic methods. The CPP induced by CPR after defibrillation was significantly lower in the initial defibrillation group than in the chest compression group; 1 minute after defibrillation (9+/-3 mmHg vs. 14.8+/-7 mmHg (P<0.05)), and after 5 minutes 16+/-5 mmHg vs. 21.7+/-1 mmHg (P<0.05). The LV volumes were reduced from 18+/-2 mmHg to 14+/-1 mmHg after defibrillation (P<0.05). In brief, this study showed that the conducting defibrillation prior to chest compression may cause a contracture of the LV, resulting in lowering CPP, thus dropping the efficiency of chest compression in a prolonged cardiac arrest model.

The Study of the Changes of Chest Wall Shape and Chest Compression Site According to Increasing Age

PURPOSE: The objective of this study is to investigate changes of chest wall shape and chest compression site according to increasing age. METHODS: This study is based on 99 patients who underwent chest computed tomography (CT) scans, and classified them into six groups according to age, from 30's to 80's. Using images of sagittal and coronal sections of chest CT scans, we found the chest compression site, which is in the lower half point of the sternal body. We calculated the vertical length to the left ventricular outflow tract and to the center of the left ventricle from the lower half point of the sternal body. We also estimated the antero-posterior (AP) diameters of the lower half region of the chest to determine how the shape of the chest changes according to increasing age. In addition, we calculated the horizontal length between the surface of the chest and center of the left ventricle. Data are classified and estimated according to age group. RESULTS: The AP diameter at the compression site was not significantly changed according to increasing age. The vertical length from the compression site to the center of the left ventricle and left ventricular outflow tract was significantly changed according to increasing age. The depth between surface of body and center of left ventricle was not significantly changed according to increasing age. CONCLUSION: There is a tendency where the position of the left ventricular outflow tract and center of the left ventricle show lower positioning according to increasing age. AP diameter at the compression point was not significantly changed according to increasing age.

Chemical Pneumonitis due to Exposure to Waterproofing Spray Containing Perfluoroalkyl Acrylate Copolymer

Waterproofing spray is used to ensure that clothing, including mountain wear, leather, and other surfaces are waterproof. Respiratory illnesses related to the use of waterproofing spray have been reported globally. The composition of waterproofing spray varies depending on the manufacturer. We treated a patient with chemical pneumonitis and alveolar hemorrhage due to exposure to waterproofing spray containing perfluoroalkyl acrylate copolymer. We diagnosed the patient with chemical pneumonitis and alveolar hemorrhage based on computed tomography (CT) and bronchoalveolar lavage (BAL) test performed within 24 h after symptom occurrence. We believe that further study regarding the exact mechanism of pulmonary toxicity for waterproofing agents is required.

Interstitial Pneumonitis after Treatment with Pemetrexed for Non-small Cell Lung Cancer / Journal of the Korean Cancer Association, 대한암학회지

Pemetrexed is approved as a first-line treatment for advanced non-squamous non-small cell lung cancer (NSCLC) with cisplatin and as a single agent for second-line treatment or for patients who show no disease progression after four cycles of platinum-based doublet induction chemotherapy as maintenance therapy. Pemetrexed has a modest toxicity profile and has not traditionally been regarded as a cause of interstitial pneumonitis. Here, we report on a rare case of pemetrexed-induced pneumonitis in a patient with NSCLC.

Efficacy and feasibility of gemcitabine and carboplatin as first-line chemotherapy in elderly patients with advanced non-small cell lung cancer / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Although platinum-based chemotherapy is a standard first-line treatment in advanced non-small cell lung cancer (NSCLC), further research for the safety and efficacy of combination chemotherapy in elderly patients has been required. The purpose of this study was to evaluate the efficacy and safety of gemcitabine and carboplatin as first-line treatment in elderly patients with advanced NSCLC and to evaluate the prognostic factors.</p><p><b>METHODS</b>Eligibility included: (1) age of 70 years or more, (2) histologically confirmed NSCLC, (3) chemotherapy-naïve, (4) advanced disease with stage IIIB or IV, (5) Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0-2, (6) adequate organ function. Patients received intravenous carboplatin (area under curve (AUC) = 5) on day 1 and gemcitabine (1000 mg/m2) on days 1 and 8, every 3 weeks.</p><p><b>RESULTS</b>The medical records of forty patients were reviewed retrospectively. Median age was 73.9 years (range, 70-84.6), and there were 27 men (67.5%). Thirty-seven patients (92.5%) had ECOG PS 0-1. Adenocarcinoma was found in 57.5%. Median cycles were administrated with 4.5 per person (range: 1-6). Best responses were partial response in 22 (55.0%) patients and stable disease (SD) in 13 (32.5%). The median progression free survival (PFS) and overall survival (OS) were 5.9 months (95% CI: 4.5-7.3 months) and 9.6 months (95% CI: 8.2-11.0 months), respectively. Grade 4 hematologic toxicities for neutropenia (7.5%), thrombocytopenia (7.5%) and anemia (5.0%) were observed. Histology was significant prognostic factor for PFS (P = 0.024).</p><p><b>CONCLUSION</b>Gemcitabine and carboplatin combination chemotherapy is an effective and manageable treatment option in elderly advanced NSCLC patients with good performance status.</p>

Four Cases of Phytolacca Esculenta Van Houtte Intoxication due to Misidentification as a Ginseng

Poisoning by Phytolacca esculenta commonly occurs by misidentification as other edible plants. The root of Phytolacca esculenta is similar to other roots, such as kudzu, balloon flower, codonopsis lanceolata, and ginseng. The author experienced four cases of Phytolacca esculenta intoxication due to misidentification as a ginseng. We report on these cases with a review of the literature.

Three Cases with Manic Symptoms and Cognitive Dysfunction after Wild Plant Ingestion

Distinguishing wild plants in spring from ingestible plants is difficult. Differentiation of budding plants from other plants is particularly difficult. Many people want to find edible plants for health during the spring season. Scopolia japonica can cause symptoms of mania. The author experienced three cases of poisoning by Scopolia japonica. We reported on the cases with literature reviews.

A Case of Multi-Organ Macronodular Tuberculosis / 결핵및호흡기질환

A 37 year old female presented with epigastric pain and weight loss over a period of 3 months. Her abdominal CT finding showed a 4.5 cm size hepatic mass and 4.3 cm size pancreatic head mass with multiple macronodules in the liver. At the same time, her chest CT revealed a 5 cm size necrotic mass in the left lower lobe of the lung with multiple bilateral pulmonary nodules. We diagnosed these lesions as tuberculosis through multiple biopsies. She was treated with anti-tuberculous medication. After taking the medications, her symptoms were improved. Twelve months later, imaging studies indicated an improvement in the patient's health. Here we report a case report of multi-organ macronodular tuberculosis in lung, liver and pancreas.

A Case of Prolonged Coagulopathy in a Patient Intoxicated with Superwarfarin Rodenticide

Superwarfarin, such as brodifacoum, is a highly lethal vitamin K antagonist used as a rodenticide. Brodifacoum has a particularly long half-life in the body, which ranges to several months, and therefore requires prolonged treatment with antidotal vitamin K. We experienced a case whereby an 18-year-old male was presented to the hospital with a severe bleeding disorder. It was discovered that he had ingested brodifacoum rodenticide with intent to commit suicide. Despite continual treatment with vitamin K, the bleeding disorder persisted for several months before he recovered. We report this case with literature review.