Identifying the optimal hand placement site for chest compression by measuring hand width and sternal length in young adults.

OBJECTIVE: There are no specific guidelines regarding the exact hand placement location for effective chest compressions. This study was designed to identify the optimal hand placement site over the chest during cardiopulmonary resuscitation (CPR). METHODS: The sternal length (SL) of young Korean adults was measured as the distance from the suprasternal notch (SN) to the lower end of the sternum. In addition, the heel width of the hand (H) was measured 1 cm (H1) and 2 cm (H2) distal to the proximal end of the carpal bones. RESULTS: A total of 300 men and 300 women were enrolled. SL positively correlated with height (R(2)=14.2), weight (R(2)=15.3), BMI (R(2)=10.3), H1 (R(2) =3.4), and H2 (R(2) = 5.0). Mean H2 and half of the SL (SL/2) for the subgroups were M 8.4 and 10.1 cm, M' 8.3 and 9.7 cm, W 7.6 and 10.1 cm, and W' 7.4 and 9.5 cm, respectively (M, men taller than the mean; M', men shorter than the mean; W, women taller than the mean; W', women shorter than the mean). Mean H2 in men was 1.1 to 1.6 cm shorter than SL/2, whereas mean H2 in women was 2.2 to 2.9 cm shorter than SL/2. CONCLUSIONS: To find the most optimal chest compression point, from the patients' left side, CPR providers need to palpate the SN using the right little finger and placing the left heel one heel width (H2) from the SN. From the patient's right side, CPR providers should use the left little finger to palpate the SN and place the right heel one heel width (H2) from the SN.

Oropharyngeal airway obstruction after the accidental ingestion of Arisaema amurense.

BACKGROUND: Arisaema amurense is widely known in Korean folklore as a poisonous plant, and its lethal toxicity has long been recognized. The toxicity of Arisaema amurense is due to its content of calcium oxalate, which causes painful oropharyngeal edema, hypersalivation, aphonia, oral ulceration, esophageal erosion, and hypocalcemia. OBJECTIVE: We report a case of accidental poisoning after ingestion of the rhizome of Arisaema amurense, resulting in airway obstruction that required endotracheal intubation. CASE REPORT: A 60-year-old man developed oral pain and swelling after accidentally ingesting a rhizome from the Arisaema amurense plant as a medicinal herb. His symptoms worsened upon his arrival in the Emergency Department, and he was unable to speak due to oral swelling and hypersalivation. The patient underwent endotracheal intubation to protect his airway and was treated with antihistamines and corticosteroids. Three days after treatment, he had improved and was extubated. CONCLUSION: We describe an emergent treatment course for a patient with acute airway obstruction resulting from the ingestion of Arisaema amurense.

The effects of incorporating a pneumonia severity index into the admission protocol for community-acquired pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is a common reason for admissions in the emergency department (ED). However, patient disposition is not always standardized. OBJECTIVE: To evaluate the effect of incorporating a pneumonia severity index (PSI) on admission rates and medical costs in CAP patients presenting to the ED. METHODS: From April 2008 to March 2009, CAP patients presenting to the ED were prospectively screened and low-risk CAP patients (PSI I, II, or III) were enrolled (after group). Discharge and outpatient care were recommended for this group in the absence of other medical conditions requiring hospitalization. Data from low-risk CAP patients from May 2003 to October 2006 were also collected for comparative analysis (before group). RESULTS: There were 365 and 174 patients in the before and after groups, respectively. The admission rate of the after group was significantly lower than that of the before group (30.4% vs. 68.2%, p < 0.01). The subsequent admission rates after ED discharge due to CAP were similar (3.2% vs. 7.7%, p = 0.10). The ultimate admission rate in the after group was significantly lower than that in the before group (32.5% vs. 70.7%, p < 0.01). Direct medical costs per patient for the before and after groups were $US 1532 and $US 1186, respectively (p = 0.03). CONCLUSIONS: Incorporation of the PSI into the admission protocol for ED patients with CAP significantly reduced the admission rates and medical costs.

Transmission of hepatitis C virus by occupational percutaneous injuries in South Korea.

Korea is an endemic area of hepatitis. Hepatitis C virus (HCV) infections caused by occupational percutaneous injuries are a serious problem for healthcare workers and there has been a gradual increase in the number of HCV infections. We therefore determined the transmission rate of HCV after occupational percutaneous injury. This was a retrospective cohort study reviewing all occupational blood exposure reports made between January 1, 2004, and December 31, 2008, at a university-affiliated acute care hospital. Over the 5-year study period, there were 1,516 accidents of occupational exposure to blood; of these, 327 (21.6%) were to the blood of HCV-infected patients and 3 (0.9%) healthcare workers became infected with HCV (95% CI 0.6-8.8). In Korea, although the bloodborne accidents leading to exposure to HCV occurred frequently (21.6%), the transmission rate was very low (0.92%).

Deliberate self-poisoning: factors associated with recurrent self-poisoning.

OBJECTIVE: To investigate potential risk factors associated with the repetition of deliberate self-poisoning (DSP). METHODS: Retrospective medical record review of all patients who presented to the emergency department of a tertiary teaching hospital after DSP between January 1, 2000, and December 31, 2009. Repetition of a suicide attempt was determined from reported episodes before the index episode or from 2 visits to the same hospital during the study period. Demographic information, clinical variables, and other variables at the first suicide attempt were investigated for factors associated with repetition of DSP. RESULTS: Of the 967 patients, 203 (21%) presented with repeated suicide attempts. Patients with repeat suicide attempts differed in sex, occupation, living condition, method of DSP, history of psychiatric treatment, reversibility, and psychiatric diagnosis. In the multivariate regression analysis, the only reliable associated factors for repeat suicide attempt were sex (P = .001), living condition (P < .001), method of DSP (P < .036), and history of psychiatric treatment (P < .001). CONCLUSION: Early psychological intervention and close observation is required for patients who are female, living without a family, use antidepressants, and have a history of psychiatric treatment.

Risk stratification nomogram for nephropathy after abdominal contrast-enhanced computed tomography.

OBJECTIVES: Abdominal contrast-enhanced computed tomography (A-CECT) is widely used in emergency departments despite the risk of contrast-induced nephropathy. We attempted to develop a risk stratification nomogram for nephropathy in patients receiving emergency A-CECT. METHODS: Seven hundred fifty patients who received emergency A-CECT between August 2003 and January 2007, with available serum creatinine (SCr) measurements before and after A-CECT were included. Nephropathy was defined as either an absolute increase of 0.5 mg/dL or greater (44 µmol/L) or a relative increase of 25% or more in the SCr from baseline. A nomogram was developed based on multivariate logistic regression analysis using clinical variables available before A-CECT. The model was internally validated with a bootstrapping method, and performance was assessed by area under the receiver operating characteristics curve (AUC) and calibration curve. RESULTS: Nephropathy was observed in 34 of 750 patients. A nomogram was developed using age (odds ratio, 1.04 per 1-year increment) and baseline SCr (odds ratio, 2.51 per 1-mg/dL increment) as risk factors. Diagnostic accuracy of the model was fair by bias-corrected calibration plot. The AUC of the model was 0.794 (95% confidence interval, 0.734-0.854), and the AUC with bootstrapping samples of 200 repetitions was 0.794 (95% confidence interval, 0.737-0.851). CONCLUSION: The risk of nephropathy after emergency A-CECT can be individually predicted by internally validated nomogram using clinical variables available before the procedure.

Low-dose diltiazem in atrial fibrillation with rapid ventricular response.

OBJECTIVES: Diltiazem is one of the most commonly used medications to control the rapid ventricular response in atrial fibrillation (AF). The recommended starting dose is an intravenous bolus of 0.25 mg/kg over 2 minutes. To avoid hypotension, we have empirically used a lower dose of diltiazem. We compared the efficacy and safety of different doses of diltiazem in rapid AF. METHODS: A retrospective chart review was undertaken in patients who presented to the emergency department with rapid AF. Patients were divided into 3 groups according to diltiazem dosage: low dose (≤ 0.2 mg/kg), standard dose (> 0.2 and ≤ 0.3 mg/kg), and high dose (> 0.3 mg/kg). We compared the rates of therapeutic response (adequate rate control) and complications (such as hypotension). Multivariate regression analysis was used to determine the effect of diltiazem dose on the occurrence of complications. RESULTS: A total of 180 patients were included in the analysis. There were no significant differences in the rates of therapeutic response for the low-, standard-, and high-dose groups (70.5%, 77.1%, and 77.8%; P = .605). The rates of hypotension in the low-, standard-, and high-dose groups were 18%, 34.9%, and 41.7%, respectively. After adjusting confounding variables, the rate of hypotension was significantly lower in the low-dose group in comparison with the standard-dose group (adjusted odds ratio, 0.39; 95% confidence interval, 0.16-0.94). CONCLUSIONS: Low-dose diltiazem might be as effective as the standard dose in controlling rapid AF and reduce the risk of hypotension.

Heart-type fatty acid binding protein as an adjunct to cardiac troponin-I for the diagnosis of myocardial infarction.

We hypothesized that when used in combination with cardiac troponins, heart-type fatty acid binding protein (H-FABP) would have greater diagnostic value than conventional markers for the early diagnosis of myocardial infarction (MI). Patients with typical chest pain at a single emergency department were consecutively enrolled. Initial blood samples were drawn for H-FABP, myoglobin, creatine kinase isoenzyme MB (CK-MB), and cardiac troponin-I (cTnI) measurements. MI was defined by serial cTnI measurements. To evaluate the adjunctive role of biochemical markers, we derived and compared logistic regression models predicting MI in terms of their discrimination (area under the receiver operating characteristics curve, AUC) and overall fit (Bayesian information criterion, BIC). Seventy-six of 170 patients were diagnosed as having MI. The AUC of cTnI, H-FABP, myoglobin, and CK-MB were 0.863, 0.827, 0.784, and 0.772, respectively. A logistic regression model using cTnI (P = 0.001) and H-FABP (P < 0.001) had the biggest AUC (0.900) and the best fit determined by BIC. Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of this model at 30% probability were 81.6%, 80.9%, 4.26, and 0.23, respectively. H-FABP has a better diagnostic value than both myoglobin and CK-MB as an adjunct to cTnI for the early diagnosis of MI.

The lack of association between age and diabetes and hospitalization in women with acute pyelonephritis.

BACKGROUND: Traditional management of acute pyelonephritis (APN) involves hospitalization and intravenous antibiotics. However, recently issued guidelines recommend that women with mild APN can be treated with oral antibiotics. OBJECTIVES: Many emergency practitioners feel compelled to admit all elderly and diabetic women with APN to the hospital. We explored the association between age and presence of diabetes with hospital admission in women with APN. METHODS: A retrospective chart review was undertaken on women with a diagnosis of APN made in the Emergency Department between May 2003 and December 2005. Exclusion criteria were as follows: pregnancy, immune suppression other than diabetes, urinary stone, septic shock, and hydronephrosis. Standardized chart review was performed and the primary outcome was admission to the hospital. Univariate and multivariate analyses were used to identify factors associated with hospital admission. RESULTS: Of the 388 patients included, 185 (47.7%) were admitted. After adjusting for confounding variables, the odds ratios of admission for those who had been recently hospitalized or had a low serum albumin level or a high C-reactive protein level were 2.10 (95% confidence interval [CI] 1.09-4.02), 1.96 (95% CI 1.09-6.05), and 2.57 (95% CI 1.11-3.46), respectively. Older age and the presence of diabetes were not found to be independently associated with admission. CONCLUSIONS: In women with acute pyelonephritis, an older age and diabetes were not found to be independently associated with hospital admission.

Prognostic value of N-terminal pro-brain natriuretic peptide in hospitalised patients with community-acquired pneumonia.

BACKGROUND: The prognostic role of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with community-acquired pneumonia (CAP) has not been evaluated. The aim of the present study was to investigate whether NT-proBNP level could predict mortality in hospitalised CAP patients. METHODS: We performed a structured medical record review of all hospitalised CAP patients from May 2003 to October 2006, and classified patients into the 30-day survival and non-survival group. Data included demographic and clinical characteristics, and laboratory findings including NT-proBNP levels. The APACHE II scores, PSI (pneumonia severity index) and CURB65 (confusion, urea, respiratory rate, blood pressure and aged 65 or more) scores were calculated. Comparisons between survivors and non-survivors were made with χ(2), non-parametric tests and logistic regression and ROC analysis were used to compare the ability of NT-proBNP (adjusted for age, heart failure and creatinine), APACHE II, PSI and CURB65 to predict mortality. RESULTS: Of 502 patients, 61 (12.2%) died within 30 days. NT-proBNP levels were measured in 167 patients and were significantly higher in non-survivors compared to survivors (median 841.7 (IQR 267.1-3137.3) pg/ml vs 3658.0 (1863.0-7025.0) pg/ml, p=0.019). NT-proBNP was an independent predictor of mortality (adjusted OR 1.53; 95% CI 1.16 to 2.02, p=0.002). The AUC for NT-proBNP was 0.712 (95% CI, 0.613 to 0.812), which was comparable to those of PSI (0.749, p=0.531) and CURB65 (0.698, p=0.693), but inferior to that of APACHE II (0.831, p=0.037). Adding NT-proBNP to APACHE II, PSI and CURB65 did not significantly increase the AUCs, respectively. CONCLUSIONS: NT-proBNP level is an independent predictor of mortality in hospitalised CAP patients. The performance of NT-proBNP level is comparable to those of PSI and CURB65 in predicting mortality.

Effectiveness of mouth-to-mouth ventilation after video self-instruction training in laypersons.

BACKGROUND: Mouth-to-mouth ventilation is a skill taught in cardiopulmonary resuscitation (CPR) training for laypersons. However, its effectiveness is questioned. Our aim was to determine the effectiveness of mouth-to-mouth ventilation training using a self-instruction CPR training video for laypersons. METHODS: Video-self-instruction CPR training was conducted with CPR Anytime (American Heart Association [AHA] & Laerdal Corporation) for laypersons who had not received CPR training during the recent 5 years. Immediately before, immediately after, and 8 weeks after the CPR training, an AHA basic life support instructor carried out a skill performance test using a standardized checklist. Also, 8 weeks after the training, a skill test concerning chest compression and mouth-to-mouth ventilation was conducted using a trained reporter. RESULTS: Cardiopulmonary resuscitation training of 84 laypersons was conducted. The mean performance score (from 0 to 2) for mouth-to-mouth ventilation was 0.24 right before the training, 1.58 right after the training, and 0.95 eight weeks after the training. The mean performance scores for chest compression were 0.13, 1.79, and 1.40, right before, right after, and 8 weeks after the CPR training, respectively. The rates of successful mouth-to-mouth ventilation and compression were 11.9%, and 39.1%, respectively. CONCLUSIONS: The effectiveness and short-term retention rate of mouth-to-mouth ventilation after video self-instruction CPR training in laypersons was significantly lower than for chest compressions.

Induced hypothermia attenuates the acute lung injury in hemorrhagic shock.

BACKGROUND: In previous animal studies, induction of therapeutic hypothermia (HT) in hemorrhagic shock (HS) had beneficial effects on the hemodynamic and metabolic parameters and on the survival. However, the effect of induced HT on acute lung injury (ALI) in HS has not been investigated. We sought to determine the effects of HT on ALI in HS. METHODS: Male Sprague-Dawley rats (350-390 g; n = 8 per group) were randomized to the normothermia (NT; 36-37 degrees C) group or the moderate HT (27-30 degrees C) group and were subjected to volume-controlled (2 mL/100 g weight) HS (90 minutes) followed by 90 minutes of resuscitation. ALI score, lung malondialdehyde content, and myeloperoxidase activity were measured. The expression of glycogen synthase kinase 3beta (GSK-3beta), phosphorylated GSK-3beta, inducible nitric oxide synthase (iNOS), heat shock protein (HSP) 72, and nuclear factor-kappaB (NF-kappaB) in the lung were compared. RESULTS: ALI score, lung malondialdehyde content, and myeloperoxidase were lower in the HT group. GSK-3beta and iNOS gene expressions in lung tissue were significantly decreased in the HT group (p < 0.05). On the contrary, the expression of phosphorylated GSK-3beta was increased in the HT group (p < 0.001). HSP 72 was expressed in the HT group but not in the NT group. The activated p65 NF-kappaB levels in lung nuclear extract were significantly lower in the NT group (p = 0.03). CONCLUSIONS: HT attenuates HS-induced ALI in rats by the modulation of GSK, HSP 72, iNOS, and NF-kappaB.

Predicting change of hemoglobin after transfusion in hemodynamically stable anemic patients in emergency department.

BACKGROUND: To investigate factors associated with change of post-transfusion hemoglobin level, and to derive an equation that predicts post-transfusion changes in hemoglobin levels in hemodynamically stable anemic patients who visited emergency department. METHODS: A retrospective medical record review of patients who were hemodynamically stable and transfused with packed red blood cells was undertaken. Patients were randomly divided into two groups. One group (derivation group, 70% of total patients) was analyzed for factors associated with changes in post-transfusion hemoglobin levels, and linear regression analysis was performed to derive a prediction equation. The derived prediction equation was then externally validated with the other group (validation group, 30% of total patients). RESULTS: A total of 196 patients were enrolled. The 137 patients (70% of total patients) in the derivation group were analyzed for factors associated with changes in post-transfusion hemoglobin. Of those, body surface area and initial hemoglobin level were significantly correlated with changes in post-transfusion hemoglobin levels (p < 0.05). From these variables, linear regression analysis resulted in a prediction equation. The derived equation was validated externally with the 59 patients (30% of total patients) in the validation group and found to have an excellent correlation (r = 0.73, intraclass correlation = 0.84, p < 0.05). CONCLUSIONS: Post-transfusion hemoglobin level in hemodynamically stable adult patients was associated with initial hemoglobin levels and body surface area. These factors must be considered when transfusing hemodynamically stable adult patients with anemia.

The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis.

OBJECTIVE: This study was conducted to compare the diagnostic accuracy for acute appendicitis between emergency medicine residents (EMRs) and surgical residents (SRs). METHODS: We conducted a prospective cohort study of adult patients with right lower quadrant pain. Each patient was evaluated by an EMR and an SR, and physicians predicted the probability of appendicitis into 4 groups from highest (group 1) to lowest (group 4). The diagnostic accuracies of EMR and SR for the diagnosis of appendicitis were compared by constructing receiver operating characteristics curves. In each case, an Alvarado score was calculated and a computed tomography (CT) scan of the abdomen and pelvis was performed, and their diagnostic accuracies were also compared with the predicted probabilities. RESULTS: Of a total 191 patients, 120 underwent surgery, and the negative appendectomy rate was 6.8%. There was a significant correlation between the predicted probabilities of EMR and SR. The areas under the curve for EMR and SR were 0.698 and 0.657, which were not statistically different. The areas under the curve of the Alvarado score and the CT were 0.735 and 0.978, respectively. The diagnostic accuracy of the CT scan was significantly higher than those of the Alvarado score and the resident-predicted probabilities. CONCLUSION: In patients with right lower quadrant abdominal pain who have already been evaluated by EMR, consultation evaluation by SR does not appear to improve clinical diagnostic accuracy, and routine performance of CT before surgical consultation should be considered for these patients.

Comparison of traditional advanced cardiac life support (ACLS) course instruction vs. a scenario-based, performance oriented team instruction (SPOTI) method for Korean paramedic students.

Current Advanced Cardiac Life Support (ACLS) course instruction involves a 2-day course with traditional lectures and limited team interaction. We wish to explore the advantages of a scenario-based performance-oriented team instruction (SPOTI) method to implement core ACLS skills for non-English-speaking international paramedic students. The objective of this study was to determine if scenario-based, performance-oriented team instruction (SPOTI) improves educational outcomes for the ACLS instruction of Korean paramedic students. Thirty Korean paramedic students were randomly selected into two groups. One group of 15 students was taught the traditional ACLS course. The other 15 students were instructed using a SPOTI method. Each group was tested using ACLS megacode examinations endorsed by the American Heart Association. All 30 students passed the ACLS megacode examination. In the traditional ACLS study group an average of 85% of the core skills were met. In the SPOTI study group an average of 93% of the core skills were met. In particular, the SPOTI study group excelled at physical examination skills such as airway opening, assessment of breathing, signs of circulation, and compression rates. In addition, the SPOTI group performed with higher marks on rhythm recognition compared to the traditional group. The traditional group performed with higher marks at providing proper drug dosages compared to the SPOTI students. However, the students enrolled in the SPOTI method resulted in higher megacode core compliance scores compared to students trained in traditional ACLS course instruction. These differences did not achieve statistical significance due to the small sample size.

Traumatic subperiosteal pseudoaneurysm: rare cause of subperiosteal hematoma.

Subperiosteal hematoma arises usually after blunt trauma to the bone. It is due to disinsertion or rupture of a muscle tendon or injury of nutrient artery of bone. Subperiosteal hematoma is a rare condition and develops mainly in the orbit because the periosteum is more loosely attached to the bone. Thus, few cases of subperiosteal hematoma in iliac bone are reported. Traumatic pseudoaneurysm develops mainly after penetrating or blunt trauma. It can be easily diagnosed by intravenous contrast computed tomography or magnetic resonance imaging by seen extravasation of contrast dye. We present a case of subperiosteal hematoma with subperiosteal pseudoaneurysm after blunt pelvic trauma in a 17-year-old adolescent boy. The pseudoaneurysm arose from a branch of superior gluteal artery, but it was not seen in the initial contrast computed tomography scan.

The presentation of 6-mercaptopurine overdose in ED.

6-Mercaptopurine (6-MP), although an effective immunosuppressive when used in the treatment of certain cancers, can have devastating effects when ingested accidentally or used in excessive amounts. We report here the case of an unintentional ingestion of a large amount of 6-MP by a woman with hypothyroidism who was erroneously given this antimetabolic agent by her pharmacist instead the propylthiouracil (PTU) she was actually prescribed. This is one of several documented cases in which 6-MP has been dispensed instead of PTU. Because of the myelosuppressive and hepatotoxic effects of 6-MP, this case reinforces the need for both physicians and patients to understand the importance of examining their medications before ingestion.

National epidemiology of cutaneous abscesses: 1996 to 2005.

OBJECTIVE: Little has been reported regarding the national epidemiology of cutaneous abscesses. We examined the National Hospital Ambulatory Medical Care Survey (NHAMCS) national estimates of all emergency department (ED) visits from 1996 to 2005 to determine the trend and the epidemiology of ED abscess visits. STUDY DESIGN: retrospective analysis of NHAMCS databases for 1996 to 2005 available from the National Center for Health Statistics. SUBJECTS: all patients with a first diagnosis of abscess based on the International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes were selected for analysis. MEASURES: estimated total numbers and percentages of patients by year. ANALYSIS: trends from 1996 through 2005 were examined overall and by demographic factors (eg, age, sex) and abscess characteristics (eg, body region affected). Linear regression was used to evaluate trends. RESULTS: Emergency department visits for abscesses more than doubled over the 10-year study period (1.2 million in 1996 to 3.28 million in 2005; trend, P < .01). The total number of ED visits increased from 90 million to 115 million over the same period, so that abscess visits are increasing faster than overall visits. Although the frequency of abscesses increased, the demographic and clinical characteristics of ED patients were unchanged over time. About half of ED patients with abscess were male, and about half were between the ages of 19 and 45 years. Annual admissions hovered around 12%. The most common abscess sites coded were the leg, ear, and "unspecified site." About 50% received antibiotics. CONCLUSIONS: Emergency department visits for abscesses have shown a large increase since 1996; however, demographic and clinical factors are uniform across years.

New classification and clinical characteristics of reexpansion pulmonary edema after treatment of spontaneous pneumothorax.

OBJECTIVE: Reexpansion pulmonary edema (REPE) is a rare yet sometimes fatal complication associated with the treatment of lung diseases such as pleural effusion, pneumothorax, and hemothorax. The current study summarizes our experience with REPE for a 3-year period. METHODS: We prospectively collected demographic and clinical data on consecutive patients presenting to an academic university-based emergency department with spontaneous pneumothorax that was treated with closed thoracostomy for a 3-year period. RESULTS: Eighty-four study patients were enrolled between December 2002 and September 2005. Reexpansion pulmonary edema developed in 25 of 84 (29.8% [95% confidence interval, 21.0-40.2]) patients. Many cases of REPE were small and asymptomatic and only diagnosed on computed tomography of the chest. There was only one death (1.2% [95% confidence interval, A to B]). Reexpansion pulmonary edema was associated with patients with larger pneumothoraces without fibrotic changes and with patients with hypoxia and fibrotic changes. Classic REPE as seen on chest radiograph was 16 (19.0%) in 84 patients. Diffuse REPE as seen only on computed tomography and involved more than 1 lobe was 1 (1.2%) in 84 patients. Isolated REPE as seen only on computed tomography and limited to lesser than 1 lobe was 8 (9.5%) in 84 patients. CONCLUSIONS: The rate of REPE after tube thoracostomy of spontaneous pneumothorax is greater than previously reported and often asymptomatic. The risk of developing REPE is greater with larger pneumothorax, especially in patients without fibrotic lung changes, and with hypoxia in patients with fibrotic changes.