Clinical factors distinguishing renal infarction from acute pyelonephritis: A randomly matched retrospective case-control study.

INTRODUCTION: Renal infarction (RI) is rare but clinically important because the appropriate treatment depends on the time of diagnosis. RI is often misdiagnosed as acute pyelonephritis (APN) because both diseases have nonspecific symptoms such as flank pain and abdominal pain. We identified predictors for distinguishing RI from APN. METHODS: The data of patients visited the emergency department and diagnosed with RI or APN from March 2016 to May 2020 were prospectively collected and retrospectively analyzed. Patients aged under 18 years, with a history of trauma, or incomplete medical records were excluded. Using a matching ratio of 1:5, RI patients were randomly matched to APN patients. Multivariable logistic regression analysis was performed to identify factors that could distinguish RI from APN. In addition, we constructed a decision tree to identify patterns of risk factors and develop prediction algorithms. RESULTS: The RI and APN groups included 55 and 275 patients, respectively. Multivariable logistic regression analysis showed that male sex (OR, 6.161; p = 0.009), atrial fibrillation (AF) (OR, 14.303; p = 0.021), costovertebral angle tenderness (CVAT) (OR, 0.106; p < 0.001), aspartate transaminase (AST) level > 21.50 U/L (OR, 19.820; p < 0.001), C-reactive protein (CRP) level < 19.75 mg/L (OR, 10.167; p < 0.001), and pyuria (OR, 0.037; p < 0.001) were significantly associated with RI distinguishing from APN. CONCLUSION: Male sex, AF, no CVAT, AST level > 21.50 U/L, CRP level < 19.75 mg/L, and no pyuria were significant factors that could distinguish RI from APN.

SYMPATHETIC NERVE ENTRAPMENT POINT INJECTION AS AN ADJUVANT TREATMENT FOR INTRACTABLE CLUSTER HEADACHE: A CASE REPORT.

BACKGROUND: Cluster headache (CH) is characterized by severe unilateral pain ranging from the orbital to the temporal regions with ipsilateral autonomic manifestations. Although most patients respond to drugs or oxygen inhalation, some do not. In this case report, we introduce sympathetic nerve entrapment point injection (SNEPI), a new adjuvant treatment for CH. CASE REPORT: We introduce two CH patients who did not respond well to pharmacological treatment or 100% oxygen inhalation, but who improved after SNEPI. Patient 1, a 42-year-old man, visited the Emergency Department (ED) with severe periorbital right frontal headache accompanied by ipsilateral rhinorrhea, conjunctival injection, and eyelid edema. The symptoms did not fully respond to drugs or oxygen inhalation, but improved after SNEPI into the tender point of the splenius capitis (SC) muscle; there was no further pain for 1 month thereafter. Patient 2, a 26-year-old woman, presented to the ED complaining of severe headache in the right supraorbital-temporal-occipital region with ipsilateral lacrimation and conjunctival congestion. The patient was taking various drugs for CH, but there was no improvement; the symptoms improved dramatically after SNEPI into the tender points of the SC and paraspinal deep muscles (levels T1-2), and the pain was well managed with reduced drug doses for 3 months. Why Should an Emergency Physician Be Aware of This? CH can cause severe acute pain, and sometimes pharmacological treatment or oxygen inhalation is not effective. SNEPI, which is inexpensive and can be easily performed, may be considered as an adjuvant treatment for intractable CH in the ED.

Factors Associated with Neuroimaging Abnormalities in Children with Afebrile Seizure: A Retrospective Multicenter Study.

INTRODUCTION: Neuroimaging is recommended for patients with seizures to identify intracranial pathology. However, emergency physicians should consider the risks and benefits of neuroimaging in pediatric patients because of their need for sedation and greater sensitivity to radiation than adults. The purpose of this study was to identify associated factors of neuroimaging abnormalities in pediatric patients experiencing their first afebrile seizure. METHODS: This was a retrospective, multicenter study that included children who presented to the emergency departments (ED) of three hospitals due to afebrile seizures between January 2018-December 2020. We excluded children with a history of seizure or acute trauma and those with incomplete medical records. A single protocol was followed in the three EDs for all pediatric patients experiencing their first afebrile seizure. We performed multivariable logistic regression analysis to identify factors associated with neuroimaging abnormalities. RESULTS: In total, 323 pediatric patients fulfilled the study criteria, and neuroimaging abnormalities were observed in 95 patients (29.4%). Multivariable logistic regression analysis showed that Todd's paralysis (odds ratio [OR] 3.72, 95% confidence interval [CI] 1.03-13.36; P=0.04), absence of poor oral intake (POI) (OR 0.21, 95% CI 0.05-0.98; P=0.05), lactic acidosis (OR 1.16, 95% CI 1.04-1.30; P=0.01), and higher level of bilirubin (OR 3.33, 95% CI 1.11-9.95; P=0.03) were significantly associated with neuroimaging abnormalities. Based on these results, we constructed a nomogram to predict the probability of brain imaging abnormalities. CONCLUSION: Todd's paralysis, absence of POI, and higher levels of lactic acid and bilirubin were associated factors of neuroimaging abnormalities in pediatric patients with afebrile seizure.

Predictors for Distinguishing Renal Infarction From Urolithiasis in the Emergency Department: A Randomly Matched Retrospective Case-Control Study.

BACKGROUND: Emergency department (ED) clinicians may misdiagnose renal infarction (RI) as urolithiasis because RI is a rare disease with presenting symptoms similar to the symptoms of urolithiasis. However, earlier diagnosis of RI can improve patient prognosis. OBJECTIVES: We investigated potential predictors for distinguishing RI from urolithiasis based on clinical findings and laboratory results. METHODS: This randomly matched retrospective case-control study included patients who had been diagnosed with acute RI or acute urolithiasis between January 2016 and March 2020. Patients were excluded if they were aged under 18 years, had a history of trauma, or had incomplete medical records. Using a matching ratio of 1:4, RI patients were randomly matched to urolithiasis patients. Multivariable logistic regression was performed to identify factors that could distinguish RI from urolithiasis. RESULTS: In total, 48 patients were included in the RI group and 192 patients were included in the urolithiasis group. Multivariable logistic regression showed that age ≥ 65 years (odds ratio [OR] 6.155; p = 0.022), atrial fibrillation (OR 18.472; p = 0.045), current smoking (OR 17.070; p = 0.001), costovertebral angle tenderness (OR 0.179; p = 0.037), aspartate aminotransferase level ≥ 27.5 U/L (OR 6.932; p = 0.009), sodium level ≥ 138.5 mEq/L (OR 0.079; p = 0.004), and hematuria (OR 0.042; p = 0.001) were significant predictors that could distinguish RI from urolithiasis. Based on these results, a nomogram was constructed. CONCLUSION: Age ≥ 65 years, atrial fibrillation, current smoking, absence of costovertebral angle tenderness, aspartate aminotransferase level ≥ 27.5 U/L, sodium level < 138.5 mEq/L, and absence of hematuria were predictors that can distinguish between RI and urolithiasis.

Fracture of an Intravenous Cannula in the Hand: A Case Report.

BACKGROUND: Intravenous cannula insertion is important, given that it is the most common invasive procedure in the emergency department for blood sampling, fluid resuscitation, and intravenous drug administration. Complications of intravenous catheterization include pain, phlebitis, extravasation, inflammation, and embolization. Fracture of an intravenous cannula is rare, but delayed removal may result in secondary damage, such as vasculitis or embolization, with critical consequences. Here, we report a case of intravenous cannula fracture that occurred in our emergency department. CASE PRESENTATION: A 63-year-old woman with a history of left ovarian cancer visited our emergency department owing to poor oral intake and general weakness. Intravenous catheterization using an 18 gauge cannula was attempted for intravenous fluid administration by a skilled operator, but it failed owing to collapsed veins and poor skin condition. After several attempts, a vein in the patient's hand was ruptured, and the patient complained of severe pain. The cannula was removed, but one-third of the cannula tip could not be seen. X-ray imaging was performed to locate the fragment of the cannula, and venotomy was performed for removal of the foreign body in the emergency department. CONCLUSION: Emergency physicians and nurses should be vigilant about potential risk factors that can cause fracture of an intravenous cannula, and after the fracture is discovered, rapid removal of the cannula tip should be performed in the emergency department.

Risk of Epilepsy in Children Presenting to Emergency Departments with Their First Afebrile Seizure: A Retrospective Multicenter Study.

Seizure is one of the most common neurologic disorders in pediatric emergency department visits. Early detection of epilepsy development in children with afebrile seizures is important. We identified predictors of epilepsy development in children with their first afebrile seizure. In this retrospective multicenter study, we enrolled pediatric patients aged 1 month to 18 years who presented with afebrile seizures at the emergency department from January 2017 to December 2020. Multivariable logistic regression analysis was performed to identify factors associated with epilepsy development. A total of 417 pediatric patients were enrolled, 161 (38.6%) of whom developed epilepsy. From the multivariable logistic regression analysis, older age at onset (2−5 years, odds ratio [OR] 2.611, p = 0.010; 11−15 years, OR 3.138, p = 0.003; 16−18 years, OR 4.292, p = 0.002), longer seizure duration of more than 10 min (OR 4.869, p = 0.006), two or more seizures (OR 2.378, p = 0.004), lethargy (OR 2.341, p = 0.021), and a lactate level > 2.27 mg/dL (OR 4.205, p < 0.001) were significant predictors for the development of epilepsy in children experiencing their first afebrile seizure.

Predictors of renal infarction in patients presenting to the emergency department with flank pain: A retrospective observational study.

OBJECTIVES: Flank pain is a common symptom in the emergency department and can be caused by a variety of diseases. Renal infarction (RI) is a very rare disease, and many RI patients complain of flank pain. However, there is no definitive predictor of RI when patients complain of flank pain. This study aimed to identify the clinical factors for predicting RI in patients with flank pain. METHODS: This retrospective single-center study was conducted on patients complaining of flank pain from January 2016 to March 2020 at a South Korean tertiary care hospital. Exclusion criteria included patients who did not undergo contrast-enhanced computed tomography, age < 18 years, and trauma. Demographic and laboratory data were obtained from medical records. Logistic regression analysis was conducted to identify predictors of RI occurrence. RESULTS: In all, 2,131 patients were enrolled, and 39 (1.8%) had RI. From a multivariable logistic regression analysis, an age ≥ 65 years (odds ratio [OR], 3.249; 95% confidence interval [CI], 1.366-7.725; p = 0.008), male sex (OR, 2.846; 95% CI, 1.190-6.808; p = 0.019), atrial fibrillation (OR, 10.386; 95% CI, 3.724-28.961; p < 0.001), current smoker (OR, 10.022; 95% CI, 4.565-22.001; p < 0.001), and no hematuria (OR, 0.267; 95% CI, 0.114-0.628; p = 0.002) were significantly associated with the occurrence of RI. CONCLUSIONS: Five clinical factors, i.e., age ≥ 65 years, male sex, atrial fibrillation, current smoker, and no hematuria, were significantly associated with the occurrence of RI in patients with flank pain.

Predictors of seizure recurrence in emergency department pediatric patients with first-onset afebrile seizure: A retrospective observational study.

INTRODUCTION: The primary goals of emergency department (ED) clinicians when dealing with a pediatric patient experiencing a seizure are to control the seizure and prevent seizure-related complications. After stabilizing the patient, the clinician should determine whether the patient is likely to have recurrent seizures that may need treatment such as antiepileptic drugs (AEDs). The early identification of pediatric seizure patients at high risk for recurrence can be of great help in consulting with their parents. This study aimed to identify predictors of seizure recurrence in pediatric patients who visited the ED for first-onset afebrile seizure. METHODS: This retrospective study was conducted with pediatric patients aged 1 month to 18 years who visited our ED for afebrile seizure from January 2016 to March 2020. Children with a known seizure disorder, known underlying genetic or metabolic disorder, or acute trauma history, and those lost to follow-up were excluded. Multivariable logistic regression analysis was performed to identify factors associated with seizure recurrence. RESULTS: A total of 253 pediatric patients were included in the study. Seizure recurrence was observed in 117 patients (46.3%). From the multivariable logistic regression analysis, older age at onset (11-15 years, odds ratio [OR] 5.781, p = 0.001; 16-18 years, OR 6.223, p = 0.002), a longer seizure duration (1-5 min, OR 3.043, p = 0.002; 6-10 min, OR 5.629, p = 0.002; >10 min, OR 8.882, p = 0.002), blood pH under 7.2 (OR 8.308, p = 0.015), and a glucose level over 144 mg/dL (OR 6.408, p = 0.030) were significantly associated with seizure recurrence. The area under the receiver operating characteristic curve for the multivariable logistic regression analysis was 0.774. CONCLUSION: Age at onset ≥11 years, a longer seizure duration, acidosis, and hyperglycemia were predictors of seizure recurrence in children who had experienced first-onset afebrile seizure.