Comparative and retrospective evaluation of the predictive performance of optic nerve sheath thickness and optic nerve sheath diameter for traumatic brain injury using facial computed tomography.

OBJECTIVE: To evaluate the predictive performance of optic nerve sheath thickness (ONST) on the outcomes of traumatic brain injury (TBI) and to compare the inter-observer agreement To evaluate the predictive performance of optic nerve sheath thickness (ONST) for traumatic brain injury (TBI) and to compare the predictive performance and inter-observer agreement between ONST and optic nerve sheath diameter (ONSD) on facial computed tomography (CT). METHODS: We retrospectively enrolled patients with a history of facial trauma and who underwent both facial CT and brain CT. Two reviewers independently measured ONST and ONSD of each patient using facial CT images. Final brain CT with clinical outcome was used as the reference standard for TBI. Multivariate logistic regression analyses, receiver operating characteristic (ROC) curves, and intraclass correlation coefficients were used for statistical analyses. RESULTS: Both ONST (P=0.002) and ONSD (P=0.001) on facial CT were significantly independent factors to distinguish between TBI and healthy brains; an increase in ONST and ONSD values corresponded with an increase in the risk of TBI by 8.9- and 7.6-fold, respectively. The predictive performances of the ONST (sensitivity, 96.2%; specificity, 94.3%; area under the ROC curve, 0.968) and ONSD (sensitivity, 92.6%; specificity, 90.2%; area under the ROC curve, 0.955) were excellent and exhibited similar sensitivity, specificity, and area under the curve (P=0.18-0.99). Interobserver and intraobserver intraclass correlation coefficients for ONST were significantly higher than those for ONSD (all P<0.001). CONCLUSION: ONST on facial CT is a feasible predictor of TBI and demonstrates similar performance and superior observer agreement than ONSD. We recommend using ONST measurements to assess the need for additional brain CT scans in TBI-suspected cases.

Massive Bleeding From Inferior Mesenteric Vein With Hypovolemic Shock: A Rare Complication of Acute Pancreatitis.

BACKGROUND: Acute pancreatitis may cause massive intra-abdominal bleeding as vascular complications caused by the erosion of a major pancreatic or peripancreatic vessel. In terms of treatment, the differentiation between arterial bleeding and venous bleeding using abdominal computed tomography (CT) angiography is important. In addition, hypovolemic shock caused by bleeding from the inferior mesenteric vein (IMV) in acute pancreatitis has not been reported. CASE REPORT: A 58-year-old man presented to our emergency department with complaints of abdominal pain of 10 hours' duration. The pain had an abrupt onset and started with alcohol consumption. After performing initial laboratory tests and an abdominal CT scan, he was diagnosed with acute pancreatitis. However, he complained of severe abdominal pain and was drowsy 2 h later. Follow-up CT angiography revealed acute necrotizing pancreatitis with massive hemoperitoneum and hypovolemic shock. We also found active bleeding from the IMV. We did not consider emergency catheter angiography with embolization; instead, exploratory laparotomy and hematoma evacuation with IMV ligation was performed. He was discharged without complications 14 days later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Massive bleeding from the IMV accompanied by shock bowel syndrome is a rare complication of acute pancreatitis that can be confused with arterial bleeding. Emergency physicians should consider this diagnosis in acute pancreatitis as a possible cause of hypovolemic shock and anatomic course of the IMV and prevent fulminant shock by administering appropriate treatment.

Air pollutants and atmospheric pressure increased risk of ED visit for spontaneous pneumothorax.

OBJECTIVE: To investigate the impact of short-term exposure to air pollutants and meteorological variation on ED visits for primary spontaneous pneumothorax (PSP). MATERIAL AND METHODS: We retrospectively identified PSP cases that presented at the ED of our tertiary center between January 2015 and September 2016. We classified the days into three types: no PSP day (0 case/day), sporadic days (1-2 cases/day), and cluster days (PSP, ≥3 cases/day). Association between the daily incidence of PSP with air pollutants and meteorological data were determined using Poisson generalized-linear-model to calculate incidence rate ratio (IRRs) and the use of time-series (lag-1 [the cumulative air pollution level on the previous day of PSP], lag-2 [two days ago], and lag-3 [three days ago]). RESULTS: Using multivariate logistic regression analysis, O3 (p = 0.010), NO2 (p = 0.047), particulate matters (PM)10 (p = 0.021), and PM2.5 (p = 0.008) were significant factors of PSP occurrence. When the concentration of O3, NO2, PM10, and PM2.5 were increased, PSP IRRs increased approximately 15, 16, 3, and 5-fold, respectively. With the time-series analyses, atmospheric pressure in lag-3 was significantly lower and in lag-2, was significantly higher in PSP days compared with no PSP days. Among air pollutant concentrations, O3 in lag-1 (p = 0.017) and lag-2 (p = 0.038), NO2 in lag-1 (p = 0.015) and lag-2 (p = 0.009), PM10 in lag-1 (p = 0.012), and PM2.5 in lag-1 (p = 0.021) and lag-2 (p = 0.032) were significantly different between no PSP and PSP days. CONCLUSION: Increased concentrations of air pollutants and abrupt change in atmospheric pressure were significantly associated with increased IRR of PSP.

Intentional cyanoacrylate ingestion: A rare cause of delayed gastric perforation requiring gastric wedge resection.

Cyanoacrylate (LOCTITE® 401™) is a fast-acting adhesive available nationwide, with medical and household uses. Most cases of cyanoacrylate exposure are accidental and occur in children less than 5years old. Various routes of exposure have been reported including the dermal, oral, ocular, otic, nasal, and urethral routes; however, very few result in serious complication and mortality. Although a few cases of airway obstruction related to cyanoacrylate ingestion have been reported, intentional cyanoacrylate ingestion-induced gastrointestinal tract injury has scarcely been reported. In addition, there have been no reports of serious complications following intentional cyanoacrylate ingestion requiring surgical intervention. Herein, we report a case of intentional ingestion of cyanoacrylate in a 70-year-old man who required gastric wedge resection due to delayed gastric perforation.

Taking varenicline for smoking cessation: A rare cause of pulmonary thromboembolism with infarction.

Varenicline (Champix®, Chantix®) is a partial agonist of the α4ß2 nicotinic acetylcholine receptor (nAChR) and a full agonist of the α7 nAChR. It has been used for smoking cessation since 2006. Varenicline has been associated with adverse cardiovascular (CV) events, including myocardial infarction, which may be caused by activation of the α7 nAChR receptor that in turn stimulates parasympathetic output from the brainstem to the heart, release of catecholamines, and has a prothrombotic effect. However, among the adverse CV events, the issue related to the varenicline-induced pulmonary thromboembolism (PTE) has not being addressed. We report a case of PTE with pulmonary infarction presenting as right flank pain that resulted from the use of varenicline (the total score of adverse drug reaction probability scale, 6; probable association between varenicline and pulmonary PTE) in a patient without underlying CV disease and in whom low probability of PTE (Wells score was zero) was identified.

Brain Computed Tomography Compared with Facial 3-Dimensional Computed Tomography for Diagnosis of Facial Fractures.

OBJECTIVES: To compare the detection of facial fractures and radiation dose between brain computed tomography (CT) and facial 3-dimensional (3D) CT in pediatric patients who have experienced a trauma. STUDY DESIGN: Four hundred pediatric patients who experienced a trauma and underwent immediate brain CT and facial 3D CT between January 2016 and June 2016 were included in this retrospective study. Two reviewers independently analyzed and determined the presence of the facial fractures of 8 anatomic regions based on brain CT and facial 3D CT over a 1-week interval. Suggested treatment decisions for facial fractures seen on brain CT and facial 3D CT were evaluated by one physician. The facial 3D CT scans, interpreted by a senior radiologist, were considered as the reference standard. Diagnostic performance, radiation dose, and interobserver agreement of the CT scans were evaluated. RESULTS: Brain CT showed a high sensitivity (94.1%-96.5%), high specificity (99.7%-100%), and high accuracy (98.8%-99.0%) in both reviewers, and performed as well as did facial 3D CT (P ≥ .25). The suggested treatment decision was not different between the brain CT and facial 3D CT findings. The agreements between the reference standard and the reviewers, and between reviewers 1 and 2 were excellent (k = 0.946-0.993). The mean effective radiation doses used in brain CT (3.6 mSv) were significantly lower than those in brain CT with facial 3D CT (5.5 mSv) (P < .001). CONCLUSIONS: Brain CT showed acceptable diagnostic performance and can be used as the first-line imaging tool in the workup of pediatric patients with suspected facial fractures.