Postobstructive pulmonary edema that developed immediately after emergency surgical cricothyroidotomy

Choi, H.L.,Min, J.H.,Kang, J.H.,Kim, H.,Park, J.S. Centrum Philadelphia 2016 The American journal of emergency medicine Vol.34 No.5

A 32-year-old man was presented at our hospital with paroxysmal dyspnea and unconsciousness. At presentation, he was in a coma and showed central cyanosis. We tried endotracheal intubation to ensure appropriate ventilation, but we were unable to intubate owing to swelling in the supraglottic area. We then immediately performed cricothyroidotomy. During the procedure, when the cricothyroid membrane was punctured, a pinkish bubble developed at the puncture site. After securing the patient's airway, we changed our approach from cricothyroidotomy to tracheostomy. A chest radiography showed diffused haziness in both lungs after the procedure. During the follow up, the chest haziness resolved. He was therefore diagnosed with postobstructive pulmonary edema. To the best of our knowledge, till date, there has been no report of postobstructive pulmonary edema that developed immediately after emergency cricothyroidotomy.

Validation of modified early warning score using serum lactate level in community-acquired pneumonia patients. The National Early Warning Score-Lactate score

Jo, S.,Jeong, T.,Lee, J.B.,Jin, Y.,Yoon, J.,Park, B. Centrum Philadelphia 2016 The American journal of emergency medicine Vol.34 No.3

<P>Study objective: The aim of this study was to investigate the prognostic prediction power of a newly introduced early warning score modified by serum lactate level, the National Early Warning Score-Lactate (NEWS-L) score, among community-acquired pneumonia (CAP) patients. We also compared the NEWS-L score with the pneumonia severity index (PSI) and CURB-65. Methods: We designed a retrospective observational study and collected data on confirmed adult CAP patients who visited the study hospital between October 2013 and September 2014. Variables relevant to, the NEWS-L score, PSI, and CURB-65 were extracted from electronic medical records. Survival status at hospital discharge was determined in the same manner. The NEWS-L score was calculated as NEWS-L=NEWS + serum lactate level (mmol/L). The NEWS-L was divided into quartiles. The ability to predict mortality was assessed through area under the receiver operating characteristic curve analysis and calibration analysis. Results: A total of 553 patients were enrolled, and the inpatient mortality rate was 10.8% (n=60). Mortality rates increased incrementally in conjunction with the NEWS-L quartiles: first quartile, 2.2%; second quartile, 7.9%; third quartile, 9.6%; and fourth quartile, 23.9%. The area under the receiver operating characteristic curve of the NEWS-L score was 0.73 (95% confidence interval [CI], 0.66-0.80), which showed no significant difference from that of the PSI (0.68; 95% CI, 0.61-0.76; P=.28) and CURB-65 (0.66; 95% CI, 0.59-0.73; P=.06). Conclusions: The newly introduced early warning score modified by serum lactate level, NEWS-L score, was comparable to PSI and CURB-65, for predicting inpatient mortality among adult CAP patients. (C) 2015 Elsevier Inc. All rights reserved.</P>

2,3-Butanedione monoxime facilitates successful resuscitation in a dose-dependent fashion in a pig model of cardiac arrest

Lee, B.K.,Kim, M.J.,Jeung, K.W.,Choi, S.S.,Park, S.W.,Yun, S.W.,Lee, S.M.,Lee, D.H.,Min, Y.I. Centrum Philadelphia 2016 The American journal of emergency medicine Vol.34 No.6

<P>Purpose: Ischemic contracture compromises the hemodynamic effectiveness of cardiopulmonary resuscitation (CPR) and resuscitability from cardiac arrest. In a pigmodel of cardiac arrest, 2,3-butanedione monoxime (BDM)attenuated ischemic contracture. We investigated the effects of different doses of BDM to determine whether increasing the dose of BDM could improve the hemodynamic effectiveness of CPR further, thus ultimately improving resuscitability. Methods: After 16 minutes of untreated ventricular fibrillation and 8 minutes of basic life support, 36 pigs were divided randomly into 3 groups that received 50mg/kg (low-dose group)of BDM, 100 mg/kg (high-dose group)of BDM, or an equivalent volume of saline (control group)during advanced cardiovascular life support. Results: During advanced cardiovascular life support, the control group showed an increase in left ventricular (LV)wall thickness and a decrease in LV chamber area. In contrast, the BDM-treated groups showed a decrease in the LV wall thickness and an increase in the LV chamber area in a dose-dependent fashion. Mixed-model analyses of the LV wall thickness and LV chamber area revealed significant group effects and group-time interactions. Central venous oxygen saturation at 3 minutes after the drug administration was 21.6% (18.4-31.9), 39.2% (28.8-53.7), and 54.0% (47.5-69.4)in the control, low-dose, and high-dose groups, respectively (P < .001). Sustained restoration of spontaneous circulation was attained in 7 (58.3%), 10 (83.3%), and 12 animals (100%)in the control, low-dose, and high-dose groups, respectively (P=.046). Conclusion: 2,3-Butanedione monoxime administered during CPR attenuated ischemic contracture and improved the resuscitability in a dose-dependent fashion. (C) 2016 Elsevier Inc. All rights reserved.</P>

Diagnostic performance of initial serum lactate for predicting bacteremia in female patients with acute pyelonephritis

Seo, D.Y.,Jo, S.,Lee, J.B.,Jin, Y.H.,Jeong, T.,Yoon, J.,Park, B. Centrum Philadelphia 2016 The American journal of emergency medicine Vol.34 No.8

<P>Objectives: The purpose of the present study was to investigate the diagnostic value of lactate for predicting bacteremia in female patients with acute pyelonephritis (APN). Methods: We conducted a retrospective study of female patients with APN who visited the study hospital emergency department. The demographics, comorbidities, physiologies, and laboratory variables including white blood cell count and segmented neutrophil count, C-reactive protein, and initial serum lactate levels were collected and analyzed to identify associations with the presence of bacteremia. Results: During the study period, a total of 314 patients were enrolled. One hundred twenty-three patients (39.2%) had bacteremia. Escherichia coli was the most frequent pathogen. Logistic regression analysis demonstrated that the lactate level was independently associated with the presence of bacteremia (odds ratio, 1.39 [ 95% confidence interval, 1.08-1.78]). The C-statistic of the lactate level was 0.67 (95% CI, 0.60-0.73). At a cutoff value of 1.4 mmol/L, the lactate level predicted bacteremia with a sensitivity (53.7%), specificity (72.3%), positive predictive value (55.5%), negative predictive value (70.8%), positive likelihood ratio (1.93), and negative likelihood ratio (0.64). Conclusion: The initial serum lactate level showed poor discriminative performance for predicting bacteremia in female patients with APN. (C) 2016 Elsevier Inc. All rights reserved.</P>

Spontaneously resolved STEMI after a hymenoptera sting

Kim, S.W.,Kim, J.H.,Kwon, O.Y. Centrum Philadelphia 2017 The American journal of emergency medicine Vol.35 No.2

Lactate clearance and mortality in septic patients with hepatic dysfunction

Ha, T.S.,Shin, T.G.,Jo, I.J.,Hwang, S.Y.,Chung, C.R.,Suh, G.Y.,Jeon, K. Centrum Philadelphia 2016 The American journal of emergency medicine Vol.34 No.6

<P>Background: Serum lactate clearance (LC) during initial resuscitation is a potentially useful prognostic marker in patients with severe sepsis or septic shock. However, it is unclear whether LC is also associated with the outcome in septic patients with hepatic dysfunction that may impair lactate elimination, which may contribute to elevated serum lactate levels or decreased LC. Methods: The relationships between LC measured within 6 and 24 h after initial resuscitation and hospital mortality were evaluated with multiple logistic regression analysis. Results: Of 770 patients with severe sepsis or septic shock, 208 (27%) with hepatic dysfunction were included in the analysis. The median LC within 6 h in survivors (31.4%) was significantly higher than that of non-survivors (9.3%) (P = .010). In addition, the median LC within 24 h was also significantly different between groups (51% vs. 12%, P < .001). Low LCs, defined as less than 10% of clearance, at 6 and 24 h were associated with in-hospital mortality. After adjusting for potential confounding factors, low LCs at 6 and 24 h remained associated with hospital mortality (adjusted OR 4.940, 95% CI 1.762-13.854 at 6 h; adjusted OR 5.997, 95% CI 2.149-16.737 at 24 h). However, LC at 24 h (area under the curve of 0.704) had higher discriminatory power to predict hospital mortality than LC at 6 h (area under the curve of 0.608) (P = .033). Conclusions: LC may be useful for predicting outcomes in septic patients with hepatic dysfunction. (C) 2016 Elsevier Inc. All rights reserved.</P>

Morphine in the setting of acute myocardial infarction: pros and cons

Zhang, N.,Chen, K.,Rha, S.W.,Li, G.,Liu, T. Centrum Philadelphia 2016 The American journal of emergency medicine Vol.34 No.4

In situ analysis of HER2 mRNA in gastric carcinoma: comparison with fluorescence in situ hybridization, dual-color silver in situ hybridization, and immunohistochemistry

Kim, M.A.,Jung, J.E.,Lee, H.E.,Yang, H.K.,Kim, W.H. W. B. Saunders Co ; Centrum Philadelphia 2013 Human pathology Vol.44 No.4

The importance of anti-HER2 therapy has focused attention on the ability of clinical assays to correctly assign HER2 amplification status. In the present study, we evaluated HER2 mRNA expression using a new mRNA in situ detection technique called RNAscope in 211 cases of formalin-fixed, paraffin-embedded gastric carcinoma. In addition, we compared the results with the conventional methods of immunohistochemistry, fluorescence in situ hybridization, and dual-color silver in situ hybridization. RNA in situ hybridization (in situ hybridization) showed that 162 cases (76.8%) were score 0, 5 cases (2.4%) were score 1, 10 cases (4.7%) were score 2, 13 cases (6.2%) were score 3, and 21 cases (10.0%) were score 4. HER2 transcription levels were found to be significantly related to pT class, pN class, and tumor recurrence. mRNA expression was well correlated with protein overexpression and gene amplification; 20 cases out of 23 with DNA amplification showed a score of 4 in RNA in situ hybridization (P < .001). Three cases showed false negative and one case showed false positive results by in situ hybridization. More studies are needed to determine whether the in situ hybridization method can identify additional patients that may benefit from anti-HER2 therapy or exclude those who may be resistant to anti-HER2 therapy.

Lymph node metastasis in early gastric cancer: evaluation of a novel method for measuring submucosal invasion and development of a nodal predicting index

Kim, J.Y.,Kim, W.G.,Jeon, T.Y.,Kim, G.H.,Jeong, E.H.,Kim, D.H.,Park, D.Y.,Lauwers, G.Y. W. B. Saunders Co ; Centrum Philadelphia 2013 Human pathology Vol.44 No.12

After endoscopic resection of early gastric cancer (EGC), it is imperative to accurately determine whether follow-up surgery is indicated, since this technique is used as a first line of treatment. Herein, we developed a scoring system to indicate the risk of lymph node metastasis in submucosal EGC (smEGC), and present a novel method to measure depth of submucosal invasion. In our series, 15.9% of the smEGC presented with lymph node metastasis. A nodal prediction index, based on the variables extracted from the univariate analysis and defined as nodal prediction index = (2.128 x lymphovascular tumor emboli) + (1.083 x submucosal invasion width ≥0.75 cm) + (0.507 x submucosal invasion depth ≥1000 μm) + (0.515 x infiltrative growth pattern), yielded an area under the receiver operating characteristic curve of 0.809 (P =.000, 95% CI = 0.713-0.096) in a training group, and showed comparable result in validation group (0.886, P =.000, 95% CI = 0.796-0.977). Depth of invasion was statistically higher in the metastatic group when measured from the lowest point of an imaginary line in continuity with the adjacent muscularis mucosa to the point of deepest tumor penetration, but not when using the classic measurement method. The area under the receiver operating characteristic curve of the alternative measurement method was 0.652 (P =.013, 95% CI = 0.550-0.754) compared to 0.620 for the classic measurement method (P =.0480, 95% CI = 0.509-0.731). In deciding whether surgery is indicated after endoscopic submucosal dissection for smEGCs, we recommend to test our alternative method of measuring submucosal invasion and to evaluate our nodal prediction index as an adjunct tool.

PDGFB rearrangement in dermatofibrosarcoma protuberans: correlation with clinicopathologic characteristics and clinical implications

Ha, S.Y.,Lee, S.E.,Kwon, M.J.,Kim, Y.J.,Lee, E.H.,Seo, J.,Jang, K.T.,Lee, J.,Choi, Y.L. W. B. Saunders Co ; Centrum Philadelphia 2013 Human pathology Vol.44 No.7

Dermatofibrosarcoma protuberans (DFSP) is characterized genetically by the translocation t(17;22)(q22;q13), which creates a COL1A1/PDGFB fusion gene. The implications of this gene for the clinicopathologic features of the disease are not fully understood. Fifty-one cases of DFSP from 46 patients were reclassified as DFSP (n=29) and DFSP-fibrosarcomatous variant (DFSP-FS; n=22). Fluorescence in situ hybridization was performed using a dual-color break-apart probe to detect rearrangements involving PDGFB, and CD34 immunohistochemistry staining was done. The DFSP-FS was found in older patients, and the tumors were larger, with a smaller mean area of staining for CD34. PDGFB rearrangement was found in 45 cases (95.7%). The mean gene copy number was 3.82 (range 2.2-6.45) and was higher in DFSP-FS than in classic DFSP (4.54 vs. 3.47; P < .001). The PDGFB copy number showed a moderate positive correlation with the number of mitotic figures and tumor size. Patients undergoing wide excision or having no involvement of the resection margin had no relapses. These results suggest a role for COL1A1/PDGFB in sarcomatous change in DFSP over time. Detection of COL1A1/PDGFB rearrangement by fluorescence in situ hybridization is useful for confirmation of the diagnosis. Patients who present with metastatic DFSP-FS show less typical histologic findings and loss of CD34 staining, leaving PDGFB rearrangement as the preferred adjunctive method for diagnosis from small biopsies and for prediction of the value of imatinib therapy.