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Undertriage of Severe Geriatric Trauma Patients: Who Are We Missing?
No full textPURPOSE: Geriatric trauma patients have unique risk factors for being undertriaged, which differ from those in young trauma patients. This study aimed to identify these risk factors and their implications for public health stakeholders and trauma surgeons to improve prehospital triage of geriatric trauma patients. MATERIALS AND METHODS: Data were retrospectively reviewed from single level-1 trauma center database in patients aged >/=65 years, with Injury Severity Score (ISS) >15 between 2016 and 2020. Pre-hospital and hospital factors were compared between correctly triaged and undertriaged patients. The probabilities of survival and outcomes for correct and undertriage were calculated using the Trauma and Injury Severity Score (TRISS), observed (O):expected (E) ratio, z-score, and w-score. RESULTS: A total of 512 patients were included in the study; 401 (78%) were correctly triaged and 111 (22%) were undertriaged. Correct triage group presented significant z-score (correct triage: 4.29 vs. undertriage: -0.11), w-score (correct triage: 7.79 vs. undertriage: 4.29), and O:E ratio of mortality (correct triage: 0.73 vs. undertriage: 1.66). Undertriaged patients were older (77 [72-82] vs. 73 [68-80], p<0.001), had a higher women proportion (53% vs. 34%, p<0.001), had lower ISS (25 [17-25] vs. 27 [19-38], p<0.001), and had more head and neck injuries (89% vs. 65%, p<0.001). On multivariable logistic regression, female sex (odds ratio 2.55, 95% confidence interval [1.07-6.09], p=0.034), ground fall injury (5.82 [1.89-17.91], p=0.002), prehospital systolic blood pressure <110 mm Hg (0.13 [0.03-0.67], p=0.003), and presence of cerebrovascular disease (5.53 [1.35-22.68], p=0.018) were significantly associated with undertriage. CONCLUSION: Geriatric trauma patients were undertriaged when they were women, sustained ground-level fall injuries, the more alert in the scene, and had cerebrovascular disease. Trauma surgeons and fire agency stakeholders should collaborate to create geriatric-specific triage guidelines and educate paramedics about these risk factors to prevent undertriage in this patient population
Characteristics and outcomes of ocular candidiasis among patients who use buprenorphine intravenously
No full textWe evaluated the characteristics and outcomes of ocular candidiasis in patients using buprenorphine intravenously. A retrospective analysis of 35 eyes of people who use drugs diagnosed with presumed ocular candidiasis between 2000 and 2017 was performed. Data on demographics, ocular findings, and microbiological results were extracted from medical records. Logistic regression was performed to identify factors of poor visual prognosis, then multivariate analysis used the variables that were statistically significant in univariate analysis. Most patients (83%) were male, with a mean duration of 7.1 +/- 7.3 years from the onset of intravenous use of buprenorphine to diagnosis of ocular candidiasis. The mean best-corrected visual acuity (BCVA in logMAR) at diagnosis was 1.33 +/- 0.73, improving significantly to 0.94 +/- 0.91 at the last follow-up (P = .019). Diagnostic samples included aqueous humor from all patients and vitrectomy samples from 26 patients (74%), with positivity rates for Candida species culture of 23% and 27%, respectively. Extraocular sites tested positive for Candida in 54% of cases. Although representing 66% of identifications, Candida albicans was not the only identified organism. Treatment involved primarily fluconazole (91%) and intravitreal amphotericin B (69%). Poor visual outcomes correlated with low BCVA and presence of retinal detachment at baseline. Ocular candidiasis occurs in the context of chronic drug use. Diagnostic yield from ocular samples is relatively low, necessitating the investigation of extraocular infection sites or injection equipment. Poor baseline vision and retinal detachment were significant predictors of poor visual prognosis
Outcomes of Endoscopic Papillectomy After an Insulated Plastic Pancreatic Stent Placement: A Retrospective Cohort Study
No full textBACKGROUND AND AIM: Insulated plastic pancreatic stent placement before endoscopic papillectomy (EP) was introduced to prevent post-EP pancreatic stenting difficulties, avoid stent transection during EP, and ensure a safe hemostatic procedure in cases of post-EP bleeding by securing the pancreatic orifice. This study aimed to evaluate the technical efficacy and long-term outcomes of this procedure. METHODS: A retrospective analysis of 84 patients who underwent EP for ampullary adenomas between August 2006 and December 2020 was conducted using a 5-Fr polytetrafluoroethylene (PTFE)-insulated handmade pancreatic stent. RESULTS: EP after pancreatic stenting was successfully performed in 73/84 patients (86.9%). En bloc resection was performed in 59/73 patients (80.8%), and complete resection was achieved in 63/73 patients (86.3%). No stent transection was observed. Delayed bleeding was encountered in seven (9.6%) and 24 (32.9%) patients based on consensus guidelines and extended definitions, respectively. The incidence of pancreatitis was less frequent in the pre-EP pancreatic stenting group than in the post-EP pancreatic stenting group but statistically nonsignificant and underpowered (6.8 vs. 18.2%; p = 0.227, 95% confidence interval 0.046-4.030). In complete resection cases, tumor recurrence was encountered in six patients (8.2%) with surveillance for a median of 24 months. In the long term, one case (1.4%) of cholangitis and four cases (5.5%) of papillary structures developed. CONCLUSIONS: Insulated PTFE plastic stent placement before EP may serve as an alternative to conventional EP, considering the feasibility of pancreatic stent placement, en bloc resectability, incidence of post-EP pancreatitis, and long-term oncological prognosis
Impact of Antihypertensive and Lipid-Lowering Agents on Hepatocellular Carcinoma Risk in Patients with Fatty Liver Disease and Diabetes
No full textBACKGROUND/AIM: This study aimed to evaluate the effects of antihypertensives, lipid-lowering agents, and antiplatelet medications on hepatocellular carcinoma (HCC) risk in patients with fatty liver disease (FLD) and type 2 diabetes (T2D). METHOD: Using data from Korea Health Insurance Review and Assessment Service, 212,443 FLD-T2D patients were analyzed through Cox regression, propensity score matching (PSM), and Kaplan-Meier analysis. The analysis considered medication use and its relation to HCC development. Cohort admission day was set as the date of the first oral hypoglycemic prescription. RESULTS: The multivariate Cox regression analysis revealed that old age, male sex, chronic viral hepatitis, alcoholic liver disease, liver cirrhosis, using a combination of insulin and oral hypoglycemic agents for antidiabetic treatment, and calcium channel blocker (CCB) use were significantly correlated with higher HCC development risk, whereas dyslipidemia and statin, ezetimibe, and fibrate use was correlated with lower HCC risk, in the study cohort of 212,443 patients. Patients who used statins (hazard ratio [HR] = 0.58, 95% confidence interval [CI] = 0.42-0.80, P = 0.001) and fibrates (HR = 0.46, 95% CI = 0.22-0.93, P = 0.031) showed a significantly lower risk of HCC development even after PSM. In contrast, CCB use was linked to an elevated HCC risk (HR = 1.35, 95% CI = 1.05-1.72, P = 0.019), highlighting the differential impact of various medications on HCC incidence. CONCLUSION: The use of specific medications, such as statins and fibrates, may offer protective effects against HCC in patients with FLD-T2D, whereas that of CCB may increase the risk. This underscores the importance of tailored medication strategies for the management of chronic conditions
A comprehensive analysis of the role of stem cell transplantation in mantle cell lymphoma: real-world data from the Korean Society of Blood and Marrow Transplantation registry: Stem cell transplantation outcomes in mantle cell lymphoma
No full textPURPOSE: Stem cell transplantation (SCT) has historically played a major role in the long-term remission of mantle cell lymphoma (MCL), an incurable hematological malignancy. Using data from the Korean Society of Bone and Marrow Transplantation registry, we retrospectively analyzed the role of autologous (auto) and allogeneic (allo) SCT in long-term MCL survival. METHODS: This study analyzed data from 188 patients (age >/= 19 years at the time of transplantation) who underwent a transplant for MCL from 2011 to 2020. Progression-free survival (PFS) was defined as the time from transplantation to disease progression, relapse, or death from any cause. Overall survival (OS) was defined as the time from transplantation to death from any cause or the last follow-up. RESULTS: In total, 109 patients underwent consolidative SCT after first-line chemotherapy. The 3-year PFS and OS rates were 65.4% and 78.5%, respectively, in the auto-SCT group, and 66.7% and 71.4%, respectively, in the allo-SCT group. The PFS and OS did not differ significantly between the auto- and allo-SCT groups. As part of salvage treatment, 52 patients with relapsed or refractory disease underwent auto- or allo-SCT. Patients who underwent auto-SCT with complete remission/partial remission status reported better outcomes. In patients with refractory status, allogeneic transplantation using human leukocyte antigen (HLA) fully matched donors was a significantly favorable factor for PFS and OS. CONCLUSION: The long-term survival of patients who underwent consolidative transplantation was similar to that reported in previous studies. Auto-SCT may be beneficial in patients who respond to salvage therapy, whereas allo-SCT with HLA-matched donors may be an alternative for patients with refractory disease
Bridging the Diagnostic Gap: Toward Non-Invasive Detection of Transthyretin Cardiac Amyloidosis in Acute Heart Failure
No full textPerformance of Open-Source Large Language Models in Psychiatry: Usability Study Through Comparative Analysis of Non-English Records and English Translations
No full textBACKGROUND: Large language models (LLMs) have emerged as promising tools for addressing global disparities in mental health care. However, cloud-based proprietary models raise concerns about data privacy and limited adaptability to local health care systems. In contrast, open-source LLMs offer several advantages, including enhanced data security, the ability to operate offline in resource-limited settings, and greater adaptability to non-English clinical environments. Nevertheless, their performance in psychiatric applications involving non-English language inputs remains largely unexplored. OBJECTIVE: This study aimed to systematically evaluate the clinical reasoning capabilities and diagnostic accuracy of a locally deployable open-source LLM in both Korean and English psychiatric contexts. METHODS: The openbuddy-mistral-7b-v13.1 model, fine-tuned from Mistral 7B to enable conversational capabilities in Korean, was selected. A total of 200 deidentified psychiatric interview notes, documented during initial assessments of emergency department patients, were randomly selected from the electronic medical records of a tertiary hospital in South Korea. The dataset included 50 cases each of schizophrenia, bipolar disorder, depressive disorder, and anxiety disorder. The model translated the Korean notes into English and was prompted to extract 5 clinically meaningful diagnostic clues and generate the 2 most likely diagnoses using both the original Korean and translated English inputs. The hallucination rate and clinical relevance of the generated clues were manually evaluated. Top-1 and top-2 diagnostic accuracy were assessed by comparing the model's prediction with the ground truth labels. Additionally, the model's performance on a structured diagnostic task was evaluated using the psychiatry section of the Korean Medical Licensing Examination and its English-translated version. RESULTS: The model generated 997 clues from Korean interview notes and 1003 clues from English-translated notes. Hallucinations were more frequent with Korean input (n=301, 30.2%) than with English (n=134, 13.4%). Diagnostic relevance was also higher in English (n=429, 42.8%) compared to Korean (n=341, 34.2%). The model showed significantly higher top-1 diagnostic accuracy with English input (74.5% vs 59%; P<.001), while top-2 accuracy was comparable (89.5% vs 90%; P=.56). Across 115 questions from the medical licensing examination, the model performed better in English (n=53, 46.1%) than in Korean (n=37, 32.2%), with superior results in 7 of 11 diagnostic categories. CONCLUSIONS: This study provides an in-depth evaluation of an open-source LLM in multilingual psychiatric settings. The model's performance varied notably by language, with English input consistently outperforming Korean. These findings highlight the importance of assessing LLMs in diverse linguistic and clinical contexts. To ensure equitable mental health artificial intelligence, further development of high-quality psychiatric datasets in underrepresented languages and culturally adapted training strategies will be essential
Relationship of parental phthalate exposure with fetal growth and placental development at birth
No full textBACKGROUND: Prenatal exposure to phthalates is reported to influence fetal growth and may lead to lasting adverse effects on infants and their future development; yet, the results remain inconclusive. OBJECTIVE: This study utilized a birth cohort of 73 pregnant women-newborn pairs, including biological fathers (73 triads), to investigate the relationship between parental phthalate exposure during pregnancy and birth outcomes in newborns. METHODS: Demographic, behavioral, and clinical information, along with urine samples from both parents, were collected prior to delivery. Sixteen phthalate metabolites were quantified in urine samples. RESULTS: Significant correlations were observed between six phthalate metabolites (MEP, MiBP, MnBP, MBzP, MEHP, and 5cx-MEPP) in maternal urine and paternal levels. Maternal MBzP was positively associated with boys' birth weight, whereas maternal 2cx-MMHP was negatively associated with girls' birth weight. The ponderal index of boys was negatively related to maternal MBzP and MMP, but positively associated with summation operatorMEHP-3 and summation operatorMEHP-5 after adjusting for confounding variables. Among paternal phthalates, MBzP showed a negative association with boys' ponderal index, whereas MEP showed a positive association. Maternal MEOHP, summation operatorMEHP-3, and summation operatorMEHP-5 were positively associated with boys' placenta weight, while MEOHP, MEHHP, 5cx-MEPP, summation operatorMEHP-3, and summation operatorMEHP-5 were negatively associated with girls' placenta weight. CONCLUSIONS: Our findings suggest that parental exposure to phthalates at birth may adversely affect fetal growth and placental development in neonates. However, further studies with larger sample sizes and datasets are necessary
Wedge fragments: no significant impact on bone healing in femoral shaft fractures treated with intramedullary nailing
No full textINTRODUCTION: Intramedullary nailing (IMN) is the treatment of choice for femoral shaft fractures with wedge-shaped fragments. However, the management of wedged fragments remains controversial. This study investigated whether wedged fragments affect bone union rates in patients treated with IMN. The primary hypothesis was that wedged fragments would not significantly affect bone union when proper IMN principles were followed. MATERIALS AND METHODS: Between March 2014 and June 2023, 162 patients were diagnosed with femoral shaft fractures (AO/OTA 32-B type) accompanied by wedge fractures. The surgeries involved the use of a reconstruction antegrade nail with a greater trochanteric entry point. Closed reduction was performed, and recon-type screws were used for proximal fixation of the femoral neck and head and at least two screws distally. The wedged fragments were not manipulated further. We analyzed the characteristics of the wedged fragments, including size, displacement, angle, and reversal morphology, and assessed the main fracture gap size in relation to bone union outcomes. RESULTS: The study included 95 of the 162 patients, of whom 82 (86.3%) achieved bone union and 13 (13.7%) experienced nonunion. Demographic and preoperative variables showed no significant differences between the union and nonunion groups. Postoperative radiographic analysis of the wedged fragments revealed no significant differences in fragment size, angle, displacement, or presence of reversed fragments. However, the main fracture gap size significantly differed, averaging 5.2 mm in the union group and 15.6 mm in the nonunion group(p = 0.01). Complications included superficial infections in four patients and malrotation in three, which were managed conservatively. CONCLUSIONS: Wedge fragments in femoral shaft fractures do not significantly affect bone union with IMN. Instead, the size of the main fracture gap is critical for healing. Surgery should focus on stable fixation and minimization of the main fracture gap rather than manipulating the wedged fragments
한국 응급실 간호사의 전문직 자아개념, 팀워크가 직무만족에 미치는 영향: 횡단적 조사연구
No full textPurpose: This study aimed to derive insights into professional self-concept, teamwork, and job satisfaction among emergency department (ED) nurses and to prepare basic data for improving job satisfaction among ED nurses. Methods: The study was conducted between October 2023 and April 2024 at two certified tertiary hospitals and one general hospital in Gyeonggi-do, Korea, among 124 ED nurses. Data were analyzed using SPSS version 26.0, and the analysis included descriptive statistics, the t-test, Pearson correlation, and multiple regression. Results: The factors affecting job satisfaction in ED nurses were professional self-concept (β =.66, p <.001), teamwork (β =.17, p =.003), and ED work satisfaction (β =.17, p =.003), and the overall explanatory power of the model was 67.7%. Conclusion: This study makes a significant contribution by demonstrating that professional self-concept and teamwork can increase job satisfaction in ED nurses. Therefore, as a strategy to increase job satisfaction through improving ED nurses’ professional self-concept and teamwork, effort should be made to apply team simulation programs that provide education and self-improvement opportunities for frequent diseases and situations encountered in the ED, and to communicate effectively about patient treatment strategies