Aim:The purpose of the present study was to investigate the predictors of clinical deterioration soon after emergency department (ED) discharge. Methods:We undertook a case-control study using the ED database of the Nagano Municipal Hospital (Nagano, Japan) from January 2012 to December 2013. We selected adult patients with medical conditions who revisited the ED with deterioration within 2 days of ED discharge (deterioration group). The deterioration group was compared with a control group.Results: During the study period, 15,724 adult medical patients were discharged from the ED. Of these, 170 patients revisited the ED because of clinical deterioration within 2 days. Among the initial vital signs, respiratory rate was less frequently recorded than other vital signs (P < 0.001 versus all other vital signs in each group). The frequency of recording each vital sign did not differ significantly between the groups. Overall, patients in the deterioration group had significantly higher respiratory rates than those in the control group (21 AE 5/min versus 18 AE 5/min, respectively; P = 0.002). A binary logistic regression analysis revealed that respiratory rate was an independent risk factor for clinical deterioration (unadjusted odds ratio, 1.15; 95% confidence interval, 1.04À1.26; adjusted odds ratio, 1.15; 95% confidence interval, 1.01À1.29).Conclusions: An increased respiratory rate is a predictor of early clinical deterioration after ED discharge. Vital signs, especially respiratory rate, should be carefully evaluated when making decisions about patient disposition in the ED.

ÖZAmaç: Bu çalışmada el bileği füzyon çubuğu (EBFÇ) kullanılan el bileği füzyonunun kısa vadeli cerrahi sonucu retrospektif olarak incelendi. Hastalar ve yöntemler: Dört kadın hastanın (ort. yaş 56 yıl; dağılım 51-62 yıl) ileri dönem Larsen IV veya V romatoid artritli altı el bileğine EBFÇ kullanılarak total el bileği füzyonu uygulandı. Klinik sonuç, ağrı memnuniyet düzeyi sayısal değerlendirme skalası ile değerlendirildi. Kemik füzyonu, palmar subluksasyon ve ulnar deviasyonun düzelmesi, çubuk eğilme açısı, el bileği füzyonu açısı ve komplikasyonlar radyografiler ile değerlendirildi. Bulgular: Radyokarpal eklemin kemik füzyonu ile tüm el bileklerinde ağrısız el bileği stabilitesi sağlandı. Tüm hastalarda hem palmar subluksasyon hem ulnar deviasyon düzeltildi. İki radyografik komplikasyon gözlemlendi: bir hastada çubuk kırığı ve bir başka hastada proksimal metakarpal kemikte radyolusent bir çizgi. Her iki komplikasyon üçüncü karpometakarpal eklemin instabilitesinden kaynaklanmış olabilir, fakat hiçbiri klinik sonucu etkilemedi. Son gözlemde, el bileği füzyonu açısı çubuk eğilme açısından küçüktü. Sonuç: El Bileği Füzyon Çubuğu kullanılan el bileği füzyonu, el bileğinin ileri dönem romatoid artritinin tedavisi için bir seçenektir. Deneyimlerimize göre, üçüncü karpometakarpal eklemin stabilitesi cerrahiden önce değerlendirilmeli ve gerekirse bu ekleme füzyon yapılmalıdır. Dorsal el bileği füzyon plağı olan olgunun aksine, intramedüller çubuğun eğilme açısı doğrudan el bileği füzyonu açısını oluşturmaz.Anahtar sözcükler: Romatoid artrit; total el bileği füzyonu; el bileği füzyon çubuğu. ABSTRACTObjectives: This study aims to retrospectively review the short-term surgical outcome of wrist fusion using wrist fusion rod (WFR). Patients and methods: Six wrists of four female patients (mean age 56 years; range 51 to 62 years) with advanced stage rheumatoid arthritis of Larsen IV or V were performed total wrist fusion using WFR. Clinical outcome was assessed using a numeric rating scale of pain satisfaction level. Bony fusion, correction of palmar subluxation and ulnar deviation, rod bending angle, wrist fusion angle, and complications were assessed from radiographs. Results: All wrists achieved painless wrist stability with bony fusion of the radiocarpal joint. Both the palmar subluxation and ulnar deviation were corrected in all patients. Two radiographic complications were observed: rod fracture in one patient and a radiolucent line in proximal metacarpal bone in another patient. Both complications might have occurred as a result of instability of the third carpometacarpal joint, but neither influenced clinical outcome. Wrist fusion angle was smaller than rod bending angle at final observation. Conclusion: Wrist fusion using WFR is an option for the treatment of advanced stage rheumatoid arthritis of wrist. According to our experience, the stability of third carpometacarpal joint should be assessed before surgery, and this joint should be fused if required. The bending angle of the intramedullary rod does not directly...

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Thyroid storm in a child after severe head injury and neurointensive care Dear Editor, We report a rare pediatric case of thyroid storm (TS) after severe head injury and neurointensive care. A 14-year-old, previously healthy girl was transported to our hospital by ambulance after losing consciousness in a traffic accident. On arrival, her Glasgow Coma Scale score was 4 (eye, 1; verbal, 1; motor, 2). Her pupils were mydriatic and did not react to light. A computed tomography scan showed a 6-mm left subdural hematoma with a 5-mm midline shift. An emergency craniotomy for removal of the hematoma and external decompression were carried out after temporary trepanation, and therapeutic hypothermia (THT) was maintained for 10 days because of severe brain edema. After rewarming, she remained comatose and her temperature was controlled with acetaminophen. Beginning on day 21, her body temperature increased to more than 38°C and she had tachycardia (>130 b.p.m.), diarrhea, and an abnormally diaphoretic appearance. Thyroid function tests were carried out on day 24. The thyroid-stimulating hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) levels were <0.005 μIU/mL, 5.0 ng/dL, and 13.5 pg/mL, respectively, and the TSH receptor antibody level was 11.7 IU/mL. Thyroid storm was diagnosed on the basis of Japan Thyroid Association criteria. 1 Treatment with methimazole, corticosteroids, propranolol, and potassium iodide was started, and her fever and

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