Maternal high-fructose intake during pregnancy and lactation induces metabolic syndrome in adult offspring

BACKGROUND/OBJECTIVES@#Nutritional status and food intake during pregnancy and lactation can affect fetal programming. In the current metabolic syndrome epidemic, highfructose diets have been strongly implicated. This study investigated the effect of maternal high-fructose intake during pregnancy and lactation on the development of metabolic syndrome in adult offspring. @*SUBJECTS/METHODS@#Drinking water with or without 20% fructose was administered to female C57BL/6J mice over the course of their pregnancy and lactation periods. After weaning, pups ate regular chow. Accu-Chek Performa was used to measure glucose levels, and a tail-cuff method was used to examine systolic blood pressure. Animals were sacrificed at 7 months, their livers were excised, and sections were stained with Oil Red O and hematoxylin and eosin (H&E) staining. Kidneys were collected for gene expression analysis using quantitative real-time Polymerase chain reaction. @*RESULTS@#Adult offspring exposed to maternal high-fructose intake during pregnancy and lactation presented with heavier body weights, fattier livers, and broader areas under the curve in glucose tolerance test values than control offspring. Serum levels of alanine aminotransferase, aspartate aminotransferase, glucose, triglycerides, and total cholesterol and systolic blood pressure in the maternal high-fructose group were higher than that in controls. However, there were no significant differences in mRNA expressions of reninangiotensin-aldosterone system genes and sodium transporter genes. @*CONCLUSIONS@#These results suggest that maternal high-fructose intake during pregnancy and lactation induces metabolic syndrome with hyperglycemia, hypertension, and dyslipidemia in adult offspring.

Maternal high-fructose intake during pregnancy and lactation induces metabolic syndrome in adult offspring

BACKGROUND/OBJECTIVES@#Nutritional status and food intake during pregnancy and lactation can affect fetal programming. In the current metabolic syndrome epidemic, highfructose diets have been strongly implicated. This study investigated the effect of maternal high-fructose intake during pregnancy and lactation on the development of metabolic syndrome in adult offspring. @*SUBJECTS/METHODS@#Drinking water with or without 20% fructose was administered to female C57BL/6J mice over the course of their pregnancy and lactation periods. After weaning, pups ate regular chow. Accu-Chek Performa was used to measure glucose levels, and a tail-cuff method was used to examine systolic blood pressure. Animals were sacrificed at 7 months, their livers were excised, and sections were stained with Oil Red O and hematoxylin and eosin (H&E) staining. Kidneys were collected for gene expression analysis using quantitative real-time Polymerase chain reaction. @*RESULTS@#Adult offspring exposed to maternal high-fructose intake during pregnancy and lactation presented with heavier body weights, fattier livers, and broader areas under the curve in glucose tolerance test values than control offspring. Serum levels of alanine aminotransferase, aspartate aminotransferase, glucose, triglycerides, and total cholesterol and systolic blood pressure in the maternal high-fructose group were higher than that in controls. However, there were no significant differences in mRNA expressions of reninangiotensin-aldosterone system genes and sodium transporter genes. @*CONCLUSIONS@#These results suggest that maternal high-fructose intake during pregnancy and lactation induces metabolic syndrome with hyperglycemia, hypertension, and dyslipidemia in adult offspring.

Development of Korean Teaching Model for Surgical Procedures in Trauma -Essential Surgical Procedures in Trauma Course-

PURPOSE@#The Essential Surgical Procedures in Trauma (ESPIT) course was developed as a model to teach necessary surgical procedures to trauma physicians. Its goals are to improve knowledge, self-confidence, and technical competence.@*METHODS@#The ESPIT course consisted of five lectures and a porcine lab operative experience. The ESPIT course has been run seven times between February 2014 and April 2016. ESPIT participants completed a questionnaire to assess self-efficacy regarding essential surgical procedures in trauma before and immediately after taking the ESPIT course. Sixty-three participants who completed both pre- and post-course questionnaires on self-efficacy were enrolled in this study.@*RESULTS@#The overall post-ESPIT mean self-efficacy score was higher than the pre-ESPIT mean self-efficacy score (8.3±1.30 and 4.5±2.13, respectively) (p5 years) were also statistically significant (p<0.001).@*CONCLUSIONS@#The data of the ESPIT participants indicated that they felt that the ESPIT course improved their self-efficacy with regard to essential surgical procedures in trauma. The ESPIT course may be an effective strategy for teaching surgical procedures, thus promoting better management of traumatic injuries.

Clinical Effects of Intra-Abdominal Pressure in Critically Ill Trauma Patients

PURPOSE@#There is increasing interest in intra-abdominal pressure (IAP) and intra-abdominal hypertension (IAH) in critically ill patients. This study investigated the effects and outcomes of elevated IAP in a trauma intensive care unit (ICU) population.@*METHODS@#Eleven consecutive critically ill patients admitted to the trauma ICU at Pusan National University Hospital Regional Trauma Center were included in this study. IAP was measured every 8–12 hours (intermittently) for 72 hours. IAP was registered as mean and maximal values per day throughout the study period. IAH was defined as IAP ≥12 mmHg. Abdominal compartment syndrome was defined as IAP ≥20 mmHg plus ≥1 new organ failure. The main outcome measure was in-hospital mortality.@*RESULTS@#According to maximal and mean IAP values, 10 (90.9%) of the patients developed IAH during the study period. The Sequential Organ Failure Assessment (SOFA) score was significantly higher in patients with IAP ≥20 mmHg than in those with IAP <20 mmHg (16 vs. 5, p=0.049). The hospital mortality rate was 27.3%. Patients with a maximum IAP ≥20 mmHg exhibited significantly higher hospital mortality rates (p=0.006). Non-survivors had higher maximum and mean IAP values.@*CONCLUSIONS@#Our results suggest that an elevated IAP may be associated with a poor prognosis in critically ill trauma patients.

CT Findings of Perforation of the Stomach after Ingestion of Glacial Acetic Acid

The ingestion of corrosive substances often leads to severe morbidity and mortality. Acids produce coagulation necrosis with a lesser degree of penetration, whereas alkalis produce liquefactive necrosis with penetration. Acetic acid is a clear, colorless organic acid with a pungent, vinegar-like odor. The ingestion of highly concentrated acetic acid (glacial acetic acid) may cause a range of complications. On the other hand, perforation of the stomach is extremely rare but it has a high mortality rate. This paper reports a case of perforation of the stomach after the ingestion of glacial acetic acid with suicidal intent in an otherwise healthy 76-year-old woman.

Iatrogenic Delayed Aortic Injury Following a Surgical Stabilization of Flail Chest

Most of aortic injuries after blunt chest trauma usually occur at the aortic isthmus and are identified in the emergency department soon after arrival. Delayed aortic injures by fractured posterior ribs, however, are relatively rare and have been reported only a few times. We recently experienced an iatrogenic descending aortic injury sustained as a result of a direct puncture by a sharp rib end after surgical stabilization of rib fractures.

Clinical Analysis of the Patients with Isolated Low-Velocity Penetrating Neck Injury

PURPOSE@#Although there has been substantial progress for the treatment of thoracic trauma, the mortality of the penetrating neck injury is still high, has been reported about 10–15%. However, there has not been a report which is reflecting Korean medical present. We retrospectively analyzed the penetrating neck injury patients based on the Korean Trauma Data Base.@*METHODS@#Between December 2013 and June 2017 at the trauma center of the Pusan National University Hospital, Busan, Korea, total of 36 patients with isolated low-velocity penetrating neck injuries were included. We analyzed the patients' age, gender, injury mechanism and causes by medical chart review.@*RESULTS@#Among total of 36 patients, 26 (72.2%) were male and 10 (27.8%) were female. Homicidal neck injuries were most common, followed by accidental and suicidal injuries (47% vs. 33% vs. 19%, respectively). All penetrating injuries in our study were low-velocity trauma such as following: knife (n=16, 44.4%); glass or glass bottle (n=11, 30.6%); scissors (n=4, 11.1%); grinder (n=2, 5.6%); and three (8.3%) of miscellaneous injuries. Twenty-seven (75.0%) patients underwent emergency surgery, and only one (2.8%) patient underwent elective surgery. Eleven (30.6) patients were diagnosed with superficial injuries, including six patients who had conservative treatment. Twelve (33.3%) patients had arterial injuries and 10 (27.8%) patients had venous injuries. The patients who had deep injuries showed significant difference against the patient with superficial injury (98.0 vs. 129.1, p=0.008).@*CONCLUSION@#Low velocity penetrating injury confined to the neck is able to be successfully treated with prompt surgical management. Regardless of the conditions which are evaluated at emergency department, all penetrating neck injury patients should be regarded as urgent surgical candidates.

Concomitant Avulsion Injury of the Subclavian Vessels and the Main Bronchus Caused by Blunt Trauma

Concomitant rupture of the subclavian vessels and the left main bronchus caused by blunt trauma is a serious condition. Moreover, the diagnosis of a tracheobronchial injury with rupture of the subclavian vessels can be difficult. This report describes the case of a 33-year-old man who suffered from blunt trauma that resulted in the rupture of the left subclavian artery and vein. The patient underwent an operation for vascular control. On postoperative day 3, the left main bronchus was found to be transected on a computed tomography scan and bronchoscopy. The transected bronchus was anastomosed in an end-to-end fashion. He recovered without any notable problems. Although the bronchial injury was not detected early, this case of concomitant rupture of the great vessels and the airway was successfully treated after applying extracorporeal membrane oxygenation.

Histone deacetylase inhibition attenuates hepatic steatosis in rats with experimental Cushing's syndrome

Cushing's syndrome (CS) is a collection of symptoms caused by prolonged exposure to excess cortisol. Chronically elevated glucocorticoid (GC) levels contribute to hepatic steatosis. We hypothesized that histone deacetylase inhibitors (HDACi) could attenuate hepatic steatosis through glucocorticoid receptor (GR) acetylation in experimental CS. To induce CS, we administered adrenocorticotropic hormone (ACTH; 40 ng/kg/day) to Sprague-Dawley rats by subcutaneous infusion with osmotic mini-pumps. We administered the HDACi, sodium valproate (VPA; 0.71% w/v), in the drinking water. Treatment with the HDACi decreased steatosis and the expression of lipogenic genes in the livers of CS rats. The enrichment of GR at the promoters of the lipogenic genes, such as acetyl-CoA carboxylase (Acc), fatty acid synthase (Fasn), and sterol regulatory element binding protein 1c (Srebp1c), was markedly decreased by VPA. Pan-HDACi and an HDAC class I-specific inhibitor, but not an HDAC class II a-specific inhibitor, attenuated dexamethasone (DEX)-induced lipogenesis in HepG2 cells. The transcriptional activity of Fasn was decreased by pretreatment with VPA. In addition, pretreatment with VPA decreased DEX-induced binding of GR to the glucocorticoid response element (GRE). Treatment with VPA increased the acetylation of GR in ACTH-infused rats and DEX-induced HepG2 cells. Taken together, these results indicate that HDAC inhibition attenuates hepatic steatosis hrough GR acetylation in experimental CS.

Delayed Pneumatosis Intestinalis Induced by Blunt Trauma in a Strangulated Small Intestine

An ischemia-reperfusion injury of the intestine due to blunt trauma is very rare. Low blood flow can result in an incarceration and an ischemia-reperfusion injury of the small intestine. A 63-year-old woman fell, producing a splenic rupture. Despite the successful angio-embolization of the splenic rupture, the patient continued to suffer from hypotension. During laparotomy to identify the bowel injury, no intestinal perforation was found. However, we found a hemorrhagic infarction of the small intestine with congestion of the submucosal blood vessels. The part of bowel with the hemorrhagic infarction was resected and reconstructed with a jejuno-colic anastomosis. After surgery, she recovered from the trauma and was discharged without complications. We present this ischemia-reperfusion injury of the intestine due to blunt trauma. Meticulous examination and computed tomography scan is mandatory for diagnosis and assessment of treatment outcome.

Successful Endovascular Management of Post-Traumatic Phlegmasia Cerulea Dolens from Rupture of the External Iliac Vein

We report a rare case of a 47-year-old male with posttraumatic phlegmasia cerulea dolens caused by a ruptured right external iliac vein and treated with an endovascular venous stent graft. The patient was the victim of motor vehicle accident, and suffered direct injuries to the head and abdomen. The patient had a cyanotic and swollen right lower leg. Abdominal and lower extremity computed tomography angiography revealed a large retroperitoneal hematoma caused by a ruptured right external iliac vein, and grade I liver injury. The right external iliac vein rupture was successfully treated with a venous stent graft, followed by inferior vena cava filtering, because a venous thrombus was identified below the stent graft. He initially was hemodynamically unstable but recovered following treatment. The patient was comatose when presenting at the emergency department. He was discharged, fully recovered, on hospital day 18.

Current status and future prospects of trauma centers in Korea

The government has implemented a regional trauma center project since 2012 with the goal of reducing the preventable trauma death rate in Korea to the level of developed countries. Regional trauma centers should organically cooperate with the government and the Korean Surgical Society to ensure that seriously injured patients are treated at regional level 1 trauma centers and to lead quantitative and qualitative growth with the aim of ensuring leadership within the regional trauma system. We expect that the finances of trauma centers will stabilize and that the role of trauma centers will become more mature by readjusting medical fees to a realistic level and expanding the scope of treatment to include acute care surgery. These efforts will ultimately reduce the preventable trauma mortality rate in Korea.

The Usefulness of the mPTS (modified pediatric trauma score) and Newly Developed Extended mPTS as a High Risk Pediatric Trauma Patients Screening Tool: Support of Two Tiered Trauma Team Activation System

PURPOSE: A secondary triage tool for pediatric trauma patients, “modified pediatric trauma score (mPTS)” was introduced to predict high risk trauma. METHODS: Pediatric trauma patients (≤15 years) presenting to the Pusan National University Hospital trauma center emergency department were analyzed retrospectively. The patients were classified into high risk and low risk groups. The high risk group was assigned an Injury Severity Score ≥12, death, intensive care unit admission, or urgent intervention (intubation, closed thoracostomy, emergency angiography and embolization, emergency surgery). The airway, blood pressure, fractures, level of consciousness, and external wounds were evaluated and the mPTS was calculated. RESULTS: One hundred seventy-seven patients were enrolled in this study. The mPTS had a sensitivity, specificity, positive predictive value, and negative predictive value of 88%, 54%, 60%, and 85%, respectively. Overtriage and undertriage was 39% and 14%, respectively. The mPTS missed 6 high risk patients and all 6 patients were abdominal injury patients. The mPTS was modified to include an abdominal physical examination and/or focused assessment with sonography for trauma. The newly developed scoring system was called the extended mPTS (E-mPTS). The E-mPTS had a sensitivity of 98% and negative predictive value of 98%. The safe level of overtriage (38%) was maintained. CONCLUSION: mPTS was applied to the patients and the undertriage rate was too high. The extended mPTS improved undertriage to 2% while maintaining the overtriage rate at a safe level. The E-mPTS is expected to have a resource saving effect when used as a pediatric trauma team activation standard.

Foodborne Infectious Diseases Mediated by Inappropriate Infection Control in Food Service Businesses and Relevant Countermeasures in Korea

OBJECTIVES: The objective of this review is to propose an appropriate course of action for improving the guidelines followed by food handlers for control of infection. For this purpose, previous epidemiological reports related to acute gastroenteritis in food service businesses mediated by food handlers were intensively analyzed. METHODS: Relevant studies were identified in international databases. We selected eligible papers reporting foodborne infectious disease outbreaks. Among primary literature collection, the abstract of each article was investigated to find cases that absolutely identified a causative factor to be food handlers’ inappropriate infection control and the taxon of causative microbial agents by epidemiological methodologies. Information about the sites (type of food business) where the outbreaks occurred was investigated. RESULTS: A wide variety of causative microbial agents has been investigated, using several epidemiological methods. These agents have shown diverse propagation pathways based on their own molecular pathogenesis, physiology, taxonomy, and etiology. CONCLUSION: Depending on etiology, transmission, propagation, and microbiological traits, we can predict the transmission characteristics of pathogens in food preparation areas. The infected food workers have a somewhat different ecological place in infection epidemiology as compared to the general population. However, the current Korean Food Safety Act cannot propose detailed guidelines. Therefore, different methodologies have to be made available to prevent further infections.

Proposal for stabilization of regional trauma centers in Korea

From 2011 to 2016, 16 regional trauma centers were designated throughout the country and 9 of the 16 centers have been operating their own trauma facilities. At present, there are some differences in treatment experiences and levels according to the type and size of the trauma centers. Treating the trauma system as a part of emergency medical service, while the field of severe trauma is clearly different from the rest of emergency medical service in particular, has become a serious problem in Korea. First of all, the role of trauma centers should have been established before they are added to the trauma care system. Beyond that, manpower is the most important factor in building a trauma center. Pusan National University Hospital offers the ideal environment for a study on the relationship between trauma centers and emergency centers. Pusan National University Hospital has 2 independent emergency rooms: one each in the trauma center and emergency center. Therefore, it is possible to compare the outcomes of 2 different emergency rooms and identify the proportion of the trauma population who is transferred from the emergency center to the trauma center due to trauma severity index. Ultimately, the government and individual hospitals must support personnel in each trauma centers administratively and financially to sustain trauma centers over the long term. The purpose of this proposal is to suggest some resolutions to the problems associated with the trauma care system in Korea.

Analysis of Sternal Fixation Results According to Plate Type in Sternal Fracture

BACKGROUND: Sternal fractures are relatively rare, and caused mainly by blunt anterior chest wall trauma. In most cases, sternal fractures are treated conservatively. However, if the patient exhibits problematic symptoms such as intractable chest wall pain or bony crepitus due to sternal instability, surgical correction is indicated. But no consensus exists regarding the most appropriate surgical method. We analyzed the results of surgical fixation in cases of sternal fracture in order to identify which surgical method led to the best outcomes. METHODS: We retrospectively reviewed the medical records of patients with sternal fractures from December 2008 to December 2011, and found 19 patients who underwent open reduction and internal fixation of the sternum with a longitudinal plate (L-group) or a T-shaped plate (T-group). We investigated patients' characteristics, clinical details regarding each case of chest trauma, the presence of other associated injuries, the type of open reduction and fixation, whether a combined operation was performed, and postoperative complications. RESULTS: Of the 19 patients, 10 patients (52.6%) were male, and their average age was 56.8 years (range, 32 to 82 years). Seven patients (36.8%) had isolated sternal fractures, while 12 (63.2%) had other associated injuries. Seven patients (36.8%) were in the L-group and 12 patients (63.2%) were in the T-group. Three patients in the L-group (42.9%) showed a loosening of the fixation. In all patients in the T-group, the fracture exhibited stable alignment. CONCLUSION: Open reduction and internal fixation with a T-shaped plate in sternal fractures is a safer and more efficient treatment method than treatment with a longitudinal plate, especially in patients with a severely displaced sternum or anterior flail chest, than a longitudinal plate.

GRP78 Protein Expression as Prognostic Values in Neoadjuvant Chemoradiotherapy and Laparoscopic Surgery for Locally Advanced Rectal Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: We investigated the relationships between biomarkers related to endoplasmic reticulum stress proteins (glucose-regulated protein of molecular mass 78 [GRP78] and Cripto-1 [teratocarcinoma-derived growth factor 1 protein]), pathologic response, and prognosis in locally advanced rectal cancer. MATERIALS AND METHODS: All clinical stage II and III rectal cancer patients received 50.4 Gy over 5.5 weeks, plus 5-fluorouracil (400 mg/m2/day) and leucovorin (20 mg/m2/day) bolus on days 1 to 5 and 29 to 33, and surgery was performed at 7 to 10 weeks after completion of all therapies. Expression of GRP78 and Cripto-1 proteins was determined by immunohistochemistry and was assessed in 101 patients with rectal cancer treated with neoadjuvant chemoradiotherapy (CRT). RESULTS: High expression of GRP78 and Cripto-1 proteins was observed in 86 patients (85.1%) and 49 patients (48.5%), respectively. Low expression of GRP78 protein was associated with a significantly high rate of down staging (80.0% vs. 52.3%, respectively; p=0.046) and a significantly low rate of recurrence (0% vs. 33.7%, respectively; p=0.008) compared with high expression of GRP78 protein. Mean recurrence-free survival according to GRP78 expression could not be estimated because the low expression group did not develop recurrence events but showed a significant correlation with time to recurrence, based on the log rank method (p=0.007). GRP78 also showed correlation with overall survival, based on the log rank method (p=0.045). CONCLUSION: GRP78 expression is a predictive and prognostic factor for down staging, recurrence, and survival in rectal cancer patients treated with 5-fluorouracil and leucovorin neoadjuvant CRT.

A Retrospective Clinical Study: Complications of Totally Implanted Central Venous Access Ports

BACKGROUND: When managing patients who require repeated venous access, gaining a viable intravenous route has been problematic. To improve the situation, various studies on techniques for venous access have been conducted. The aim of this study is to evaluate the clinical results of complications following totally implanted central venous access port (TICVAP) insertion. METHODS: A retrospective analysis was conducted on 163 patients, from December 2008 to March 2013. The occurrence of complications was studied in three separate periods of catheter use: the intraoperative period, postoperative period, and period during the treatment. RESULTS: A total of 165 cases of TICVAP insertions involving 156 patients were included in the final analysis. There were 35 complications (21%) overall. Among these, 31 cases of complications (19%) occurred during the treatment period and the other 4 cases were intraoperative and postoperative complications (2%). There were no statistically significant differences in age and gender of the patients between the two groups to be risk factors (p=0.147, p=0.08). Past history of chemotherapy, initial laboratory findings, and the locations of TICVAP insertion also showed no statistical significance as risk factors (p>0.05). CONCLUSION: Because the majority of complications occurred after port placement and during treatment, meticulous care and management and appropriate education are necessary when using TICVAPs.

Traumatic Tracheobronchial Injury: Delayed Diagnosis and Treatment Outcome

BACKGROUND: Most traumatic tracheobronchial injuries are fatal and result in death. Some milder cases are not life threatening and are often missed at the initial presentation. Tracheobronchial rupture is difficult to diagnose in the evaluation of severe multiple trauma patients. We reviewed the traumatic tracheobronchial injuries at Konyang University and Eulji University Hospital and analyzed the clinical results. MATERIALS AND METHODS: From January 2001 to December 2011, 23 consecutive cases of traumatic tracheobronchial injury after blunt trauma were reviewed retrospectively. We divided them into two groups by the time to diagnosis: group I was defined as the patients who were diagnosed within 48 hours from trauma and group II was the patients who diagnosed 48 hours after trauma. We compared the clinical parameters of the two groups. RESULTS: There was no difference in the age and gender between the two groups. The most common cause was traffic accidents (56.5%). The Injury Severity Score (ISS) was 19.6 in group I and 27.5 in group II (p=0.06), respectively. Although the difference in the ISS was not statistically significant, group II tended toward more severe injuries than group I. Computed tomography was performed in 22 cases and tracheobronchial injury was diagnosed in 5 in group I and 6 in group II, respectively (p=0.09). Eighteen patients underwent surgical treatment and all four cases of lung resection were exclusively performed in group II (p=0.03). There were two mortality cases, and the cause of death was shock and sepsis. CONCLUSION: We believe that close clinical observation with suspicion and rigorous bronchoscopic evaluation are necessary to perform diagnosis earlier and preserve lung parenchyma in tracheobronchial injuries from blunt trauma.

Extended Aortic Arch Replacement Through the L-Incision Approach

There are various methods for approaching the aortic arch, such as median sternotomy or lateral thoracotomy. However, accessing the site of distal anastomosis is problematic when the distal arch is extensively involved. We report a case of extended aortic arch replacement and coronary artery bypass through the L-incision approach.