Immunomodulatory Effects of Hypertonic Saline: The Effects on Nuclear Translocation of NF-kappaB and TNF-alpha Synthesis in Stimulated PMNs

PURPOSE: According to current research, hypertonic saline has immunomodulatory effects. NF-kappaB is known as an important transcription factor involved in the production of inflammatory mediators during an inflammatory response. The purpose of this study was to determine the effect of hypertonic saline on both the NF-kappaB signaling pathway and on TNF-alphasynthesis in stimulated PMNs. METHODS: Isolated PMNs from healthy volunteers were subdivided into 3 groups by the incubation conditions: control (not stilmulated, isotonic condition), isotonic (stimulated, isotonic condition), hypertonic (stimulated, hypertonic condition). After nuclear proteins were isolated from the incubated PMNs, NF-kappaB was measured by Western blot. TNF-alpha was measured by ELISA from the culture media. RESULTS: The relative densities of nuclear NF-kappaB after 45 minute incubation were 0.28+/-0.14 (control group), 0.97+/- 0.16 (isotonic group), and 0.58+/-0.07(hypertonic group). Isotonic and hypertonic groups (fMLP stimulated groups) showed a significantly higher relative density than control groups. Among the study groups, the hypertonic groups had a smaller increased level compared to isotonic groups and were found to be statistically significant. The results from the 90 minute incubated groups were similar to that of the 45 minute incubated groups. The concentration of TNF- alphameasured from stimulated groups (isotonic group, hypertonic group) were significantly higher than control groups. Similar to the NF-kappaB result, the concentrations of TNF-alphain the hypertonic groups were significantly lower than isotonic groups. Longer incubation times were noted to display higher concentration in the stimulated groups. CONCLUSION: Stimulated PMNs incubated under hypertonic conditions showed a smaller increase in level of nuclear NF-kappaB and TNF-alphasynthesis compared to isotonic conditions. As a result, suppression of the NF-kappaB signaling pathway in stimulated PMNs is considered one of the mechanisms of hypertonic saline's immunomodulatory effect.

The Effects of Urinary Trypsin Inhibitor on the Outcomes of Severe Sepsis and Septic Shock Patients

PURPOSE: We purposed to determine the effects of urinary typsin inhibitor (ulinastatin) on the outcomes of severe sepsis and septic shock patients. METHODS: This is a prospective case control study of severe sepsis and septic shock patients who visited emergency department of university hospital from January 2005 to June 2008. For study group, 100,000 U of ulinastatin was initially infused and then additional infusions of ulinastatin were determined by the mean arterial pressure. We compared the predicted mortality and the actual in-hospital mortality between the ulinastatin group and the control group. We also compared the improvement of the SOFA score according to time between the groups. RESULTS: There were 43 patients in the ulinastatin group and 126 patients in the control group. The predicted mortality and the actual mortality of the ulinastatin group were 31.2% and 18.6%, respectively. The predicted and actual mortalities of the control group were 33.1% and 27.0%, respectively. The improvement of the SOFA score for the ulinastatin group was 6.8+/-3.9 and 5.0+/-4.5 at 0 and 24 hours (p<0.001), 6.5+/-3.7 and 3.9+/-4.3 at 0 and 48 hours (p<0.001) and, 6.3+/-3.6 and 3.0+/-4.1 at 0 and 72 hours (p<0.001). For the control group, the change of the SOFA score was 4.9+/-2.9 and 5.8+/-4.1 at 0 and 24 hours (p=0.003), 5.0+/-2.8 and 5.1+/-4.2 at 0 and 48 hours (p=0.760) and, 4.8+/-2.7 and 4.34.1 at 0 and 72 hours (p=0.105). CONCLUSION: The ulinastatin group showed significantly lower mortality than the predicted mortality and the ulinastatin group's SOFA score was improved in the early hospital days.

The Relationship of Shockable ECG Rhythm During Cardiopulmonary Resuscitation to Outcomes in Cardiac Arrest Patients

PURPOSE: The purpose of this study was to investigate the relationship of ECG change during CPR to outcomes in cardiac arrest patients. METHODS: A total of 170 patients who received cardiopulmonary resuscitation (CPR) in the emergency department from January 2005 to December 2006 were included for analysis. Medical records of study patients were reviewed, retrospectively. Age, sex, cause of arrest, location of arrest, arrest time, CPR time, initial ECG rhythme, changes in ECG during CPR, ROSC, 24 h survival, and number discharged alive were extracted from the medical records. Outcomes studied were ROSC rate and , survival rate at 24 h and at discharge. Student's t-test, the Chi-square test and one-way ANOVA were used for statistical analysis. RESULTS: The patients were divided into three groups according to the initial EKG rhythm. The groups showed no difference in ROSC rate, but the initial VF/VT group and the initial PEA group showed higher survival discharge rates than the initial asystole group (p=0.002). Patients whose rhythm changed from asystole to VF/VT showed significantly higher ROSC and 24 h survival rates but showed no difference in the survival to discharge rate. Patients whose rhythm changed from initial PEA to VF/VT showed no significance difference in ROSC rate, 24 h survival rate, or survival discharge rate. CONCLUSIONS: Although patients whose rhythm changed from initial asystole or PEA to shockable rhythm (VF/VT) showed no significant difference in survival discharge rate compared to those without change to shockable rhythm, in the long run, they may benefit from essential therapies to increase survival because of their higher ROSC rate and 24 h survival rate.

Impact of Initial Helical Abdominal Computed Tomography on the Diagnosis of Hollow Viscus Injury and Blunt Abdominal Traumare

PURPOSE: This study was conducted to examine the clinical significance IV-contrasted helical abdomen computed tomography (CT) as a diagnostic screening tool to evaluate hollow viscus injury in blunt abdominal trauma patients. METHODS: This is a retrospective study encompassing 108 patients, presenting to Korea University Medical Center (KUMC) Emergency Department (ED) from January 2007 to December 2007, with an initial CT finding suggestive of intra-abdominal injury. An initial non-enhanced abdomen CT was taken, followed by an enhanced CT with intravenous contrast. Patients' demographic data, as well as the mechanisms of injury, were inquired upon and obtained, initial diagnosis, as dictated by specialized radiologists, were added to post-operational (post-OP) findings and to additional CT findings acquired during their hospital stays, and all were combined to arrive at final diagnosis. Initial CT findings were further compared with the final diagnosis, yielding values for sensitivity, specificity, and accuracy, as well as positive and negative predictive values. Patients were further divided into two groups, namely, those that underwent operational intervention and those that did not. The initial CT findings of each group were subsequently compared and analyzed. RESULTS: Initial CT scans revealed abnormal findings in a total of 212 cases - solid organ injuries being the most common finding, as was observed in 97 cases. Free fluid accumulation was evident in another 69 cases. Based on the CT findings, 77 cases (71.3%) were initially diagnosed as having a solid organ injury, 20 cases (18.5%) as having a combined (solid organ + hollow viscus) injury, and 11 cases (10.2%), as having an isolated hollow viscus injury. The final diagnosis however, were somewhat different, with only 67 cases (62.0%) attributed to solid organ injury, 31 cases (28.7%) to combined injury (solid + hollow), and 10 cases (9.3%) to hollow viscus injury. The sensitivity (CI 95%) of the initial helical CT in diagnosing hollow viscus injury was 75.6%, and its specificity was 100%. The accuracy in diagnosing hollow viscus injury was also meaningfully lower compared to that in diagnosis of solid organ injury. Among patients initially diagnosed with solid organ injuries, 10 patients (2 from follow-up CT and 8 from post-OP finding) turned out to have combined injuries. A total of 38 patients underwent an operation, and the proportion of initial CT findings suggesting free air, mesenteric hematoma or bowel wall thickening turned out to be significantly higher in the operation group. CONCLUSION: Abdominal CT was a meaningful screening test for hollow viscus injury, but the sensitivity of abdominal CT was significantly lower in detecting hollow viscus injury as compared to solid organ injury. This calls for special consideration and careful observation by the ED physicians when dealing with cases of blunt abdominal trauma.