Secondary hypoxic ischemia alters neurobehavioral outcomes, neuroinflammation, and oxidative stress in mice exposed to controlled cortical impact

Objective@#Hypoxic ischemia (HI) is a secondary insult that can cause fatal neurologic outcomes after traumatic brain injury (TBI), ranging from mild cognitive deficits to persistent vegetative states. We here aimed to unravel the underlying pathological mechanisms of HI injury in a TBI mouse model. @*Methods@#Neurobehavior, neuroinflammation, and oxidative stress were assessed in a mouse model of controlled cortical impact (CCI) injury followed by HI. Mice underwent CCI alone, CCI followed by HI, HI alone, or sham operation. HI was induced by one-vessel carotid ligation with 1 hour of 8% oxygen in nitrogen. Learning and memory were assessed using the novel object recognition test, contextual and cued fear conditioning, and Barnes maze test. Brain cytokine production and oxidative stress-related components were measured. @*Results@#Compared to TBI-only animals, TBI followed by HI mice exhibited significantly poorer survival and health scores, spatial learning and memory in the Barnes maze test, discrimination memory in the novel object recognition test, and fear memory following contextual and cued fear conditioning. Malondialdehyde levels were significantly lower, whereas glutathione peroxidase activity was significantly higher in TBI followed by HI mice compared to TBI-only and sham counterparts, respectively. Interleukin-6 levels were significantly higher in TBI followed by HI mice compared to both TBI-only and sham animals. @*Conclusion@#Post-traumatic HI aggravated deficits in spatial, fear, and discrimination memory in an experimental TBI mouse model. Our results suggest that increased neuroinflammation and oxidative stress contribute to HI-induced neurobehavioral impairments after TBI.

Secondary hypoxic ischemia alters neurobehavioral outcomes, neuroinflammation, and oxidative stress in mice exposed to controlled cortical impact

Objective@#Hypoxic ischemia (HI) is a secondary insult that can cause fatal neurologic outcomes after traumatic brain injury (TBI), ranging from mild cognitive deficits to persistent vegetative states. We here aimed to unravel the underlying pathological mechanisms of HI injury in a TBI mouse model. @*Methods@#Neurobehavior, neuroinflammation, and oxidative stress were assessed in a mouse model of controlled cortical impact (CCI) injury followed by HI. Mice underwent CCI alone, CCI followed by HI, HI alone, or sham operation. HI was induced by one-vessel carotid ligation with 1 hour of 8% oxygen in nitrogen. Learning and memory were assessed using the novel object recognition test, contextual and cued fear conditioning, and Barnes maze test. Brain cytokine production and oxidative stress-related components were measured. @*Results@#Compared to TBI-only animals, TBI followed by HI mice exhibited significantly poorer survival and health scores, spatial learning and memory in the Barnes maze test, discrimination memory in the novel object recognition test, and fear memory following contextual and cued fear conditioning. Malondialdehyde levels were significantly lower, whereas glutathione peroxidase activity was significantly higher in TBI followed by HI mice compared to TBI-only and sham counterparts, respectively. Interleukin-6 levels were significantly higher in TBI followed by HI mice compared to both TBI-only and sham animals. @*Conclusion@#Post-traumatic HI aggravated deficits in spatial, fear, and discrimination memory in an experimental TBI mouse model. Our results suggest that increased neuroinflammation and oxidative stress contribute to HI-induced neurobehavioral impairments after TBI.

Characteristics of the pneumonia patients transferred from long-term care hospitals:retrospective study of one regional emergency medical center

Objective@#This study investigated the characteristics of elderly pneumonia patients transferred from long-term care hospitals(LTCH). @*Methods@#The initial emergency department (ED) data of patients, who were transferred from other hospitals and over 65years old and hospitalized from 2014 to 2018 for pneumonia management through the ED, were extracted from the electronicmedical records. The differences in the initial status and prognosis between the LTCH group and non-LTCH groupwere compared, and the initial ED variables that affect the in-hospital mortality of the LTCH group were investigated. @*Results@#The total number of patients was 1,032; 423 (41.0 %) were included in the LTCH group. Compared to the non-LTCH group, the following severity indices, some laboratory data, and mortality were worse in the LTCH group: systemicinflammatory reaction syndrome (SIRS) criteria ≥2 (65.0% vs. 56.7%, P=0.008), quick Sequential Organ FailureAssessment score ≥2 (48.2% vs. 20.4%, P<0.001), CURB-65 (Confusion, Urea nitrogen, Respiration rate, Blood pressure,Age≥65 years) criteria ≥3 (51.8% vs. 29.2%, P<0.001), pneumonia severity index (PSI) class ≥4 (86.5% vs.61.2%, P<0.001), modified early warning score ≥5 (38.8% vs. 18.4%, P<0.001), serum albumin (median [IQR], 2.6 [2.2-2.9] g/dL vs. 2.8 [2.4-3.2] g/dL; P<0.001), blood urea nitrogen/albumin (B/A) ratio (median [IQR], 8.0 [5.0-12.8] vs. 6.6[4.4-10.4]; P<0.001), and in-hospital mortality (26.0% vs. 15.9%, P<0.001). Multivariate regression analysis revealed thealbumin grade, B/A ratio grade, PSI class, and SIRS criteria to independently affect the in-hospital mortality of the LTCHgroup. @*Conclusion@#The LTCH group had poorer initial severity indices and higher in-hospital mortality than the non-LTCHgroup. In addition, the albumin grade, B/A ratio grade, could be used for the severity index of pneumonia patients transferredfrom the LTCH.

Evaluation of pneumonia management effectiveness associated withinternal medicine management changes in the emergency department:a retrospective cohort study using a historically controlled group

Objective@#In Korea, many hospitals have recently changed the process of internal medicine management in the emergencydepartment (ED) because of reduced manpower, raising concerns regarding the decreased quality of medicalcare. The process of medical management in the ED was streamlined to resolve the reduced manpower. Thus, this studycompared the pneumonia treatment effectiveness before and after the process changes. @*Methods@#This study included patients who were diagnosed with pneumonia in the ED and hospitalized from January2014 to December 2016. They were divided into two groups based on before and after the changes. The disease severity,management adequacy, and prognosis were compared using the initial quick sequential organ failure assessmentscore (qSOFA), systemic inflammatory response syndrome criteria (SIRS), CURB-65 score, door-to-antibiotic time(DAT), length of stay (LOS), hospitalization period (HP), and in-hospital mortality, were collected retrospectively from themedical records. @*Results@#The qSOFA, SIRS, and CURB-65 scores did not differ between the two groups. The median (interquartilerange) DAT, LOS, and HP were reduced after the process changes: DAT (160.0 minutes [111.0-230.0] vs. 120.0 minutes[74.0-175.0], P<0.001), LOS (7.6 hours [4.8-15.8] vs. 4.7 hours [3.2-6.8], P<0.001), and HP (9.0 days [6.0-16.0] vs. 8.0days [5.0-15.0], P=0.011). On the other hand, the in-hospital mortality was similar in the two groups (14.1% vs. 11.2%,P=0.162). @*Conclusion@#The DAT, LOS, and HP decreased after the process changes, but the in-hospital mortality did not worsen.This shows that pneumonia management in the ED was not compromised, but rather improved, after the changes.

A Case Report Hemiparesis Caused by Ipsilateral Middle Cerebral Artery Infarction

As the corticospinal tract crosses at the medulla, supratentorial stroke generally influences the opposite extremity. However, new incidences of hemiparesis might occur in the ipsilateral brain if there was a previous infarction in the opposite brain or a congenital structural abnormality. The occurrence of ipsilateral hemiparesis after cerebral infarction is very rare; however, we report here the case of a patient who developed right hemiparesis that was identified as acute right middle cerebral artery infarction.

A Case Report Reversible Cerebral Vasoconstriction Syndrome with Thunderclap Headache During Swimming

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe thunderclap headache with multifocal segmental vasoconstriction of the cerebral arteries. RCVS can be diagnosed if the cerebral angiogram shows segmental stenosis and spontaneously resolves within weeks to months. RCVS is reversible, but might cause brain lesions such as subarachnoid hemorrhage or cerebral infarction. We report a 45-year-old woman with severe sudden onset frontal headache who was identified with reversible cerebral vasoconstriction syndrome.

A Clinical Analysis of Patient Exposure to Sulfuric Acid Injured

PURPOSE: This study was conducted to identify the characteristics associated with sulfuric acid injury in the emergency department. METHODS: Data were collected retrospectively from January 2007 to December 2015 on all sulfuric acid injuries presenting to the emergency department in Gu-mi Soonchunhyung University Hospital. Patients injured by sulfuric acid were recorded over a nine year study period and collected data included demographics, injury mechanism, injured body part, hospital care and final diagnosis. RESULTS: A total of 26 cases were identified. Most patients were male (88.5%) and the face was the most commonly injured body part. The most common mechanism of injury was splashing injury. A total of 16 (61.5%) patients were identified as having lesions worse than second degree burns. CONCLUSION: Sulfuric acid can cause severe and fatal skin burn. When working with sulfuric acid, acid proof protect clothing, goggles and glove should be worn. Furthermore, safety education and workplace environment improvement are necessary to reduce sulfuric acid injury.

A Clinical Analysis of Patients Who Visited Emergency Department due to Chemical Incident Occurred at Industrial Place: A Retrospective Study

PURPOSE: The purpose of this study is to understand what kinds of chemical substances have been used annually and to investigate incidents that occurred due to chemical hazard release and to analyze statistically clinically chemical injury patients who visited one regional emergency medical center in Gumi city with documented references review. METHODS: Annual chemical waste emission quantity (Kg/Year) (Cwep) was reproduced using national web site data governed by the Ministry of Environment and 5 years (from 1 .Jan. 2010 to 31. Dec. 2014) of medical records of chemical injury patients who visited our emergency department were reviewed retrospectively. By applying exclusion criteria, 446 patients of 460 patients were selected. RESULTS: Dichloromethane, Toluene, Trichloroethylene, and Xylene were always included within Top 5 of Cweq. Six cases of chemical incidents were reported and in 3 of 6 cases involving Hydrogen fluoride were included during the study period. Male gender and twenties were the most prevalent group. Injury evoking chemicals were Hydrogen fluoride, unknown, complex chemicals (over 2 substances) in sequence. The most frequent site of wounds and injuries was the respiratory tract. Gas among status, intoxication among diagnosis, and discharge among disposition was most numerous in each group. CONCLUSION: There have been no uniform clinical protocols for chemical wounds and injuries due to various kinds of chemicophysical properties and ignorance of antidotes. Therefore conduct of a multicenter cohort study and experiments for ruling out chemicals according to chemicophysical priority as well as development of antidotes and clinical protocols for chemical injury patients is needed.

Epileptic Seizure Revealing a Fahr's Syndrome with Pseudohypoparathyroidism: A Case Report

Fahr's disease is a rare disease characterized by idiopathic abnormal deposits of calcium in intracranial areas. Fahr's syndrome occurs secondarily to other diseases. Endocrine disorders, particularly parathyroid hormone disorders, are most commonly associated with Fahr's syndrome. Common clinical features of Fahr's disease or syndrome include movement disorder, phychiatric disorder, epileptic seizure, dementia, headache, dystonia, myoclonus, tremor, and parkinsonism. We report on a case of a 35-year-old woman with Fahr's syndrome who presented with epileptic seizure and pseudohypoparathyroidism.

Correlation Between Inferior Vena Cava/Aorta Diameter Index and CVP - A Retrospective Study

PURPOSE: To evaluate whether the inferior vena cava/aorta diameter index correlates with central venous pressure (CVP) in the emergency department. METHODS: We selected patients who had computed tomography and had their central venous pressure checked between September 2008 and December 2008. Measurement of the IVC and aorta diameters was performed in conjunction with computed tomography. Subjects were divided into two groups: those with a CVP of less than 8 cm H2O (group A), and those with a CVP greater than 8 cm H2O (group B). Data collected included the patient's age, sex, height, systolic blood pressure, heart rate, hemoglobin level, IVC diameter and aorta diameter. We analyzed the correlation between the IVC/aorta index and the CVP. RESULTS: A total of 80 patients were enrolled in the study. Of the 80, 39 patients were assigned to group A and 41 to group B. The mean IVC diameter in group A was 14.98+/-2.58 mm; in group B it was and 18.84+/-3.01 (p<0.01). The IVC/aorta index in group A was 0.72+/-0.12; in group B it was 0.96+/-0.20 (p<0.01). The correlation coefficient for CVP and IVC was 0.72 (p<0.01); for CVP and aorta it was - 1.5 (p=0.17); for CVP and the IVC/aorta index it was 0.69 (p<0.01). CONCLUSION: The IVC/aorta index is related to the CVP. There is a difference in the IVC diameter and IVC/aorta index between groups A and B. The IVC/aorta index may be a predictor of body fluid status in the emergency department.

Comparison between the Glasgow Coma Scale and Simplified Motor Score as a Tools to Predict Outcome for Adult Stroke Patients

PURPOSE: We wanted to evaluate the utility of the Simplified Motor Score (SMS) for prediction of outcome for adult stroke patients. METHODS: This was a prospective study of adult stroke patients from May to October, 2007. Emergency medicine residents independently checked the Glasgow Coma Scale (GCS) for each patient at the same time that interns otherwise, senior medical students (MS) and nurses checked the 3-point SMS within 5 minutes of patients arrival at our emergency care center. We telephoned the patients or their families to inform them of intubation, or death and to check the cerebral performance category (CPC) on the first- day and- first month after the patients' visits. RESULTS: Fifty-eight patients were enrolled in this study. Each SMS of evaluation by interns, MS and nurses was correlated with GCS (Correlation Coefficient=0.63, 0.59, 0.61; p<0.01, respectively). In the case of mortality within 24 hours, the AUC (area under the curve) for GCS was 0.46 and the AUCs for SMS of interns, MS and nurses were 0.94, 0.94, and 0.94. In the case of intubation within 24 hours, the AUC for GCS was 0.81 and the AUCs for SMS of interns, MS and nurses were 0.78, 0.79, and 0.77. In the case of CPC at one month, the AUC for GCS was 0.82 and the AUCs for SMS of interns, MS and nurses were 0.74, 0.75, and 0.73, respectively. CONCLUSION: The accuracy of SMS was equal to that of GCS for predicting outcome for adult stroke patients in such parameters as mortality, intubation and CPC.

Comparison of Ultrasound-assisted Lumbar Puncture with Lumbar Puncture using Palpation of Landmarks in Aged Patients in an Emergency Center

PURPOSE: We evaluated the utility of ultrasound-assisted lumbar puncture (UALP) in aged patients who visited our emergency center. METHODS:This was a prospective, randomized, controlled study. From July to December 2007 we enrolled patients who were at least 60 years of age . Patients were divided into a group that had lumbar puncture (LP) using landmark palpation (group A) and a UALP group (group B). We did between-group comparisons for the number of attempts, procedure time, the number of LP failures, and whether traumatic LP was done. For all hypotheses, a significance level of 0.05 was used. Variables are reported as percentages and mean +/-standard deviation. RESULTS: We enrolled sixty aged patients: 30 in group A and 30 in group B. There were 5 cases of LP failure in group A and none in group B (p<0.05). There were 6 cases of traumatic lumbar puncture in group A, and one case in group B (p=0.05). The number of attempts was 3.3+/-2.4 in group A and 1.5+/-0.8 in group B (p<0.05). It took 10.6+/-7.7 minutes to finish each LP in group A compared to 5.3+/-4.2 minutes in group B (p<0.05). CONCLUSION: The use of ultrasound-assisted lumbar puncture significantly reduces the number of failures, the number of attempts, and the procedure time in aged patients.

Utility of Optic Nerve Sheath Diameter Measured by Ultrasonography for the Detection of Increased Intracranial Pressure in Adults

PURPOSE: To evaluate the utility of ONSD (optic nerve sheath diameter) measured by US (ultrasonography) in detecting the presence of increased intracranial pressure. METHODS: This prospective study was done from October, 2007, to March, 2008. Patients who were 18 years or younger, had a recent ocular or periocular disease, had an abnormal Q test (Queckenstedtis test), or were uncooperative were excluded. The patients were divided into group A (increased CSF pressure group > or =200 mmCSF) and group B (normal CSF pressure <200 mmCSF). The ONSDs were measured using a 3~12 MHz ultrasonographic probe on the closed eyelids. We analyzed the correlation between the CSF (cerebrospinal fluid) pressure and the ONSD. RESULTS: There were 21 patients in group A and 70 patients in group B. The mean for binocular ONSDs in group A was 5.1+/-0.6 mm and 4.5+/-0.4 mm in group B (plt;0.01). The CSF pressure correlated with the ONSD (Correlation Coefficient=0.54) (plt;0.01). In the ROC curve (Receiver operating characteristic curve) for ONSD to distinguish group A from B, the AUC was 0.8 (95% confidence interval 0.7~0.9) with a sensitivity of 81.0%, and a specificity of 75.7% when the cut off value was set at 4.7 mm. CONCLUSION: The ONSD was related to the CSF pressure, with a difference in the ONSD between group A and group B. The ONSD, as measured by US, can be used to detect the presence of high ICP.

A Clinical Analysis of Hiccup Patients who Visited the Emergency Department

PURPOSE: There have been few studies concerned with the hiccup patients who visit the emergency department. The purpose of this study is to investigate the epidemiology and clinical characteristics of hiccup patients. METHODS: We retrospectively reviewed 60 hiccup patients who visited the emergency departments of Chungbuk National University Hospitals, Chungnam National University Hospital and Chonnam National University Hospital in Korea from January 2005 to December 2007. We categorized the patients into 2 groups of the discharged and the admitted and also into groups of patients who had different types of treatments. We compared clinical outcomes and characteristics of the groups. RESULTS: A total of 60 cases of hiccup patients visited the emergency department from January 2005 to December 2007. There was a significant difference in the recovery rate from hiccups between the discharged group and the admission group (72.4% & 100.0%, p=0.04). The 3 major drugs used for treatment were metoclopramide, chlorpromazine, and benzodiazepine. The patients showed a broad spectrum for the final diagnosis, from the benign hiccups to ischemic stroke in the pons area. CONCLUSION: In this study, the hiccup patients who visited the ED showed simple temporal signs to various severe diseases such as the ischemic stroke in the pons. These findings can be useful reference for the decision making at admission or discharge and for predicting the prognosis of the hiccup patients who visit the emergency department.

Advanced Cardiac Life Support for Hyperkalemic Cardiac Arrest

The acceptable total number of electrical shocks used in treating cardiac arrest is not exactly defined in any of the literature. It is generally expressed as "the more trials the less chance". Electrical therapy should be promptly performed in the presence of "shockable"rhythm. But for pulseless patients bystander cardiopulmonary resuscitation (CPR) should be done on instead. The most reasonable number of attempts of electrical therapy and the length of CPR or unresponsive ventricular fibrillation or pulseless ventricular tachycardia are not well defined. We report the case of 57-year-old woman presenting with mental change due to sustained pulseless ventricular tachycardia who survived to hospital discharge without neurological sequelae after 45 defibrillations and prolonged CPR for 86 minutes.

A Case of Status Epilepticus Following High Dose of Intradermal Lidocaine Injection

Lidocaine is widely used as local anesthetic agent in the emergency department. Lidocaine crosses the blood brain barrier rapidly, and has been recognized generally as a proconvulsant drug. Acute lidocaine intoxication has a variety of causes, most of which related to excessive or inappropriate therapeutic dose. It has been recommended the total amount of lidocaine should not exceed 5 mg/kg without epinephrine and 7 mg/kg with epinephrine. We present a case of a patient who developed generalized convulsive status epilepticus following administration of lidocaine for epidermograft.

A study on the preparation of an acellular allogenic dermis and usefulness in a full thickness wound model

The use of artificial skins for full thickness wounds is an accepted technique, but unfortunately the take rate is low and the aesthetical result is not acceptable. The freeze-drying treatment of allogenic tissues can destroy cells with preserving the structural organization of extracellular matrices, permitting allogenic transplantation. In this study we investigated a new method to process the allogenic skin for transplantable allogenic dermis and this dermis was evaluated in a full thickness wound model. The results are as followings; 1. After treatment with NaCl and SDS solution and then with freeze-drying method, the allogenic dermis shows acellular dermal matrix with preserved normal extracellular matrix. 2. This allogenic dermis became completely incorporated into the wound without evidence of rejection or replacement by scar tissue. 3. The take rate of thin autografts overlying the allogenic dermis that were applied simultaneously was comparable to take rate of autograft alone. 4. The reduction in secondary contraction by allogenic dermis treated wounds was significant. 5. After grafting with cultured keratinocytes, the degree of epithelial coverage was 70% at 2 weeks. In conclusion, the allogenic dermis processed with our method displayed lack of antigenicity, and rapid revascularization. This allogenic dermis can permit simultaneous engraftment of an overlying STSG or cultured kerationocytes, reduce secondary contraction and improve cosmesis of full thickness wounds.

A case of tongue volume measurement with the plaster tongue model for partial glossectomy in macroglossia

The tongue is located inside the oral cavity at rest, and the structural interrelations between the tongue and the oral cavity is essentially important for normal tongue function. Macroglossia is clinically diagnosed whenever the tongue does not fit the oral cavity, thus patients complain of noisy breathing, drooling, speech and swallowing dysfunction, malocclusion, and social ridicule. Partial glossectomy for macroglossia volume has been assumed to be difficult. In this study, we attempted to measure the tongue volume with the plaster tongue model in a 7-year-old macroglossia patient. This method is reliable and simple for measuring the tongue volume in macroglossia.

Breast Reconstruction Using the Pedicled Transverse Rectus Abdominis Myocutaneous (Tram) Flap

In many cases the breast reconstruction surpasses the goal of a normal breast mound appearance in clothing and achieves a result that, in time, may look almost normal in the unclothe state. Breast reconstructions with autologous transverse rectus abdominis myocutaneous (TRAM) flaps are well known to produce the most aesthetically excellent results. the pedicled to TRAM flap cannot be used in high risk patient such as obese or smoking patients due to partial flap necrosis. But, the free TRAM flap have more robust blood supply and less donor site morbidity than the pedicled TRAM flap and is therefore the currently preferred technique in western. However, the free TRAM flaps has a problem related to the anastomotic failure which has been reported as high as 6% to 10%. Moreover many Korean women have smaller sized breast than western women and have no risk factors compromising flap circulation. So the single pedicled TRAM flap can be safely used for breast reconstruction without any flap necrosis. 60% of the elevated flap area has a sufficient volume to mold a new breast that matches with the contralateral breast and the unneccessary distal portion of the flap that has the marginal circulation can be resected. In this study we review our 20 consecutive cases of breast reconstruction using the pedicled TRAM flap and have a conclusion that the pedicled TRAM flap produce an aesthetically acceptable new breast in Korean mastecotmy patients without any flap necrosis or donor site morbidity.