A quick Sequential Organ Failure Assessment–negative result at triage is associated with low compliance with sepsis bundles: a retrospective analysis of a multicenter prospective registry

Objective@#We investigated the effects of a quick Sequential Organ Failure Assessment (qSOFA)–negative result (qSOFA score <2 points) at triage on the compliance with sepsis bundles among patients with sepsis who presented to the emergency department (ED). @*Methods@#Prospective sepsis registry data from 11 urban tertiary hospital EDs between October 2015 and April 2018 were retrospectively reviewed. Patients who met the Third International Consensus Definitions for Sepsis and Septic Shock criteria were included. Primary exposure was defined as a qSOFA score ≥2 points at ED triage. The primary outcome was defined as 3-hour bundle compliance, including lactate measurement, blood culture, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration. Multivariate logistic regression analysis to predict 3-hour bundle compliance was performed. @*Results@#Among the 2,250 patients enrolled in the registry, 2,087 fulfilled the sepsis criteria. Only 31.4% (656/2,087) of the sepsis patients had qSOFA scores ≥2 points at triage. Patients with qSOFA scores <2 points had lower lactate levels, lower SOFA scores, and a lower 28-day mortality rate. Rates of compliance with lactate measurement (adjusted odds ratio [aOR], 0.47; 95% confidence interval [CI], 0.29–0.75), antibiotics administration (aOR, 0.64; 95% CI, 0.52–0.78), and 30 mL/kg crystalloid administration (aOR, 0.62; 95% CI, 0.49–0.77) within 3 hours from triage were significantly lower in patients with qSOFA scores <2 points. However, the rate of compliance with blood culture within 3 hours from triage (aOR, 1.66; 95% CI, 1.33–2.08) was higher in patients with qSOFA scores <2 points. @*Conclusion@#A qSOFA-negative result at ED triage is associated with low compliance with lactate measurement, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration within 3 hours in sepsis patients.

Association between body temperature measured at the emergency department with prognosis in septic shock patients

Objective@#Prior studies have explored the relationship between initial body temperature (BT) and mortality in patients with sepsis in the emergency department (ED). However, there has been no study on whether or not changes in BT are associated with prognosis in these patients. We hypothesize that BT measured upon ED arrival and septic shock registry enroll time are related to the prognosis of patients with septic shock. @*Methods@#We conducted a prospective, observational, registry-based study. Each patient was assigned to 1 of 4 groups according to BT upon ED arrival and registry enrollment. Odds ratios for 28-day mortality according to the patient group were estimated using multivariable logistic regression. We also conducted logistic regression sensitivity analysis, except for patients whose time interval between arrival and enrollment was less than 1 hour. @*Results@#A total of 2,138 patients with septic shock were included. The 28-day mortalities were 13.7%, 11.2%, 13.0%, and 25.8% in groups 1, 2, 3, and 4, respectively (P<0.001). After adjusting for age, sex, mean atrial pressure, respiratory rate, Sequential Organ Failure Assessment score, lactate concentration, comorbidity, and suspicious infection focus, the risk of mortality was significantly low in patients from group 1 (adjusted odds ratio [aOR], 0.433; 95% confidence interval [CI], 0.310-0.604) and group 2 (aOR, 0.540; 95% CI, 0.336-0.868) compared with group 4. In the sensitivity analysis, group based on BT measured upon ED arrival and registry enrollment also remained an independent predictor of mortality. @*Conclusion@#Afebrile status upon ED arrival and registry enrollment were strongly associated with higher 28-day mortality in patients with septic shock.

Comparison of traumatic brain injury patients with brain computed tomography in the emergency department by age group

Objective@#Traumatic brain injury (TBI) is an important public health concern due to its high prevalence and mortality rate among young people. We investigated the clinical and social characteristics of patients who visited the emergency department due to TBI in whom brain computed tomography, was performed by age. @*Methods@#We retrospectively analyzed 15,567 TBI patients who received a brain computed tomography evaluation at the emergency department of Korea University Hospital from March 2013 to February 2016. We divided patients into age groups by decade and analyzed factors such as sex, trauma mechanism, need for operation, hospitalization, and results of treatment. @*Results@#The mean age was 42.0±22.8 years; the most common age group was the 50s (16.5%). Except for the age group over 70 years, males predominated. Under 9 years of age, public ambulance usage rate was lower than in other age groups. Regarding severity based on the Glasgow Coma Scale score, the proportion of mild cases was higher in those under 9 years of age (99.3%) and the proportion of severe cases was higher in those in their 20s (4.6%). The most common injury mechanism was blunt trauma, followed by car accidents. For those under 9 years of age, falls were more common than in other age groups. Only 20.5% of TBI patients were hospitalized and 11.9% were treated surgically, while 70.6% of patients were discharged home after treatment. @*Conclusion@#TBI may present with different characteristics depending on the age of the patients, thus prevention policies and clinical practice should be tailored to age.

Significance of Biomarkers as a Predictive Factor for Post-Traumatic Sepsis

PURPOSE@#Many traumatic patients die from sepsis and multiple organ failure. Early recognition of post-traumatic sepsis in traumatic patients will help improve the prognosis. Recently, procalcitonin (PCT), macrophage migration inhibitory factor (MIF), and lactic acid have emerged as predictive factors. Our study aims to explore the significance of PCT, MIF and lactic acid as a predictor of posttraumatic-sepsis in trauma patients.@*METHODS@#This study was conducted on prospective observational study patients who visited an emergency medical center in a university hospital from March 2014 to February 2016. We measured the white blood cells, c-reactive protein (CRP), lactic acid, PCT, and MIF with serum taken from the patient's blood within 1 hour of the occurrence of the trauma. The definition of post-traumatic sepsis was defined as being part of systemic inflammation response syndrome criteria with infections within a week.@*RESULTS@#A total of 132 patients were analyzed, wherein 74 patients were included in the low injury severity score (ISS) group (ISS < 15) and 58 patients were included in the high ISS group (ISS ≥15). The mean PCT, MIF, and lactic acid levels were higher in the high ISS group (p < 0.05). Meanwhile, 38 patients were included in the early sepsis group and 94 patients were included in the non-sepsis group. The mean MIF levels were higher in the sepsis group than the non-sepsis group (p < 0.05) and there were no significant differences in the initial CRP, lactic acid, and PCT levels in these two groups.@*CONCLUSIONS@#MIF may be considered as a predictive factor for sepsis in trauma patients.

Characteristics and outcomes of patients with septic shock who transferred to the emergency department in tertiary referral center: multicenter, retrospective, observational study

OBJECTIVE: We evaluated the clinical characteristics and prognoses of patients with septic shock who transferred to the emergency department (ED) in a tertiary referral center. METHODS: This study was performed using a prospective, multi-center registry of septic shock, with the participation of 11 tertiary referral centers in the Korean Shock Society between October 2015 and February 2017. We classified the patients as a transferred group who transferred from other hospitals after meeting the inclusion criteria upon ED arrival and a non-transferred group who presented directly to the ED. Primary outcome was hospital mortality. We conducted multiple logistic regression analysis to assess variables related to in-hospital mortality. RESULTS: A total of 2,098 patients were included, and we assigned 717 patients to the transferred group and 1,381 patients to the non-transferred group. The initial Sequential Organ Failure Assessment score was higher in the transferred group than the non-transferred group (6; interquartile range [IQR], 4–9 vs. 6; IQR, 4–8; P < 0.001). Mechanical ventilator (29% vs. 21%, P < 0.001) and renal replacement therapy (12% vs. 9%, P=0.034) within 24 hours after ED arrival were more frequently applied in the transferred group than the non-transferred group. Overall hospital mortality was 22% and there was no significant difference between transferred and non-transferred groups (23% vs. 22%, P=0.820). Multivariable analysis showed an odds ratio for in-hospital mortality of 1.00 (95% confidence interval, 0.78–1.28; P=0.999) for the transferred group compared with the non-transferred group. CONCLUSION: The transferred group showed higher severity and needed more organ support procedures than the nontransferred group. However, inter-hospital transfer did not affect in-hospital mortality.

Analysis of Patients with Acute Toxic Exposure between 2009 and 2013: Data from the Korea Health Insurance Review and Assessment Service and the National Emergency Department Information System

BACKGROUND: According to domestic studies, patients visiting the emergency departments (ED) with acute toxic exposure comprise 0.68%–5.5% of all ED patients, with various causes and motives. The purpose of this study is to investigate the clinical and social characteristics of patients with toxic exposure visiting the ED. METHODS: This study spanned a period of five years, from January 1, 2009 to December 31, 2013. The data were extracted using the National Emergency Department Information System (NEDIS) and The Korea Health Insurance Review and Assessment Service (HIRA). RESULTS: From the HIRA database, during the study period (2009–2013); 310,159 (2009), 289,829 (2010), 288,906 (2011), 285,514 (2012), and 279,575 (2013) patients, respectively, visited EDs with diagnoses related to exposure to toxic substances. The number of patients who presented with acute toxic exposure compared to all ED visits significantly decreased consistently (7.8%, 6.9%, 6.0%, 5.0%, 4.1%) over 5 years. Regarding the cause of toxic exposure, substances other than drugs accounted for the largest percentage, and increased annually. Acetylcysteine was the most commonly prescribed antidote, and patients in their 40s and 50s showed the most frequent visits. The monthly distribution was highest in July-September, and higher in January than in other months. CONCLUSION: This study found that the percentage of patients visiting the ED is decreasing, the exposure to quasi-drugs was the most common, and the exposure to antipsychotic drugs was the most frequent.

Korean Shock Society septic shock registry: a preliminary report

OBJECTIVE: To evaluate the clinical characteristics, therapeutic interventions, and outcomes of patients with septic shock admitted to the emergency department (ED). METHODS: This study was a preliminary, descriptive analysis of a prospective, multi-center, observational registry of the EDs of 10 hospitals participating in the Korean Shock Society. Patients aged 19 years or older who had a suspected or confirmed infection and evidence of refractory hypotension or hypoperfusion were included. RESULTS: A total of 468 patients were enrolled (median age, 71.3 years; male, 55.1%; refractory hypotension, 82.9%; hyperlactatemia without hypotension, 17.1%). Respiratory infection was the most common source of infection (31.0%). The median Sepsis-related Organ Failure Assessment score was 7.5. The sepsis bundle compliance was 91.2% for lactate measurement, 70.3% for blood culture, 68.4% for antibiotic administration, 80.3% for fluid resuscitation, 97.8% for vasopressor application, 68.0% for central venous pressure measurement, 22.0% for central venous oxygen saturation measurement, and 59.2% for repeated lactate measurement. Among patients who underwent interventions for source control (n=117, 25.1%), 43 (36.8%) received interventions within 12 hours of ED arrival. The in-hospital, 28-day, and 90-day mortality rates were 22.9%, 21.8%, and 27.1%, respectively. The median ED and hospital lengths of stay were 6.8 hours and 12 days, respectively. CONCLUSION: This preliminary report revealed a mortality of over 20% in patients with septic shock, which suggests that there are areas for improvement in terms of the quality of initial resuscitation and outcomes of septic shock patients in the ED.

Learning curve and period of experience required for the competent diagnosis of acute appendicitis using abdominal computed tomography: a prospective observational study

OBJECTIVE: To assess the learning curve of novice residents in diagnosing acute appendicitis using abdominal computed tomography (CT) scans. METHODS: This prospective observational study was conducted within a 4-month period from March 1 to June 30, 2015. After CT scans for right lower quadrant pain or similar acute abdomen were evaluated, postgraduate year 1 (PGY-1) residents completed an interpretation checklist. The primary outcome was evaluation of the learning curve for competent CT scan interpretation under suspicion of acute appendicitis. Secondary outcomes were cumulative numbers of accurate abdominal CT interpretations regardless of initial clinical impression and training period. RESULTS: PGY-1 residents recorded a total of 230 interpretation checklists. There were 53, 51, 46, 44, and 36 checklists recorded by individual residents and 92, 92, 91, 91, and 61 respective training days in the emergency department, excluding rotation periods in other departments. After 16 to 20 interpretations of abdominal CT scans performed under suspicion of acute appendicitis, the residents could diagnose acute appendicitis with more than 95% accuracy. Overall, the sensitivity and specificity for diagnosing acute appendicitis were 97% (95% confidence interval, 94 to 100) and 83% (95% confidence interval, 80 to 87), respectively. After 61 to 80 abdominal CT interpretations regardless of suspicion of acute appendicitis and after 41 to 50 days in training, PGY-1 emergency department residents could diagnose acute appendicitis with more than 95% accuracy. CONCLUSION: PGY-1 residents require 16 to 20 checklist interpretations to acquire acceptable abdominal CT interpretation. After performing 61 to 80 CT scans regardless of suspicion of acute appendicitis, they could diagnose acute appendicitis with acceptable accuracy.

The inflammatory response of neutrophils in an in vitro model that approximates the postcardiac arrest state

PURPOSE: Postcardiac arrest syndrome (PCAS) shares many features with sepsis including plasma cytokine elevation with dysregulation of cytokine production, and the presence of endotoxin in plasma. PCAS is closely related to ischemia-reperfusion injury. During ischemia-reperfusion injury, neutrophil, which is the first line of innate immunity, plays a major role. In this study, we investigated the inflammatory response of human neutrophils in an in vitro model which we simulated with hypoxia-normoxia and hypoxia-hyperoxia environments. METHODS: After separation of neutrophils from the whole blood, they were divided into 3 experimental groups: normoxia-normoxia, hypoxia-normoxia, and hypoxia-hyperoxia groups. The production of H₂O₂, the expression of Toll-like receptor 4 (TLR₄) receptor, and the extent of apoptosis of the neutrophils were checked. RESULTS: The in vitro hypoxia-normoxia and -hyperoxia models, which simulated the PCAS, showed initiation of the neutrophils' inflammatory reaction by hypoxia insult. Lipopolysaccharide amplifies such inflammation; therefore, prevention of secondary infection may be critical in postresuscitation patients. Temporary hyperoxia following hypoxic insult showed no difference in inflammatory reaction compared with hypoxia-normoxia. Rather, temporary hyperoxia may suppress or minimize inflammation by attenuation of TLR4 receptor. CONCLUSION: It is well known that continuous hyperoxygenation after successful cardiac arrest harms patients, but temporary hyperoxygenation with 100% O₂ in a clinical situation may be helpful.

Analysis of Trauma Patients with Massive Transfusion in the Emergency Department / 대한수혈학회지

BACKGROUND: It is important that proper protocols are in place for trauma patients who require massive transfusion upon arrival at the emergency department. This study is a preliminary analysis of massive transfusion cases at the emergency department of our institution aimed to review the characteristics and situations in which massive transfusion occurs in an effort to better manage trauma patients receiving massive transfusion in the emergency department. METHODS: This study was conducted at the Department of Emergency Medicine in the Korea University Guro Hospital. We retrospectively reviewed the medical charts of trauma-related patients who required massive blood transfusions between January 2013 and December 2015. The inclusion criteria were as follows: patients who were over the age of 18 years and received more than 4 packed RBC (pRBC) units per hour, or 10 or more pRBC units during a period of 24-hours. RESULTS: A total of 669 patients were included in the study. There were significant differences of initial systolic blood pressure (P<0.0001), diastolic blood pressure (P<0.0001), and Injury Severity Score (P<0.0001) between those who survived and those who expired. CONCLUSION: Proper initial resuscitation is essential for the improvement of outcome in trauma patients that require a massive transfusion. The findings from this study may serve as preliminary data in developing proper transfusion protocols for massive transfusion among trauma patients.

Relation between Inferior Vena Cava Collapsibility and Central Venous Pressure

PURPOSE: For evaluation of volume status in the emergency department, central venous pressure (CVP) measurement is a standard practice. However, this is an invasive method. Measuring inferior vena cava (IVC) size through ultrasound is promising as a non-invasive method. However, few studies have been reported in Korea. Therefore this study measured IVC size and collapsibility in order to examine the clinical usefulness. METHODS: In a prospective study setting, IVC size was measured with ultrasound for patients whose CVP was measured in the emergency department. IVC size of healthy applicants was measured. RESULTS: The healthy group included 100 people: 68 men and 32 women. The average IVC size of men was 1.8+/-0.4 cm and that of women was 1.8+/-0.3 cm. For collapsibility, men were 0.28+/-0.14 and women were 0.23+/-0.14, thus there was no statistical difference in size and collapsibility between men and women. The patient group included 51 people, average age was 59.9+/-18.5, and 28 (54.9%) were men. This group showed a significant negative correlation between CVP and collapsibility. IVC Max was 1.7+/-0.5 cm, IVC Min was 1.2+/-0.5 cm, median collapsibility was 0.26 (0.15-0.38), mean lactate was 6.4+/-4.4 mmol/L, and median CVP was 10.0 (1.0-14.5) cmH2O. CONCLUSION: IVC collapsibility can be used as a reference measure, or even instead of CVP in certain cases.

Effects of Adenosine after Instruction of Injection in Patients with Paroxysmal Supraventricular Tachycardia Presented to the Emergency Department

PURPOSE: There are many cases of paroxysmal supraventricular tachycardia (PSVT) presenting to the emergency department (ED) with palpitation as the presenting symptom. Adenosine is usually administered for conversion to normal sinus rhythm, with a possible second dose in the case of no response. As adenosine has a short acting time, administration of the drug at a vessel as close to the heart as possible is recommended, followed by an extra normal saline bolus infusion. In this study, we hypothesized a better outcome when adenosine was administered after proper injection method instruction was given to the medical staff. METHODS: We retrospectively studied the population of PSVT patients treated with adenosine. The cases were divided into two groups: one group consisted of cases a year before instruction for adenosine use became routine practice, and the second was comprised of cases a year after instruction protocols had been put into place. We further analyzed the proportion of patients who converted to normal sinus rhythm after a single dose of adenosine. RESULTS: All 306 patients were included. Before instruction, 46 patients (40.0% of 115) converted to normal sinus rhythm after the first dose. After instruction, 108 patients (56.5% of 191) converted to normal sinus rhythm after the first dose, which was statistically significant (p<0.05). CONCLUSION: After receiving proper education, more patients converted to normal sinus rhythm after the first dose. Instruction for proper adenosine injection technique for PSVT cases can increase the success rate of rhythm conversion on the first attempt.

Comparative Analysis of Acute Toxic Poisoning in 2003 and 2011: Analysis of 3 Academic Hospitals

Social factors may affect the available sources of toxic substances and causes of poisoning; and these factors may change over time. Additionally, understanding the characteristics of patients with acute toxic poisoning is important for treating such patients. Therefore, this study investigated the characteristics of patients with toxic poisoning. Patients visiting one of 3 hospitals in 2003 and 2011 were included in this study. Data on all patients who were admitted to the emergency departments with acute toxic poisoning were retrospectively obtained from medical records. Total 939 patients were analyzed. The average age of patients was 40.0 +/- 20 yr, and 335 (36.9%) patients were men. Among the elements that did not change over time were the facts that suicide was the most common cause, that alcohol consumption was involved in roughly 1 of 4 cases, and that there were more women than men. Furthermore, acetaminophen and doxylamine remained the most common poisoning agents. In conclusion, the average patient age and psychotic drug poisoning has increased over time, and the use of lavage treatment has decreased.

Clinical Features of Patients with False Negative Diffusion-weighted MR Findings in Acute Ischemic Stroke

PURPOSE: Diffusion-weighted magnetic resonance (MR) image (DWI) has advantages for the assessment of acute stroke. However, false negative DWI findings in acute ischemic stroke have been reported. Our purpose was to estimate the rate of initial false negative DWI studies in acute ischemic stroke patients and to identify characteristics of false negative DWI stroke patients. METHODS: In this retrospective study from January 2010 to June 2011, acute ischemic stroke patients (within 6 hours after stroke onset) were enrolled. A total of 56 patients were included in this study. Cases with negative initial DWI findings, with an ischemic lesion visible on follow-up MR studies, were analyzed for times between the onset of symptoms and initial DWI, National Institute of Health Stroke Scale (NIHSS), and the location of the ischemic stroke lesion. RESULTS: We found seven cases (12.5%) of false negative initial DWI studies. The initial false negative DWI group had a significantly shorter time from the onset of symptoms to the initial DWI compared to the initial positive DWI group (p=0.011). The false negative group had a lower NIHSS without significance (p=0.091). CONCLUSION: A false-negative DWI study is not uncommon in the assessment of acute ischemic stroke. Thus, patients suspected of having a stroke should not be ruled out on the basis of a negative DWI, especially a suspected low NIHSS, for an early onset of symptoms.

Analysis of Measured Quality Variables in Basic Life Support Training for First Responder

PURPOSE: As an emergency medical system provider, cardiopulmonary resuscitation (CPR) quality for first responder is an important determinant of cardiac arrest outcome. However, feedback on their CPR performance is often lacking. In this simulation study, we analyzed their CPR variables after CPR training based on high-quality CPR requirements highlighted by the 2010 American Heart Association updated guidelines. Furthermore, we aimed to compare the CPR quality between first responders and emergency medical technicians. METHODS: Firefighters employed at Seoul metropolitan fire and disaster headquarters in 2011 and 2012 were included in the study. The data were collected from a PC Skill reporting System(R) (Laerdal, Norway) 5 hours after CPR training. Outcomes included compression variables (depth, rate, hand position, full release, delivered per minute, duty cycle), ventilation variables (volume, flow rate) and hands-off time variables (hands-off fraction, time for airway and breathing, automated external defibrillator (AED)). RESULTS: Sixty-one members to the emergency medical technician group and 66 members to the first responder group were recruited and were tested after CPR training. Results of the first responder group were as follows: for average compression variables, depth 57.6 mm, rate 108.3 numbers/min, correct hand position 90.0%, full release 100.0%, and duty cycle 40.8%. For average ventilation variables, volume 526.2 ml and flow rate 316.8 ml/sec. These values were same for both groups and showed no statistical significance. The number of compressions performed per minute was better in the emergency medical technician group (74.4 versus 70.6, p<0.002), as was total hands-off time (65.5 sec versus 73.2 sec, p<0.000) and hand-off fraction (32.0% versus 35.2%, p<0.000). Time for operating AED was found to be same for both groups but time for airway and breathing management was shorter in the emergency medical technician group (41.0 sec versus 48.0 sec, p<0.000). CONCLUSION: The first responder group showed that through short-term CPR training, overall measured quality of CPR was in compliance with international consensus guidelines. But total hands-off time was longer in the first responder group and the time spent for airway and breathing management rather than operating AED was significantly different between the two groups. Appropriate training programs for first responder's airway and breathing skills are required to minimize interruption time.

Prediction of Massive Blood Transfusion at Emergency Department in Non-trauma Patients / 대한수혈학회지

BACKGROUND: Many patients received transfusion in emergency department because of blood loss. There are few studies on massive transfusion for non-traumatic patients. This study investigated mortality and risk factor for non-traumatic bleeding patients who received transfusion. METHODS: Non-trauma patients who received transfusion at the emergency department for 3 years from March 2009 to February 2011 were enrolled. The patients who are younger than 15 years, trauma patients, and transfused FFP or platelet alone are excluded. Medical records was investigated retrospectively. We investigated predictive factors for MT on non-trauma patients and predictive factors for mortality on MT patients. RESULTS: Among 1655 non-trauma patients, 150 patients (9.24%) received MT. The age of MT group was younger than that of non-MT group and systolic bloor pressure, diastolic blood pressure, mean arterial pressure were significantly lower. Base excess, pH, lactate levels were significantly different between MT and non-MT group. Intensive care unit length of stay was longer, mortality of 24 hours was higher and survival discharge was lower than non-MT group. Mortality rate of MT group was 20.7% which was significantly higher than non-MT group's 9.3%. FFP:RBC ratio was higher in MT group than non-MT group. Among the MT group, non-survival group used higher FFP:RBC ratio product than survival group. On multivariate analysis, sBP, MAP, lactate, pH, BE were significant as predictors of MT. CONCLUSION: For non-trauma patients in emergency department, if sBP, MAP, lactate, pH, BE are abnormal, massive transfusion could be expected. Like trauma patients, basic scoring system that can predict MT would be necessary and useful.

Hypertonic saline downregulate the production level of lipopolysaccharide-induced migration inhibitory factor in THP-1 cells / 대한외과학회지

PURPOSE: Macrophage migration inhibitory factor (MIF) may serve as a general marker for systemic inflammation in septic and nonseptic acute critical illness. Additionally, our previous experiment has demonstrated that immunosuppressant Prostaglandin E2 (PGE2) lowered MIF levels and inhibited T-cells proliferation when compared to control levels. The addition of hypertonic saline (HTS) increased MIF production as compared with PGE2-stimulated T-cells in concordance with restore PGE2-suppressed T-cells proliferation. Generally, HTS has been well known for its anti-inflammatory effect so far. Therefore, the experiments were conducted to evaluate MIF after stimulating lipopolysaccharide (LPS) either in the presence or absence of HTS in monocyte, in response to early phase injury. METHODS: Human acute monocytic leukemic cell line (THP-1) cells were cultured in RPMI media, to a final concentration of 1 x 10(6) cells/mL. The effect of HTS on LPS-induced MIF was evaluated in monocyte with 1 microg/mL LPS. HTS at 10, 20 or 40 mmol/L above isotonicity was added. MIF concentrations of the supernatant were determined by enzyme-linked immunosorbent assay, and cell lysates were used for Western blots analysis to determine the MIF expression. RESULTS: MIF concentrations in the cell supernatant increased in LPS-induced cells compared to control cells. Also, levels of MIF protein expression were higher in LPS stimulating cells. However, the addition of HTS to LPS stimulated cell restored MIF concentrations and MIF expression. CONCLUSION: The role of HTS in maintaining physiological balance in human beings, at least in part, should be mediated through the MIF pathway.

Detecting Potassium Imbalance: Whole Blood vs. Serum / 대한수혈학회지

BACKGROUND: Potassium, the most common cation in the intracellular space, plays a critical role in our physiology. Potassium imbalance may cause life-threatening problems, ranging from general weakness to cardiac arrest due to ventricular fibrillation. For emergency physicians, detection of such derangement within a short period of time is of critical importance. In this study, we wanted to determine whether analysis of whole blood samples can be used as a screening tool for potassium imbalance by comparative analysis of whole blood and serum samples. METHODS: Two samples were drawn from 227 patients. The whole blood sample was taken from the radial artery and contained in a commercially available arterial blood collection syringe with a lithium-heparin coating. The serum sample was contained in a commercially available vacuum bottle in a non-additive silicone coated tube and transported to the laboratory. The study population was divided into three groups, patients with normal whole blood potassium, patients with decreased whole blood potassium, and patients with elevated whole blood potassium. Potassium levels for each group were coupled with serum potassium levels and compared. RESULTS: No significant difference in potassium values was observed between whole blood and serum samples (P<0.05). Strong associations were observed among the three groups (normal range, hypokalemia, and hyperkalemia group). Compared to the normal group (r=0.851), the hyperkalemia group showed a stronger association between variables (r=0.897), and the hypokalemia group showed a weaker association (r=0.760). Their correlation coefficients were highly significant (P<0.05). CONCLUSION: Our study illustrates that point-of-care testing using whole blood with whole blood can be a reliable screening tool when treating patients with suspicious potassium abnormality, especially in hyperkalemia patients.

Effect of hypertonic saline and macrophage migration inhibitory factor in restoration of T cell dysfunction / 대한외과학회지

PURPOSE: Trauma-induced suppression of cellular immune function likely contributes to sepsis, multiple organ dysfunction syndrome and death. T cell proliferation decreases after traumatic stress. The addition of prostaglandin E2 (PGE2), which depresses immune function after hemorrhage and trauma, to T-cells decreases T-cell proliferation; and hypertonic saline restores PGE2-induced T-cell suppression. Recently, it has become apparent that macrophage migration inhibitory factor (MIF) plays a central role in several immune responses, including T-cell proliferation. However, the role of MIF in mediating hypertonic saline (HTS) restoration of T cell dysfunction is unknown. Therefore, we hypothesize that T cell immune restoration by HTS occurs, at least in part, by a MIF-mediated mechanism. METHODS: Jurkat cells were cultured in Roswell Park Memorial Institute media, at a final concentration of 2.5 x 106 cell/mL. The effects of HTS on T-cell proliferation following PGE2-induced suppression were evaluated in Jurkat cells: HTS at 20 or 40 mmol/L above isotonicity was added. MIF levels were determined by enzyme-linked immunosorbent assay and western blot analysis. RESULTS: PGE2 caused a 15.0% inhibition of Jurkat cell proliferation, as compared to the control. MIF levels decreased in PGE2-suppressed cells, as compared to the control. MIF levels were higher in cells treated with HTS than PGE2-stimulated cells. CONCLUSION: The role of HTS in restoring Jurkat cells proliferation suppressed by PGE2, at least in part, should be mediated through a MIF pathway.

Effect of beta-hCG with a Point-of-Care Test in the Emergency Department

PURPOSE: The rapid and accurate diagnosis of pregnancy is important in the emergency department (ED) before evaluation of radiologic tests and medication decisions. Our primary objective was to assess the agreement between whole blood pregnancy tests done in the emergency department and those done in laboratory [serum human chorionic gonadotropin (beta-hCG) and urine beta-hCG]. The secondary objective was to compare turnaround times for tests done in the ED and those done in the laboratory. METHODS: This prospective study enrolled females of childbearing age needing a pregnancy test who visited an ED. Using whole blood, urine and serum from each patient, testing was done in the ED (whole blood - Hubi Quan pro-point of care test, POCT) and in the laboratory using a urine hCG kit (iIexscreen) and in serum (ADVIA centaur). The data included time of each test, beta-hCG result, and urine pregnancy test result. RESULTS: There was a high level of agreement between the POCT using whole blood and the serum beta-hCG as indicated by a kappa value of 0.921(95% confidence interval). The POCT performed in the ED was significantly faster in time to report than tests performed in the laboratory, with mean differences of 20.21+/-2.0 minutes and 36.14+/-20.86 minutes. The sensitivity and specificity of POCT was 98.18% and 93.75%, respectively. CONCLUSION: In ED, the POCT test can perform pregnancy test as accurately as in the laboratory, and can provide results on which to base care much faster than waiting for the laboratory results. POCT may expedite the ED management of patients who require pregnancy tests. Especially, this POCT uses whole blood instead of the urine, since the latter was inconvenient for the test.