The association between transferrin saturation and all-cause mortality in chronic kidney disease: findings from Korean Cohort Study for Outcome in Patients with Chronic Kidney Disease.

Background: Transferrin saturation (TSAT) has been used as an indicator of iron deficiency. However, there is no consensus regarding its optimal range for patient with chronic kidney disease (CKD). We aimed to analyze the effect of TSAT on the prognosis of patients with non-dialysis CKD (NDCKD). Methods: From 2011 to 2016, 2157 NDCKD patients with baseline TSAT measurements were followed for 10 years. Patients were divided into three groups based on baseline TSAT values: <25%, ≥25% and <45%, and ≥45%. All-cause mortality and 4-point major adverse cardiovascular events (MACE) were analyzed using multivariable Cox regression analysis. Other iron biomarkers and mortality were also analyzed. Results: During a mean follow-up of 7.1 ± 2.9 years, 182 of a total of 2,157 patients (8.4%) died. Compared with the TSAT ≥25% and <45% group, the TSAT <25% group showed significantly increased all-cause mortality (hazard ratio [HR], 1.44; 95% confidence interval (CI), 1.02-2.03; p = 0.04). The occurrence of 4-point MACE was significantly increased in univariable analysis in the TSAT <25% group (HR, 1.48; 95% CI, 1.02-2.15; p = 0.04), but it was not significant in the multivariable analysis (HR, 1.38; 95% CI, 0.89-2.15; p = 0.15). Tertile comparisons of the iron-to-log-ferritin ratio showed increased mortality in the first tertile group. Conclusion: TSAT <25% is an independent risk factor for all-cause mortality in patients with NDCKD and care should be taken to prevent TSAT values of <25%. Other indicators, such as serum iron and iron-to-log-ferritin ratio, may also be used to assess iron deficiency.

Precisely Tunable Synthesis of Binder-Free Cobalt Oxide-Based Li-Ion Battery Anode Using Scalable Electrothermal Waves.

Binder-free transition metal oxide-based anodes for lithium-ion batteries (LIBs), having high capacity and abundance, have received considerable attention. However, their low conductivity and unstable charge-discharge cycles must be addressed, and scalable fabrication routes for binder-free design with optimal phase tuning are necessary. Herein, we report a precisely tunable synthesis of binder-free cobalt oxide-based LIB anodes using scalable electrothermal waves. Needle-like nanoarrays of cobalt hydroxide on nickel foams are prepared as precursors, and Joule-heating-driven electrothermal waves passing through the metal foams cause transition to cobalt oxides with preserved structures and adjustable phase tuning of grains and oxygen vacancies. The rapid heating-cooling environment using electrothermal waves causes extreme input thermal energy over the activation energy of phase transitions and metastable phase trapping. This programmable route completes the selective grain characteristics and vacancy concentrations. The electrothermally tuned binder-free LIB anodes employing the CoO/Co3O4@Ni foam-based electrodes exhibit a high-rate capacity (3.7 mAh cm-2) at 2.4 mA cm-2 for 70 charge-discharge cycles. Accumulated electrothermal waves from multiple cycles broaden the tunable ranges of the morphological and chemical transitions causing rapid screening of the optimal phases for LIB anodes. This phase-tuning strategy will inspire precise yet efficient synthesis routes for diverse binder-free electrodes and catalysts.

Dabrafenib- and trametinib-associated glomerular toxicity: A case report.

RATIONALE: Combined treatment with dabrafenib, a B-RAF inhibitor, and trametinib, a mitogen-activated protein kinase inhibitor, is an effective option for patients with metastatic melanoma. A few cases of acute kidney injury associated with tubulointerstitial nephritis and 1 case of nephrotic syndrome have been reported in patients on this drug combination; however, progressive renal injury has not been reported. In this case study, we report a patient with metastatic melanoma who developed glomerular capillary endothelial toxicity and progressive glomerular sclerosis during combination therapy. PATIENT CONCERN: Our patient was an 80-year-old woman with a history of type 2 diabetes and chronic kidney disease. DIAGNOSIS AND INTERVENTION: She was diagnosed with metastatic melanoma and commenced combination therapy with dabrafenib and trametinib. OUTCOMES: Her renal function progressively deteriorated; by month 20 after treatment commencement, her serum creatinine level had increased from 1.59 to 3.74 mg/dL. The first kidney biopsy revealed marked glomerular and endothelial cell damage. Her medication was stopped, but no improvement was evident. At 5 months after the first biopsy, her serum creatinine level had increased to 5.46 mg/dL; a second kidney biopsy revealed focal segmental glomerular sclerosis and marked tubulointerstitial fibrosis. She was started on hemodialysis. LESSONS: We describe a patient with a metastatic melanoma who developed progressive kidney failure during treatment with dabrafenib and trametinib. The most prominent microscopy findings were glomerular endothelial damage in the initial kidney biopsy and accelerated glomerular sclerosis and tubulointerstitial fibrosis in the follow-up biopsy. We hypothesize that a decreased renal reserve and impairment of kidney repair capacity caused by inhibition of B-RAF, a downstream mediator of vascular endothelial growth factor, may explain the progressive kidney injury.

Effect of problem-based learning on severity classification agreement by triage nurses.

BACKGROUND: Differences in the classification results among triage nurses in the emergency room can be improved by training or applying an algorithm. This study aimed to confirm whether the agreement among triage nurses could be improved through learner-led problem-based learning. METHODS: This study had a single-group time series design to investigate the effect of problem-based learning led by triage nurses on the agreement of Korean Triage and Acuity Scale classification results for patients who visited the emergency department. We extracted 300 patients each in May and August 2018 before learning began and 300 patients each in May and August 2019 after learning. RESULTS: After problem-based learning was applied, the self-efficacy of triage nurses for emergency patient classification increased statistically significantly compared to before learning (7.88 ± 0.96, p < .001), and the weighted kappa coefficient was also found to be almost perfectly agreement (0.835, p < .001). CONCLUSIONS: In this study, problem-based learning improved the inter-rater agreement of Korean Triage and Acuity Scale classification results and self-efficacy of triage nurses. Therefore, problem-based learning can contribute to patient safety in the emergency department by enhancing the expertise of triage nurses and increasing the accuracy of triage classification.

In-Depth TEM Investigation on Structural Inhomogeneity within a Primary Lix Ni0.835 Co0.15 Al0.015 O2 Particle: Origin of Capacity Decay during High-Rate Discharge.

The structural stability of cathode materials during electrochemical reactions, in particular, under high-rate discharge, is pertinent to the design and development of new electrode materials. This study investigates the structural inhomogeneity that develops within a single LiNi0.835 Co0.15 Al0.015 O2 (NCA83) particle during a fast discharging process under different cutoff voltages. Some of the NCA83 particles discharged from a high cutoff voltage (4.8 V) developed surface areas in which the layered structure was recovered, although the interiors retained the degraded spinel structure. These micro- and nano-scale structural inversions from high cutoff voltage seem highly correlated with structural evolutions in the initial charged state, and may ultimately degrade the cycling stability. This study advances understanding of the structural inhomogeneity within primary particles during various electrochemical processes and may facilitate the development of new Ni-rich cathode materials.

Structural Evolution of LixNiyMnzCo1-y-zO2 Cathode Materials during High-Rate Charge and Discharge.

Ni-rich lithium transition metal oxides have received significant attention due to their high capacities and rate capabilities determined via theoretical calculations. Although the structural properties of these materials are strongly correlated with the electrochemical performance, their structural stability during the high-rate electrochemical reactions has not been fully evaluated yet. In this work, transmission electron microscopy is used to investigate the crystallographic and electronic structural modifications of Ni-based cathode materials at a high charge/discharge rate of 10 C. It is found that the high-rate electrochemical reactions induce structural inhomogeneity near the surface of Ni-rich cathode materials, which limits Li transport and reduces their capacities. This study establishes a correlation between the high-rate electrochemical performance of the Ni-based materials and their structural evolution, which can provide profound insights for designing novel cathode materials having both high energy and power densities.

Investigation of Thermal Stability of P2-NaxCoO2 Cathode Materials for Sodium Ion Batteries Using Real-Time Electron Microscopy.

Here, we take advantage of in situ transmission electron microscopy (TEM) to investigate the thermal stability of P2-type NaxCoO2 cathode materials for sodium ion batteries, which are promising candidates for next-generation lithium ion batteries. A double-tilt TEM heating holder was used to directly characterize the changes in the morphology and the crystallographic and electronic structures of the materials with increase in temperature. The electron diffraction patterns and the electron energy loss spectra demonstrated the presence of cobalt oxides (Co3O4, CoO) and even metallic cobalt (Co) at higher temperatures as a result of reduction of Co ions and loss of oxygen. The bright-field TEM images revealed that the surface of NaxCoO2 becomes porous at high temperatures. Higher cutoff voltages result in degrading thermal stability of NaxCoO2. The observations herein provide a valuable insight that thermal stability is one of the important factors to be considered in addition to the electrochemical properties when developing new electrode materials for novel battery systems.

Reliability and Validity of Culturally Adapted Executive Function Performance Test for Koreans with Stroke.

BACKGROUND: Executive Function Performance Test was unusable in Asia because of cultural differences, although evaluating the effect that executive function has on real life is essential to people with stroke. The aims of this study were to report the development and standardization of culturally appropriate Executive Function Performance Test for Koreans (EFPT-K) and to verify its reliability and validity in the stroke population. METHODS: EFPT-K was developed by going through the process of translation, back-translation, and an expert committee's conference on cultural adaptation. Inter-rater reliability was examined and 34 people with stroke were recruited to test the internal consistency and criterion validity of EFPT-K. To verify the criterion validity, EFPT-K scores were compared with those of the Trail-Making Test, the Korean Color-Word Stroop Test, the Digit Span Test, and the Assessment of Motor and Process Skills (AMPS). RESULTS: Inter-rater reliability and internal consistency of the total score of EFPT-K supported high levels of reliability. In the criterion validity of EFPT-K, all neuropsychological tests but digits backward showed a correlation with the total score of EFPT-K, and AMPS components of initiation, notice/response, and termination showed a moderate correlation with the EFPT-K score. CONCLUSIONS: EFPT-K is a useful tool to evaluate the executive functioning of patients with stroke in real-life tasks and could be used as a sample in other Asian cultures where thorough evaluation of executive function in the performance of daily life is needed.

The Automated Alert System for the Hospital Infection Control and the Safety of Medical Staff Based on EMR Data.

This report is about planning, developing, and implementing the automated alert system for the Hospital infection control and the safety of medical staffs about information on patients exposed to infection based on EMR Data in a tertiary hospital in Korea.

An automated information system for families of patients in the operation room based on EMR data.

When children undergo surgery, the parents waiting for them outside the room feel extreme anxiety. SNUH was a full EMR hospital. But nurses had to manually operate an electronic display board which provided information regarding the progresses of the operations. The parents had to be located in front of the board. It was a unilateral and passive system. Therefore, we were about to improve the system to provide efficient information satisfying both parents and nurses. This service, which connected to the EMR system to provide real time location of patients undergoing operations, provide information through an electronic display board outside the operating room and SMS messages. We could reduce uneasiness of patients' families, increase satisfactions, and further, not only contribute to establishing the improved service of SNUH but also lessening unnecessary duties of nurses.

Development of an early detection and monitoring system for deteriorating patients.

A number of methods of preventing cardiopulmonary arrest are currently in use. One such method is the alert response system developed by Seoul National University Children's Hospital, which is an early detection and monitoring system for deteriorating patients who are at risk of cardiopulmonary arrest. This system offers an effective means of detecting early warning signs and monitoring deteriorating patients, and its application can reduce rates of cardiopulmonary arrest.

The relationship between the fish consumption and blood total/methyl-mercury concentration of costal area in Korea.

The purpose of this study was to evaluate the relationship between fish consumption and blood THg/MeHg concentration in Korean adults by measuring MeHg concentration in blood directly. The study subjects consisted of 400 adults aged 20 or older from 30 subareas in Busan, Ulsan and Gyeongsangnam-do province in Korea from August to October, 2010. We tried to recruit the same number of male and female participants in different age groups (20s, 30s, 40s, 50s and 60s) and allocated 13-16 subjects by district to represent Hg concentration in the research areas. The geometric means of THg and MeHg concentration in blood were 5.27 µg/L (5.00-5.57) and 4.05 µg/L (3.81-4.32), respectively. The proportion of MeHg/THg concentration was 78.53% (77.09-79.97). MeHg concentration was higher in coastal areas (4.26 µg/L) than in inland areas (3.52 µg/L) and was higher in men (4.68 µg/L) than in women (3.52 µg/L). In male participants, blood MeHg concentration increased with increasing annual fish consumption, and the proportion of MeHg/THg concentration showed an upward trend as THg concentration increased. However, none of the measures of the proportion of MeHg/THg showed significant differences. This is the first report in Korea about the relationship between blood MeHg concentration and related factors. Our findings suggest that MeHg concentration is affected by fish consumption as well as by gender difference and drinking status. Since the pathological mechanism has not been clarified, additional studies are needed for explaining the biological and lifestyle differences in the risk of adverse health effects by Hg exposure.

Analysis of methylmercury concentration in the blood of Koreans by using cold vapor atomic fluorescence spectrophotometry.

BACKGROUND: Methylmercury is an organic form of mercury that is highly toxic to humans. Here, we present and establish a novel method to detect methylmercury concentrations in the blood of Koreans. METHODS: Methylmercury concentration was analyzed with an automated methylmercury analytic system (MERX, Brooks Rand Co., USA) using cold vapor atomic fluorescence spectrophotometry (CVAFS). A variety of biological materials were digested in methanolic potassium hydroxide solution. The analysis method was validated by examination of certified reference material (955c, National Institute of Standard and Technology, USA). We randomly selected 30 Korean adults (age 20 yr or older) to analyze total blood mercury and methylmercury concentrations. RESULTS: The detection limit and methylmercury recovery rate using this method were 0.1 pg/L and, 99.19% (range: 89.33-104.89%), respectively. The mean blood concentration of methylmercury was 4.54±2.15 µg/L (N=30). The mean proportion of methylmercury to the total mercury concentration was 78.27% (range: 41.37-98.80%). CONCLUSIONS: This study is the first report to analyze blood methylmercury concentration using CVAFS in Korea. We expect that this method will contribute to the evaluation of mercury exposure and the assessment of the toxicological impact of mercury in future studies.

Case study: analysis of end-user requests on electronic medical record and computerized physician order entry system of Seoul National University Hospital in Korea.

Seoul National University Hospital (SNUH) in Korea has utilized the full Electronic Medical Record (EMR) system since October 2004. Unlike other countries, most EMR systems in Korean teaching and general hospitals are in-house development systems. Therefore, we can actively respond to user requests on EMR. Here, based on 5 years of experience in EMR system operation, we analyzed 2,339 SNUH EMR user requests from 2006 to 2008 for improvement of EMR system operation and management. We classify user requests into 9 criteria based on guidelines from the SNUH medical information management team. In conclusion, the most common requests (73%) are for improvement of improving quality of care. However, requests associated with hospital enterprise, public policy, and customer service are gradually increased every year. Therefore, we suggest that suitable EMR management criteria are necessary for reliable EMR operation and management.

Classification of nursing statements based on the ICNP, the HHCC, and the nursing process for use in electronic nursing records.

The purposes of this study were to identify nursing-phenomena-related statements and nursing-action- related statements for use in nursing records, to link nursing statements for the nursing process, to develop integrated nursing terms using the ICNP, to identify new terms for inclusion, and to group statements using the HHCC in a user interface. We extracted 5,133 nursing-phenomena-related statements and 3,844 nursing-action-related statements, with the former including 233 nursing diagnoses. A total of 2791 nursing terms were mapped and 287 new terms were developed. Synonyms of 827 standard nursing terms were extracted. We developed trees of nursing statements using the HHCC for the user interface in an electronic nursing record. The quality of nursing documentation and the nursing performance improved with the standardization process.