Joong Eui Rhee

Red cell distribution width as a prognostic marker in patients with community-acquired pneumonia.

BACKGROUND Red cell distribution width (RDW) is associated with mortality in both the general population and in patients with certain diseases. However, the relationship between RDW and mortality in patients with community-acquired pneumonia (CAP) is unknown. The objective of this study was to evaluate the association of RDW with mortality in patients with CAP. METHODS We performed a retrospective analysis of a prospective registry database of patients with CAP. Red cell distribution width was organized into quartiles. The pneumonia severity index (PSI) and CURB-65 were calculated. The primary outcome was 30-day mortality. Secondary outcomes included the length of hospital stay, admission to the intensive care unit, vasopressor use, and the need for mechanical ventilation. RESULTS A total of 744 patients were included. The PSI and CURB-65 were higher in patients with a high RDW. Multivariate logistic regression analysis identified higher categories of RDW, PSI, CURB-65, and albumin as statistically significant variables. Thirty-day mortality was significantly higher in patients with a higher RDW. Among the secondary outcomes, the length of hospital stay and vasopressor use were significantly different between the groups. In a Cox proportional hazard regression analysis, patients with higher categories of RDW exhibited increased mortality before and after adjustment of the severity scales. Receiver operating characteristics curves demonstrated improved mortality prediction when RDW was added to the PSI or CURB-65. CONCLUSION Red cell distribution width was associated with 30-day mortality, length of hospital stay, and use of vasopressors in hospitalized patients with CAP. The inclusion of RDW improved the prognostic performance of the PSI and CURB-65.

Acute Appendicitis in Young Adults: Low- versus Standard-Radiation-Dose Contrast-enhanced Abdominal CT for Diagnosis

PURPOSE To compare low and standard radiation doses in intravenous contrast material-enhanced abdominal computed tomography (CT) for the diagnosis of acute appendicitis in young adults. MATERIALS AND METHODS The institutional review board approved this retrospective study and waived informed consent. The study included 257 patients (age range, 15-40 years) who underwent CT for suspected appendicitis performed by using a low radiation dose (n = 125) or a standard radiation dose (n = 132). Receiver operating characteristic (ROC) analysis, Fisher exact tests, and Mann-Whitney U tests were used to compare the diagnosis of appendicitis and diagnostic confidence as recorded in prospective CT reports between the two groups. RESULTS For 55 low-radiation-dose (median dose-length product, 122 mGy · cm) and 44 standard-dose (median dose-length product, 544 mGy · cm) examinations, one of two abdominal radiologists made primary reports that served as final reports. For the remaining examinations, on-call radiologists with differing levels of experience issued preliminary reports and the two abdominal radiologists then provided final reports. In the primary reports, the low- and standard-dose CT groups did not significantly differ in area under the ROC curve (0.96 vs 0.97, P = .76), sensitivity (90% [38 of 42] vs 89% [47 of 53], P > .99), or specificity (92% [76 of 83] vs 94% [74 of 79], P = .74) in the diagnosis of appendicitis. There was also no significant difference between the two groups in the confidence level when diagnosing (P = .71) or excluding (P = .20) appendicitis in the primary reports. Similar results were observed for the final reports. The two dose groups also did not significantly differ in terms of appendiceal visualization, diagnosis of appendiceal perforation, or sensitivity for alternative diagnoses. CONCLUSION Low-dose CT may have comparable diagnostic performance to standard-dose CT for the diagnosis of appendicitis in young adults.

Epidemiologic Characteristics of Death by Poisoning in 1991-2001 in Korea

The purpose of this study was to investigate the epidemiologic characteristics of the death by poisoning in Korea. We recoded the Death Certificates Database by injury based on the short version of the International Classification of External Causes of Injuries (ICECI). We evaluated the mortality rate by total injury and poisoning, and analyzed the mortality rate by age, gender, year and month, toxic agent, and intent. Adjusted odds ratios were calculated to evaluate the effects of socioeconomic factors on suicidal poisoning death. The total number of death cases by injury was 346,656. The proportion of death cases by injury decreased from 13.53% of all death cases in 1991 to 11.89% in 2001. However, the mortality rate by poisoning increased rapidly from 1998, and then remained stable. The number of suicidal poisoning deaths has gradually increased, and its mortality rate was 6.41 (per 100,000) in 2001. Major toxic agents were pesticides and herbicides (50.90%) in 2001. Adjusted odds ratios of suicidal poisoning versus other poisonings showed significant differences in education attainment, region, and marital status. In conclusion, the mortality rate by poisoning has increased, and the proportion of suicidal poisoning also has increased compared to that of accidental poisoning.

Impact of helical computed tomography in clinically evident appendicitis

Objectives: To determine the utility of multidetector computed tomography (MDCT) in patients with clinically evident acute appendicitis and to compare the test characteristics of overall clinical impression, Alvarado scores, and MDCT in suspected appendicitis. Methods: A prospective observational cohort study was conducted in two urban emergency departments (ED). Consecutive patients with suspected acute appendicitis were clinically evaluated by an emergency physician who was asked to determine whether appendicitis was clinically evident or not. Elements of the Alvarado scores were collected and all patients then underwent MDCT and a decision to operate, observe, or discharge the patients was made by a surgeon. The final diagnosis was based on surgical pathology or clinical follow-up. The test characteristics of clinical impression, Alvarado scores and MDCT were then calculated and the rates at which acute appendicitis was falsely diagnosed based on clinical impression and MDCT were compared using McNemar’s test. Results: Of 157 study patients, 71 were considered to have clinically evident appendicitis before MDCT and 91 had findings of acute appendicitis on MDCT. 19 of the 71 patients with clinically evident appendicitis did not have appendicitis. 14 of 52 patients with an Alvarado score ⩾8 also did not have appendicitis. Three of 91 patients with acute appendicitis based on MDCT did not have appendicitis. The specificities of clinical impression and Alvarado score ⩾8 were 71.6% and 79.1%, respectively, and these were significantly lower than that of MDCT (95.5%, p<0.05). Conclusion: The performance of abdominal MDCT in patients with a high degree of clinical suspicion for acute appendicitis reduces the number of false positives and has the potential to reduce negative appendectomies.

Prognostic implication of initial coagulopathy in out-of-hospital cardiac arrest.

OBJECTIVE We sought to investigate the prognostic implication of early coagulopathy represented by initial DIC score in out-of-hospital cardiac arrest (OHCA). METHODS OHCA registry was analyzed to identify patients with ROSC without recent use of anticoagulant between 2008 and 2011. Patients were assessed for prehosptial factors, initial laboratory results and therapeutic hypothermia. Outcome variables were survival discharge, 6-month CPC and survival duration within the first week after ROSC. Logistic regression and Cox proportional hazards models were used for both univariable and multivariable analysis. RESULTS Among 273 eligible patients, initial DIC score was available in 252 (92.3%). Higher DIC score was associated with increased inhospital death (odds ratio [OR], 1.89 per unit; 95% confidence interval [CI], 1.48-2.41) and unfavorable long-term outcome (6-month CPC 3-5; OR, 2.21 per unit; 95% CI, 1.60-3.05). The adjusted ORs for both outcomes were 1.61 (95% CI, 1.17-2.22) and 1.84 (95% CI, 1.26-2.67), respectively. We categorized DIC score in five groups as <3, 3, 4, 5 and >5 and analyzed differential mortality risk using Cox proportional hazards model. Compared with reference group (DIC score<3), the adjusted HR for early mortality in each remaining group was 1.96 (95% CI, 1.13-3.40), 2.26 (95% CI, 1.27-4.02), 2.77 (95% CI, 1.58-4.85) and 4.29 (95% CI, 2.22-8.30), respectively (p-trend<0.001). The area under the receiver operating characteristic of DIC score for prediction of unfavorable long-term outcome was 0.79 (95% CI, 0.69-0.88). CONCLUSION Increased initial DIC score in OHCA was an independent predictor for poor outcomes and early mortality risk.

Red blood cell distribution width as an independent predictor of all-cause mortality in out of hospital cardiac arrest

OBJECTIVE Post-resuscitation period is characterized by high early mortality due to post-cardiac arrest syndrome. Recent studies found that elevated red cell distribution width (RDW) is a strong predictor of mortality in critically ill patients. We investigated the prognostic significance of RDW in out-of-hospital cardiac arrest (OHCA) victims. METHODS Analysis of emergency department OHCA registry extending from January 2007 to December 2010 was conducted. Patients with ROSC were assessed for Utstein predictors including sex, age, arrest location, presence of witness, bystander cardiopulmonary resuscitation, response time, initial rhythm and cause of arrest. RDW, hematocrit, white blood cell and platelet counts, blood urea nitrogen (BUN), creatinine and albumin were also obtained. Outcome variable was survival duration within 30 days. RDW was categorized in quartiles as <13.2%, 13.2% to 14.0%, 14.1% to 15.4% and >15.4%. Hazard ratios (HRs) were estimated using Cox-proportional hazard models in both univariate and multivariate analysis. All prognostic variables with their p value<0.1 in univariate analysis were used in multivariate analysis for adjustment. RESULTS Among 409 OHCA patients, 219 patients had ROSC. Highest RDW quartile (RDW>15.4%), female sex, older age, non-shockable initial rhythm, increased BUN and creatinine and decreased albumin, hematocrit and platelet count were associated with increased mortality in univariate analysis. In multivariate analysis, the highest RDW quartile was independently associated with all-cause mortality (HR=1.95; 95% CI 1.05-3.60; p=0.034) during 30-day post-resuscitation period. Other significant variables were age, initial rhythm and serum albumin. CONCLUSIONS Initial RDW is an independent predictor of all-cause mortality in post-resuscitation patients.

Induced Hypothermia Attenuates the Acute Lung Injury in Hemorrhagic Shock

BACKGROUND In previous animal studies, induction of therapeutic hypothermia (HT) in hemorrhagic shock (HS) had beneficial effects on the hemodynamic and metabolic parameters and on the survival. However, the effect of induced HT on acute lung injury (ALI) in HS has not been investigated. We sought to determine the effects of HT on ALI in HS. METHODS Male Sprague-Dawley rats (350-390 g; n = 8 per group) were randomized to the normothermia (NT; 36-37 degrees C) group or the moderate HT (27-30 degrees C) group and were subjected to volume-controlled (2 mL/100 g weight) HS (90 minutes) followed by 90 minutes of resuscitation. ALI score, lung malondialdehyde content, and myeloperoxidase activity were measured. The expression of glycogen synthase kinase 3beta (GSK-3beta), phosphorylated GSK-3beta, inducible nitric oxide synthase (iNOS), heat shock protein (HSP) 72, and nuclear factor-kappaB (NF-kappaB) in the lung were compared. RESULTS ALI score, lung malondialdehyde content, and myeloperoxidase were lower in the HT group. GSK-3beta and iNOS gene expressions in lung tissue were significantly decreased in the HT group (p < 0.05). On the contrary, the expression of phosphorylated GSK-3beta was increased in the HT group (p < 0.001). HSP 72 was expressed in the HT group but not in the NT group. The activated p65 NF-kappaB levels in lung nuclear extract were significantly lower in the NT group (p = 0.03). CONCLUSIONS HT attenuates HS-induced ALI in rats by the modulation of GSK, HSP 72, iNOS, and NF-kappaB.

Therapeutic hypothermia attenuates acute lung injury in paraquat intoxication in rats

AIM OF THE STUDY Paraquat intoxication induces acute lung injury and numerous fatalities have been reported. The mechanism of toxic effect of paraquat is oxidative injury and inflammation. Therapeutic hypothermia has been known to have antioxidant and anti-inflammatory effects. This study was designed to evaluate the effect of therapeutic hypothermia on paraquat intoxication. METHODS Male Sprague-Dawley rats were given 50 mg/kg of paraquat intraperitoneally and divided into the normothermia (36-38°C) group and the hypothermia (30-32°C) group after 1h of paraquat administration. The hypothermia group underwent 2 h of hypothermia followed by 2 h of rewarming. In the survival study, mortality was observed for 24 h after paraquat administration. An in the second experiment, lung tissues and plasma were harvested at 6 h after paraquat administration. RESULTS The 12 h survival rate was significantly higher in the hypothermia group than in the normothermia group (100% vs. 50%, p<0.05), but survival rates for 24 h were not different. Acute lung injury score was lower in the hypothermia group than in the normothermia group (p<0.05). Thmalondialdehyde contents of lung tissues, plasma interleukin-6 and nitrite/nitrate concentrations were significantly decreased in the HT group compared to the NT group (p<0.05). CONCLUSION Therapeutic hypothermia delayed early mortality and attenuated acute lung injury in paraquat intoxication.

Effect of N-acetylcysteine (NAC) on acute lung injury and acute kidney injury in hemorrhagic shock ,

AIM OF THE STUDY N-acetylcysteine (NAC) has been investigated to attenuate organ injury in various experimental and clinical studies. However, results in hemorrhagic shock (HS) were controversial. We determined the effects of continuous administration of NAC on acute lung injury (ALI) and acute kidney injury (AKI) in HS model. METHODS Twenty male Sprague-Dawley rats were used. Pressure controlled HS model defined by mean arterial pressure (MAP) 40±2 mmHg for 90 min followed by resuscitation and observation was used. Rats (n=10 per group) were randomized into 2 groups with NAC or dextrose. Intravenous NAC was given continuously from 15 min after induction of HS to the end of observation period (2 h). We measured serum IL-6, nitrite/nitrate concentration. NF-κB p65 DNA binding activity, expressions of cytoplasmic phosphorylated IκB-α (p-IκB-α) and IκB-α, malondialdehyde (MDA) and histopathological injury scores in lung and kidney were also evaluated. RESULTS MAP did not show any difference during the study period. NAC decreased histopathologic scores in both lung and kidney. Lung and kidney MDA levels were significantly lower in the NAC group compared to control group. Serum nitrite/nitrate and IL-6 were also significantly lower in the NAC group. The levels of lung cytoplasmic p-IκB-α expression was mitigated by NAC, and NF-κB p65 DNA binding activity was also significantly decreased in the NAC group. CONCLUSIONS Continuous infusion of NAC attenuated inflammatory response and acute lung and kidney injury after hemorrhagic shock in rats.

Empirical Use of Ciprofloxacin for Acute Uncomplicated Pyelonephritis Caused by Escherichia coli in Communities Where the Prevalence of Fluoroquinolone Resistance Is High

ABSTRACT There is little information about the effectiveness of ciprofloxacin in regions where ciprofloxacin-resistant Escherichia coli is prevalent. This study was conducted to evaluate whether ciprofloxacin is effective as the initial empirical antibiotic for treatment of uncomplicated acute pyelonephritis (APN) due to ciprofloxacin-resistant E. coli. A total of 255 women with clinical diagnoses of uncomplicated APN due to E. coli were enrolled in the emergency department between March 2005 and December 2008. All enrolled patients were initially treated with ciprofloxacin. Patients were followed up 4 to 7 days after the start of therapy and 14 to 21 days after its completion. At the first follow-up visit, ciprofloxacin was changed to the appropriate antibiotic when necessary, depending on the antibiotic susceptibility results. Not only improvement of symptoms and signs but also microbiologic eradication was assessed at each visit. Fifteen percent (39/255) of the E. coli isolates were resistant to ciprofloxacin. There was no statistically significant difference between the clinical cure rates of the ciprofloxacin-susceptible group and the ciprofloxacin-resistant group at the first follow-up (87.0% versus 76.9%, P = 0.135) or the second follow-up (98.6% versus 94.9%, P = 0.177). However, there was a lower microbiologic cure rate in the ciprofloxacin-resistant group than in the ciprofloxacin-susceptible group (92.4% versus 41.7%, P = 0.000) at the first follow-up visit. No complications occurred in the ciprofloxacin-resistant group during the follow-up period. Our findings indicate that ciprofloxacin is an appropriate choice for empirical therapy of uncomplicated APN and has no serious adverse outcomes, if it is tailored appropriately, even for women infected with ciprofloxacin-resistant E. coli.