Jung Soo Park

Hospital‐based influenza surveillance in Korea: Hospital‐based influenza morbidity and mortality study group

Influenza epidemics occur annually with variations in size and severity. Hospital‐based Influenza Morbidity & Mortality was established to monitor influenza epidemics and their severity, which is composed of two surveillance systems: emergency room‐based and inpatient‐based surveillance. Regarding emergency room‐based surveillance, influenza‐like illness index (influenza‐like illness cases per 1,000 emergency room‐visiting subjects), number of laboratory‐confirmed cases and the distribution of influenza types were estimated weekly. Inpatient‐based surveillance included monitoring for hospitalization, complications, and mortality. The emergency room influenza‐like illness index correlated well with the number of laboratory‐confirmed influenza cases, and showed a bimodal peak at Week 4 (179.2/1,000 emergency room visits) and Weeks 13‐14 (169.6/1,000 emergency room visits) of 2012. Influenza A was the predominant strain during the first epidemic peak, while influenza B was isolated exclusively during the second peak. In 2011–2012 season, the mean admission rate of emergency room‐visiting patients with influenza‐like illness was 16.3% without any increase over the epidemic period. Among the hospitalized patients with influenza, 33.6% (41 out of 122 patients) were accompanied by complications, and pneumonia (28.7%, 35 out of 122 patients) was the most common. Most fatal cases were caused by influenza A (96.2%) after the first epidemic peak. In conclusion, Hospital‐based Influenza Morbidity & Mortality was effective for monitoring the trends in circulating influenza activity concurrently with its severity. In the 2011–2012 season, the influenza epidemic persisted for a ≥5‐month period, with a bimodal peak of influenza A and B in sequence. Overall, influenza A was more severe than influenza B. J. Med. Virol. 85:910–917, 2013.

Efficacy of diffusion-weighted magnetic resonance imaging performed before therapeutic hypothermia in predicting clinical outcome in comatose cardiopulmonary arrest survivors

AIM OF THE STUDY To develop a clinically relevant and qualitative brain magnetic resonance imaging (MRI) scoring system for acute stage comatose cardiac arrest patients. METHODS Consecutive comatose post-cardiopulmonary arrest patients were prospectively enrolled. Routine brain MRI sequences were scored by two independent and blinded experts. Predefined brain regions were qualitatively scored on diffusion-weighted imaging (DWI) sequences according to the severity of the abnormality on a scale from 0 to 4. The mean score provided by the raters determined poor outcome defined under the Cerebral Performance Categories 3, 4, or 5. DWI scans were repeated after therapeutic hypothermia (TH). The same qualitative scoring system was applied and results were compared to the initial scores. RESULTS Out of 24 recruited patients, 19 with brain MRI scans were included. Of the 19 included patients, seven showed a good outcome at hospital discharge and 12 patients showed poor neurologic outcome. Median time from the arrest to the initial DWI was 166min (IQR 114-240min). At 100% specificity, the overall, cortex, and cortex plus deep grey nuclei scores predicted poor patient outcome with a sensitivity of 91.7-100% (95% CI). Follow-up DWI scans after TH showed worse results than initial scans. CONCLUSION A qualitative MRI scoring system effectively assessed the severity of hypoxic-ischaemic brain injury following cardiopulmonary arrest. The scoring system may provide useful prognostic information in comatose cardiopulmonary arrest patients.

Spontaneous diaphragmatic rupture complicated with perforation of the stomach during Pilates

Diaphragmatic rupture (DR) is most commonly seen after a blunt trauma. It rarely occurs spontaneously. Many cases of spontaneous DR followed by strenuous sports activity have been reported in the medical literature. However, there has been no previous report on a case of spontaneous DR after a static sport activity. We report the case of a 29-year old woman who presented to the emergency department (ED) with pain in the epigastric area that started 1 day before visiting the ED during deep breathing in Pilates. The radiography and computed tomography of her chest demonstrated a left diaphragmatic rupture complicated with the perforation of viscera. She immediately underwent left thoracotomy. In addition, primary repair of the diaphragm and stomach was performed. On the basis of our findings, we conclude that spontaneous DR may be caused by a static sport activity, such as Pilates, causing a serious life threatening condition.

Effect of the influenza virus rapid antigen test on a physician's decision to prescribe antibiotics and on patient length of stay in the emergency department.

Background Influenza virus infection is a common reason for visits to the emergency department (ED) during the influenza season. A rapid and accurate diagnosis of influenza virus infection is important to reduce unnecessary antibiotic prescription and to improve patient care. The aim of this study was to examine whether using the Influenza Virus Rapid Antigen Test (IVRAT) in the ED affects the decision to prescribe antibiotics or the length of hospital stay (LOS). Methods Data from patients suffering from an influenza-like illness (ILI) and who were discharged after visiting the ED at Chungbuk National University Hospital were reviewed over two influenza seasons: 2010–2011, when IVRAT was not used in the ED, and 2011–2012, when it was. The numbers of antibiotic prescriptions issued and the ED LOS during these two seasons were then compared. Results The number of antibiotic prescriptions was significantly lower in 2011–2012 (54/216, 25.0%) than in 2010–2011 (97/221, 43.9%; P<0.01). However, the median ED LOS for patients in 2011–2012 was much longer than that of patients in 2010–2011 (213 minutes vs. 257 minutes; P<0.01). During the 2011–2012 influenza season, 73 ILI patients showed a positive IVRAT result whereas 123 showed a negative result. Upon discharge, antibiotics were given to 42/123 (34.1%) ILI patients with a negative IVRAT result, but to only 7/73 (9.6%) patients with a positive IVRAT result (P<0.01). Conclusions Performing IVRAT in the ED reduced the prescription of antibiotics to ILI patients discharged after ED care. However, the ED LOS for patients who underwent IVRAT was longer than that for patients who did not. Thus, performing IVRAT in the ED reduces the unnecessary prescription of antibiotics to ILI patients during the influenza season.

An Outbreak of Food Borne Illness Due to Methomyl Pesticide Intoxication in Korea

On February 21, 2013, 6 elderly people collapsed abruptly after eating bean sprout bibimbab (boiled rice mixed with bean sprouts and seasoned with soybean sauce) at a countryside restaurant in the Chungbuk Province, Korea. Minutes after eating the meal, all of the patients lapsed into a state of stupor. Respiratory arrest developed in 2 patients; and one of two patients died of cardiac arrest. The autopsy identified methomyl and methanol in the deceased patients gastric contents and in the remaining soybeanbean sauce seasoning. Five of the 6 patients ingested one spoonful of the soybeanbean sauce seasoning and survived, while one patient who died of cardiac arrest, ingested approximately two spoons. Symptoms of toxicity presented quickly in the subjects and progressed rapidly, including chest tightness, an unusual sensation in the pit of the stomach, dizziness, ataxia, and finally, collapse. Three patients who drank ethanol with the meal experienced only mild toxic symptoms. Our analysis of the clinical observations in these cases suggests that ingestion of methomyl pesticide and the additive toxicity of methanol may have been responsible for the intoxication.

Genomic analysis of [d-Ala2, d-Leu5] enkephalin preconditioning in cortical neuron and glial cell injury after oxygen deprivation.

[d-Ala2, d-Leu5] enkephalin (DADLE) is a synthetic δ-opioid agonist that induces hibernation and promotes survival of neurons and glial cells in the central nervous system. Several mechanisms for the attenuation of hypoxic injury have been suggested, including control of intracellular signaling pathways via the δ-opioid receptor (DOR). However, the cellular and molecular mechanisms of DADLE in hypoxic injury are largely unknown. To investigate neuronal injury after oxygen-deprivation (OD) and DOR stimulation by DADLE, we used a lactate dehydrogenase assay, MTT assay, and immunofluorescence live/dead staining. And we used cDNA microarrays to investigate the influence of DADLE exposure on transcription after OD in rat cortical glial and neuronal co-culture. DADLE reduced neuronal injury after 24 h of OD. Preconditioning with DADLE before 24 h hypoxia exposure also altered gene expression in comparison with 24h OD without pretreatment. After DADLE exposure and hypoxia, 1917 of 39,511 genes (4.9%) were significantly induced or repressed at least 2.5-fold. Assigning differentially expressed ESTs (expressed sequence tags) to molecular functional groups revealed that DADLE affected many pathways including apoptosis, intracellular ion homeostasis, molecular chaperones, and glucose metabolism. We observed a coordinated change in expression of many genes (increased expression of potentially protective genes and decreased expression of potentially harmful genes) after DADLE exposure. A comprehensive list of regulated genes should prove valuable in advancing our understanding of the neuroprotective mechanisms of DADLE under OD.

Successful treatment of methemoglobinemia and acute renal failure after indoxacarb poisoning

Context. We report a case of systemic toxicity induced by indoxacarb, an oxadiazine insecticide. Previous reports have suggested the occurrence of methemoglobinemia after indoxacarb ingestion, but no case of indoxacarb-induced systemic toxicity, such as acute renal failure, has been reported thus far. Case details. A 71-year-old woman presented with indoxacarb poisoning, resulting in methemoglobinemia and acute renal failure. The methemoglobinemia improved after methylene blue administration, but rapidly progressive acute renal failure occurred 7 h after admission. She was treated with continuous veno-venous hemofiltration and intravenous sodium bicarbonate and recovered successfully. Discussion. Ingestion of indoxacarb may produce not only methemoglobinemia, but also systemic toxicities like acute renal failure, which can be successfully treated with aggressive therapy such as continuous veno-venous hemofiltration. Physicians should be alert to acute renal failure as a possible complication of indoxacarb ingestion, and treat it accordingly.

Comparison of brain computed tomography and diffusion-weighted magnetic resonance imaging to predict early neurologic outcome before target temperature management comatose cardiac arrest survivors

AIM We previously reported that diffusion-weighted magnetic resonance imaging (DW-MRI) could be used to predict neurologic outcomes before targeted temperature management (TTM) after return of spontaneous circulation (ROSC) from cardiac arrest (CA). We compared the efficacy of brain computed tomography (CT) and DW-MRI to predict neurologic outcome before TTM in comatose cardiac arrest survivors. METHODS We performed a retrospective study of CA patients treated with TTM. The brain CT and DW-MRI were both obtained before TTM. We analysed the grey matter to white matter ratio (GWR) on the brain CT and the presence of high signal intensity on DW-MRI, alone or in combination, to predict poor neurologic outcome (CPC 3-5). RESULTS Of 47 comatose CA patients treated with TTM, 39 patients with brain CT and DW-MRI data were included. Median time from the ROSC to the brain CT and DW-MRI was 90min (52-150) and 175min (118-240), respectively. There was no significant difference in predicting poor neurologic outcome between average GWR (area under the curve [AUC] 0.891, sensitivity/specificity 78.8%/100%) and DW-MRI (AUC 0.894, sensitivity/specificity 75.8%/100%) (p=0.963). The combination of average GWR and DW-MRI (AUC 0.939, sensitivity/specificity 87.9%/100%) improved the prediction of poor neurologic outcome rather than each one alone and in other combinations. CONCLUSION Our preliminary finding suggests that DW-MRI is potentially useful for early prediction of neurologic outcome (i.e., before TTM) in CA patients. The combination of GWR on brain CT and that on DW-MRI, rather than on each modality alone, appears to improve the sensitivity for predicting neurologic outcome after ROSC from CA. Large prospective multicenter studies should be conducted to confirm these results.

Neurologic outcome of comatose survivors after hanging: a retrospective multicenter study

PURPOSE The aim of this study is to identify the neurologic outcome of hanging patients and prognostic factors. MATERIALS AND METHODS We retrospectively investigated comatose hanging patients who arrived at the emergency departments (EDs) of twelve academic tertiary care centers during a period of seven years (2006-2012). Patients were analyzed separately according to whether out-of-hospital cardiac arrest (OHCA) occurred or not. The neurologic outcome was evaluated using the Cerebral Performance Category (CPC) at the time of hospital discharge. RESULTS A total of 1118 patients were admitted to the ED after hanging attempts. There were 159 comatose patients who did not experience OHCA. Twelve (7.5%) of 159 patients were discharged from the hospital with a poor neurologic outcome (CPC 3-5). These 12 patients received only conservative management without therapeutic hypothermia. On multivariate logistic regression analysis, mental state upon ED arrival and arterial pH were predicting factors for poor prognosis. One hundred twenty-one patients suffered OHCA and experienced restored spontaneous circulation after cardiopulmonary resuscitation. Among them, only five (4.1%) patients recovered consciousness to the level of CPC 1-2. The initial arterial pH and HCO3(-) were prognostic factors in hanging patients with OHCA. CONCLUSIONS Even though cardiac arrest did not occur after hanging injuries, 7.5% of patients could not recover consciousness. Therapeutic hypothermia should be considered for such patients. If OHCA occurred after the hanging injury, the proportion of patients with good neurologic outcome was very low at 4.1%.

A comparison of the area of chest compression by the superimposed-thumb and the alongside-thumb techniques for infant cardiopulmonary resuscitation

OBJECTIVES We investigated whether the superimposed-thumb technique could reduce the chest compression area in infant cardiopulmonary resuscitation (CPR). METHODS Charts and multidirectional computed tomography images of infants presented to four hospitals from January 2007 to September 2010 were reviewed retrospectively. We measured at the point of maximal anterior-posterior heart diameter the width of the sternum meter (S(ap)), vertical heart length from S(ap), length and width of the superimposed-thumb technique and length and width of the alongside-thumb technique. We studied the structures located underneath thumbs superimposed and thumbs alongside at S(ap) and S(nipple) (the sternum of the inter-nipple line). RESULTS In the 84 infants enrolled, the width of the sternum at S(ap), and the vertical heart length from S(ap) were 0.85 ± 0.31 and 1.71 ± 0.47 cm, respectively. The length and width of the superimposed-thumb technique were 1.65 ± 0.13 and 2.73 ± 0.22 cm, respectively. The length and width of the alongside-thumb technique were 3.00 ± 0.48 and 3.77 ± 0.24 cm, respectively. The liver was situated underneath thumbs superimposed at S(ap) in 59.5% infants. The livers and lungs of 73.8% and 64.3% infants, respectively, were underneath thumbs alongside at S(nipple). CONCLUSION In this study, we confirmed that the superimposed-thumb technique may reduce chest compression area in infant CPR. The lungs or livers were located more often underneath thumbs alongside at S(nipple) than underneath thumbs superimposed at S(ap). However, further studies are needed to validate the efficiency and safety of this technique.