Jung Youn Kim

Lactic acidosis not hyperlactatemia as a predictor of inhospital mortality in septic emergency patients

Objective: To compare the prognostic abilities of lactic acidosis and hyperlactatemia and determine the influence of metabolic acidosis when attempting to predict the outcome of septic patients using serum lactate levels. Method: 126 patients with severe sepsis or septic shock were prospectively included in this study at an emergency department. Haemodynamic variables, simplified acute physiology score (SAPS) II, arterial blood gas studies and serum lactate levels were obtained at the time of presentation (0 h) and 4 h after presentation. The probability of mortality was calculated using SAPS II scores and compared with actual inhospital mortality at different serum lactate levels and arterial pH. Survival curves for lactic acidosis and severe hyperlactatemia were analysed using the Kaplan–Meier method. Results: The calculated probability of mortality decreased from 35.7% (95% CI 30.2 to 41.2) at presentation to 29.3% (95% CI 24.2 to 34.4) at 4 h post-presentation. 27.0% of patients (34) died in hospital. Arterial pH and SAPS II scores were independent factors for predicting mortality of septic patients, at 0 h and 4 h. Serum lactate levels were closely related to severity of illness and metabolic acidosis in septic patients. Patients with lactic acidosis had significantly higher inhospital mortality than patients with normal pH and normal lactate levels by Kaplan–Meier survival analysis as determined based on measurements made at 0 h and 4 h (p<0.001, p<0.001 by the log-rank test, respectively). No significant difference in survival was found between patients with hyperlactatemia and those with normal pH and serum lactate levels. Conclusion: Lactic acidosis not hyperlactatemia was found to predict inhospital mortality more exactly in severe sepsis and septic shock patients. The acid-base state should be considered when attempting to predict the outcome of septic patients using serum lactate levels.

Effects of hypertonic saline on macrophage migration inhibitory factor in traumatic conditions

Trauma-induced suppression of cellular immune function contributes to sepsis, multiple organ dysfunction syndrome (MODS) and mortality. Macrophage migration inhibitory factor (MIF) has been revealed to be central to several immune responses. However, the role of MIF in trauma-like conditions is unknown. Therefore, the present study evaluated MIF in macrophages and polymorphonuclear neutrophils (PMNs). The effects of hypertonic saline (HTS) on lipopolysaccharide (LPS)-induced MIF levels were evaluated in macrophages. MIF concentrations were determined by an enzyme-linked immnosorbent assay (ELISA) and cell lysates were used for western blot analysis. The effects of HTS on N-formyl-methionyl-leucyl-phenylalanine (fMLP)-induced MIF were evaluated in PMNs. MIF concentrations were determined by ELISA, western blotting and real time-polymerase chain reaction (RT-PCR) to determine MIF expression. MIF levels, which were measured by the ELISA, increased by 1.24±0.38 ng/ml in the supernatants of LPS-stimulated macrophages compared with the controls (0.79±0.07 ng/ml) at 2 h. HTS10 (150 mmol/l) partially restored MIF levels (0.84±0.22 ng/ml; P<0.05). Also, western blotting was performed and MIF protein levels were higher in the LPS-stimulated macrphages (20% increase in band density) compared with the controls (P<0.05). The addition of HTS decreased MIF protein expression. MIF levels in fMLP-stimulated PMN cells were unchanged compared with the controls according to the ELISA, western blotting and RT-PCR. No effects were observed following treatment with HTS. MIF concentrations and MIF expression were higher in LPS-stimulated macrophages than controls and HTS restored MIF levels to those of the controls. MIF levels were unchanged in PMNs stimulated by fMLP.

Effect of hypertonic saline on apoptosis of polymorphonuclear cells

BACKGROUND The function of polymorphonuclear (PMN) cells can be influenced by the choice of resuscitation fluids in hemorrhagic shock. Widespread interest in the use of hypertonic solutions for resuscitation has led to extensive investigation of their immune-modulating properties. Hypertonic saline (HTS) is known to modulate immune reactions, preventing the multiorgan failure mediated by immune reactions in trauma and hemorrhagic shock. PMN cells play a key role in such immune-mediated inflammatory processes, and HTS is believed to affect these PMN cells. However, how these events influence the actual event of apoptosis has not yet been described. Thus, in the present study, we aimed to investigate the differences in the apoptosis of PMN cells when exposed to isotonic and hypertonic environments and the temporal relations between the interval of administration of HTS after the stimulation of PMN cells. METHODS Whole blood was sampled from healthy volunteers, and the PMN cells were isolated. The isolated layer of PMN cells was washed twice with phosphate-buffered saline to yield the PMN cells. The number of cells was kept uniform, and an overall survival rate greater than 95% was maintained. After stimulation of the isolated PMN cells with N-formyl-methionyl-leucyl-phenylalanine, the PMN cells were allocated into 3 study groups (i.e., 1 isotonic group and 2 hypertonic groups with an osmolarity of 160 mM and 180 mM each). The extent of apoptosis was investigated in each group after culturing the PMN cells for 0, 1, 3, 6, 12, 15, 18, and 24 h. Depending on whether the PMN cells were stimulated with N-formyl-methionyl-leucyl-phenylalanine, they were also divided into stimulated and nonstimulated groups. In the stimulated group, the hypertonic environment was fostered immediately (HTS 0 h) and 6 h (HTS 6 h) after stimulation, which was accomplished after allocating the cells into an isotonic group (140 mM) and a hypertonic group (180 mM), according to the concentration of the culture medium. The PMN cells were then cultured at 37°C for 15 h with 5% carbon dioxide incubation. Each PMN suspension was labeled with Annexin V-fluorescein isothiocyanate and propidium iodide. Each sample underwent immediate flow cytometric analysis. PMN cells with high propidium iodide uptake were considered nonviable (necrotic). Among the viable PMN cells, those with no Annexin V uptake were considered normal and those with Annexin V uptake were considered apoptotic. RESULTS Decreased apoptosis was observed in the PMN cells stimulated with N-formyl-methionyl-leucyl-phenylalanine. Increased apoptosis was observed in the stimulated PMN cells incubated in hypertonic condition compared with the cells incubated in isotonic condition. Early HTS administration demonstrated increased apoptosis compared with late administration. CONCLUSIONS HTS treatment resulted in increased PMN apoptosis and an anti-inflammatory effect. Decreased apoptosis (prolonged lifespan) has been implicated in neutrophil-mediated tissue damage. HTS, by increasing the apoptosis of PMN cells, attenuates the postinjury inflammatory response. Also, early treatment with HTS was more efficient than delayed treatment.

Reversible pancytopenia following the consumption of decoction of Ganoderma neojaponicum Imazeki

The Ganoderma species are mushrooms used for herbal medicinal purposes in northeast Asia. Two cases of simultaneous reversible pancytopenia following the consumption of decoction of Ganoderma neojaponicum Imazeki are presented. Other than decoction of G. neojaponicum Imazeki no cause of pancytopenia could be identified. The patients recovered fully after conservative treatment. People who consume herbal medicines are often not aware of their side effects. Patients should be knowledgeable regarding the possible side effects of Ganoderma prior to its consumption.

Clinician awareness of tetanus-diphtheria vaccination in trauma patients: a questionnaire study

BackgroundMost trauma patients visit the hospital via the emergency department. They are at high risk for tetanus infection because many trauma patients are wounded. Tetanus immunity in the Korean population has been revealed to be decreased in age groups over 20 years old. It is important for emergency physicians to vaccinate patients with the tetanus booster in wound management.MethodsQuestionnaires were sent to the directors of the emergency departments of resident training hospitals certified by the Korean Society of Emergency Medicine.ResultsTwo thirds of the emergency department directors surveyed reported applying tetanus prophylaxis guidelines to more than 80% of wounded patients. However, about 45% of clinicians in the emergency departments considered giving less than half of the wounded patient tetanus booster vaccinations, and there were no distinct differences in tetanus booster vaccination rates among different age groups. Most emergency physicians are familiar with tetanus prophylaxis guidelines for wound management. However, more than half of the emergency department directors reported that the major reason for not considering tetanus-diphtheria vaccination was due to assumptions that patients already had tetanus immunity.ConclusionAttitude changes should be encouraged among emergency physicians regarding tetanus prophylaxis. As emergency physicians are frequently confronted with patients that are at a high risk for tetanus infection in emergency situations, they need to be more informed regarding tetanus immunity epidemiology and encouraged to administer tetanus booster vaccines.

Accuracy of transcutaneous carbon dioxide monitoring in hypotensive patients

Objectives Continuous blood gas monitoring is frequently necessary in critically ill patients. Our aim was to assess the accuracy of transcutaneous CO2 tension (PtcCO2) monitoring in the emergency department (ED) assessment of hypotensive patients by comparing it with the gold standard of arterial blood gas analysis (ABGA). Methods All patients receiving PtcCO2 monitoring in the ED were included. We excluded paediatric patients, patients with no ABGA results during a hypotensive event, patients whose ABGA was not performed simultaneously with PtcCO2 monitoring, and patients who received sodium bicarbonate for resuscitation. The included patients were classified into hypotensive patients and normotensive patients. A hypotensive patient was defined as a patient showing a mean arterial pressure under 60 mm Hg. The agreement in measurement between PaCO2 tension (PaCO2) and PtcCO2 were investigated in both groups. Results The mean difference between PaCO2 and PtcCO2 was 2.1 mm Hg, and the Bland–Altman limits of agreement (bias±1.96 SD) ranged from −15.6 to 19.7 mm Hg in the 28 normotensive patients. The mean difference between PaCO2 and PtcCO2 was 1.1 mm Hg, and the Bland–Altman limits of agreement (bias±1.96 SD) ranged from −19.5 to 21.7 mm Hg in the 26 hypotensive patients. The weighted κ values were 0.64 in the normotensive patients and 0.60 in the hypotensive patients. Conclusions PtcCO2 monitoring showed wider limits of agreement with PaCO2 in urgent situations in the ED environment. However, acutely developed hypotension does not affect the accuracy of PtcCO2 monitoring.

The Effect of Hypertonic Saline on mRNA of Proinflammatory Cytokines in Lipopolysaccharide-Stimulated Polymorphonuclear Cells

Background Hypertonic saline is often used to resuscitate patients experiencing shock. In such conditions, polymorphonuclear cells and Toll-like receptors (TLRs) form an essential part of early induced innate immunity. Objective To investigate the immunomodulatory effect of hypertonic saline on polymorphonuclear cells by evaluating the changes in TLR-4 receptors and proinflammatory cytokines. Methods Polymorphonuclear cells were isolated from whole blood using Polymorphprep (Axis-Shield, Oslo, Norway). The isolated polymorphonuclear cells were plated at a density of 1 × 106 cells/mL in 6-well flat-bottomed culture plates and were stimulated with 1 μg/mL lipopolysaccharide or N-formyl-methionyl-leucyl-phenylalanine. The stimulated polymorphonuclear cells were cultured in hypertonic saline at 10, 20, or 40 mmol/L above isotonicity. After that, the changes in TLR-4 and cytokines were measured by quantitative real-time polymerase chain reaction and flow cytometry. Results The level of TLR-4 mRNA expression decreased after stimulation with N-formyl-methionyl-leucyl-phenylalanine, but hypertonic saline did not affect the TLR-4 mRNA expression. TLR-4 mRNA expression was clearly induced upon stimulation with lipopolysaccharide, and the addition of hypertonic saline restored TLR-4 mRNA expression in polymorphonuclear cells. The interleukin-1β mRNA expression was decreased in the hypertonic environment. On the other hand, the tumor necrosis factor-α value was not influenced by the addition of hypertonic saline. Conclusions Hypertonic saline has an immunomodulatory effect on polymorphonuclear cells through the TLR-4 pathway, and the interleukin–1β-associated pathway is influenced more by hypertonic saline than is the tumor necrosis factor–α-associated pathway.

The Effect of the Rapid Antigen Test for Influenza on Clinical Practice in the Emergency Department: A Comparison of Periods before and After the 2009 H1N1 Influenza Pandemic

Introduction. The rapid antigen test (RAT) plays an important role in the Emergency Room (ER). In this study, we investigated the effect of the RAT for influenza on clinical practice in an emergency department.Methods. A retrospective chart review was conducted considering two periods, namely before and after the 2009 influenza pandemic. The rate of antibiotic administration, the use of blood sample tests, the use of simple chest X-rays, the rate of antibiotic administration according to the result of the RAT, and the duration of ER stay in the case of influenza-like illnesses were investigated for the two study periods considered.Results. The use of the RAT increased from 23.9% to 39.8% in influenza-like pediatric patients (p<0.05) and from 4.9% to 67.6% in adult patients (p<0.001). After the 2009 influenza pandemic, the number of cases of antibiotic administration, blood sample test and simple chest X-ray decreased by 19.0%, 46.2%, and 27.4%, respectively, in pediatric patients with the use of RAT. Among RAT-positive patients, after the 2009 influenza pandemic, none of the pediatric patients and only 3 of the adult patients (17.6%) were administered antibiotics. The duration of ER stay was longer in patients who underwent RAT than in those who did not.Conclusion. The increased use of RAT for influenza has led to a decrease in antibiotic administration and a reduction in additional diagnostic tests in influenza-like illnesses. However, the use of RAT has not contributed to a decrease in the duration of ER stay.

Use of an external-cooling device for the treatment of heat stroke.

Heat stroke is caused by losing control of one’s body temperature. It can be life threatening without proper treatment. In this case report, we describe a heat stroke patient treated with an external-cooling device, which is commonly used for therapeutic hypothermia after cardiac arrest. A 67-year-old woman was found unconscious with spontaneous breathing in a sauna. Her body temperature was 40.5°C when she arrived at the emergency department, and she was diagnosed with heat stroke. At seven hours after applying the Arctic Sun Temperature Management System (Medivance), her body temperature declined to 36.5°C, with neurologic improvement (Glasgow Coma Scale score increased from 3 to 12). She was admitted to an intensive care unit and discharged 14 days after admission without any neurological sequelae. In conclusion, an external-cooling device can be used effectively for heat stroke, in addition to therapeutic hypothermia after cardiac arrest.

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

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 × 106 cells/mL. The effect of HTS on LPS-induced MIF was evaluated in monocyte with 1 µg/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.