Kyung Hye Park

Compression of the Left Ventricular Outflow Tract During Cardiopulmonary Resuscitation

OBJECTIVES This prospective observational study was performed to investigate if the hand position used for external chest compressions is in an optimal position for compressing the ventricles during standard cardiopulmonary resuscitation (CPR). METHODS Transesophageal echocardiography (TEE) was performed during standard CPR in 34 patients with nontraumatic cardiac arrest (24 males, mean +/- standard deviation [SD] age = 56 +/- 12 years). On the recorded image of TEE, an area of maximal compression (AMC) was identified, and the degree of compression at the AMC and the left ventricular stroke volume was calculated. RESULTS A significant narrowing of the left ventricular outflow tract (LVOT) or the aorta was noted in all patients, with the degree of compression at the AMC ranging from 19% to 83% (mean +/- SD = 49 +/- 19%). The AMC was found at the aorta in 20 patients (59%) and at the LVOT in 14 patients (41%). A significant narrowing of more than 50% of the diameter at the end of the relaxation phase occurred in 15 patients (44%). On linear regression, the left ventricular stroke volume was correlated with the location of the AMC (R(2) = 0.165, p = 0.017). CONCLUSIONS The outflow of the left ventricle is affected during standard CPR, resulting in varying degrees of narrowing in the LVOT and/or the aortic root.

The Anti-Inflammatory Effects of Ulinastatin in Trauma Patients with Hemorrhagic Shock

We investigated the use of ulinastatin in association with the suppression of polymorphonuclear leukocyte elastase (PMNE), tumor necrosis factor alpha (TNF-α) and interleukin 6 (IL-6), and its effects on the prognosis of patients with traumatic hemorrhagic shock. Nineteen patients who visited the emergency department for traumatic hemorrhagic shock were enrolled. Eleven patients were randomly selected to receive a total of 300,000 IU of ulinastatin. Measurements of serum PMNE, TNF-α and IL-6 were taken before ulinastatin treatment at 24 hr, two days, three days, and seven days after admission. We compared the Systemic Inflammatory Response Syndrome scores, Multiple Organ Dysfunction Syndrome scores and Acute Physiology, age, Chronic Health Evaluation III scores of the control and ulinastatin groups. There were no significant differences in baseline values, laboratory data, treatment or mortality between the two groups. The serum PMNE levels in the ulinastatin group were lower than in the control group on the second hospitalized day. Serum TNF-α and IL-6 levels in the ulinastatin group decreased 24 hr after admission but had no significance. It is suggested that ulinastatin treatment could decrease the serum PMNE levels in trauma patients with hemorrhagic shock at 48 hr after treatment.

The relationships between empathy, stress and social support among medical students

Objectives To examine the relationship between stress, social support, and empathy among medical students. Methods We evaluated the relationships between stress and empathy, and social support and empathy among medical students. The respondents completed a question-naire including demographic information, the Jefferson Scale of Empathy, the Perceived Stress Scale, and the Multidimensional Scale of Perceived Social Support. Corre-lation and linear regression analyses were conducted, along with sub-analyses according to gender, admission system, and study year. Results In total, 2,692 questionnaires were analysed. Empathy and social support positively correlated, and empathy and stress negatively correlated. Similar correla-tion patterns were detected in the sub-analyses; the correla-tion between empathy and stress among female students was negligible. In the regression model, stress and social support predicted empathy among all the samples. In the sub-analysis, stress was not a significant predictor among female and first-year students. Conclusions Stress and social support were significant predictors of empathy among all the students. Medical educators should provide means to foster resilience against stress or stress alleviation, and to ameliorate social support, so as to increase or maintain empathy in the long term. Furthermore, stress management should be emphasised, particularly among female and first-year students.

Effect of hypothermia on coagulatory function and survival in Sprague–Dawley rats exposed to uncontrolled haemorrhagic shock

BACKGROUND Acute coagulopathy, hypothermia, and acidosis are the lethal triad of conditions manifested by major trauma patients. Recent animal studies have reported that hypothermia improves survival in animals subjected to controlled haemorrhagic shock. The objective of this study was to investigate the effect of hypothermia on coagulation in rats subjected to uncontrolled haemorrhagic shock. METHODS Thirty-two male Sprague-Dawley rats were randomly divided into four groups: normothermia (control, group N), hypothermia (group H), hypothermic haemorrhagic shock (group HS), and normothermic haemorrhagic shock (group NS). Haemorrhagic shock was induced by splenic laceration. Capacity for coagulation was measured by rotation thromboelastometry (ROTEM(®)), and was measured at baseline as well as the end of the shock and resuscitation periods. Survival was observed for 48 h post-trauma. RESULTS Baseline parameters were not different amongst the groups. Rats exposed to hypothermia alone did not differ in coagulation capacity compared to the control group. Clot formation time (CFT) and maximal clot firmness (MCF) in group HS decreased as the experiment progressed. Maximal clot firmness time (MCFt) in groups H and HS was significantly prolonged during shock and resuscitation compared with that in group NS. In group NS, MCF did not change significantly, but MCFt was reduced compared with baseline. Group HS had poor survival when compared with normovolaemic groups. CONCLUSION Blood clotted less firmly in traumatic haemorrhagic shock, and hypothermia prolonged clotting. However, clot firmness maximised rapidly under normothermic haemorrhagic shock. Haemorrhage would continue for a longer time in hypothermic haemorrhagic shock. Survival of hypothermic shock was not significantly different compared to that of normothermic haemorrhagic shock.

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.

Dapsone intoxication: clinical course and characteristics

Background and objectives. Dapsone is used as an antibiotic for leprosy and for dermatological disorders and may cause methemoglobinemia. The aims of this study are to analyze the clinical characteristics of patients presenting to the emergency department (ED) with dapsone ingestion to identify risk factors associated with mortality. Methods. We conducted a retrospective observational study of adult ED patients with methemoglobinemia because of dapsone intoxication admitted to a tertiary care hospital from September 2003 to December 2008. Data collected included demographic, clinical, and laboratory characteristics, as well as survival to discharge. Characteristics of young (less than or equal to 55 years) and older (greater than age 55) patients were compared. The main outcome was in-hospital mortality. Results. There were 46 patients included in the study. The minimum intoxication dose was two 100 mg tablets and the maximum was 100 tablets. Changes in mental status were more common in the older patients. Methemoglobin levels were slightly higher in the younger patients, but both groups were treated with similar doses of methylene blue. Shock and death were more common in the older patients. Conclusions. Late presentation to medical care and an altered mental status at the time of presentation were predictive of death after dapsone intoxication. Methemoglobin levels tended to be higher in those who died.

Empathy in Korean medical students: Findings from a nationwide survey

Abstract Background: Previous studies on empathy in Korean medical students were conducted on small populations or with different scales of measurement, resulting in low representativeness and generalisability of the findings. Aim: To evaluate empathy in Korean medical students throughout the country and to make suggestions to improve empathy. Methods: The Jefferson Scale of Empathy (JSE) (Korean) was used, and the impact of sex, age, the medical school admission system, and grade of the respondents was investigated. Results: We analyzed 5343 questionnaires and found a mean empathy score of 105.9 ± 12.8. Females and post-baccalaureate students had higher scores as compared with their counterparts. There was a significant difference between the admission systems after controlling for gender. Students from higher grade levels had lower scores than those from the lower grade levels. Conclusions: The JSE score of Korean medical students was lower than that of students in Western countries. The difference of gender and medical school admission system should be considered, and capability to apply empathy to clinical practice should be focused upon in medical training.

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.

Six nails in the head: multiple pneumatic nail gun head injury.

A 62-year-old man was admitted to our hospital after attempting to commit suicide with a pneumatic nail gun. Six nails were launched. Because the nail head acted as a brake, the launched nail could make a hole in the skull but could not entirely pass it.

Effects of sivelestat treatment on acute lung injury in paraquat-intoxicated rats

Abstract Lung injury is the main cause of death in acute paraquat (PQ) intoxication. Sivelestat (SV), a neutrophil elastase inhibitor, is effective in reducing inflammation in acute lung injury. The aim of this study was to examine the effect of SV on acute lung injury in PQ-intoxicated rats. Seven-week-old male Sprague-Dawley rats were randomly assigned to four groups: (1) control group (group N; n = 5); (2) PQ + normal saline (group P; n = 6); (3) normal saline + SV (group S; n = 6) and (4) PQ + SV (group PS; n = 6). SV treatment (intraperitoneally [i.p.], 20 mg/kg) was performed 30 minutes after PQ injection (i.p., 100 mg/kg), and injections were continued every hour for a total of five doses. One hour after the last treatment, blood samples were obtained for analysis of interleukin (IL)-6 and tumor necrosis factor alpha (TNF-α). Lung sections were stained with hematoxylin--eosin for light microscopic analysis. Neutrophil infiltration score of group PS was significantly lower than that of group P (p < 0.05). But, other scores and total score had no significant differences. IL-6 of group PS did not differ, compared to group P. In addition, there were no differences among the four groups. TNF-α of group PS was reduced, in comparison to the level of group P. SV attenuated neutrophil infiltration in PQ-induced acute lung injury in rats. In addition, systemic inflammation was partially suppressed with SV treatment, suppressing TNF-α production. These results suggest that SV reduces paraquat-induced lung injury, at least partially, by inhibiting neutrophil infiltration and TNF-α secretion.