Mu-Shun Huang

Ultrasonography for the evaluation of hemoperitoneum during resuscitation : a simple scoring system

To assess the need for therapeutic laparotomy in patients with blunt abdominal trauma (BAT), ultrasonography (US) and a simple US scoring system were used to estimate the amount of hemoperitoneum during resuscitation. In group I (BAT with a US score > or = 3), 24 of 25 patients (96%) required therapeutic laparotomy. In group II (BAT with a US score < 3), therapeutic laparotomy was required in only 9 of 24 patients (38%); nonsurgical treatment may be justified in hemodynamically stable patients. Appropriate decisions can be made to perform urgent laparotomy when intra-abdominal bleeding is the culprit in BAT patients. Unnecessary laparotomy can be avoided when the major site of blood loss is not in the abdomen. Ultrasonography, an initial rapid screening procedure in BAT patients, is useful for trauma surgeons in decision making during resuscitation.

First Identification of a Patient Colonized With Klebsiella pneumoniae Carrying blaNDM-1 in Taiwan

New Delhi metallo-β-lactamase 1 (NDM-1) is a novel type of metallo-β-lactamase (MBL). Enterobacteriaceae carrying this NDM-1 encoding gene, bla(NDM-1), have been identified worldwide. Bacteria carrying bla(NDM-1) are not only resistant to carbapenem, but also highly resistant to many classes of antibiotics, which indicate the importance of prompt identification of these bacteria and implementation of strict infection control measures to prevent their transmission. Here, we report the first identification and management of a patient colonized with Klebsiella pneumoniae carrying bla(NDM-1) in Taiwan, who returned from New Delhi where he had been hospitalized for a gun-shot injury.

Urgent laparotomy versus emergency craniotomy for multiple trauma with head injury patients.

In blunt multiple trauma (MT) with head injury (HI) patients, it is difficult to decide whether to proceed with immediate laparotomy or craniotomy. In August 1989, abdominal ultrasonography (US) using a simple US scoring system was introduced for MT and HI patients as an initial rapid screening procedure. In MT and HI patients with a US score > or = 3 (n = 14), urgent laparotomy was the procedure of first choice. However, immediate head CT scan, then emergency craniotomy, may be justified in hemodynamically stable MT and HI patients with a US score < 3 (n = 98). Appropriate decision making can be applied to decide which procedure is most exigent.

Prognostic factors for mortality following falls from height

AIM To identify the potential prognostic factors for mortality after falls from height. METHOD A retrospective clinical observational study included victims of fall of >6m from October 2000 to December 2007. Variables studied comprised each casualtys age, gender, height of fall, Glasgow Coma Scale (GCS) score, Abbreviated Injury Scale scores, Injury Severity Score, heart rate, Mean Arterial Pressure (MAP), White Blood Cell (WBC) count, haemoglobin, serum glucose, Creatine Kinase and duration of hospital stay. The relationships between these variables and outcomes were evaluated. RESULTS Among the 66 patients studied the mortality rate was 22.7%, i.e. 7 out-of-hospital and 8 in-hospital deaths. In univariate analysis, Glasgow Coma Score < or =14, Injury Severity Score > or =16, head/neck Abbreviated Injury Scale score > or =4, chest Abbreviated Injury Scale score > or =4, heart rate > or =100 or < or =50 beats/min, Mean Arterial Pressure < or =60 and serum glucose > or =140 mg/dl were significantly related to mortality. In multivariate analysis, head/neck Abbreviated Injury Scale score > or =4 was independently correlated with mortality. CONCLUSIONS Severe head injury (head/neck Abbreviated Injury Scale score > or =4) is a significant factor for mortality following falls from >6 m.

Expression profile of MicroRNAs in gram-negative bacterial sepsis.

ABSTRACT Bacterial lipopolysaccharide (LPS) is an effective trigger of the inflammatory response during infection with gram-negative bacilli (GNB), which implicates the pathogenesis of sepsis and septic shock. MicroRNAs (miRNAs) are shown to have a significant role in the fine-tuning of toll-like receptor (TLR)–mediated inflammatory response. We profiled miRNA expression levels in peripheral leukocytes of GNB urosepsis patients and compared them with those of healthy controls. We further explored the regulatory mechanism of endotoxin-responsive miRNAs in TLR and cytokine signaling by using human monocytic cell line (THP-1 cells) treated with LPS antigen stimulation. The expression of two miRNAs, that is, let-7a (P < 0.001) and miR-150 (P < 0.001), were confirmed to be significantly downregulated in GNB urosepsis patients compared with healthy controls. The expression of let-7a is first to be identified as a biomarker of GNB sepsis. By using an in vitro model with the human monocytic cell line, we demonstrated that LPS stimulation downregulated the THP-1 cell expression of let-7a. The downregulation of let-7a is correlated with the induced expression of cytokine-inducible Src homology 2–containing protein without change in cytokine-inducible Src homology 2–containing protein mRNA levels in THP-1 cells via TLR signaling pathway activation. Moreover, gain of function by overexpression of let-7a revealed that let-7a significantly decreased tumor necrosis factor-&agr; and interleukin-1&bgr; production in response to LPS. Reduced let-7a and miR-150 levels in peripheral leukocytes correlate with GNB urosepsis patients. Furthermore, let-7a is relevant to the regulation of TLR-mediated innate immune response.

The association between on-scene blood pressure and early neurological deterioration in patients with spontaneous intracerebral haemorrhage

Objective To determine whether on-scene BP is associated with early neurological deterioration (END) in patients with spontaneous intracerebral haemorrhage (SICH). Methods This retrospective cohort study enrolled consecutive ambulance-transported adult SICH patients treated at our emergency department (ED) from January 2007 through December 2012. END was defined as a ≥2-point decrease in GCS within 24 h of ED arrival. The exact relationship between on-scene BP and END was assessed using multiple logistic regression analyses for adjusting age, gender, Charlson Index, aspirin use, smoking, elapsed time, consciousness level on ED arrival, haematoma size, intraventricular extension, midline shift and infratentorial ICH. We further calculated the −2 log-likelihood decrease for each regression model incorporated with the BP values measured at different times to compare model fitness. Results After adjusting for the covariates, on-scene systolic BP (by 10 mm Hg incremental: OR = 1.126, 95% CI 1.015 to 1.265), diastolic BP (by 10 mm Hg incremental: OR=1.146, 95% CI 1.019 to 1.303) and mean arterial pressure (MAP) (by 10 mm Hg incremental: OR=1.225, 95% CI 1.057 to 1.443) were significantly associated with END; adding on-scene MAP into the regression model yielded the highest model fitness increase. Adding on-scene BPs into the regression model yielded higher model fitness increase than adding ED and admission BPs. Conclusions Few on-scene BP indices were associated with neuroworsening within 24 h after ED arrival in non-comatose SICH patients. Compared with BP measured on ED arrival or admission, on-scene BP had a stronger correlation with END.

Persistently high serum carcinoembryonic antigen levels after surgery indicate poor prognosis in patients with stage I non-small-cell lung cancer.

BACKGROUND The aim of this study is to evaluate the prognostic significance of preoperative and postoperative serum carcinoembryonic antigen (CEA) levels in patients with stage I non-small-cell lung cancer. MATERIAL AND METHODS A retrospective review of the medical records of 257 patients with stage I lung cancer undergoing surgical resection was performed. The clinical data of each patient was collected for analysis including age, smoking habits, gender, preoperative and postoperative serum CEA levels, tumor diameter, histologic type, visceral pleural invasion, pathologic stage, and type of operation. RESULTS Adenocarcinoma was more often associated with elevated preoperative CEA level compared with non-adenocarcinoma. Tumor histology, however, did not influence postoperative CEA levels. In the univariate analysis, age, serum CEA level, and pathologic stage were prognostic factors. Patients with normal preoperative serum CEA levels had better 5-y survival than patients with high preoperative serum CEA levels (71.1% versus 54.6%, P = 0.016). The patients with a persistently high serum CEA level after surgery had worst prognosis. Multivariate analysis demonstrated that older age (≥65) and persistently high serum CEA levels were independent significant prognostic factors in patients with stage I lung cancer. CONCLUSIONS Age (≥65 years) and preoperative and postoperative serum CEA levels are independent prognostic factors in patients with stage I lung cancer. Patients with a persistently high serum CEA level after surgery had worst survival, and may be good candidates for adjuvant chemotherapy.

Estrogen augments the protection of hypertonic saline treatment from mesenteric ischemia-reperfusion injury.

Either estrogen or hypertonic saline (HTS) administration can decrease lung inflammation after ischemia-reperfusion. The present study investigated whether combined treatment with estrogen and HTS could provide further protection from mesenteric ischemia-reperfusion (MSIR) injury. Male C3H/HeOuJ mice were randomly segregated into the following groups: sham-operated (sham), vehicle treatment followed by MSIR (vehicle treated), estrogen treatment followed by MSIR (estrogen treated), HTS treatment and MSIR (HTS treated), and combined treatment of estrogen plus HTS and MSIR (combined treated). In MSIR, mice were subjected to mesenteric ischemia for 60 min followed by reperfusion for 30 min. The histology of the lung and the gut was obtained. Lung injury was evaluated by lung edema and myeloperoxidase (MPO) activity; lung protein expression of macrophage migration inhibitory factor (MIF), toll-like receptor-4 (TLR4), phosphorylated inhibitory &kgr;B&agr; (p-I&kgr;B&agr;), and inducible nitric oxide synthetase (iNOS) were assayed. Survival analysis was monitored after MSIR for 120 min. Compared with those in the sham-treated group, the lung water ratio, MPO activity, and expressions of MIF, TLR4, p-I&kgr;B&agr;, and iNOS were significantly increased in the vehicle-treated group. Diminished MIF, TLR4, p-I&kgr;B&agr;, and iNOS expressions were found in the estrogen-treated group, whereas suppression of p-I&kgr;B&agr; and iNOS was found in the HTS-treated group. Treatment with estrogen or HTS decreased the lung water and MPO activity. The combined treatment of estrogen and HTS further significantly diminished p-I&kgr;B&agr; and iNOS expression, lung edema, and MPO activity and improved the inflammation of the lung and the morphology of the gut in histology compared with the results of a single treatment of estrogen or HTS. Survival analysis showed significantly increased survival in the combination-treated group compared with survival in the HTS-treated group. In conclusion, compared with single-agent use, treatment combining estrogen and HTS further decreases lung p-I&kgr;B&agr; and iNOS expressions, as well as the degree of lung injury. These effects may result in better rates of survival from MSIR injury.

Spleen artery embolization aggravates endotoxin hyporesponse of peripheral blood mononuclear cells in patients with spleen injury.

BACKGROUND : Spleen artery embolization (SAE) increases the success of nonoperative management of spleen injury; however, the immune alternation after SAE is unclear. This study searched the endotoxin responses of peripheral blood mononuclear cells (PBMCs) in injured patients who received SAE. METHODS : Patients were subsequently enrolled when their spleen injuries were confirmed by computed tomographic scan. Peripheral blood samples were obtained within first, at third, fifth, and seventh postinjury days. PBMCs were isolated; nuclear factor (NF)-kB translocations, phosphorylated I-kB expressions, and in vitro tumor necrosis factor (TNF)-alpha levels were assayed after endotoxin stimulation (ES). RESULTS : Sixteen patients who received nonoperative managements were enrolled. Five patients received SAE (embolized patients) and 11 patients did not (nonembolized patients). Compared with those in controls, NF-kB translocations, phosphorylated I-kB expressions, and TNF-alpha levels after ES decreased significantly early in injured patients. NF-kB translocation and TNF-alpha levels after ES were indifferent at seventh day between nonembolized patients and controls, whereas significantly lower NF-kB p65 translocation and TNF-alpha levels after ES were found at seventh postinjury day in embolized patients than in controls. Compared with nonembolized patients, embolized patients had significantly lower levels of NF-kBp50 translocations after ES from first to third postinjury days and lower levels of NF-kB p65 translocations, TNF-alpha, and phosphorylated I-kB expressions after ES from first to fifth postinjury days. CONCLUSIONS : SAE dysregulates the NF-kB system and aggravates the cytokine hyporesponse upon ES of PBMCs in patients with spleen injury. These results implicate that SAE alters immune response and may increase susceptibility to infections in injured patients.

Magnolol Attenuates the Lung Injury in Hypertonic Saline Treatment from Mesenteric Ischemia Reperfusion through Diminishing iNOS

BACKGROUND Hypertonic saline (HTS) administration can decrease the inflammation following ischemia reperfusion. Magnolol is a potent antioxidant. The present study investigated whether combined treatment of magnolol and HTS could provide further protection in mesenteric ischemia reperfusion injury. METHODS Male C3H/HeOuJ mice were randomly segregated into the following groups: sham-operated (sham), vehicle treatment and mesenteric ischemia reperfusion (MSIR) (vehicle-treated), magnolol treatment and MSIR (magnolol-treated), HTS treatment and MSIR (HTS-treated), as well as co-administration of magnolol plus HTS and MSIR (combined-treated). In MSIR, mice were subjected to mesenteric ischemia for 60 min followed by reperfusion for 30 min. Lung injury was evaluated by lung edema (water ratio) and myeloperoxide (MPO) activity; RNA expression of inducible nitric oxide synthetase (iNOS), TNF-α, and IL-6 were assayed by real time RT-PCR. The formation of peroxynitrite in plasma was assayed by the peroxynitrite-dependent oxidation of dihydrorhodamine 123 (DHR 123) to rhodamine. RESULTS Compared with those in the sham-treated group, lung edema and MPO activity, expressions of iNOS, TNF-α and IL-6, and plasma peroxynitrite were significantly increased in the vehicle-treated group. Significant attenuations of these parameters were found in the magnolol-treated or HTS-treated animals. Combined treatment of magnolol and HTS further suppressed the lung edema, iNOS, and TNF-α expressions, and plasma peroxynitrite, compared with the results of a single treatment of magnolol or HTS. CONCLUSIONS Compared with single-agent use, co-administration of magnolol and HTS further decreases iNOS expression and plasma peroxynitrite as well as the degree of lung injury from MISR. These results may provide another treatment measure for post-injury immunomodulation.