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Objectives: Many patients with massive hemorrhage, respiratory failure due to trauma admit the emergency department, and further that the experience can fall into shock, inducing to sepsis, multiple organ failure due to hyperinflammation or immunosuppression. In the these patients, the low oxygen flow with immunosuppression is believed to play a significant role. Hence, oxygen supply and medicines is essential in severe trauma patients. Therefore, this study aims to investigate the effects of oxygen and variable medicines in hypoxic condition. Methods: T cells and macrophages were plated into trans-well plate for co-culture for 30 minutes in hypoxia. After that, the cells were stimulated with lipopolysaccharide (LPS) followed by variable medicines by normoxia or oxygen supply for 2 hrs and cells were inculated overnight under normoxic conditions. The T cell viability was measured by MTT, and the expression of interleukin-2 (IL-2), interleukin-8 (IL-8) and macrophage migration inhibitory factor (MIF) were measured by western blots using the T cells with co-culture with inflammatory maccrophages. Also, the concentration of MIF was analyzed by ELISA. Results: The T cells viability was decreased in hypoxia with LPS stimulation, however, pentoxifylline (PTX) effectively restored cell viability regardless of oxygen state (p < 0.05). Besides, PTX in oxygen supply status restored the decreases in IL-2 expression of T cells and the increases MIF in the LPS stimulation with hypoxia (p < 0.05). Conclusions: PTX has more effectively restored the T cells immunosuppression in hypoxia during oxygen supply, and has an immunomodulation effect by controlling hyperinflammation.

Background: Hospital use patterns of patients with human immunodeficiency virus (HIV) in Korea were investigated in this study. The prevalence of HIV infections in Korea is very low. Therefore, we decided to perform a complete enumeration on the medical utilization of HIV patients using a nationwide claims database. Methods: Using the nationwide Health Insurance Review and Assessment (HIRA) service claims database, all new patients with HIV infection from 2013 to 2018 were included. Current inpatient, outpatient, and emergency service use were investigated. The number of invasive procedures, interventions, and operations performed on HIV patients; death rate; and prevalence of colon polyp were also investigated. Results: The number of patients visiting outpatient departments increased by 44% from 2013 to 2018. The most frequently visited department was internal medicine, followed by emergency medicine. Dental procedures were the most common procedures undertaken in patients with HIV after intravenous line insertion. Colon polyp estimated based on diagnostic codes was not more frequent in patients with HIV than in the general population. Interpretation: The results of this study show the status of hospital visits by patients with HIV in Korea and provide basic data upon which policy decisions can be based. Funding Statement: Korea University Grant. Declaration of Interests: The authors have no potential conflicts of interest to disclose. Ethics Approval Statement: This study was approved by the Institutional Review Board of the Korea University Guro Hospital. Informed consent was waived because of the retrospective nature of the study and the analysis used anonymous clinical data [K2019-1979-001].

Background: Among major trauma patients in the emergency department (ED), the leading cause of morbidity and mortality is a hemorrhagic shock. The low oxygen flow with hypovolemia in trauma patients is believed to play a significant role. Hence, oxygen supply is essential in severe trauma patients with massive hemorrhage. This study aimed to investigate the effect of different oxygen environments (hypoxia 1%, normoxia 20%, hyperoxia 80% oxygen) and variable treatments such as pentoxifylline (PTX), glycerol, hypertonic saline (HTS), protease inhibitor and dexamethasone (DEXA) in macrophage and T cells. Methods: Nitric oxide synthase (iNOS) and macrophage migration inhibitory factor (MIF) were measured for macrophage. MIF, interleukin (IL)-2 and 8 were measured for T cells. MTT assay was done for measuring T cell viability. Coculture was done on T cells on top of macrophages and the same protocols were carried out. Results: PTX decreased iNOS expression mostly followed by Glycerol under hypoxia. Under the hyperoxia, PTX and other treatments decreased iNOS expressions. MIF expression was lowered with PTX under hypoxia. PTX, glycerol, HTS, and protease inhibitor were effective under hyperoxia. PTX increased T cell survival under hypoxia. Under the hyperoxia, IL-2 expressions were upregulated with PTX, Glycerol, and HTS. PTX and other treatments were effective for IL-8, too. Our results indicate that PTX, HTS, and other medications with oxygen showed an effect on macrophage and T cells under various insults and stimulations. Conclusion: Our study demonstrated potential usefulness in improving immune systems during severe inflammatory conditions similar to septic shock possibly caused by massive hemorrhage.

Background: Immunity is the state of having sufficient biological defenses to avoid infection, trauma, or other unwanted biological invasions. T-cells and macrophages play important role in cell-mediated immunity. Pentoxifylline (PTX) is known to decrease pro-inflammatory cytokine and tumor necrosis factor (TNF-α). However, the effect on the immune system is not known well. This study aims to investigate the effect of PTX on inflammation. Methods: THP-1 derived macrophages were incubated with lipopolysaccharide (LPS) and/or indicated concentration of PTX for 8hr and wash with PBS to eliminate the effect of LPS. In this media, Jurkat cells were plated into trans-well plate and co-culture was done at 12hr. The T cell viability was measured by MTT. Also, the expression of Interleukin-2 (IL-2) was analyzed by RT-PCR and western blots. Results: PTX restored the increased concentration of MIF, TLR4 protein level and mRNA expression of TLR4 in LPS stimulated THP-1 derived macrophages. However, PTX did not restore the decreased T cell proliferation with PGE2 in Jurkat cells. In the co-culture study, The T cell viability was decreased in the THP-1 derived macrophage cells stimulated with LPS. The additional PTX restored the T cell's viability. Besides, PTX restored the decrease in the IL-2 expression of Jurkat cells in the LPS stimulated THP-1 derived macrophages. Conclusion: LPS stimulated THP-1 derived macrophages inhibited the T cell viability in hyper-inflammation conditions. However, PTX restored the T cells viability with increase IL-2. PTX influenced the cell-cell interaction, therefore, had its immunomodulatory effects.

Many patients are admitted to the emergency department due to trauma. Patients with massive hemorrhage and respiratory failure can fall into hypovolemic shock. Thereafter, oxygen is an essential part of the treatment of trauma patients, but the mechanisms of its effects in the management of trauma patients remain unknown. Therefore, we conducted an experiment to apply hypoxia, hyperoxia, and other treatment with the goal of decreasing hypoxic neuronal cells damage, as reflected by cell survival, apoptosis, hydrogen peroxide (H2O2) production, and hypoxia-inducible factor 1α (HIF) expression in SH-SY5Y cells. Under hypoxic insults, cell survival percentages decreased and apoptosis was seen with increased necrotic cell death. High-pressure oxygen (80% O2) had no effect compared with normal-pressure oxygen (20% O2). After exposure to hypoxia, H2O2 production and levels of HIF significantly increased compared with normoxia. However, when pentoxifylline (PTX), steroid, and hypertonic saline (HTS) were added after exposure to hypoxic conditions, the production of H2O2 and HIF levels significantly decreased in the groups treated with PTX and HTS. That is, the neuroprotective effect of PTX and HTS alleviated the impacts of hypoxic insulted on neuronal cells.

Introduction: Pentoxifylline (PTX) reduces the levels of pro-inflammatory cytokines; however, its effects on immune system is not well understood. The aim of this study was to investigate the effect of PTX on T cells under inflammatory conditions in co-culture with THP-1-derived macrophages.Methods: Toll-like receptor 4 (TLR4) and macrophage migration inhibitory factor (MIF) levels were measured after addition of PTX to lipopolysaccharide (LPS)-stimulated differentiated THP-1 cells. T cell viability and MIF levels were measured after PTX was added to prostaglandin E2(PGE2)-stimulated Jurkat T-cell leukemia line. Co-culture was conducted to determine the effect of LPS-stimulated differentiated THP-1 cells that are affected by PTX on Jurkat cells. To prevent the direct effects of LPS and PTX on Jurkat cells, LPS and PTX were washed from THP-1 cells before co-culture. T cell viability and interleukin-2 (IL-2) levels were determined in Jurkat cells. Results: Increase in the MIF concentration and TLR4expression level in differentiated THP-1 cells stimulated with LPS were reversed after PTX addition. However, PTX did not improve T cell viability in PGE2–stimulated Jurkat cells. Co-culturing Jurkat cell and LPS-stimulated differentiated THP-1 cells resulted in a decreased viability of T cells. The addition of PTX restored T cell viability to normal control levels and IL-2 expression level in Jurkat cells. Conclusion: LPS-stimulated THP-1-derived macrophages reduced the T cell viability under inflammation. However, PTX restored T cells viability and IL-2 back to normal levels. Therefore, the immunomodulatory action of PTX may be mediated by macrophage-T cell interactions.

We investigated the clinical value of whole blood procalcitonin using point of care testing, quick sequential organ failure assessment score, C-reactive protein and lactate in emergency department patients with suspected infection and assessed the accuracy of the whole blood procalcitonin test by point-of-care testing. Participants were randomly selected from emergency department patients who complained of a febrile sense, had suspected infection and underwent serum procalcitonin testing. Whole blood procalcitonin levels by point-of-care testing were compared with serum procalcitonin test results from the laboratory. Participants were divided into two groups&mdash, those with bacteremia and those without bacteremia. Sensitivity, specificity, positive predictive value, negative predictive value of procalcitonin, lactate and Quick Sepsis-related Organ Failure Assessment scores were investigated in each group. Area under receiving operating curve of C-reactive protein, lactate and procalcitonin for predicting bacteremia and 28-day mortality were also evaluated. Whole blood procalcitonin had an excellent correlation with serum procalcitonin. The negative predictive value of procalcitonin and lactate was over 90%. Area under receiving operating curve results proved whole blood procalcitonin to be fair in predicting bacteremia or 28-day mortality. In the emergency department, point-of-care testing of whole blood procalcitonin is as accurate as laboratory testing. Moreover, procalcitonin is a complementing test together with lactate for predicting 28-days mortality and bacteremia for patients with suspected infection.

Objective We compared patient satisfaction with scarring after facial laceration repair in the emergency department (ED) based on the specialty of the provider. Methods Patients with facial lacerations admitted to the ED from 2009 to 2013 were divided into two groups. One group of patients underwent repair by an emergency physician (EP) and the other by a plastic surgeon (PS). From August 2014 to September 2014, we randomly selected 10% of all patients and assessed their degree of satisfaction with scarring over the phone using a 5-point Likert scale. Results The male to female ratio was 2.81 in the EP group and 2.05 in PS (P

Recently, several researchers have reported that direct reprogramming techniques can be used to differentiate fibroblasts into hepatocyte-like cells without a pluripotent intermediate step. However, the use of viral vectors for conversion continues to pose important challenges in terms of genome integration. Herein, we propose a new method of direct conversion without genome integration with potential clinical applications. To generate hepatocyte-like cells, mRNA coding for the hepatic transcription factors Foxa3 and HNF4α was transfected into mouse embryonic fibroblasts. After 10-12 days, the fibroblasts converted to an epithelial morphology and generated colonies of hepatocyte-like cells (R-iHeps). The generated R-iHeps expressed hepatocyte-specific marker genes and proteins, including albumin, alpha-fetoprotein, HNF4α, CK18, and CYP1A2. To evaluate hepatic function, indocyanine green uptake, periodic acid-Schiff staining, and albumin secretion were assessed. Furthermore, mCherry-positive R-iHeps were engrafted in the liver of Alb-TRECK/SCID mice, and we confirmed FAH enzyme expression in Fah1RTyrc/RJ models. In conclusion, our data suggest that the nonintegrating method using mRNA has potential for cell therapy.

Many patients are admitted to the emergency department due to trauma. Trauma patients suffer from hypoxia due to massive hemorrhage, respiratory failure, and hypovolemic shock. Further damage is caused by reduced immune function and over-expression of inflammatory response. We conducted an experiment to determine the effects of hyperoxia and hypoxia on apoptosis and expression of Toll-like receptor 4 (TLR4) in polymorphonuclear neutrophils (PMNs). Initially, the PMNs were placed in normoxic and hypoxic conditions, and these PMNs were divided into two groups as stimulated or not stimulated with lipopolysaccharide (LPS). Levels of apoptosis and TLR4 expression were measured under normoxic, hypoxic, and hyperoxic conditions. Apoptosis decreased in the hypoxic group than in the normoxic group. With LPS stimulation, apoptosis was decreased in all three treatment groups and even more reduced in the hypoxic group. TLR4 expression increased in all three treatment groups with LPS stimulation, increased further in the hypoxic group, and to a lesser degree in the hyperoxic group. Unlike the cells exposed to hypoxic conditions, the cells exposed to the hyperoxic condition reacted similarly to the cells in the control (normoxic) group. Therefore, the inflammatory reactions can be stronger in the hypoxic group than in the other two groups.

Target cells differentiation techniques from stem cells are developed rapidly. Recently, direct conversion techniques are introduced in various categories. Unlike pluripotent stem cells, this technique enables direct differentiation into the other cell types such as neurons, cardiomyocytes, insulin-producing cells, and hepatocytes without going through the pluripotent stage. However, the function of these converted cells reserve an immature phenotype. Therefore, we modified the culture conditions of mouse direct converted hepatocytes (miHeps) to mature fetal characteristics, such as higher AFP and lower albumin (ALB) expression than primary hepatocytes. First, we generate miHeps from mouse embryonic fibroblasts (MEFs) with two transcription factors HNF4α and Foxa3. These cells indicate typical epithelial morphology and express hepatic proteins. To mature hepatic function, DMSO is treated during culture time for more than 7 days. After maturation, miHeps showed features of maturation such as exhibiting typical hepatocyte-like morphology, increased up-regulated ALB and CYP enzyme gene expression, down-regulated AFP expressions, and acquired hepatic function over time. Thus, our data provides a simple method to mature direct converted hepatocytes functionally and these cells enable them to move closer to generating functional hepatocytes.

Objectives Inflammation makes an influence on autonomic nervous system and a change in autonomic nervous activity affects heart rate. Heart rate variability (HRV) test can quantify the autonomous nervous activity. In this study, we evaluated the meaning of heart rate variability in sepsis patients. Methods Heart rate variability test was performed for sepsis patients and healthy volunteers. Normalised low frequency power, reflecting sympathetic activity, was compared to acute physiology and chronic health evaluation II (APACHE II) score and mortality in emergency department sepsis (MEDS) score in sepsis patients. Then the patients were divided into four groups: 1) severe sepsis patients, 2) sepsis patients admitted to general ward, 3) sepsis patients discharged within 24 hours and 4) healthy volunteers. We obtained averages for the HRV results in all four groups. The receiver operating characteristics curve was examined to determine whether or not HRV variables could be used to triage sepsis patients. Results Correlations between normalised low frequency power (LFnu) with APACHE II score and MEDS score were −0.595 and −0.514, respectively. Low frequency power (LF) and LFnu values decreased in sepsis patients with the higher scores observed in the discharged sepsis patients and healthy volunteers. The areas under the curve for the values of LF and LFnu in the admission and discharge groups were 0.746 and 0.635, respectively (pConclusion Variables related to heart rate variability are significantly correlated with the severity of sepsis patients. Although the HRV test alone cannot accurately predict the disposition of sepsis patients, in the emergency room setting it helps to assign beds to sepsis patients within the triage system, and avoid over-population. (Hong Kong j.emerg.med. 2014;21:73-79)

The Hospital-based Influenza Morbidity and Mortality (HIMM) surveillance system is an emergency room (ER)-based influenza surveillance system in Korea that was established in 2011. The system was established under the assumption that integrated clinical and virologic surveillance could be performed rapidly and easily at seven tertiary hospitals' ER. Here, we assessed the correlation between data generated from the HIMM surveillance system and the Korean national influenza surveillance systems during the 2011-2012 influenza season using cross-correlation analysis and found strong correlations. Rapid antigen-test-based HIMM surveillance would predict the start of influenza epidemic earlier than pre-existing influenza-like-illness-based surveillance.

Purpose Postcardiac arrest syndrome (PCAS) shares many features with sepsis including plasma cytokine elevation with dysregulation of cytokine production, and the presence of endotoxin in plasma. PCAS is closely related to ischemia-reperfusion injury. During ischemia-reperfusion injury, neutrophil, which is the first line of innate immunity, plays a major role. In this study, we investigated the inflammatory response of human neutrophils in an in vitro model which we simulated with hypoxia-normoxia and hypoxia-hyperoxia environments. Methods After separation of neutrophils from the whole blood, they were divided into 3 experimental groups: normoxia-normoxia, hypoxia-normoxia, and hypoxia-hyperoxia groups. The production of H2O2, the expression of Toll-like receptor 4 (TLR4) receptor, and the extent of apoptosis of the neutrophils were checked. Results The in vitro hypoxia-normoxia and -hyperoxia models, which simulated the PCAS, showed initiation of the neutrophils' inflammatory reaction by hypoxia insult. Lipopolysaccharide amplifies such inflammation; therefore, prevention of secondary infection may be critical in postresuscitation patients. Temporary hyperoxia following hypoxic insult showed no difference in inflammatory reaction compared with hypoxia-normoxia. Rather, temporary hyperoxia may suppress or minimize inflammation by attenuation of TLR4 receptor. Conclusion It is well known that continuous hyperoxygenation after successful cardiac arrest harms patients, but temporary hyperoxygenation with 100% O2 in a clinical situation may be helpful.

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

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.

Objective. The purpose of this study is to identify problems of emergency transfu-sion at the bedside and to determine need for massive transfusion protocol. Methods. We included patients who met the criteria for “trauma team activation” and were admitted to division of trauma. The amount of blood product transfused in each unit was investigated for balanced transfusion. We also investigated the com-pliance with assessment of blood con-sumption score. The correlation between the time elapsed from patient visit to first transfusion order and time elapsed from first transfusion order to transfusion start was analyzed. Finally, we investigated vari-ous factors which serve to influence the decision-making process regarding early transfusion order. Results. Ratio of packed Red blood cells (pRBC): Fresh frozen plasma (FFP) was well-balanced, but platelet transfusion done was much lower than pRBC and FFP in emergency room. The application of emergency blood release did not match the criteria of assessment of blood consump-tion (ABC) score. The time from the first transfusion order to the transfusion start was found to be constant irrespective of time from patient visit to first transfusion order. And, the time from the first transfu-sion order to transfusion start did not dif-fer significantly among patients with early transfusion order and delayed transfusion order. Only systolic blood pressure of < 90 mmHg was identified as a major predictor for early transfusion order. Conclusion. Balanced transfusion is not easy and emergency transfusion could be delayed at the bedside. Integrated and sys-tematic structures for massive transfusion protocol would be invaluable and indis-pensable.

BACKGROUND The role of migration inhibitory factor (MIF) is best understood in septic shock and septic disease; however, the role of MIF in a secondary infection after trauma has not yet been completely studied. This study aimed to evaluate the role of MIF in trauma patients. METHODS The patients in the study population were divided into two groups according to the results of their MIF levels. The initial MIF levels, trauma mechanism, revised trauma score, survival rate, length of stay (LOS) in the intensive care unit (ICU), level of leukocytes, and level of C-reactive protein (CRP) were compared between the groups. RESULTS Overall, 116 patients were enrolled from August 1, 2014 to July 31, 2015. LOS in ICU in the elevated MIF group was 5.67±7.54 days compared with 2.09±2.26 days in the normal MIF group. Further, CRP level in the elevated MIF group was higher than that in the normal MIF group. CONCLUSION In a place such as the department of emergency medicine, it is critical and important for emergency physicians to make a proper judgment and to prepare for the worst scenario. Therefore, the utilization of MIF level in trauma patients has a possibility for assisting emergency physicians.

Background Prediction of the return of spontaneous circulation (ROSC) in cardiac arrest patients is a parameter for deciding when to stop cardiopulmonary resuscitation (CPR) or to start extracorporeal CPR. We investigated the change in transcutaneous PCO2 (PtcCO2) in cardiac arrest patients. Methods This study was carried out as a retrospective chart review. Patients with out-of-hospital cardiac arrest or in-hospital cardiac arrest within the emergency department were included. PtcCO2 monitoring with a V-Sign™ combined monitor (SenTec Inc., Therwil, Switzerland) was applied to patients at the start of CPR. We divided the included patients into the ROSC group and the no ROSC group. The ROSC group was subdivided into those achieving ROSC 15 min CPR. The change in the PtcCO2 value was analyzed at 0 min, 5 min, 10 min, and 15 min from PtcCO2 stabilization and was compared among the groups. Results A total of 42 patients were enrolled. Twenty-eight patients achieved ROSC; 13 patients achieved ROSC 15 min CPR. Fourteen patients expired without ROSC. The absolute values of PtcCO2 was lower in the ROSC group than in the no ROCS group. The PtcCO2 change over time had a tendency to decrease or to remain constant in the ROSC groups. In contrast, all patients in the no ROSC group experienced an increase in the PtcCO2 change during CPR except one case. Conclusions PtcCO2 monitoring provides non-invasive, continuous, and useful monitoring in cardiac arrest patients.

Introduction. Patients with symptoms suggestive of acute coronary syndrome (ACS) have various medical backgrounds and different stages of underlying coro-nary disease. Hence, patients entering the emergency room (ER) with ACS sug-gestive symptoms, present a challenge to emergency physicians. We hypothesized that a point-of-care test (POCT) for mul-tiple cardiac biomarkers can be used as a prognostic tool for predicting severity and hospital mortality in acute myocardial in-farction (AMI) patients.Methods . We conducted a retrospective analysis of all patients who presented to the ER of a university urban hospital with chest pain, chest discomfort and short-ness of breath of potential cardiovascular origin during a 3-year period. Biomarkers from the POCT and coronary angiography (CAG) results were used for diagnosis. Se-verity was evaluated based on involvement and status of major coronary arteries, ejec-tion fraction and in-hospital mortality. Results. Out of 1336 patients, 329 patients were diagnosed with AMI. Risk of major coronary artery occlusion was increased with an increased number of positive POCT findings. The percentage of patients with severe left ventricular dysfunction was higher in the group with 2 or 3 posi-tive POCTs than 0 or 1. As the number of positive POCTs increased from 1 to 3, our results showed an increment in the per-centage of in-hospital mortality Conclusions. This study identified the pos-sibility of a POCT as a prognostic tool. The POCT is easy to use by the bedside and can be checked relatively quickly? in a short period of time. If the POCT result is used to predict the prognosis in ACS patients, emergency physicians may approach pa-tients with more caution.

ObjectivesContinuous 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).MethodsAll 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.ResultsThe 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.ConclusionsPtcCO2 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.

Background Most 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. Methods Questionnaires were sent to the directors of the emergency departments of resident training hospitals certified by the Korean Society of Emergency Medicine. Results Two 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. Conclusion Attitude 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.

Background: As the use of CT increases, it has raised the question for the radiation induced adverse effect. The management of blunt trauma has been influenced by the advance in the technology of CT. CT makes it possible to characterize the multiple injured patient and establish the priorities of management with more precise information. With the liberal use of CT for blunt trauma, whole body CT scanning, the-so called panscan, has often been used in trauma center to detect possible missed injuries. Within the Organization of Economic Cooperation Development (OECD) countries, South Korea has the third largest number of CT scanners per million people after Japan and Australasia. The annual number of CT examination is increasing every year. The object of this study was to assess the radiation exposure from computed tomography in multiple blunt trauma patients. Methods: This study was a retrospective cross sectional study performed for multiple blunt trauma patients visiting the OOOO Emergency Department during one year. Using data from our Hospital information system, we selected patients provided with trauma code of Korean Standard Classification of Diseases and three or more types of computed tomography at the same time in ED. The data collected by patients chart review were age, sex, initial vital signs, Glasgow coma scale (GCS), final diagnosis, injury severity score (ISS), cause of injury, mode of transportation, body location of injury, dispatch route from ED, received types CT, and the reading of CT by radiologist. Each CT conducted to patients was categorized into CT related to final diagnosis or CT unrelated to final diagnosis. Dose length product (DLP) depending on the type of CT was also examined by review of Picture Archiving and Communication System (PACS) in each patient. Total number of initial CT conducted to patients and average estimated effective dose depending type of CT were investigated. Estimated effective dose was calculated as DLP multiplied by a“ k”conversion factor. The reference for conversion factor was AAPM reports NO. 96. (9) Characteristics of CT and average effective dose unrelated to final diagnosis were also analyzed. Finally, we tried to find the factor affecting estimated effective dose. Results: 1. Clinical data of include patients and Injury details of patients. Total 110 patients were searched on the database of hospital information system during a study period. The included patients received radiographic evaluation using 16-slice CT scanner (SOMATOM Sensation 16, Siemens, Forchheim, Germany). Clinical data of included patients are shown in table 1. About one third of the patients had initial GCS score under 14 and 60 percentage of patients had ISS score under 15. The most common causes of injury were fall and motor crash injury. They occupied near half of all cause. Almost patients visited emergency department by emergency medical service (EMS) and only 13 patients visited ED via other than EMS. Head and limb were the major body location of injury. Dispatch route from ED were transferred, intensive unit, general ward, discharged home, operation and died in the order of frequency. 2. The characteristics of initial computed tomography (CT) conducted to patients. The 105 patients received total 408 CT scans initially. The main conducted types of CT were head, chest and abdomen. Estimated effective dose depending on type of CT did not differ from the levels of radiation exposure ever known. No. of patients receiving estimated effect dose over 20 mSv is 59(56.2%). About 60 percentages of total CT examinations was not associated with the final diagnosis. The patients received 2.35±1.26 (mean± standard deviation) CT scans unrelated to final diagnosis. Accordingly, average estimated effective dose due to CT unrelated to final diagnosis was 12.80±8.54 (mean±standard deviation) mSv. 3. The factors affecting the estimated effective dose. Estimated effective dose according to the sex, age, GCS, ISS, dispatched route and cause of injury was investigated. The mean values of total estimated effective dose were not different in subgroup of variables. The mean values of estimated effective dose unrelated final diagnosis were also not different in all subgroup of variables except ISS. The patients with ISS

Polyethylene glycol (PEG) 용액을 이용한 대장 전 처치는 비교적 안전하지만 드물게 치명적인 합병증이 발생할 수 있다. 그 중에서 PEG 용액의 흡인에 의한 폐렴 및 급성호흡곤란증후군은 아주 드문 경우로 저자들은 대장 내시경 검사를 위해서 PEG 용액을 복용한 후 발생한 흡인성폐렴 및 급성호흡곤란증후군에서 기관지폐포세척술과 스테로이드 치료로 극적인 호전이 있었던 증례를 문헌고찰과 함께 보고한다.

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.