Since the mid-2000s, massive blood transfusion protocols and damage control resuscitation have improved the prognosis of trauma patients. As a part of damage control resuscitation, whole blood transfusion, especially using low titer group O whole blood (LTOWB), has been widely accepted in both military and civilian trauma settings based on its safety and significant advantages in terms of efficiency and efficacy. To implement LTOWB effectively, each institution should establish relevant policies which should simultaneously consider safety and accessibility factors, including titer threshold, blood management, blood supply, and transfusion protocols for LTOWB. These policies will need to be revised through continuous audits and monitoring. Additionally, whole blood and LTOWB may benefit hemorrhagic patients in non-trauma contexts, or in rural and pre-hospital settings. Further supporting evidence for these applications is needed.

BACKGROUND: The possible impact of hemodilution during acute normovolemic hemodilution (ANH) using hydroxyethyl starch (HES) on intraoperative serum concentration of creatinine (s-Cr) has not been well investigated. METHODS: Patients undergoing cardiac surgery were randomly allocated into Group-ANH (n = 15) or Group-C (control; n = 17). In Group-ANH, 5 ml/kg whole blood was collected, and they were administered 5 ml/kg of HES 130/0.4 after anesthesia induction and before initiating cardiopulmonary bypass (CPB). In both groups, moderate hypothermic CPB was initiated using 1,600–1,800 ml of bloodless priming solution. The changes of s-Cr, blood urea nitrogen, hematocrit (Hct), electrolytes, and osmolality were determined before ANH administration (T1), after administering ANH 5 ml/kg (T2), 30 and 60 s after the initiation of CPB (T3, T4), and at the end of surgery (T5). RESULTS: In Group-ANH, the s-Cr values at T2 (median [IQR25–75%], 0.83 [0.71–1.00] mg/dl) were not significantly different compared to those at T1 (0.84 [0.64–1.00] mg/dl), while those at T3 and T4 (0.68 [0.61–0.80] and 0.76 [0.59–0.92] mg/dl, respectively) were significantly lower than those at T2 (0.83 [0.71–1.00] mg/dl, P < 0.001). Hct at T3, T4 and T5 were significantly lower than those of T1 in both groups, and those at T2 and T4 of Group-ANH were significantly lower than those of Group-C (P < 0.001). There was no significant inter-group difference in all other parameters. CONCLUSIONS: Intraoperative s-Cr was not affected by the administration of ANH 5 ml/kg, although it reduced transiently at the beginning of CPB. Further study is needed to determine the clinical relevancy of our results.
Anesthesia ; Blood Urea Nitrogen ; Cardiopulmonary Bypass ; Creatinine ; Electrolytes ; Hematocrit ; Hemodilution* ; Humans ; Osmolar Concentration ; Starch ; Thoracic Surgery*

BACKGROUND: The impact of volatile induction using large-dose sevoflurane (VI-S) on cerebral blood flow has not been well investigated. The present study compared the changes in cerebral blood flow of middle cerebral artery using transcranial Doppler (TCD) during VI-S and conventional induction using propofol. METHODS: Patients undergoing elective lumbar discectomy were randomly allocated to receive either sevoflurane (8%, Group VI-S, n = 11) or target-controlled infusion of propofol (effect site concentration, 3.0 microg/ml; Group P, n = 11) for induction of anesthesia. The following data were recorded before and at 1, 2, and 3 min after commencement of anesthetic induction (T0, T1, T2, and T3, respectively): mean velocity of the middle cerebral artery (V(MCA)) by TCD, mean blood pressure (MBP), heart rate, bispectral index score (BIS) and end-tidal CO2 (ETCO2). Changes in V(MCA) and MBP from their values at T0 (DeltaV(MCA) and DeltaMBP) at T1, T2, and T3 were also determined. RESULTS: BISs at T1, T2 and T3 were significantly less than that at T0 in both groups (P < 0.05). DeltaVMCA in Group VI-S at T2 and T3 (18.1% and 12.4%, respectively) were significantly greater than those in Group P (-7.6% and -19.8%, P = 0.006 and P < 0.001, respectively), whereas ETCO2 and DeltaMBP showed no significant intergroup difference. CONCLUSIONS: VI-S using large-dose sevoflurane increases cerebral blood flow resulting in luxury cerebral flow-metabolism mismatch, while conventional propofol induction maintains cerebral flow-metabolism coupling. This mismatch in VI-S may have to be considered in clinical application of VI-S.
Anesthesia ; Blood Pressure ; Diskectomy ; Heart Rate ; Humans ; Middle Cerebral Artery ; Propofol*

BACKGROUND: This study evaluated the efficacy of ulinastatin for attenuating organ injury and the release of proinflammatory cytokines due to cardiopulmonary bypass (CPB) during cardiac surgery. METHODS: Patients undergoing valvular heart surgery employing CPB were assigned to receive either ulinastatin (group U, n = 13) or a placebo (group C, n = 11) before the commencement of CPB. Hemodynamic data, parameters of major organ injury and function, and proinflammatory cytokines were measured after the induction of anesthesia (T1), after CPB (T2), at the end of anesthesia (T3), and at 24 hours after surgery (POD). RESULTS: The demographic data, CPB duration, and perioperative transfusions were not different between the groups. PaO2/FiO2 in group U was significantly higher than that in group C at T3 (3.8 +/- 0.8 vs. 2.8 +/- 0.7, P = 0.005) and at POD (4.0 +/- 0.7 vs. 2.8 +/- 0.7, P < 0.001). Creatine kinase-MB at POD in group U was significantly lower than that in group C (17.7 +/- 8.3 vs. 33.7 +/- 22.1, P = 0.03), whereas troponin I at POD was not different between the groups. Creatinine clearance and the extubation time were not different between the groups at POD. The dopamine infusion rate during the post-CPB period in group U was significantly lower than that in group C (1.6 +/- 1.6 vs. 5.5 +/- 3.3 microg/kg/min, P = 0.003). The interleukin-6 and tumor necrosis factor-alpha concentrations at T1, T2, and T3 as well as the incidences of postoperative cardiac, pulmonary and kidney injuries were not different between the groups. CONCLUSIONS: Ulinastatin pretreatment resulted in an improved oxygenation profile and reduced inotropic support, probably by attenuating the degree of cardiopulmonary injury; however, it did not reduce the levels of proinflammatory cytokines.
Anesthesia ; Cardiopulmonary Bypass ; Creatine ; Creatinine ; Cytokines ; Dopamine ; Glycoproteins ; Hemodynamics ; Humans ; Incidence ; Interleukin-6 ; Kidney ; Oxygen ; Thoracic Surgery ; Troponin I ; Tumor Necrosis Factor-alpha

BACKGROUND: Prescribing potentially harmful drugs and omitting essential drugs to older patients is a common problem because they take so many medications. In this study, our goal was to identify potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) using Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to the Right Treatment (START) criteria to improve proper prescription and reduce improper prescription. METHODS: Enrolled in this study were 117 patients older than 65 years old who were hospitalized at Inha University Hospital in Incheon due to pneumonia from January 2012 to March 2012. Patient data, including medical histories, current diagnoses, current medications, and biochemical data were recorded from electronic records. STOPP and START were applied to their clinical datasheets. RESULTS: STOPP criteria identified 24 patients who had 29 PIMs. Most potential inappropriate prescribing was of cardiovascular medications, followed by drugs whose primary effect is on the urogenital system and gastrointestinal system. START criteria identified 31 patients who had 46 PPOs. The cardiovascular system drugs comprised most of the PPOs. No PPOs were identified under the central nervous system criteria. CONCLUSION: Given the current Korean medical system conditions and considering the many clinically important situations when prescribing drugs, STOPP/START criteria are not absolute criteria to prevent improper prescription, but sagacious usage of these standards can help physicians to prescribe properly in clinical practice.
Cardiovascular System ; Central Nervous System ; Drugs, Essential ; Electronics ; Electrons ; Humans ; Inappropriate Prescribing ; Mass Screening ; Pneumonia ; Prescriptions ; Urogenital System

We report an unusual case of Plasmodium vivax malaria that occurred in a 22-year-old ankylosing spondylitis patient after initiating adalimumab therapy. P. falciparum malaria was initially included as a possible differential diagnosis due to hyperparasitemia and similar features in the peripheral blood smear. The patient was successfully treated with conventional therapy for P. vivax malaria.
Antibodies, Monoclonal, Humanized ; Diagnosis, Differential ; Humans ; Malaria ; Malaria, Vivax ; Plasmodium ; Plasmodium vivax ; Spondylitis, Ankylosing ; Young Adult ; Adalimumab

Traumatic brain injury can cause movement disorders such as tremor, dystonia, myoclonus, parkinsonism and chorea. After the severe traumatic brain injury, movement disorders have been reported in 13 to 66% of patients and 20% of cases combined with weakness, spasticity, cognitive impairment and ataxia. Postural/kinetic tremor, which is the most common type of movement disorder after traumatic brain injury, may be transient or persistent however the other syndromes tend to persist and produce significant impairment in activity of daily living. The symptomatic relief can generally be achieved with medical treatment and some cases with neurosurgical intervention such as functional stereotactic surgery or deep brain stimulation. This article reviews the epidemiology, underlying mechanism, the type and treatment of movement disorders follow traumatic brain injury.
Ataxia ; Brain Injuries ; Chorea ; Deep Brain Stimulation ; Dystonia ; Humans ; Movement Disorders ; Muscle Spasticity ; Myoclonus ; Parkinsonian Disorders ; Tremor

BACKGROUND: Uncomplicated acute cystitis (CA-UAC) is one of the most common infections treated with antibiotics in the community. However, few data on etiology of CA-UAC and its susceptibility to antibiotics are available, primarily because, in Korea, insurance does not allow reimbursement for microbiological evaluation of CA-UAC. However, microbiologic data on community-acquired uncomplicated acute pyelonephritis (CA-UAPN) are available. The objective of the study was to evaluate the question of whether microbiologic data on CA-UAPN can be used for treatment of CA-UAC; therefore, etiology and antimicrobial susceptibility were compared between pathogens of CA-UAC and those of CA-UAPN. MATERIALS AND METHODS: During 2008, 538 CA-UACs and 1,265 CA-UAPNs were recruited retrospectively from 14 hospitals (UTI research group). Microbiologic data on etiology and susceptibility to antibiotics were collected retrospectively. RESULTS: Urine culture was positive in 131 CA-UACs (131/469, 27.9%) and 719 CA-UAPNs (719/1249, 57.6%). Escherichia coli was the most common pathogen in both groups [83.2% (109/131) in CA-UAC vs. 91.9% (661/719) in CA-UAPN]. Susceptibility to common UTI regimens, such as ciprofloxacin, extended-spectrum cephalosporins, and trimethoprim/sulfamethoxazole did not differ between urinary pathogens of CA-UACs and CA-UAPNs, however, a significant difference was observed in rates of resistance to ampicillin/sulbactam (16.5% vs. 42.9%, P<0.001, respectively). CONCLUSIONS: Rates of resistance of E. coli from CA-UAC and CA-UAPN to most antibiotics did not differ. For proper treatment, further microbiological evaluation for CA-UAC is mandatory.
Anti-Bacterial Agents ; Cephalosporins ; Ciprofloxacin ; Cystitis ; Escherichia coli ; Insurance ; Korea ; Pyelonephritis ; Retrospective Studies

Stenotrophomonas maltophilia is a ubiquitous, Gram-negative organism. It is an emerging causative pathogen for severe hospital- acquired infections, particularly in debilitated or immunocompromised patients because of its resistance to various antibiotics. Soft tissue infection caused by S. maltophilia, however, is uncommon. A patient with leukemia was referred for the evaluation of subcutaneous nodules that developed after chemotherapy. With the pathological finding of neutrophilic panniculitis, S. maltophilia was confirmed in a bacteriological study of the biopsied tissue. The nodules regressed spontaneously with recovery from the neutropenia. We report a case of S. maltophilia infection that manifested as soft tissue nodules, which resolved spontaneously in a patient with leukemia.
Anti-Bacterial Agents ; Humans ; Immunocompromised Host ; Leukemia ; Neutropenia ; Neutrophils ; Panniculitis ; Soft Tissue Infections ; Stenotrophomonas ; Stenotrophomonas maltophilia

BACKGROUND AND OBJECTIVES: The aim of this study was to evaluate the incidence and prognostic significance of cervical lymph node metastasis in squamous cell carcinoma (SCC) of the hypopharynx. SUBJECTS AND METHOD: A retrospective review of the 64 patients who were previously untreated for SCC of the hypopharynx and underwent surgery was performed from October 1993 to June 2008. Fifty-six patients had simultaneous bilateral neck dissection, whereas eight had unilateral neck dissection. RESULTS: The median age was 61.0 years (range, 34-75 years) for the study group consisting of 62 males and two females. Evaluating according to the N stages, there were 15 (23.4%), 10 (15.6%), 37 (57.8%), and 2 (3.1%) cases with N0, N1, N2 and N3, respectively. Forty-nine patients (76.6%) had pathologically proven cervical metastasis. Contralateral occult lymph node metastasis occurred in 20.5%. Ipsilateral and contralateral occult metastasis rates for clinically node negative patients were 41.2% and 11.8%, respectively. The most frequent sites for positive neck nodes occuring at each level were as follows: II (48.5%), level III (40.6%), level IV (26.6%), paratracheal node (21.4%), level V (9.4%), levels I (7.8%), and retropharyngeal node (6.3%). The 5-year overall survival and disease-specific survival rates were 50% and 53%, respectively. Cervical nodal metastasis (p=0.044) was statistically significant prognostic factors for disease-specific survival. CONCLUSION: Metastasis to the cervical lymph node group is very frequent and has an impact on survival in patients with hypopharyngeal SCC. Therefore, we advocate bilateral neck dissection in patients with hypopharyngeal SCC with clinically positive metastasis. Ipsilateral elective neck dissection may be needed for clinically node negative patients.
Carcinoma, Squamous Cell ; Female ; Humans ; Hypopharynx ; Incidence ; Lymph Nodes ; Lymphatic Metastasis ; Male ; Neck ; Neck Dissection ; Neoplasm Metastasis ; Retrospective Studies ; Survival Rate