BACKGROUND: Red blood cell (RBC) transfusion is one of the major treatments for correcting anemia, but its use should be carefully considered because of adverse transfusion reactions and inappropriate usage. Therefore, individual health care facilities have self evaluated their use of transfusion in an attempt to decrease unnecessary procedures. In this study, we evaluated the differences in the minimum hemoglobin (Hb) trigger for RBC transfusion among clinical departments in Severance Hospital. METHODS: We analyzed the electronic medical records of RBC transfusion episodes that were conducted at a Hb level above 8 g/dL from July 2014 to September 2015. We classified these data by clinical department, and considered the overall medical conditions of the patients. The minimum Hb trigger level in this study was defined as the lowest Hb level within 24 hours prior to RBC transfusion. RESULTS: A total of 4,953 RBC transfusion episodes that were conducted at Hb levels above 8 g/dL were analyzed over that period. In general, the minimum Hb trigger level was higher in the operation group than the hemorrhage group. When compared among clinical departments, the department of orthopedic surgery, neurosurgery, rehabilitation medicine, and anesthesiology showed high levels of minimum Hb trigger equal to or greater than 10 g/dL. CONCLUSION: The minimum Hb trigger level differed among clinical departments, with the operation group showing a much higher level of minimum Hb trigger. We hope that these data will be practically applied to establish plans and strategies for managing the appropriateness of RBC transfusions in Korea. In addition, continuous evaluation and transfusion education for clinical departments should be performed.
Anemia ; Anesthesiology ; Delivery of Health Care ; Education ; Electronic Health Records ; Erythrocyte Transfusion* ; Erythrocytes* ; Hemorrhage ; Hope ; Humans ; Korea ; Neurosurgery ; Orthopedics ; Rehabilitation ; Transfusion Reaction ; Unnecessary Procedures

BACKGROUND: Interpretation of changes in serial laboratory results is necessary for both clinicians and laboratories; however, setting decision limits is not easy. Although the reference change value (RCV) has been widely used for auto-verification, it has limitations in clinical settings. We introduce the concept of overlapping confidence intervals (CIs) to determine whether the changes are statistically significant in clinical chemistry laboratory test results. METHODS: In total, 1,202,096 paired results for 33 analytes routinely tested in our clinical chemistry laboratory were analyzed. The distributions of delta% absolute values and cut-off values for certain percentiles were calculated. The CIs for each analyte were set based on biological variation, and data were analyzed at various confidence levels. Additionally, we analyzed the data using RCVs and compared their clinical utility. RESULTS: Most analytes had low indexes of individuality with large inter-individual variability. The 97.5th percentile cut-offs for each analyte were much larger than conventional RCVs. The percentages of results exceeding RCV(95%) and RCV(99%) corresponded to those with no overlap at the 83.4% and 93.2% confidence levels, respectively. CONCLUSIONS The use of overlapping CIs in serial clinical chemistry test results can overcome the limitations of existing RCVs and replace them, especially for analytes with large intra-individual variation.

BACKGROUND: Diagnosis of tuberculous pleurisy is sometimes difficult using conventional diagnostic methods. We have investigated the utility of pleural fluid cell IFN-gamma production assay in the diagnosis of tuberculous pleurisy. METHODS: We prospectively performed pleural fluid cell IFN-gamma production assay in 39 patients with tuberculous pleural effusions (TPE) and in 26 patients with nontuberculous pleural effusions (NTPE) (13 malignant pleural effusions and 13 parapneumonic effusions). Pleural fluid cells were cultured in DMEM media and stimulated with purified protein derivatives (PPD), and phytohemagglutinin (PHA) for 24 hr. The amount of IFN-gamma released in the culture supernatant was quantitated by IFN-gamma ELISA assay. We have also measured adenosine deaminase (ADA) activities and IFN-gamma concentrations in the pleural fluid. RESULTS: 1) The pleural fluid levels of ADA activity and IFN-gamma concentrations were significantly higher in TPE than NTPE (p<0.01). 2) IFN-gamma production in TPE cells stimulated by PPD (755,266+/-886,636 pg/ml) was significantly higher than NTPE cells (3,509+/-6,980 pg/ml) (p<0.01). By considering the fact that IFN-gamma concentrations over 10,000 pg/ml is a criteria for the diagnosis of TBE, sensitivity and specificity of the test were 97.4 and 92.3%, respectively. 3) The ratios of IFN-gamma production by the stimulation with PPD and PHA (PPD/PHA) were significantly higher in TPE cells (59+/-85) than NTPE cells (5+/-18)(p<0.01). Considering the criteria for the diagnosis of TBE as PPD/PHA ratio over 5, sensitivity and specificity of the test were 76.9 and 92.3%, respectively. CONCLUSION: Pleural fluid cell IFN-gamma production assay may be useful for the diagnosis of tuberculous pleurisy.
Adenosine Deaminase ; Diagnosis* ; Enzyme-Linked Immunosorbent Assay ; Humans ; Pleural Effusion ; Pleural Effusion, Malignant ; Pleurisy ; Prospective Studies ; Tuberculosis ; Tuberculosis, Pleural*

BACKGROUND: Recently, a new automated chemistry analyzer, Atellica CH930 (Siemens, Germany), was introduced. It automatically measures internal quality control (QC) materials according to a pre-determined schedule. For this purpose, the instrument has space for storage of QC materials. We evaluated the analytical performance of chemistry items by using the Atellica system. METHODS: The precision of 29 items was evaluated with three levels of QC materials with two storage methods. We stored the QC materials in the dedicated storage space in the instrument during the precision evaluation period. In addition, we aliquoted and stored the materials in the refrigerator, and then loaded the material in a timely manner. Linearity, carry-over, and agreement with current methods were also evaluated. RESULTS: The within-laboratory coefficient of variation (CV) of most items, except for total CO2 (tCO2), was within 5.0% in both QC storage methods without significant differences in CV between storage methods. The CV of tCO2 was 5.2%, 5.8%, and 5.1% at three different levels when the QC materials were stored in a dedicated space in the instrument. The linearity was acceptable, showing <5% nonlinearity. Although good agreement was observed for most items, some items, such as calcium, total bilirubin, aspartate transaminase, and chloride, showed unequivalent results. CONCLUSIONS: Atellica CH930 showed acceptable precision, linearity, and agreement in routine chemistry items. The automatic QC function using the storage device has no problem with stability or precision. It can reduce the manual process, allowing technicians to focus on reviewing the QC results and reporting reliable results.
Appointments and Schedules ; Aspartate Aminotransferases ; Bilirubin ; Calcium ; Chemistry ; Quality Control

PURPOSE: Abdominal computed tomography (CT) is a widely recognized method to diagnose patients with acute abdominal pain in the emergency departments (EDs). We aimed to investigate the current state and interpretations of abdominal CT performed in the ED of a tertiary university hospital. METHODS: This was a retrospective study based on an abdominal CT database and medical records of patients over 15 years of age, who had visited our ED between January 1 and December 31, 2013. The data collected included CT types, final interpretations, characteristics of the patients, and location of pain at the time of CT. RESULTS: A total of 1,978 abdominal CTs were performed among 1,923 patients during the research period. The most frequent organs involved in the major diagnosis were those in the urinary system, followed by the appendix, liver, large intestine, and gallbladder. The most frequently interpreted diagnoses in these organs were in the order of urinary stone, appendicitis, liver cirrhosis, infectious colitis, and acute cholecystitis. The most frequent location of pain was the right lower quadrant (429 cases, 21.7%), and the most frequently performed CT types were contrast-enhanced abdominal and pelvic CT (1,260 cases, 63.7%). CONCLUSION: Various interpretations were derived based on the abdominal CTs, ranging from critical to mild diseases and from common to rare diseases. Based on this study, we have developed a preliminary interpretation checklist for abdominal CTs.
Abdominal Pain ; Appendicitis ; Appendix ; Checklist* ; Cholecystitis, Acute ; Colitis ; Diagnosis ; Emergencies* ; Emergency Service, Hospital* ; Gallbladder ; Humans ; Intestine, Large ; Liver ; Liver Cirrhosis ; Medical Records ; Methods ; Rare Diseases ; Retrospective Studies ; Tomography, X-Ray Computed ; Urinary Calculi

PURPOSE: This study aims to review the appropriateness of the issued death certificates and autopsy reports and to evaluate the improvement points of these documents in accordance with the guidelines of the Korean Medical Association and the National Statistical Office. Moreover, this study also examines why the guideline is necessary for the credibility of these documents. METHODS: The death certificates and autopsy reports written by a training hospital were analyzed for a 12-month period, between December 2014 and November 2015. The reference to analysis was the “guidelines to medical certificate 2015” written by the Korean Medical Association, “World Health Organization (WHO) death certificate principle”, and “guideline leaflet,” as provided by the National Statistical Office. Two researchers analyzed the documents that were against the guidelines, and suggested improvement points. The analyzed variables were age, sex, issued date, direct cause of death, manner of death, location of death, and types of accident. The primary goal was to see the rate of issued documents written correctly according to the guidelines and to suggest possible improvement points. The secondary goal was to analyze the reason for accordance and discordance between researchers. RESULTS: There were a total of 603 death certificates and autopsy reports issued during the research period; 562 (93.2%) and 41 (6.8%) cases, respectively. As for the manner of death, 521 cases were “death from disease,” 64 were “external causes,” and 18 were “others or unknown” (86.4%, 10.6%, and 3.0%, respectively). As for the issued department, internal medicine and emergency medicine issued 301 (49.9%) and 126 (20.9%) documents, respectively. Of these, 139 (23.1%) cases were regarded to be in accordance with the guidelines, while 304 (50.4%) were considered to be discordant cases. Among the discordant cases, there were 177 (29.4%) cases that were the mode of death directly written to cause of death. As for the records of “period of occurrence to death” were recorded only 70 (11.7%) cases (including “unknown” 65 cases) and the others were blank. The Kappa number of analysis regarding the evaluation correspondence of the two researchers was 0.44 (95% confidence interval, 0.38 to 0.51). CONCLUSION: The most frequent error was ‘the condition of death to direct cause of death’ with the ratio of 29.4%. This may have been because the rate of concordance between the researchers based on the guidelines was not high enough. There is a need to provide specific guidelines for each case, and also promote and educate regarding significant errors.
Autopsy ; Cause of Death ; Death Certificates* ; Emergency Medicine ; Internal Medicine ; Medical Errors ; Observational Study*

Herein, we report a patient showing panagglutination in the unexpected antibody identification test after the administration of daratumumab. The patient was a 66-year-old woman who had undergone multiple cycles of chemotherapy and autologous peripheral blood stem cell transplantation for treating multiple myeloma; however, despite treatment, she had relapsed. Therefore, daratumumab, on clinical trials in Korea, started to be administered. After administration of daratumumab, the result of antibody screening test was positive, on the contrary to the result prior to the administration. Moreover, all positive reactions were shown in the antibody identification to the panel cells. After destroying CD38 antigens on the surface of RBCs using DTT, negative results were obtained. Daratumumab—a novel therapeutic human CD38 monoclonal antibody that can be used as targeted immunotherapy—is an FDA-approved drug for treating multiple myeloma. Because CD38 is expressed not only on myeloma cells, but also on red blood cells (RBCs), the use of daratumumab might lead to RBC agglutinations, and thereby resulting in false-positive results on the pre-transfusion tests. Therefore, caution is needed in case of a patient receiving daratumumab. Furthermore, additional test using DTT is required, especially when panagglutination was shown in the antibody identification test, as in this case.
Aged ; Antigens, CD38 ; Drug Therapy ; Erythrocytes ; Female ; Humans ; Korea ; Mass Screening ; Multiple Myeloma* ; Peripheral Blood Stem Cell Transplantation

BACKGROUND: Although transfusion is a paramount life-saving therapy, there are multiple potential significant risks. Therefore, all adverse transfusion reaction (ATR) episodes require close monitoring. Using the computerized reporting system, we assessed the frequency and pattern of non-infectious ATRs. METHODS: We analyzed two-year transfusion data from electronic medical records retrospectively. From March 2013 to February 2015, 364,569 units of blood were transfused. Of them, 334,582 (91.8%) records were identified from electronic nursing records. For the confirmation of ATRs by blood bank physicians, patients' electronic medical records were further evaluated. RESULTS: According to the nursing records, the frequency of all possible transfusion-related events was 3.1%. After the blood bank physicians' review, the frequency was found to be 1.2%. The overall frequency of febrile non-hemolytic transfusion reactions (FNHTRs) to red blood cells (RBCs), platelet (PLT) components, and fresh frozen plasmas (FFPs) were 0.9%, 0.3%, and 0.2%, respectively, and allergic reactions represented 0.3% (RBCs), 0.9% (PLTs), and 0.9% (FFPs), respectively. The pre-storage leukocyte reduction significantly decreased the frequency of FNHTRs during the transfusion of RBCs (P<0.01) or PLTs (Pfalling dots0.01). CONCLUSIONS: The frequency of FNHTRs, allergic reactions, and "no reactions" were 22.0%, 17.0%, and 60.7%, respectively. Leukocyte-reduction was associated with a lower rate of FNHTRs, but not with that of allergic reactions. The development of an effective electronic reporting system of ATRs is important in quantifying transfusion-related adverse events. This type of reporting system can also accurately identify the underlying problems and risk factors to further the quality of transfusion care for patients.
Blood Transfusion/*adverse effects/statistics & numerical data ; Humans ; Republic of Korea/epidemiology ; Retrospective Studies ; Tertiary Care Centers ; Transfusion Reaction/*epidemiology/etiology

OBJECTIVES: It is not clear which clinical variables are most closely associated with delirium in the Intensive Care Unit (ICU). By comparing clinical data of ICU delirium and non-delirium patients, we sought to identify variables that most effectively differentiate delirium from non-delirium. METHODS: Medical records of 6,386 ICU patients were reviewed. Random Subset Feature Selection and Principal Component Analysis were utilized to select a set of clinical variables with the highest discriminatory capacity. Statistical analyses were employed to determine the separation capacity of two models-one using just the selected few clinical variables and the other using all clinical variables associated with delirium. RESULTS: There was a significant difference between delirium and non-delirium individuals across 32 clinical variables. Richmond Agitation Sedation Scale (RASS), urinary catheterization, vascular catheterization, Hamilton Anxiety Rating Scale (HAM-A), Blood urea nitrogen, and Acute Physiology and Chronic Health Examination II most effectively differentiated delirium from non-delirium. Multivariable logistic regression analysis showed that, with the exception of vascular catheterization, these clinical variables were independent risk factors associated with delirium. Separation capacity of the logistic regression model using just 6 clinical variables was measured with Receiver Operating Characteristic curve, with Area Under the Curve (AUC) of 0.818. Same analyses were performed using all 32 clinical variables;the AUC was 0.881, denoting a very high separation capacity. CONCLUSIONS The six aforementioned variables most effectively separate delirium from non-delirium. This highlights the importance of close monitoring of patients who received invasive medical procedures and were rated with very low RASS and HAM-A scores.

BACKGROUND: Liver fibrosis evaluation is an important issue in chronic liver disease patients. We aimed to develop noninvasive liver fibrosis biomarkers based on transient elastography (TE, FibroScan®) through retrospective review of clinicopathological data. METHODS: We recruited 278 chronic hepatitis B patients who underwent Fibroscan and HBV DNA testing. A total of 115 HBeAg-positive and 159 HBeAg-negative chronic hepatitis B patients were analyzed. A total of 100 hepatitis C patients were analyzed. Successful fibroscan data, gamma-glutamyl transferase (GGT) to platelet ratio (GPR), platelet count, AST, ALT, international normalized ratio of prothrombin time, total cholesterol, triglycerides, bilirubin, mean platelet volume, AST to platelet ratio index, fibrosis index based on four factors (FIB-4), neutrophil to lymphocyte ratio (NLR), and NLR to platelet ratio were analyzed to determine the new noninvasive markers for assessing liver fibrosis. RESULTS: Elevated GPR (OR=9.1, P=0.011) and FIB-4 (OR=2.3, P=0.01) were associated with greater risk of liver fibrosis in chronic hepatitis B patients. FIB-4 (OR=6.04, P=0.005) was a risk factor for liver fibrosis in HBeAg-positive patients. FIB-4 (OR=2.371, P=0.015) and GPR (OR=33.78, P=0.003) were liver fibrosis risk factor in HBeAg-negative patients. In chronic hepatitis C patients, GGT (OR=1.033, P=0.002), triglyceride (OR=−0.990, P=0.038) and FIB-4 (OR=3.499, P=0.006) showed statistical significances. The AUCs were 0.816 in FIB-4 (P<0.001) and 0.849 in GPR (P<0.001). CONCLUSIONS: FIB-4 and GPR may be useful blood markers for assessing liver fibrosis in chronic hepatitis B and hepatitis C patients. Further well-designed prospective study is required to validate these noninvasive blood markers in clinical practice.
Area Under Curve ; Bilirubin ; Biomarkers ; Blood Platelets ; Cholesterol ; DNA ; Elasticity Imaging Techniques ; Fibrosis ; Hepatitis B ; Hepatitis B, Chronic ; Hepatitis C ; Hepatitis C, Chronic ; Hepatitis ; Hepatitis, Chronic ; Humans ; International Normalized Ratio ; Liver Cirrhosis ; Liver Diseases ; Liver ; Lymphocytes ; Mean Platelet Volume ; Neutrophils ; Platelet Count ; Prospective Studies ; Prothrombin Time ; Retrospective Studies ; Risk Factors ; Transferases ; Triglycerides