Protein C exerts anticoagulant effects by inactivating factor Va and VIIIa and stimulating fibrinolysis. The homozygous protein C deficiency is extremely rare and often results in life threatening thrombosis and purpura fulminans with necrotic cutaneous lesions. A child with homozygous protein C deficiency was treated at 6 months by a living-related liver transplantaion. After induction of anesthesia, we started an FFP infusion for protein C replacement and a low molecular weight heparin continuous infusion to prevent thrombosis. A complete reconstitution of protein C activity and resolution of the thrombotic condition occured postoperatively. So we report this case with a brief review of the literature.
Anesthesia* ; Child ; Factor Va ; Fibrinolysis ; Heparin, Low-Molecular-Weight ; Humans ; Liver Transplantation* ; Liver* ; Protein C Deficiency* ; Protein C* ; Purpura Fulminans ; Thrombosis

Melanotic oncocytic metaplasia (MOM) in the nasopharyngeal space is a very rare entity. Only 35 cases have been reported in the English literature, and most patients were East Asian males between 60 and 70 years of age. MOM presents as a brown or black lesion with slight elevation of the mucosa. These lesions are benign and defined as cellular enlargement with eosinophilic granular melanin-pigmented cytoplasm caused by mitochondrial accumulation. However, such presentation can lead physicians to misjudge MOM as a malignant lesion. Recently, we experienced a case of MOM of the nasopharynx. A 58-year-old woman was admitted to the internal medicine department with small-volume hemoptysis and referred to the ENT department for evaluation. She was a regular smoker without any medical history. Sinus endoscopy showed black pigmented lesions on both the torus tubaris and left posterior tonsillar pillar, with low bleeding risk. Excisional biopsy of the lesion was performed, and oncocytic metaplasia was confirmed pathologically. Hemoptysis showed spontaneous remission and no recurrence or other symptoms over 12 months of follow up. Melanotic oncocytic metaplasia in the nasopharynx should be clinically recognized to avoid misdiagnosis as a malignancy like melanoma.

OBJECTIVE: To estimate the failure rate of medical treatment and to identify variables associated with treatment failure in patients with tubal pregnancy and an initial serum level of human chorionic gonadotropin (HCG) over 10,000 IU/L. METHODS: The inclusion criteria were tubal pregnancy diagnosed using ultrasonography, primary treatment of intramuscular methotrexate injection at one of the four institutions between January 2003 and December 2011, a serum HCG level within two days before treatment>10,000 IU/L, and follow-up data to determine treatment success or failure. Exclusion criteria were other primary treatments besides intramuscular methotrexate injection. The clinicopathologic data of 36 patients were collected and analyzed. RESULTS: Medical treatment failed and surgery was performed in 19 (53%) patients. In univariable analysis, age, parity, and size of the gestational sac were associated with treatment failure, but none of the variables were associated with treatment failure in multivariable analysis. The failure rate in the subgroup with age<33 years and size of gestational sac> or =1.1 cm was significantly higher than those of the other subgroups (82% vs. 41% [mean of the other subgroups], respectively). CONCLUSION: Patients with a serum HCG level>10,000 IU/L who received medical treatment had a high failure rate. Among them, patients aged<33 years and with a gestational sac> or =1.1 cm had an extremely high failure rate.
Chorionic Gonadotropin* ; Female ; Follow-Up Studies ; Gestational Sac ; Humans ; Humans* ; Methotrexate* ; Parity ; Pregnancy ; Pregnancy, Tubal* ; Treatment Failure ; Ultrasonography

Background: The coronavirus disease 2019 (COVID-19) pandemic has caused health problems and distress among healthcare workers (HCWs), so supportive measures to promote their health and relieve distress are needed. Materials and Methods: We conducted two rounds of Delphi surveys with 20 COVID-19-related frontline healthcare professionals and public officials. The surveys evaluated means of supporting HCWs’ health by improving health care systems and working environments in terms of effectiveness and urgency. The validity of the measures was assessed by calculating the content validity ratio. Results: The top-priority measures to support HCWs were “secure isolation units capable of treating severe cases” in the facility infrastructure category, “secure nursing staff dedicated for patients in the intensive care units” in the personnel infrastructure category, “improve communication between central office and frontline field” in the cooperation system category, “support personal protective equipment and infection control supplies” in the aid supplies category, and “realization of hazard pay” in the physical/mental health and compensation category. Conclusion There was consensus among the experts on the validity and priorities of policies in the facility, personnel, cooperation, supplies, and compensation categories regarding measures to promote COVID-19 related HCWs’ health.

Background: As the coronavirus disease 2019 (COVID-19) pandemic is ongoing, heavy workload of healthcare workers (HCWs) is a concern. This study investigated the workload of HCWs responding to the COVID-19 outbreak in South Korea. Methods: A nationwide cross-sectional survey was conducted from September 16 to October 15, 2020, involving 16 healthcare facilities (4 public medical centers, 12 tertiary-care hospitals) that provide treatment for COVID-19 patients. Results: Public medical centers provided the majority (69.4%) of total hospital beds for COVID-19 patients (n = 611), on the other hand, tertiary care hospitals provided the majority (78.9%) of critical care beds (n = 57). The number of beds per doctor (median [IQR]) in public medical centers was higher than in tertiary care hospitals (20.2 [13.0, 29.4] versus 3.0 [1.3, 6.6], P = 0.006). Infectious Diseases physicians are mostly (80%) involved among attending physicians. The number of nurses per patient (median [interquartile range, IQR]) in tertiarycare hospitals was higher than in public medical centers (4.6 [3.4–5] vs. 1.1 [0.8–2.1], P =0.089). The median number of nurses per patient for COVID-19 patients was higher than the highest national standard in South Korea (3.8 vs. 2 for critical care). All participating healthcare facilities were also operating screening centers, for which a median of 2 doctors, 5 nurses, and 2 administrating staff were necessary. Conclusion As the severity of COVID-19 patients increases, the number of HCWs required increases. Because the workload of HCWs responding to the COVID-19 outbreak is much greater than other situations, a workforce management plan regarding this perspective is required to prevent burnout of HCWs.

The continuous emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) variants has provided insights for updating current coronavirus disease 2019 (COVID-19) vaccines. We examined the neutralizing activity of Abs induced by a BA.4/5-containing bivalent mRNA vaccine against Omicron subvariants BN.1 and XBB.1.5. We recruited 40 individuals who had received a monovalent COVID-19 booster dose after a primary series of COVID-19 vaccinations and will be vaccinated with a BA.4/5-containing bivalent vaccine. Sera were collected before vaccination, one month after, and three months after a bivalent booster.Neutralizing Ab (nAb) titers were measured against ancestral SARS-CoV-2 and Omicron subvariants BA.5, BN.1, and XBB.1.5. BA.4/5-containing bivalent vaccination significantly boosted nAb levels against both ancestral SARS-CoV-2 and Omicron subvariants. Participants with a history of SARS-CoV-2 infection had higher nAb titers against all examined strains than the infection-naïve group. NAb titers against BN.1 and XBB.1.5 were lower than those against the ancestral SARS-CoV-2 and BA.5 strains. These results suggest that COVID-19 vaccinations specifically targeting emerging Omicron subvariants, such as XBB.1.5, may be required to ensure better protection against SARS-CoV-2 infection, especially in high-risk groups.

Background: Antimicrobial prescriptions for serious chronic or acute illness nearing its end stages raise concerns about the potential for futile use, adverse events, increased multidrugresistant organisms, and significant patient and social cost burdens. This study investigated the nationwide situation of how antibiotics are prescribed to patients during the last 14 days of life to guide future actions. Methods: This nationwide multicenter retrospective cohort study was conducted at 13 hospitals in South Korea from November 1 to December 31, 2018. All decedents were included in the study. Antibiotic use during the last two weeks of their lives was investigated. Results: A total of 1,201 (88.9%) patients received a median of two antimicrobial agents during the last two weeks of their lives. Carbapenems were prescribed to approximately half of the patients (44.4%) in the highest amount (301.2 days of therapy per 1,000 patient-days).Among the patients receiving antimicrobial agents, 63.6% were inappropriate and only 327 patients (27.2%) were referred by infectious disease specialists. The use of carbapenem (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.13–2.03; P = 0.006), underlying cancer (OR, 1.56; 95% CI, 1.20–2.01, P = 0.047), underlying cerebrovascular disease (OR, 1.88; 95% CI, 1.23–2.89, P = 0.004), and no microbiological testing (OR, 1.79; 95% CI, 1.15–2.73; P = 0.010) were independent predictors for inappropriate antibiotic prescribing. Conclusion A considerable number of antimicrobial agents are administered to patients with chronic or acute illnesses nearing their end-of-life, a high proportion of which are prescribed inappropriately. Consultation with an infectious disease specialist, in addition to an antimicrobial stewardship program, may be necessary to induce the optimal use of antibiotics.

Background: A healthcare system’s collapse due to a pandemic, such as the coronavirus disease 2019 (COVID-19), can expose healthcare workers (HCWs) to various mental health problems. This study aimed to investigate the impact of the COVID-19 pandemic on the depression and anxiety of HCWs. Methods: A nationwide questionnaire-based survey was conducted on HCWs who worked in healthcare facilities and public health centers in Korea in December 2020. Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) were used to measure depression and anxiety. To investigate factors associated with depression and anxiety, stepwise multiple logistic regression analysis was performed. Results: A total of 1,425 participating HCWs were included. The mean depression score (PHQ-9) of HCWs before and after COVID-19 increased from 2.37 to 5.39, and the mean anxiety score (GAD-7) increased from 1.41 to 3.41. The proportion of HCWs with moderate to severe depression (PHQ-9 ≥ 10) increased from 3.8% before COVID-19 to 19.5% after COVID-19, whereas that of HCWs with moderate to severe anxiety (GAD-7 ≥ 10) increased from 2.0% to 10.1%. In our study, insomnia, chronic fatigue symptoms and physical symptoms after COVID-19, anxiety score (GAD-7) after COVID-19, living alone, and exhaustion were positively correlated with depression. Furthermore, post-traumatic stress symptoms, stress score (Global Assessment of Recent Stress), depression score (PHQ-9) after COVID-19, and exhaustion were positively correlated with anxiety. Conclusion In Korea, during the COVID-19 pandemic, HCWs commonly suffered from mental health problems, including depression and anxiety. Regularly checking the physical and mental health problems of HCWs during the COVID-19 pandemic is crucial, and social support and strategy are needed to reduce the heavy workload and psychological distress of HCWs.