A regionalization strategy is a model for improving the performance of the emergency medical service (EMS) system. The regionalization strategy has goals to provide appropriate, timely, effective, and efficient EMS in a region. However, the current EMS regionalization model in Korea is insufficient to achieve these goals due to a shortage of resources in rural regions, crowded emergency departments in metropolitan regions, and non-customized and mismatched levels of emergency departments. Recently, the concept of the regionalization model has been changed from a general regionalized model to a specialty care regionalization one. For example, the trauma care system, cardiac arrest care system, stroke care system, and ST elevation myocardial infarction care system are modern regionalization strategies to improve the performance of EMS. This is a new method of customizing and matching between region-based needs and the supply of EMS. If we can implement this strategy, we can expect improved performance of regional EMS systems.
Emergencies ; Emergency Medical Services ; Heart Arrest ; Korea ; Myocardial Infarction ; Stroke

Inflammatory mediators, such as oxidants, TNF-alpha, and IL-6, play a major role in the systemic response to bum injury It has been known that a continuing inflammatory response cause a sepsis and subsequent multiple organ failure. Recent studies have shown that burn patients receiving recombinant human growth hormone(rhGH) therapy have an improvement of the general condition, but the mechanism by which rhGH exerts its effects has not been clearly understood. The aim of this study was to evaluate the effect of rhGH on the early bum injury. Female Sprague-Dawley rats were divided into four groups : control group, bum group, burn plus rhGH treated group, and rhGH only treated group. Animals were killed at 30min., 3, 6, 24, and 48 hours after treatment. Histology and biochemical changes including malondialdehyde(MDA) content, tissue reduced glutathione(GSH) and catalase activity in the lung and liver, and plasma TNF-alpha and IL-6 levels were examined. Lung histology in the bum plus rhGH treated group showed decreased inflammtory response such as neutrophil and lymphocyte infiltrations, interstitial thickening, and edema compared with the bum group. Liver histology in the bum group revealed mild neutrophil and lymphocyte infiltrations, vacuolization .of hepatocytes, disrupted lobular structures, and dilated sinusoids. But liver histology of the bum plus rhGH was similar to control group. Lung and liver MDA in the burn plus rhGH and rhGH only treated groups were decreased with time compared with the burn group. Lung and liver GSH and catalase activities in the bum plus rhGH and GH only treated groups remained significantly increased compared with the bum group for the 48-hours period. Plasma TNF-alpha levels in the bum group remained elevated for the 48-hours period compared with the bum plus rhGH and rhGH only treated groups. Plasma IL-6 levels in the burn group were significantly increased only at first compared with the bum plus rhGH and rhGH only treated groups. These results suggested that rhGH showed inhibitory effects on the inflammatory cell infiltration and lipid peroxidation in the lung and liver after bum injury. Increased GSH levels and catalase activities seemed to be associated with the antioxidant effect of rhGH. But the inhibitory effect of rhGH on plasma TNF- and R-6 levels was not clearly demonstrated.
Animals ; Antioxidants ; Burns ; Catalase ; Edema ; Female ; Hepatocytes ; Human Growth Hormone* ; Humans* ; Interleukin-6* ; Lipid Peroxidation* ; Liver ; Lung ; Lymphocytes ; Multiple Organ Failure ; Neutrophils ; Oxidants ; Plasma* ; Rats* ; Rats, Sprague-Dawley ; Sepsis ; Tumor Necrosis Factor-alpha*

BACKGROUND: One of the problem in emergency room(ER) of university hospital is over-crowdedness that causes exhaustion of medical resources (personnel, device, space) and disturbes optimal treatment. METHODS: This is an evaluative research for the purpose of promoting efficient operation system in ER of university hospital. RESULTS: 1) In 387 visitors, mean age was 47.5 years, and male to female ratio 1.21:1. As the specialty in charge, 28.9%f them were internal medicine, 26.6%mergency medicine, 9.9%eurology, and 8.5%eurosurgery. 24%f visitors have come by ambulances. The patients stayed for average 16.1 hours. The admission rate of ER visitors was 33.4 %60.3 %returned home after some management. 2) The visitors had various causes without correlation between the severity of conditions and the choice of high level hospital ER. They perceived their situations emergent in 78.4% but after triage only 25.6%were classified emergent. 48.6%of the visitors were the patients of out-patient department of this hospital due to chronic diseases. 3) The patients were assessed within 9.5 minutes after arrival at ER by nurse and within 34 minutes by doctor. If they were in need of consultation to second/third department, they waited for 141.5/460 minutes respectively to see the doctor. They waited for 59.9/52.7 minutes to get routine laboratory sampling/radiologic examination respectively. 4) Every 2.3 new patients visited this ER per hour. Average 63.2 patients were taken over to next shirt of nurse duty, and 60%of them had chronic degenerative diseases. CONCLUSION: The causes of overcrowding in ER of the university hospital were (1) huge number of patients at out-patient department of the hospital, (2) shortage of beds compared to the number of patients waiting admission, (3) too many kinds of procedures performed in ER, (4) cooperation failure among doctors of different specialty, and (5) no definite criteria of admission/discharge into/from ER. To solve these problems, conversion of ER management policy from complete examination and treatment to more simple and rapid one is necessary.
Ambulances ; Chronic Disease ; Emergencies* ; Emergency Service, Hospital* ; Female ; Hospitals ; Humans ; Internal Medicine ; Male ; Outpatients ; Triage

BACKGROUND: The toxicity of paraquat has been known to be caused by oxygen free radicals which leads to the lipid peroxidation and multiple organ failure. Although vitamin C has been known to be a potent antioxidant, recently there are numerous data which have shown that a low dose of vitamin C may act as a prooxidant due to the stimulation of the Fenton reaction with metal ions, which produces hydroxyl radicals. It has been reported that a deferoxamine in paraquat intoxication could reduce the production of the hydroxyl radicals by the inhibition of the Fenton reaction through the reduction of iron ion in tissue. The aim of this study was to evaluate the effect of the high and low dose of vitamin C and deferoxamine on lipid peroxidation and plasma TNF-alpha in paraquat intoxication. METHODS: Female Sprague-Dawley rats were divided into seven groups: control group which was not given paraquat(20mg/kg), P group which was given paraquat only, PVH group given paraquat and high dose of vitamin C(100mg/kg), PVL group given paraquat and low dose of vitamin C(10mg/kg), PVHD given paraquat, high dose of vitamine C and deferoxamine(100mg/kg), PVLD given paraquat, low dose of vitamin C and deferoxamine, and PD given paraquat and deferoxamine. Animals were killed at 6 and 24 hours after treatment. Malondialdehyde(MDA), superoxide dismutase(SOD) and glutathione(GSH) contents, catalase activity, plasma TNF-alpha, and histologic changes in the lung and liver tissue were measured. RESULTS: The lung histology in the PVH and PD or PVHD groups showed the significant decreases in the alveolar edema and interstitial thickness compared to the P group. The liver histology in the PVH and PVHD groups demonstrated marked differences in the central venous and sinusoidal dilatation compared to that of the P group. While the MDA levels of the lung and liver in the PVH and PD groups showed the significant reduction compared to that of the P group at 6 hours after treatment, all groups showed the significant changes compared to the P group at 24 hours. There was no significant change of the SOD levels of the lung and liver at 6 hours among all groups. At 24 hours, the SOD levels of the lung in PVH, PVL, and PVHD groups showed the significant increases compared to the P group. The increase of the SOD level in groups combined with deforoxamine, however, revealed a little reduction. The SOD level of the liver in PVH group only significantly increased compared to the P group at 24 hours. There was no significant change of the GSH level of the lung and liver among all groups at 6 hours. At 24 hours, the GSH level of the lung and liver were significantly increased in both PVH and PD group and PVH group, respectively, compared to the P group. Although the catalase activity of the lung was not significantly increased, that of liver was significantly increased in both PVHD and PD groups compared to the P group at 6 hours. The catalase activities of the lung and liver were significantly increased in PVH, PD, and PVHD at 24 hours. The concentrations of the Plasma TNF-alpha were slightly decreased at 6 hours and slightly increased at 24 hours compared to that of the P group, but they were not significant. CONCLUSION: This study showed that although the low dose of vitamin C had no effect, the high dose of vitamin C revealed a decrease of the MDA level and an increase of SOD, GSH, and catalase activity in the lung and lung and liver tissues, and the effect of the high dose of vitamin C increased with time. The administration of the deferoxamine with or without high dose of vitamin C, however, significantly showed the inhibition of the lipid peroxidation and antioxidant effect and low dose vitamin C decreased the effect of deferoxamine. The effects of the vitamin C and deferoxamine on plasma TNF-alpha were not clearly shown.
Animals ; Antioxidants* ; Ascorbic Acid* ; Catalase ; Deferoxamine* ; Dilatation ; Edema ; Female ; Free Radicals ; Humans ; Ions ; Iron ; Lipid Peroxidation* ; Liver ; Lung ; Multiple Organ Failure ; Oxygen ; Paraquat* ; Plasma ; Rats* ; Rats, Sprague-Dawley ; Superoxides ; Tumor Necrosis Factor-alpha ; Vitamins*

BACKGROUND: Multi-organ failure from sepsis is very lethal disease entity, which is suspected to be caused by activated inflammatory cells. Inflammatory cells activated by endotoxins generate oxidants and cytokines such as TNF-alpha and IL-6, which in turn stimulate macrophages and neutrophils. Augmented inflammation makes an organ-injury deteriorate into an organ-failure, which may progress to multi-organ failure. This study is designed to evaluate the therapeutic effects of vitamin-C, a scavenger of oxidants, in sepsis. METHODS: Male Sprague-Dawley rats were divided into 3 groups : a control group, a group injected intrapetoneally with LPS(lipopolysaccharide), and a group injected intraperitoneally with LPS and vitamin-C. Each eight rats were sacrified 24 hours and 48 hours after injection, and samples of the blood, the liver and the lung were obtained. Biochemical assays of TNF-alpha level in the blood and malondialdehyde(MDA) level, catalase activity and nitric oxide synthase(NOS) activity in the liver and the lung tissues were performed. RESULTS: Serum TNF-alpha level, tissue lipid peroxidation and tissue i-NOS activity were dramatically increased, and tissue catalase activity was exhausted rapidly in sepsis. High dose vitamin-C administration decreased serum TNF-alpha level, tissue lipid peroxidation and tissue i-NOS induction, and protected against catalase exhaustion. CONCLUSION: high dose vitamin-C therapy was proved to have definite antioxidant effect in septic condition.
Animals ; Antioxidants ; Catalase ; Cytokines ; Endotoxins ; Humans ; Inflammation ; Interleukin-6 ; Lipid Peroxidation ; Liver ; Lung ; Macrophages ; Male ; Models, Animal* ; Neutrophils ; Nitric Oxide ; Oxidants ; Rats* ; Rats, Sprague-Dawley ; Sepsis* ; Tumor Necrosis Factor-alpha

Some proto-oncogenes in human malignancies can be primary cause of carcinogenesis and can be correlated to histologic aggressiveness or prognosis. In this study, to define the role of c-myc and c-fos protooncogenes in multistage tumorigenesis of thyroid tumor and to correlate the expression of c-myc protooncogene with the degree of histologic aggressiveness and EORTC prognostic index in patients of thyroid carcinoma, 132 fresh specimens obtained at surgery from 71 cases of thyroid tumor were analysed by slot blot hybridization for the expression of c-myc and c-fos proto-oncogene, and 42 formalin-fixed paraffin-embedded tissues were analysed by immunohistochemical staining with monoclonal c-myc antibody and monoclonal Ki-67 antibody, and in 34 paraffin-embedded malignant tissues, the degree of histologic aggressiveness was determined, and in 42 cases of thyroid cancer, EORTC prognostic index were determined. And each item was compared to c-myc mRNA expression level. The results obtained were as follows: 1. The level of c-myc mRNA was significantly higher in malignant thyroid tissues as compared to normal or benign thyroid tissues(p=0.01). 2. The level of c-fos mRNA was similar in normal, benign and well differentiated thyroid carcinoma 3. There was no difference of c-myc mRNA expression levels between central and peripheral tumor tissues. 4. C-myc expression of normal tissues originated from cancer was higher than those from benign tumor(p=0.01) 5. A high level of c-myc mRNA in differentiated thyroid cancer corresponded to a high degree of histologic aggressiveness, although there was no statistically significant correlation between two. 6. High levels of c-myc mRNA were more frequently found in thyroid carcinoma with unfavourable prognosis, although there was no statistically significant correlation between c-myc mRNA expression and EORTC prognostic index or other prognostic factors such as age, sex, tumor size, tumor extent in thyroid carcinoma. 7. C-myc mRNA expression was statistically significantly correlated to the degree of immunohistochemical staining of monoclonal c-myc antibody(p=0.01). 8. C-myc mRNA expression was statistically significantly correlated to Ki-67 cell proliferative index score(p=0.005). On the basis of results, it can be suggested that overexpression of c-myc protooncogene in thyroid carcinoma is secondary phenotype of growth signal rather than primary cause of thyroid carcinogenesis, and expression of c-fos protooncogene was similar in normal, benign and malignant tumor tissues. C-myc may be useful prognostic indicator because there was some relationship between c-myc mRNA expression and EORTC prognostic index score or histologic aggressiveness score. And because c-myc correaltes significantly to Ki-67 cell proliferative index score, c-myc expression will be important growth signal in follicular cell of thyroid and have a role of progression of thyroid carcinoma.
Carcinogenesis ; Genes, fos ; Humans* ; Phenotype ; Prognosis ; Proto-Oncogenes ; RNA, Messenger ; Thyroid Gland* ; Thyroid Neoplasms

A retrospective analysis was performed on 69 follow-up cases of ducal carcinoma in situ(DCIS) treated from Jan. 1981 to Dec. 1995 at Department of Surgery, Seoul National University Hospital. The results are as follows. The mean age was 45.4 years that ranged from 28 to 68. The proportion of DCIS to breast cancer was increased from 1.3% to 7.2% for 15 years. Clinical presentations of DCIS were mass, nipple discharge and suspicious mammographic findings. Patients presenting mass were decreased, while mammographically detected DCIS were increased. In 49.3% of cases, the tumor size was smaller than 2cm and in 21.3% of the cases, the tumor was not palpable. Treatment modality was changed to more conservative procedures. All of the patients survived well without local recurrence or distant metastasis for a mean follow-up of 36.3 months(range 7 to 146). Histopathologic review was also performed on 52 cases of which paraffin blocks were saved, by one pathologist and diagnosis was confirmed. Pure DCIS composed 16 cases(30.8%), and DCIS with microinvasion was 36 cases(69.2%). Clinical presentation of DCIS, such as age, nipple discharge, calcification on mammography and mass size were not related to the microinvasion, but mass palpability was related to microinvasion(p=0.018). There was no histopathologic features to predict progression to invasive carcinoma, regardless of comedo type, histologic grade and nuclear grade. The expression of cathepsin-D, nm23, p53 and c-erbB-2 protein, was also evaluated using immunohistochemical methods. The relationship between expression of immunohistochemical antibodies and prognostic variables such as tumor size, histologic grade, nuclear grade, and microinvasion was assessed. The overexpression of c-erbB-2 protein was associated with lower nuclear grade(p=0.033), and a strong correlation was seen between tumor size and cathepsin-D and p53 protein(p=0.035, p=0.016). In this study, we conclude that the fine classification and analysis of DCIS subtype, not only by histopathologic but also by immunohistochemical study can be helpful to predict biological behaviour of DCIS and decide the modality of treatment.
Antibodies ; Breast ; Breast Neoplasms ; Carcinoma in Situ* ; Carcinoma, Intraductal, Noninfiltrating ; Classification ; Diagnosis ; Follow-Up Studies ; Humans ; Mammography ; Neoplasm Metastasis ; Nipples ; Paraffin ; Receptor, erbB-2 ; Recurrence ; Retrospective Studies ; Seoul

BACKGROUND: Most febrile neutropenic patients are treated in an aggressive manner. However, identification of low-risk patients may enable clinicians to administer risk-based treatment. The object of this study is to certify the factors associated with increased risk at the time of visiting the emergency department. METHODS: This is a retrospective study. We reviewed the medical records of 101 febrile neutropenic patients who had visited the emergency department of Seoul National University Hospital from January 1998 to August 1999. We assumed 22 risk prediction factors that could be assessed at admission to the emergency department and 5 factors that could be assessed during treatment course. To find independent risk-prediction factors, we analyzed these factors respectively by using multiple regression analysis. RESULTS: Tachycardia(aOR=136.5), altered mentality(aOR=28.8), decreased renal function(aOR=20.1), and significant comorbidity(aOR=17.2) are the independent factors associated with higher mortality. Altered mentality(aOR=31.6) and decreased renal function(CCr<75ml/min, aOR=5.4) are those associated with a higher incidence of septic shock. Independent factors associated with persistent(more than 3 days) fever are the early(within 10 days) onset of fever after last chemotherapy(aOR=8.8) and the existence of new pulmonary infiltrates on a simple chest X-ray(aOR=4.3). CONCLUSION: The stability of vital signs, the change of mentality, the renal function, the existence of significant comorbidity, the existence of new pulmonary infiltrates, and the rate of neutropenia are clinically useful risk-predication factors in febrile neutropenia at the time of visiting the emergency department.
Comorbidity ; Emergency Service, Hospital ; Febrile Neutropenia ; Fever ; Humans ; Incidence ; Medical Records ; Mortality ; Neutropenia ; Retrospective Studies ; Seoul ; Shock, Septic ; Thorax ; Vital Signs

BACKGROUND: This study was conducted to analyze the current problems in completing death certificates and to identify the correct method for completing death certificates. METHODS: We reviewed 262 death certificates in three hospitals from March 1 to April 30, 2000, and 119 death certificates in one hospital from March 1 to 31, 2000. We identified major and minor errors and analyzed and compared them retrospectively. RESULTS: A total of 381 death certificates were reviewed: 59 in Seoul National University Hospital, 101 in Ewha Woman's University Hospital, and 102 in Gachon Medical College Hospital, which has no education program for completing death certificates in postgraduate training, and 119 in Samsung Medical Center which has an education program for completing death certificates. 358 certificates(94.0%) had at least one error. There were only 23 death certificates(6.0%) without an error. In 182 cases(47.8%), there was one major error. In 321 death certificates(84.3%), there were more than two errors. A comparison of Samsung Medical Center with the other hospitals showed that the number of total errors was statistically different(p=0.001). CONCLUSION: There were few death certificates without an error in this study. In a hospital which has postgraduate training in completing death certificates, there are fewer errors than in other hospitals which have no training course. Emergency physicians actually certify many deaths, so they must know the correct method of completing death certificates for statistics on morbidity and mortality.
Death Certificates* ; Education ; Emergencies ; Mortality ; Retrospective Studies ; Seoul

More than 80% of cases of patients with sporadic primary hyperparathyroidism are caused by a single parathyroid adenoma. Therefore, traditional bilateral neck exploration has been replaced by minimally invasive parathyroidectomy (MIP) in recent years. Benefits, of MIP include decreased pain and complications, a shorter length of hospital stay, and improved cosmesis. Preoperative imaging studies for localization and intraoperative PTH assay (IoPTH) play an essential role for in MIP. The standard imaging studies are cervical ultrasound and 99mTc sestamibi scanning (with SPECT/CT), while 4D CT is attracting significant interest. The half-life of PTH is less than 5 minutes and PTH rapidly drops after the resection of target lesions. These characteristics of PTH enable IoPTH. If target lesions are localized by recent imaging studies and IoPTH is adopted, MIP can be performed successfully in patients with primary hyperparathyroidism.
Four-Dimensional Computed Tomography ; Half-Life ; Humans ; Hyperparathyroidism, Primary ; Length of Stay ; Neck ; Parathyroid Neoplasms* ; Parathyroidectomy* ; Surgical Procedures, Minimally Invasive ; Technetium Tc 99m Sestamibi ; Ultrasonography