While Joint Commission on Accreditation of Healthcare Organizations(JCAHO) and American College of Surgeon(ACS) have identified certain audit filters in trauma care, there are few studies to substantiate the value of these audit filters. Some researchers found that audit filters qualifiers were significantly associated with adverse outcomes, however, others were unable to reproduce such association. It is also necessary to test their validity and applicability in Korea. The purpose of this present study was to validate two trauma audit filters proposed by the JCAHO and the ACS, through the analysis of the relationship between timeliness of operation and risk-adjusted mortality. Among trauma audit filters, timeliness of operation in epidural or subdural hematoma(EDH/SDH) and intraabdominal injury were selected. By stratified random cluster sampling, 19 emergency medical centers (EMCs) were selected from 30 EMCs and all patients who received craniotomy or laparotomy in 1996 were evaluated in each hospital. Six medical records administrators reviewed medical records of 463 patients with EDH/SDH and of 508 patients with intraabdominal injury retrospectively. In other to adjust risk of mortality, timeliness of operation, age, Revised Trauma Score(RTS), ICD-9CM based ICISS, and experiences of transfer were included in logistic regression model. In the logistic regression models of all EDH/SDH or intraabdominal injury patients, timeliness of operation was not significant predictor of mortality. However, if patients who have been operated later than 12 hours were excluded from the statistical model, timeliness of operation showed significant or marginally significant relationship with mortality in the following situations; craniotomy > 4 hours in EDH(OR=30.46, p=0.032), craniotomy > 8 hours in SDH(OR=6.50, p=0.020), laparotomy > 2 hours in shock patients(OR=9.26, p=0.055). In addition to timeliness of operation, RTS and ICISS were significant variables in every logistic regression model, and experience of transfer and types of EMC were significant or marginally significant only in EDH. Timeliness of operation as audit filters for trauma care could not be applied to all cases. Early operations seem to improve clinical outcome only in the patients for whom emergent craniotomy or laparotomy were indicated. It could be interpreted as a phenomenon of 'confounding by indication'. Additional studies to establish more objective eligibility criteria for these audit filiters are needed.
Accreditation ; Administrative Personnel ; Craniotomy ; Delivery of Health Care ; Emergencies ; Humans ; Joint Commission on Accreditation of Healthcare Organizations ; Joints ; Korea ; Laparotomy ; Logistic Models ; Medical Records ; Models, Statistical ; Mortality ; Retrospective Studies ; Shock

BACKGROUND: Emergency Medical Technicians can do emergency care only under the control of the physicians. Emergency medical services system(EMSS) in Korea is now extended from the level of basic life support(BLS) to advanced life support(ALS). Unfortunately we don't have any official medical control system yet. We and regional EMSS, 119 rescue team(BLS), have had monthly joint meeting to validate and improve the prehospital care since August, 1998. METHODS: From August, 1998 to February, 1999, 1,708 patients were transported to Ewha Mokdong Hospital by regional 119 rescue team. Eight hundred and six(47.2%) run record were collected and analyzed. The appropriateness of the prehospital care were evaluated based on the comparison of assessment data and treatment data in each run record. The run record were divided into 5 groups; 1) necessary-adequate, 2) necessary-inadequate, 3) necessary-undo, 4) unnecessary-done, and 5) unnecessary-undo. 1) and 5) were judged as acceptable, and 2), 3), and 4) as unacceptable. RESULTS: Among 806 transported patients, 60.8% required one or more emergency care. 21.0% of required care were not provided, and 20.7% of provided care were not adequate. 78.8% of unprovided and 75.9% of inadequate care were 'airway and oxygen supply'. Overall unacceptable rate was decreased from 31.7% to 17.0% during first 5 months, but it rose up again to 24.7% after 2 months. Cardiopulmonary resuscitation(CPR) was performed in 29 prehospital cardiac arrest victims and admitted to ICU in 5 cases. CPR was not provided in 8 necessary situations, and unnecessary CPR was done in 3 cases. CONCLUSION: EMSS in Korea also need a kind of medical control system, even for BLS level. Major portion of the quality assurance program could be 'airway and oxygen supply', but attention should be focused in cardiac arrest victims and CPR. Record keeping and reliance of run record data are now pending problems. Fire department should develop a formal medical control system and the referring hospital should have an organization for maintaining the quality of prehospital care.
Cardiopulmonary Resuscitation ; Emergency Medical Services* ; Emergency Medical Technicians ; Fires ; Heart Arrest ; Humans ; Joints ; Korea ; Oxygen ; Retrospective Studies*

BACKGROUND: Studies of human coronary plaque specimens have shown that T lymphocytes and macrophages are present in all types of lesions, from fatty streaks to advanced plaques. There is growing evidence for a pathogenic role for immune response in progression of atherosclerosis. This study was designed to investigate cytokine production by mononuclear leukocytes from patients with myocardial infarction. METHOD: We measured the kinetics of secretion of tumor necrosis factor-alpha (TNF-alpha) and interferon-r (IFN-r) by mononuclear leukocytes from 8 control subjects and 12 patients with acute myocardial infarction. Mononuclear leukocytes were isolated and incubated with plant lectin mitogen concanavalin-A for 24 and 48 hours. TNF-alpha and IFN-r secretions were measured by ELISA. RESULTS:There were no significant differences between TNF-alpha and IFN-r secretions by mononuclear leukocytes at and before 24 hours of incubation from both patients and control subjects, but TNF-alpha and IFN-r secretions at 48 hours of incubation were higher (p<0.005, p<0.05) in patients when compared with control subjects. TNF-alpha and IFN-r secretions by mononuclear leukocytes after incubation correlated with the peak level of creatine phosphokinase (CK) and CK-MB. CONCLUSION: Increased cytokine secretory capacity of mononuclear leukocytes may be due to the acute inflammatory response of myocardial infarction. Further trials may be needed to determined the effects of increase in secretory capacity of mononuclear leukocytes before myocardial infarction.
Atherosclerosis ; Creatine Kinase ; Enzyme-Linked Immunosorbent Assay ; Humans ; Kinetics ; Leukocytes, Mononuclear* ; Macrophages ; Myocardial Infarction* ; Plants ; T-Lymphocytes ; Tumor Necrosis Factor-alpha*

No abstract available in English.
Clinical Study ; Humans ; Upper Extremity

BACKGROUND: There are many suggested methods for the indirect determination of anaerobic threshold(AT) using the changes of ventilatory parameters in respones to ventilatory load accompanying the increase of blood lactic acid level during exercise and the threshold derived from them is called ventilatory threshold( VT). They include ventilatory equivalent method(VEM), End-tidal PO2 method(PETO2), V-slope method(VSM), and respiratory quotient method(RQ). But in the patients with chronic airway ohstruction(CAO), the AT determined by ventilatory methods may not reflect true AT because the patients with GAO show inadequate ventilatory response to the increase of blood lactic acid level during excercise. METHODS: For the investigation of detection rate and reliability of above four VT determination methods in the patients with GAO, we performed the symptom-limited and maximal incremental exercise test in 17 patients with GAO and 12 normal controls. The incremental workload was 10 W/min in GAO group and 25 W/min in control group. The reliability of VT in each group was investigated by the calculation of Spearman correlation coefficient. RESULTS: The detection rates of VT were 100% by RQ, 91.7% by both VEM and POETO2, and 83.3% by VSM in normal control group, while 94.1% by RQ, 64.7% by VEM and PETO2, and 83.3% by VSM in GAO group. Good correlations were noted among VEM, PETO2, and VSM except RQ in normal control group. But there was no significant correlation except between VEM and PETO2 in GAO group. CONCLUSIONS: RQ is very sensitive but crude and VEM is near similar to PETO2. The clinical usefulness of VT determined by ventilatory method might be limited in patients with severe GAO.
Airway Obstruction* ; Exercise Test ; Humans ; Lactic Acid

BACKGROUND: Normal humans meet the increased ventilatory need during exercise initially by the increase of tidal volume (TV) and later by the increase of respiratory frequency (Rf). And the inspiratory duty cycle (Ti/Ttot) is also increased more than 50% for the compensation of the decrease of respiratory cycle provoked by the increase of respiratory frequency. The patients with chronic airflow obstruction show rapid and shallow breathing pattern during exorcise because of the degreased ventilatory capacity and the increased dead space ventilation. However, the studies about the change of inspiratory duty cycle are only a few and there is no literature about the relationship between the change of inspiratory duty cycle and the degree of airflow obstruction. METHODS: The subjects were the twelve patients with chronic airflow obstruction (CAO) and ten normal people. The incremental exercise test was done. The increase of work load was 10 Win CAO group and 25 Win normal control group. The analysis of the results was done by the comparison of the parameters such as minute ventilation (VE), TV, Rf, physiologic dead space (Vd/vt), and inspiratory duty cycle between the two groups. Each parameters were compared after transformation into % control duration base that means dividing the total exercise time into five fractons and % control duration data were obtained at rest, 20%, 40%, 60%, 80%, and max. Statistical analysis was done by repeated measure ANOVA using SAS program. RESULTS: The changes of VE and TV were significantly different between two groups while the change of Rf was not significant. The decrease of Vd/vt was significantly low in CAO group. Ti/Ttot was markedly increased from 38.4+3.0% at rest to 48.6+4.5% at max in normal control group while Ti/Ttot showed little change from 40.5+2.2% at rest to 42.6+3.5% at max. And the change of inspiratory duty cycle showed highly good correlation with the degree of airflow obstruction (FEVl%). (r=0.8151, p<0.05) CONCLUSIONS: The increase of Ti/Ttot during exercise observed in normal humans is absent in the patients with CAO and the change of Ti/TtDt is well correlated with the degree of airflow obstruction.
Compensation and Redress ; Exercise Test* ; Humans ; Pulmonary Disease, Chronic Obstructive* ; Respiration* ; Tidal Volume ; Ventilation

BACKGROUND: Hemodynamic derangements of cardiac tamponade are generally believed to result from compression of the cardiac chambers, which limits diastolic filling. The character and magnitude of the alternation are determined by the compliance characteristics of the pericardium and the total pericardial fluid volume. During serial pericardial fluid withdrawal, improvement of hemodynamic alternations is expected in patients with pericardial effusion. Method : Hemodynamic study was performed before and during serial fluid drainage in 11 patients with chronic moderate to severe pericardial effusion. RESULTS: 1) Intrapericardial pressure was elevated and equal to mean right atrial ventricular diastolic, and pulmonary capillary wedge pressure. Pulmonary arterial and right ventricular systolic pressure were also midly elevated equal to one another. 2) Pericardial fluid was gradually removed in 50ml aliquots in all patients. The most significant hemodynamic improvement occured during intial 50mL withdrawal. Futher drainage of intrapericardial fluid was accompanied by slight hemodynamic improvement. 3) There were significant correlations between total pericardial fluid volume and intrapericardial and right atrial pressure (r=0.75 (p<0.005), r=0.71(p<0.01)). Correlations between intrapericardial pressure and right atrial, right ventricular diastolic and pulmonary capillary wedge pressure were also significant. 4) Two groups of patient could be distinguished based upon intrapericardial pressure as 7mmHg. More significant hemodynamic changes were in 6 patients with higher intrapericardial pressure after withdrawal of 200mL fluid. CONCLUSION: In chronic moderate to severe pericardial effusion, the most significant hemodynamic improvement occurred during initial fluid drainage. Early pericardiocentesis is important in management of pericardial effusion with high intrapericardial pressure.
Atrial Pressure ; Blood Pressure ; Cardiac Tamponade ; Compliance ; Drainage* ; Hemodynamics* ; Humans ; Pericardial Effusion* ; Pericardiocentesis ; Pericardium ; Pulmonary Wedge Pressure

No abstract available.
Congenital Abnormalities* ; Humerus*

BACKGROUND: The stratum corneum presents a significant barrier to transdermal drug delivery. Approaches to improve percutaneous absorption of drugs have included iontophoresis and skin penetration enhancers. Oleic acid has been studied as a skin penetration enhancer for drugs, primarily via its action mainly on the stratum corneum lipid structure. OBJECTIVE: The purpose of this study was to assess the interaction between oleic acid and stratum corneum lipids in vivo. METHODS: Male hairless mice were treated topically with oleic acid. Barrier function was assessed by transepidermal water loss measurement and ultrastructural observation with ruthenium tetroxide (RuO₄) staining. RESULTS: Oleic acid in propylene glycol had a profound effect on epidermal barrier function and was found to be concentration dependent. Moreover, ultrastructural examination with RuO4 post-fixation demonstrated that there were marked alterations in the stratum corneum lipid structure. CONCLUSION: This study provides direct evidence that oleic acid increases the epidermal permeability through a mechanism involving the stratum corneum lipid membrane perturbation via the lacunae formation within the stratum corneum.
Animals ; Humans ; Iontophoresis ; Male ; Membranes ; Mice ; Mice, Hairless ; Oleic Acid* ; Permeability ; Propylene Glycol* ; Ruthenium ; Skin ; Skin Absorption ; Water

No abstract available.
Extremities* ; Gangrene* ; Haemophilus influenzae type b* ; Haemophilus influenzae* ; Haemophilus*