Delta neutrophil index and shock index can stratify risk for the requirement for massive transfusion in patients with primary postpartum hemorrhage in the emergency department

Background: Postpartum hemorrhage (PPH) constitutes a major risk for maternal mortality and morbidity. Unfortunately, the severity of PPH can be underestimated because it is difficult to accurately measure blood loss by visual estimation. The delta neutrophil index (DNI), which reflects circulating immature granulocytes, is automatically calculated in hematological analyzers. We evaluated the significance of the DNI in predicting hemorrhage severity based on the requirement for massive transfusion (MT) in patients with PPH. Methods: We retrospectively analyzed data from a prospective registry to evaluate the association between the DNI and MT. Moreover, we assessed the predictive ability of the combination of DNI and shock index (SI) for the requirement for MT. MT was defined as a transfusion of ≥10 units of red blood cells within 24 h of PPH. In total, 278 patients were enrolled in this study and 60 required MT. Results: Multivariable logistic regression revealed that the DNI and SI were independent predictors of MT. The optimal cut-off values of ≥3.3% and ≥1.0 for the DNI and SI, respectively, were significantly associated with an increased risk of MT (DNI: positive likelihood ratio [PLR] 3.54, 95% confidence interval [CI] 2.5-5.1 and negative likelihood ratio [NLR] 0.48, 95% CI 0.4-0.7; SI: PLR 3.21, 95% CI 2.4-4.2 and NLR 0.31, 95% CI 0.19-0.49). The optimal cut-off point for predicted probability was calculated for combining the DNI value and SI value with the equation derived from logistic regression analysis. Compared with DNI or SI alone, the combination of DNI and SI significantly improved the specificity, accuracy, and positive likelihood ratio of the MT risk. Conclusion: The DNI and SI can be routinely and easily measured in the ED without additional costs or time and can therefore, be considered suitable parameters for the early risk stratification of patients with primary PPH.ope

The effect of paramedic’s emergency patient simulation training - course using standardized communication tools and simulation

Background : Since primary emergency treatment should be performed appropriately and promptly, efficient and accurate communication between paramedics and medical staff is paramount to a successful primary emergency treatment and patient handover. The problem of the training program in Korea is that it concentrates more on in-class lectures, often delivered by non-medical specialists, who may lack in practical experience and without proper communication training. To solve this problem, we have devised a simulation based training that focuses on event debriefings and two-way communication. Methods : 62 paramedics from 3 stations enrolled in the study. 4 different courses with different emergency situations were created and each course was taken twice resulting in a total of 8 classes. All courses were based on actual cases. The curriculum consisted of subject lectures with guidelines, skill practice courses, and simulation courses based on hands-on method. In simulation courses, paramedics use standardized check list to communicate with medical specialists. All curriculums except subject lectures include debriefing, which allows free talking with educators comprised of medical specialists. In order to measure the educational impact, all students performed self-assessment through a structured questionnaire before and after the training. Results : Regardless different situations and paramedics’ education level, their performance and communication skills have improved after simulation training course. Paramedics mentioned learning skills in simulation course through communication with medical staffs as the biggest advantage. Conclusion : Receiving the simulation training with standardized communication tools is effective at enhancing the communication between the paramedics and medical staff.ope

생물정보학적 접근방법을 이용한 유전적 표지인자 탐색과 유전체데이터의 유용한 정보 발굴

학위논문 (석사)-- 서울대학교 대학원 : 협동과정 생물정보학전공, 2016. 2. 김희발.These studies are mainly focusing on the deciphering biologically meaningful information in genome sequences of living organisms using bioinformatics techniques. In chapter 2, I investigate the relationship between genomic composition and Berkshire pigs meat quality trait by scanning for signatures of positive selection in whole-genome sequencing data. Berkshire pigs are regarded as having superior meat quality compared to other breeds. As the meat production industry seeks selective breeding approaches to improve profitable traits such as meat quality, information about genetic determinants of these traits is in high demand. However, most of the studies have been performed using trained sensory panel analysis without investigating the underlying genetic factors. Results revealed several candidate genes involved in Berkshire meat qualitymost of these genes are involved in lipid metabolism and intramuscular fat deposition. In chapter 3, I construct the HGTree: database of horizontally transferred genes determined by tree reconciliation. In Bacteria and Archaea, Horizontal gene transfer (HGT) plays an important role in the acquisition of biological advantages such as virulence factor and antibiotic resistance and provides significant genetic diversity. It is important to have a well-defined database containing precise information about HGT events between Prokaryotes in order to understand prokaryotic evolution and discover genes which have led to adaptive genetic variation through HGT as opposed to processes such as mutation, natural selection, or genetic drift. The HGTree database provides putative genome-wide horizontal gene transfer information for 2,472 prokaryotic genomes by reconciling gene trees against species trees. The tree reconciliation method is considered to be a useful way to detect HGT events but has not been utilized extensively by existing databases because the method is computationally intensive and conceptually challenging. In this regard, HGTree represents a useful addition to the biological community, enabling quick and easy retrieval of information for HGT-acquired genes and better understanding of microbial taxonomy and evolution. The database is freely available and can be easily scaled and updated to keep pace with the rapid rise in genomic information.ABSTRACT 4 CONTENTS 7 LIST OF TABLES 9 LIST OF FIGURES 10 CHAPTER 1. LITERATURE REVIEW 12 1.1 Detecting positive selection 13 1.2 Detecting horizontal gene transfer 15 CHAPTER 2. EXPLORING EVIDENCE OF POSITIVE SELECTION REVEALS GENETIC BASIS OF MEAT QUALITY TRAITS IN BERKSHIRE PIGS THROUGH WHOLE GENOME SEQUENCING 19 2.1 Introduction 20 2.2 Material and methods 21 2.3 Results 27 CHAPTER 3. HGTREE: DATABASE OF HORIZONTALLY TRANSFERRED GENES DETERMINED BY TREE RECONCILIATION 54 3.1 Introduction 55 3.2 Material and Methods 56 3.3 Results 62 3.4 Discussion 67 REFERENCES 82 국문초록 97Maste

Development and psychometric evaluation of the Resuscitation Self-efficacy Scale for nurses

PURPOSE: The purpose of this study was to develop and evaluate psychometric properties of the instrument, Resuscitation Self-Efficacy Scale for nurses. METHODS: This was a methodological study for instrument development and psychometric testing. The initial item pool derived from literature review and experts resulted in 30 items linked to resuscitation self-efficacy. A convenience sample of 509 Korean nurses from eleven academic teaching hospitals participated in a survey to examine psychometric properties of the scale. To examine construct validity, exploratory factor analysis and known-group comparison were used. Cronbach's coefficient alpha was used to determine the scale's internal consistency reliability. RESULTS: The final scale included 17 items with four-component structure termed 'Recognition', 'Debriefing and recording', 'Responding and rescuing', and 'Reporting'. These four factors accounted for 57.5% of the variance. Each subscale and the total scale demonstrated satisfactory internal consistency: .82; .88; .87; .83; and .91 respectively. Experienced nurses reported significantly higher self-efficacy mean scores in both total and subscales compared to new graduate nurses. CONCLUSION: The Resuscitation Self-Efficacy Scale for nurses yields reliable and valid results in appraising the level of resuscitation self-efficacy for Korean nurses. Further study is needed to test and refine the scale.ope

The Current Status and Activities of Emergency Physician-Performed Ultrasonography in Seoul and Gyeonggi do

Purpose: There have been reports that have focused on the usefulness of ultrasonography (US), yet there are no reports on its current status and activities. This study evaluated the current status and activities of US in Seoul and Gyeong-gi do. Methods: This study was conducted using a questionnaire developed by emergency physicians who were experienced in workshops for emergency US. The activities of US were established by assessing the average frequency of US examination among 5 clinical situations as recommended by the American College of Emergency Physicians (ACEP). We assessed the association between these activities and the variables using linear regression analysis and regression trees. Results: The overall response rate was 85.2%. The average frequencies of US examination are as follows: multiple trauma (75.1±29.5%), right upper abdominal pain (57.6±29.6%), cardiac arrest (54.4±30.6%), suspected ureter stone (42.4±31.6%), other abdominal pain (41.6±29.2%), chest pain or dyspnea (35.8±27.3%), right lower abdominal pain (33.6±28.9%), hypotension (33.3±27.8%), procedures (21.3±22.6%), intussusceptions (17.1±26.5%), central line access (16.2±21.4%), testicular torsion (14.7±23.7%) and assessing a pregnancy or a fetus (9.1±10.8%). The average percentage of current activities was 52.6%. The factors associated with current activities are as follows: the presence of supervisor for US training (p=0.030), the quality of the US machine (p=0.007), the number of patients (p=0.001) and the accreditation system for emergency US (p=0.014). Conclusion: The current status and activities of US are varied. The factors associated with current activities are the presence of a supervisor for US training, the accreditation system for emergency US, the quality of the US machine and the number of patients. It is important to improve these factors to effectively use US.ope

Tube thoracostomy training with a medical simulator is associated with faster, more successful performance of the procedure

OBJECTIVE: Tube thoracostomy (TT) is a commonly performed intensive care procedure. Simulator training may be a good alternative method for TT training, compared with conventional methods such as apprenticeship and animal skills laboratory. However, there is insufficient evidence supporting use of a simulator. The aim of this study is to determine whether training with medical simulator is associated with faster TT process, compared to conventional training without simulator. METHODS: This is a simulation study. Eligible participants were emergency medicine residents with very few (≤3 times) TT experience. Participants were randomized to two groups: the conventional training group, and the simulator training group. While the simulator training group used the simulator to train TT, the conventional training group watched the instructor performing TT on a cadaver. After training, all participants performed a TT on a cadaver. The performance quality was measured as correct placement and time delay. Subjects were graded if they had difficulty on process. RESULTS: Estimated median procedure time was 228 seconds in the conventional training group and 75 seconds in the simulator training group, with statistical significance (P=0.040). The difficulty grading did not show any significant difference among groups (overall performance scale, 2 vs. 3; P=0.094). CONCLUSION: Tube thoracostomy training with a medical simulator, when compared to no simulator training, is associated with a significantly faster procedure, when performed on a human cadaver.ope

Disaster medicine: current status and future directions of emergency medical team for overseas disaster crisis

Through the Declaration of Montevideo in 2011, the World Medical Association suggested that doctors worldwide should be trained in basic disaster response regardless of their specialty. The Haiti earthquake in 2010, which had the highest number of foreign medical team dispatched from all over the world, proved that untrained and disorganized team only brought confusion. This event led the World Health Organization to develop the ‘Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters’ in 2013. This guideline will become the standard for organizing an international emergency medical team. We should be able to provide high standard of care through field hospital set up and continuous training of disaster medicine specialists.ope

Clinical outcomes of early gastric cancer with non-curative resection after pathological evaluation based on the expanded criteria

Additional surgical resection should be considered for the patients with pathological findings beyond the expanded criteria with the risk for LN metastasis. However, close observation without additional surgery may be applied because of various reasons. We aimed to determine the clinical outcomes of early gastric cancer beyond the expanded criteria after endoscopic resection according to the pathological extent. A total of 288 patients with 289 lesions beyond the expanded criteria of endoscopic submucosal dissection for early gastric cancer were analyzed between 2005 and 2016, and classified into two groups according to additional treatment: observation (n = 175 patients, 175 lesions) and surgery (n = 113 patients, 114 lesions). The depth of tumor invasion was greater and the tumor-positive vertical margin and lymphatic and venous invasion were more common in the surgery group than in the observation group (P<0.001). Residual, synchronous, and metachronous tumors were more common in the observation group; however, the occurrence of regional lymph node and distant metastasis did not differ between the groups. Overall survival and 5-year disease-specific survival did not differ between the groups (observation vs surgery, 88.6 vs 93.8%; P = 0.259, 98.2 vs 100%; P = 0.484, respectively), but the 5-year disease-free survival was lower in the observation group (73.5 vs 97.9%; P<0.001). On multivariate analysis, tumor-positive lateral margin was a risk factor for residual tumor and lymphatic and venous invasion were risk factors for regional lymph node metastasis. In conclusion, the clinical course of beyond the expanded criteria of endoscopic submucosal dissection for early gastric cancer showed good prognosis over 98% in 5-year disease specific survival. If additional surgery cannot be performed, a close follow-up with endoscopy and abdominal computed tomography can be considered as an alternative for carefully selected patients without lymphatic and vascular invasion.ope

Development of an Emergency Abdominal Ultrasound Course in Korea: 1-Year Experience

Purpose: This report describes our 1-year experience with an emergency abdominal ultrasound course that we developed for emergency medicine residents and physicians. Methods: The five-hour course consisted of didactic lectures and hands-on practice. A 1-hour didactic lecture was provided. The lecture consisted of basic ultrasound physics and principles, and anatomy for abdominal ultrasound. In the hands-on session, the instructors demonstrated the abdominal ultrasound techniques and then the students practiced on standard patients. Participants evaluated the programs using a five or ten point Likert scale. After two months to one year, the participants evaluated the usefulness of the course, their knowledge, and their self confidence. Results: A total of 61 trainees participated in eight courses. The evaluation scores for overall quality of content, clinical utility, quality of educational method, quality of instructor, and time allocation were 4.4±0.7, 4.5±0.6, 4.3±0.6, 4.4 ±0.6, 4.1±0.7, respectively. Score of self-confidence of each scan before and after the course were as follows: liver scan, 3.2±2.1 to 6.9±1.2; gallbladder and bile duct scan 3.0±2.5 to 6.9±1.2; pancreas scan, 2.4±2.1 to 6.3±1.3; renal scan, 3.6±2.6 to 7.6±1.3. Evaluation scores were followed up after two months to one year to estimate self confidence of each scan. Results were as follows: liver scan, 6.1±1.5; gallbladder and bile duct scan, 6.5±1.6; pancreas scan, 5.5±1.8; renal scan, 7.2±1.5. Conclusion: The Emergency Abdominal Ultrasound Course is a fairly successful course. But continuous improvement of educational content, and development of an objective evaluation tool need to be done.ope

Endoscopically injectable and self-crosslinkable hydrogel-mediated stem cell transplantation for alleviating esophageal stricture after endoscopic submucosal dissection

Esophageal stricture after extensive endoscopic submucosal dissection impairs the quality of life of patients with superficial esophageal carcinoma. Beyond the limitations of conventional treatments including endoscopic balloon dilatation and the application of oral/topical corticosteroids, several cell therapies have been recently attempted. However, such methods are still limited in clinical situations and existing setups, and the efficacies are less in some cases since the transplanted cells hardly remain at the resection site for a long time due to swallowing and peristalsis of the esophagus. Thus, a cell transplantation platform directly applicable with clinically established equipment and enabling stable retention of transplanted cells can be a promising therapeutic option for better clinical outcomes. Inspired by ascidians that rapidly self-regenerate, this study demonstrates endoscopically injectable and self-crosslinkable hyaluronate that allows both endoscopic injection in a liquid state and self-crosslinking as an in situ-forming scaffold for stem cell therapy. The pre-gel solution may compatibly be applied with endoscopic tubes and needles of small diameters, based on the improved injectability compared to the previously reported endoscopically injectable hydrogel system. The hydrogel can be formed via self-crosslinking under in vivo oxidative environment, while also exhibiting superior biocompatibility. Finally, the mixture containing adipose-derived stem cells and the hydrogel can significantly alleviate esophageal stricture after endoscopic submucosal dissection (75% of circumference, 5 cm in length) in a porcine model through paracrine effects of the stem cell in the hydrogel, which modulate regenerative processes. The stricture rates on Day 21 were 79.5% ± 2.0%, 62.8% ± 1.7%, and 37.9% ± 2.9% in the control, stem cell only, and stem cell-hydrogel groups, respectively (p < 0.05). Therefore, this endoscopically injectable hydrogel-based therapeutic cell delivery system can serve as a promising platform for cell therapies in various clinically relevant situations.ope