Performance of patient acuity rating by rapid response team nurses for predicting short-term prognosis.

BACKGROUND: Although scoring and machine learning methods have been developed to predict patient deterioration, bedside assessment by nurses should not be overlooked. This study aimed to evaluate the performance of subjective bedside assessment of the patient by the rapid response team (RRT) nurses in predicting short-term patient deterioration. METHODS: Patients noticed by RRT nurses based on the vital sign instability, abnormal laboratory results, and direct contact via phone between November 1, 2016, and December 12, 2017, were included. Five RRT nurses visited the patients according to their shifts and assessed the possibility of patient deterioration. Patient acuity rating (PAR), a scale of 1-7, was used as the tool of bedside assessment. Other scores, including the modified early warning score, VitalPAC early warning score, standardised early warning score, and cardiac arrest risk triage, were calculated afterwards. The performance of these scores in predicting mortality and/or intensive care unit admission within 1 day was compared by calculating the area under the receiver operating curve. RESULTS: A total of 1,426 patients were included in the study, of which 258 (18.1%) died or were admitted to the intensive care unit within 1 day. The area under the receiver operating curve of PAR was 0.87 (95% confidence interval [CI] 0.84-0.89), which was higher than those of modified early warning score (0.66, 95% CI 0.62-0.70), VitalPAC early warning score (0.69, 95% CI 0.66-0.73), standardised early warning score (0.67, 95% CI 0.63-0.70) and cardiac arrest risk triage (0.63, 95% CI 0.59-0.66) (P<0.001). CONCLUSIONS: PAR assessed by RRT nurses can be a useful tool for assessing short-term patient prognosis in the RRT setting.

Intra-hospital transport of critically ill patients with rapid response team and risk factors for cardiopulmonary arrest: A retrospective cohort study.

INTRODUCTION: This study aimed to determine the occurrence rate and risk factors of cardiopulmonary arrest (CPA) during intra-hospital transport (IHT) among critically ill patients, accompanied by a rapid response team (RRT). METHODS: We performed a retrospective cohort study in a 1300-bed tertiary-care teaching hospital. Data of all admitted patients transported within the hospital and accompanied by the RRT from October 2012 to May 2016 were included. We compared patients with CPA (+) and patients without CPA (-) to identify risk factors for CPA during transport. RESULTS: Among 535 patients, CPA occurred in eight (1.5%) patients during IHT. There were no significant differences in age, sex, and comorbidities between groups. More patients in the CPA (+) group than in the CPA (-) group received manual ventilation during IHT (75% vs. 23.0%, p = 0.001). An increased risk of CPA (p<0.001) corresponded with a higher number of vasopressors used during IHT. In univariate logistic regression analysis, history of myocardial infarction (OR 10.7, 95% CI 2.4-50.5, p = 0.005), manual ventilation (OR 10.1, 95% CI 2.0-50.5, p = 0.005), and use of three or more vasopressors (OR 11.1, 95% CI 2.5-48.9, p = 0.001) were significantly associated with risk of CPA during RRT-led IHT. CONCLUSIONS: Despite accompaniment by a specialized team such as the RRT, CPA can occur during IHT. History of myocardial infarction, manual ventilation with bag-valve mask, and the use of three or more vasopressors were independent risk factors of CPA during IHT of critically ill patients accompanied by the RRT.

Usefulness of ascitic fluid lactoferrin levels in patients with liver cirrhosis.

BACKGROUND: Although elevated levels of lactoferrin provide a biomarker for inflammatory bowel diseases and colorectal cancer, the clinical significance of these elevated levels in ascitic fluid of patients with ascites caused by liver cirrhosis is limited. The aims of our study were to investigate the usefulness of ascitic fluid lactoferrin levels for the diagnosis of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and to evaluate the association between lactoferrin levels and the development of hepatocellular carcinoma (HCC). METHODS: A total of 102 patients with ascites caused by cirrhosis were consecutively enrolled into the study, from December 2008 to December 2011. Ascitic fluid lactoferrin levels were quantified using a human lactoferrin enzyme-linked immunosorbent assay kit. RESULTS: The median ascitic fluid lactoferrin levels were significantly higher in patients with SBP than in those without SBP (112.7 ng/mL vs. 0.6 ng/mL; p < 0.001). The area under the receiver operator characteristic curve for the diagnosis of SBP was 0.898 (95 % confidence interval, 0.839-0.957, p < 0.001), with a sensitivity and specificity for a cut-off level of 51.4 ng/mL of 95.8 % and 74.4 %, respectively. Moreover, the incidence of HCC in the 78 patients without SBP was significantly higher in patients with high ascitic fluid lactoferrin levels (≥35 ng/mL) than in those with low ascitic fluid lactoferrin level (<35 ng/mL). CONCLUSIONS: Ascitic fluid lactoferrin level can be a useful diagnostic tool to identify SBP in patients with ascites caused by cirrhosis. Elevated ascitic fluid lactoferrin level in patients without SBP may be indicative of a developing hepatocellular carcinoma.

Risk Factors for Hepatitis C Virus (HCV) Infection in Areas with a High Prevalence of HCV in the Republic of Korea in 2013.

BACKGROUND/AIMS: The prevalence of hepatitis C virus (HCV) infection in Busan, Gyeongnam, and Jeonnam Provinces in Korea is more than twice the national average. This study aimed to examine whether demographic and lifestyle characteristics are associated with HCV infection in these areas. METHODS: A case control study was performed at three study hospitals. HCV cases were matched with two controls for sex and age. Patient controls were selected from non-HCV patients at the same hospital. Healthy controls were subjects participating in medical checkups. Conditional logistic regression models were used. RESULTS: A total of 234 matched-case and patient- and healthy-control pairs were analyzed. The significant risk factors for both controls were sharing razors (adjusted odds ratio [aOR], 2.39 and 3.29, respectively) and having more than four lifetime sexual partners (aOR, 2.15 and 6.89, respectively). Contact dockworkers (aOR, 1.91) and tattoos (aOR, 2.20) were significant risk factors for the patient controls. Transfusion (aOR, 5.38), a bloody operation (aOR, 5.02), acupuncture (aOR, 2.08), and piercing (aOR, 5.95) were significant risk factors for the healthy controls. Needle stick injuries and intravenous drug abuse were significant in the univariate analysis. CONCLUSIONS: More education concerning the dangers of sharing razors, tattoos and piercings is required to prevent HCV infection. More attention should be paid to needle stick injuries in hospitals and the community.

Comparison and analysis of the prevalence of hepatitis C virus infection by region in the Republic of Korea during 2005-2012.

BACKGROUND/AIMS: This study compared the prevalence of hepatitis C virus (HCV) infection in the Republic of Korea and estimated the high-risk regions and towns. METHODS: National Health Insurance Service data for 8 years from 2005 to 2012 were used. The subjects of the study had visited medical facilities and been diagnosed with or received treatment for acute or chronic HCV as a primary or secondary disease according to ICD-10 codes of B17.1 or B18.2, respectively. Any patient who received treatment for the same disease multiple times during 1 year was counted as one patient in that year. To correct for the effect of the age structure of the population by year and region, the age-adjusted prevalence was calculated using the direct method based on the registered population in 2010. RESULTS: The overall prevalence of HCV infection among Korean adults (>20 years old) increased from 0.14% in 2005 to 0.18% in 2012. The sex-, age-, and region-adjusted prevalence in 2012 was 0.18%. The prevalence was highest in Busan, Jeonnam, and Gyeongnam, and there were towns with noticeably higher prevalences within these regions: Jindo (0.97%) in Jeonnam, Namhae (0.90%) in Gyeongnam, and Seo-gu (0.86%) in Busan. CONCLUSIONS: The prevalence of HCV infection differs by regions as well as towns in the Republic of Korea, and is highest in Busan, Jeonnam, and Gyeongnam. The reasons for the high prevalence in these specific regions should be identified, since this could help prevent HCV infections in the future. In addition, active surveillance and treatment policies should be introduced to stop any further spread of infection in these high-prevalence regions.

Ectopic Opening of the Common Bile Duct into the Duodenal Bulb Accompanied with Cholangitis and Gallbladder Cancer: A Report of Two Cases.

An ectopic opening of the common bile duct (CBD) into the duodenal bulb is a very rare congenital anomaly of the biliary system, which may cause recurrent duodenal ulcer or biliary diseases such as choledocholithiasis and cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in the diagnosis of this anomaly. We report two such cases: one in a 61-year-old man and the other in a 57-year-old man. In the first case, this anomaly caused acute cholangitis with multiple CBD stones, which were successfully treated by ERCP. In the second case, abdominal computed tomography showed pneumobilia, which was further evaluated using ERCP. Besides, this patient was diagnosed with an ectopic opening of the CBD associated with gallbladder cancer. We report these unusual cases and review the relevant medical literature.

[Clinicopathological characteristics and prognosis of alpha-fetoprotein producing gastric cancer].

BACKGROUND/AIMS: Several studies reported a subgroup of gastric cancer patients showing elevated serum alpha-fetoprotein (AFP) at the time of diagnosis. We investigated the clinicopathological characteristics and prognostic factors of AFP producing gastric cancer (AFPPGC) by comparing with AFP non-producing gastric cancer (AFPNPGC). METHODS: A total of 909 patients were diagnosed with gastric cancer from January 2005 to March 2013 at Gyeongsang National University Hospital and their AFP levels were measured at the time of diagnosis. After excluding 138 patients with underlying liver diseases, 34 patients with elevated serum AFP level over 10 mg/mL were assigned to AFPPGC group and the remaining 737 patients with serum level of AFP below 10 ng/mL were assigned to AFPNPGC group. RESULTS: The median survival length was shorter in AFPPGC group than AFPNPGC group (18.3 ± 25.5 months vs. 30.0 ± 22.0 months, p=0.004). The incidence of liver metastasis (47.1% vs. 3.3%, p<0.001) and lymph node metastasis (91.2% vs. 31.6%, p<0.001) was significantly higher in AFPPGC group. The probability of encountering metachronous liver metastasis after the operation was higher in AFPPGC group (44.4% vs. 2.0%, p<0.001). Multivariate analysis revealed that patients in the AFPPGC group who received chemotherapy (p=0.037) or underwent operation (p=0.001) had a better survival rate. CONCLUSIONS: AFPPGC behaves more aggressively and shows a worse prognosis. Therefore, serum AFP level should be routinely checked in all patients diagnosed with gastric cancer.

Genotype-4 hepatitis E in a human after ingesting roe deer meat in South Korea.

The recent increase in the number of cases of indigenous hepatitis E virus (HEV) infection highlights the importance of identifying the transmission routes for the prevention of such infections. Presented herein is the first case of acute HEV infection after ingesting wild roe deer meat in South Korea. A 43-year-old male presented with abdominal discomfort and jaundice. He had not recently traveled abroad, but had eaten raw roe-deer meat 6-8 weeks before the presentation. On the 7th day of hospitalization the patient was diagnosed with acute viral hepatitis E. Phylogenetic analysis of his serum revealed genotype-4 HEV. This case supports the possibility of zoonotic transmission of HEV because the patient appears to have been infected with genotype-4 HEV after ingesting raw deer meat.

Clinical features of autoimmune hepatitis and comparison of two diagnostic criteria in Korea: a nationwide, multicenter study.

BACKGROUND AND AIM: As a rare liver disease, little is known about autoimmune hepatitis (AIH). This study investigated the clinical features and compared two diagnostic criteria of AIH in Korea. METHODS: A nationwide, multicenter, retrospective analysis was done of data of adult patients diagnosed with AIH from January 2005 to December 2009. RESULTS: The enrolled patients (n = 343; mean age, 52.8 years; range, 19-87 years; 12% male, 88% female) met diagnostic criteria of AIH according to the revised original criteria (n = 311) or the simplified criteria (n = 250). At diagnosis, 30.6% were asymptomatic, 22.7% were cirrhotic, and 4.3% displayed hepatic decompensation. The positive results for anti-nuclear antibody, smooth muscle antibody, and anti-liver/kidney microsomal antibody were 94.2%, 23.0%, and 2.9%, respectively. Definite AIH and probable AIH according to the revised original criteria were 24.8% and 65.3%, respectively, while those according to the simplified criteria were 34.4% and 38.5%, respectively. The diagnostic sensitivity and positive predictive value of simplified criteria in comparison with the revised original criteria were 69.9% and 86.4%, respectively. As an initial therapy, corticosteroid (37.7%) or corticosteroid with azathioprine (36.8%) was administered. Remission, incomplete response, and treatment failure were noted with 85.7%, 10.5%, and 3.9% of patients, respectively. CONCLUSIONS: Autoimmune hepatitis in Korea is mostly type I, showing a mean age of 53 years with comparable clinical features to other countries. The concordant rate of the two diagnostic criteria was rather low with modest sensitivity of the simplified criteria. Further studies on the validation of the diagnostic criteria are warranted.

An indigenous case of intestinal capillariasis with protein-losing enteropathy in Korea.

We encountered an indigenous case of intestinal capillariasis with protein-losing enteropathy in the Republic of Korea. A 37-year-old man, residing in Sacheon-si, Gyeongsangnam-do, admitted to the Gyeongsang National University Hospital (GNUH) due to long-lasting diarrhea, abdominal pain, anasarca, and weight loss. He recalled that he frequently ate raw fish, especially the common blackish goby (Acanthogobius flavimanus) and has never been abroad. Under the suspicion of protein-losing enteropathy, he received various kinds of medical examinations, and was diagnosed as intestinal capillariasis based on characteristic sectional findings of nematode worms in the biopsied small intestine. Adults, juvenile worms, and eggs were also detected in the diarrheic stools collected before and after medication. The clinical symptoms became much better after treatment with albendazole 400 mg daily for 3 days, and all findings were in normal range in laboratory examinations performed after 1 month. The present study is the 6th Korean case of intestinal capillariasis and the 3rd indigenous one in the Republic of Korea.

Drug-Induced Liver Injury: Twenty Five Cases of Acute Hepatitis Following Ingestion of Polygonum multiflorum Thunb.

BACKGROUND/AIMS: Complementary medicines, including herbal preparations and nutritional supplements, are widely used without prescriptions. As a result, there has been growing interest in the risk of hepatotoxicity with these agents. It is difficult to determine causal relationships between these herbal preparations and hepatotoxicity. We report on 25 patients diagnosed with toxic hepatitis following ingestion of Polygonum multiflorum Thunb. METHODS: Twenty-five patients (median age, 48 years [24 to 65 years]; M:F=18:7) with suspected P. multiflorum Thunb-induced liver injury were admitted to our hospital between 2007 and 2009. We analyzed clinical and histological data, including the types and the duration of P. multiflorum Thunb intake and the duration of hospital care. We also determined the type of liver injury using the R ratio (serum activity of ALT/serum activity of ALP). RESULTS: The types of complementary medicine used included tea (n=16), liquor (n=5), tea and liquor (n=2), powder (n=1), and honeyed pudding (n=1). The most common presenting sign was jaundice (76%), and 18 patients (72%) had evidence of hepatocellular liver injury. Histological findings were consistent with acute hepatitis in all cases (n=10) for which liver biopsy was performed. Twenty-three patients (91.6%) recovered with conservative management, 1 patient (4%) had a liver transplant, and 1 patient (4%) died of hepatic failure. CONCLUSIONS: In our cases, we found that P. multiflorum Thunb could be hepatotoxic and could lead to severe drug-induced liver injury, and even death.

The synchronous prevalence of colorectal neoplasms in patients with stomach cancer.

PURPOSE: The association between stomach cancer and colorectal cancer is controversial. The purpose of this study was to determine the synchronous prevalence of colorectal neoplasms in patients with stomach cancer. METHODS: A total of 123 patients with stomach cancer (86 male) and 246 consecutive, age- and sex-matched persons without stomach cancer were analyzed from July 2005 to June 2010. All of them underwent colonoscopy within 6 months after undergoing gastroscopy. RESULTS: The prevalence of colorectal neoplasms was significantly higher in the stomach cancer group (35.8%) than in the control group (17.9%) (P < 0.001). Colorectal neoplasms were more prevalent in the patients with stomach cancer (odds ratio [OR], 3.10; 95% confidence interval [CI], 1.71 to 5.63). In particular, the difference in the prevalence of colorectal neoplasms was more prominent in the patients above 50 years old (OR, 3.54; 95% CI, 1.80 to 6.98). CONCLUSION: The results showed that the synchronous prevalence of colorectal neoplasms was higher in patients with stomach cancer than in those without stomach cancer. Therefore, patients with stomach cancer should be regarded as a high-risk group for colorectal neoplasms, and colonoscopy should be recommended for screening.

[Clinical features and prognosis of primary biliary cirrhosis in Korea].

BACKGROUND/AIMS: This study investigated the clinical features and prognosis of primary biliary cirrhosis (PBC) in Korea. METHODS: Clinical data of patients diagnosed as PBC between 1997 and 2008 at eight referral hospitals were analyzed retrospectively. PBC was diagnosed based on liver function tests, presence of serum antimitochondrial antibody (AMA), and histopathological findings. RESULTS: In total, 251 patients (218 females, 33 males; mean age 54 years) were enrolled, and the mean follow-up duration was 33.5 months. At the diagnosis, 61% of the patients were asymptomatic, 12% had decompensated liver cirrhosis, and 98% were positive for AMA. The serum alkaline phosphate (ALP) level was 2.6 times the upper limit of normal, aspartate aminotransferase was 105 U/L, and bilirubin was 2.0 mg/dL. The mean Mayo risk score was 5.5, and the Child-Pugh class was A, B, and C in 79%, 19%, and 2% of the patients, respectively. Ursodeoxycholic acid (UDCA) was used for treatment in 88% of the patients, among which 70% exhibited biochemical responses defined as normalization or a > 40% decrease in ALP at 6 months. Eight deaths occurred during the follow-up; the causes were variceal bleeding, hepatic failure, and sepsis. The overall 5-year survival rate was 95%. The poor prognostic factors were being older than 60 years, high bilirubin, low albumin, ascites, high Mayo risk score, Child-Pugh class C, and initial presence of hepatic decompensation. CONCLUSIONS: Most patients diagnosed as PBC were asymptomatic, and these patients had a favorable short-term prognosis. The prognosis of PBC was dependent on the initial severity of liver disease.

Unusual gastrointestinal metastases from an alveolar soft part sarcoma.

Alveolar soft part sarcoma (ASPS) is a rare subtype of soft tissue sarcoma that occurs predominantly in young patients. Despite its relatively indolent course, it generally has a poor prognosis with widespread metastases. The common metastatic sites from an ASPS include the lung, brain and bone. However, metastasis of an ASPS to the gastrointestinal tract is extremely rare. Here, we report a rare case of upper gastrointestinal bleeding and jejunal intussusception due to gastrointestinal metastases from an ASPS.

[A case of sudden-onset hearing loss in a patient treated with peginterferon alpha-2b and ribavirin for chronic hepatitis C].

Combination therapy of pegylated interferon alpha and ribavirin has been associated with various adverse effects, but sudden-onset hearing loss is uncommon. We report a 60-year-old male patient who developed sudden-onset hearing loss during combination therapy with pegylated interferon alpha and ribavirin for chronic hepatitis C. This patient had been diagnosed with chronic hepatitis C (genotype Ib) and early-stage liver cirrhosis 3 years previously, and had been treated with conventional interferon-alpha and ribavirin for 12 months. However, 6 months from the end of the treatment course the patient relapsed and received combination retreatment with pegylated interferon alpha-2b and ribavirin. He developed sudden-onset right-side hearing loss and tinnitus 42 weeks after the start of this retreatment. Pure-tone audiometry revealed a right-side hearing loss of 60 approximately 90 dB. The patient consequently immediately discontinued the pegylated interferon therapy and was given prednisone 60 mg/day for 10 days, after which the hearing loss had almost completely recovered.

Reactivation of Pulmonary Tuberculosis in a Patient with Polygonum multiflorum Thunb-Induced Hepatitis.

Several cases of Polygonum multiflorum Thunb-induced hepatitis have been reported worldwide. Anthraquinone is an active ingredient of P. multiflorum Thunb. that has been thought to play a role in its hepatotoxicity. Here we report the case of a 34-year-old Korean man who had P. multiflorum Thunb-induced hepatitis and reactivation of pulmonary tuberculosis caused by bone marrow suppression, which developed simultaneously. He was admitted to our hospital with recently developed fatigue and aggravated jaundice. He was a previously healthy man except for the sequelae of pulmonary tuberculosis seen on chest X-ray. He had a 30-day history of ingesting the root of P. multiflorum as a form of liquor and tea. The patient was diagnosed with P. multiflorum Thunb-induced hepatitis after excluding all other potential causes of acute hepatitis. Liver function gradually improved following the total cessation of the consumption of the material. However, he suffered from spiking fever with progressive pancytopenia during the hospital stay. A bone marrow biopsy showed markedly hypocellular marrow, suggesting transient bone marrow suppression, which was probably caused by extrinsic factors such as drugs, toxins, and viral infection. Although he began to complain of a dry cough, repeated sputum investigations revealed positive acid-fast bacillus staining. The fever subsided and pancytopenia improved after treatment for pulmonary tuberculosis. These observations suggest that P. multiflorum Thunb induces both bone marrow suppression and hepatotoxicity.

Benign schwannoma of the liver: a case report.

A primary benign schwannoma of the liver is extremely rare. Only nine cases have been reported in the medical literature worldwide and no case has been reported in Korea previously. A 36-yr-old woman was admitted to our hospital with vague epigastric pain. The ultrasound and computed tomography scan revealed a multi-septated cystic mass in the right lobe of the liver. The mass was resected; it was found to be a 5 x 4 x 2 cm mass filled with reddish yellow fluid. The histological examination confirmed the diagnosis of a benign schwannoma, proven by positive immunoreaction with the neurogenic marker S-100 protein and a negative response to CD34, CD117 and smooth muscle actin. This is the first report of a benign schwannoma of the liver parenchyma in a Korean patient.

Successful endoscopic treatment of biliary stricture following mesenteric tear caused by blunt abdominal trauma.

Biliary duct injuries are frequently iatrogenic, being associated with surgery for gallbladder stones. However, blunt abdominal trauma such as a motor vehicle crash is a rare cause of extrahepatic biliary stricture. A few reports have been published on biliary strictures treated with endoscopic therapy. In the present study, we describe a suprapancreatic biliary stricture associated with mesenteric tear following road traffic accident. We performed endoscopic stent placement, which was successful in relieving the biliary stricture.

Neural cadherin overexpression is a predictive marker for early postoperative recurrence in hepatocellular carcinoma patients.

BACKGROUND AND AIM: Recent studies have disclosed alterations in neural and/or epithelial cadherin (E-cadherin) expression in several epithelial tumors. However, the clinical relevance of these phenomena in hepatocellular carcinoma (HCC) remains to be established. In this study, we investigated the expression patterns of neural and epithelial cadherins and their clinical implications in HCC. METHODS: Immunohistochemical staining for neural and epithelial cadherins was performed on tumor and adjacent non-tumor tissue sections of 52 HCC patients subjected to curative surgical resection. Clinical, radiological, and histopathological characteristics were analyzed, relative to the degree of neural and E-cadherin expression. RESULTS: The neural cadherin (N-cadherin) expression was upregulated in 67% of HCC tissues, compared to adjacent non-tumoral liver tissues. Patients expressing high levels of N-cadherin experienced more frequent tumor recurrences within 2 years (50% vs 12.5%; P = 0.01) after surgical resection. Consequently, the cumulative overall survival rate tended to be lower in patients overexpressing N-cadherin (P = 0.08). The N-cadherin overexpression was the only independent predictive factor for postoperative recurrence within 2 years in both univariate and multivariate analyses (odds ratio: 8.5; 95% confidence interval: 1.625-44.46; P = 0.011). No correlation was evident between E-cadherin expression patterns and clinicopathological parameters. CONCLUSION: The overexpression of N-cadherin is significantly related to postoperative recurrence within 2 years after surgical resection in HCC. Therefore, immunohistochemical staining for N-cadherin may be effectively applied as a predictive marker for early postoperative recurrence in HCC.