Evaluation of the Potential for Improvement of Clinical Outcomes in Trauma Patients with Massive Hemorrhage by Maintaining a High Plasma-to-Red Blood Cell Ratio during the First Hour of Hospitalization.

Several reports indicate that early plasma transfusion may promote survival and reduce the incidence of traumatic coagulopathy in situations of massive bleeding. Consequently, it is recommended to maintain a plasma and RBC transfusion ratio between 1 : 1 and 1 : 2 at the start of admission. This retrospective study examined the effect of an early high plasma : RBC ratio on mortality rates by adopting a massive transfusion protocol (MTP) that forced an early and rapid issue of plasma products. Patients who received massive transfusions at a single trauma center between January 2014 and May 2020 were included in the study. A new protocol was established in January 2020, wherein a fixed amount of plasma was issued following MTP activation. Patients who underwent massive transfusions before and after the adoption of the new protocol were compared. In total, 1059 patients met the inclusion criteria. Fifty-one patients who underwent MTP were propensity score-matched with the patients who received a nonprotocolized massive transfusion. The MTP group had a higher plasma : RBC ratio at 1 h (0.8 vs. 0.2) and 4 h of hospitalization (1.1 vs. 0.6), with no significant between-group difference in the plasma : RBC ratio at 24 h of hospitalization. The MTP group had a lower 24 h mortality rate than the control group. There was no significant difference in the 30-day mortality. Using MTP to achieve a high plasma : RBC ratio in the early period of hospitalization appeared to affect 24-hour mortality; however, 30-day mortality did not change.

Ketamine versus etomidate for rapid sequence intubation in patients with trauma: a retrospective study in a level 1 trauma center in Korea.

BACKGROUND: Ketamine and etomidate are commonly used as sedatives in rapid sequence intubation (RSI). However, there is no consensus on which agent should be favored when treating patients with trauma. This study aimed to compare the effects of ketamine and etomidate on first-pass success and outcomes of patients with trauma after RSI-facilitated emergency intubation. METHODS: We retrospectively reviewed 944 patients who underwent endotracheal intubation in a trauma bay at a Korean level 1 trauma center between January 2019 and December 2021. Outcomes were compared between the ketamine and etomidate groups after propensity score matching to balance the overall distribution between the two groups. RESULTS: In total, 620 patients were included in the analysis, of which 118 (19.9%) were administered ketamine and the remaining 502 (80.1%) were treated with etomidate. Patients in the ketamine group showed a significantly faster initial heart rate (105.0 ± 25.7 vs. 97.7 ± 23.6, p = 0.003), were more hypotensive (114.2 ± 32.8 mmHg vs. 139.3 ± 34.4 mmHg, p < 0.001), and had higher Glasgow Coma Scale (9.1 ± 4.0 vs. 8.2 ± 4.0, p = 0.031) and Injury Severity Score (32.5 ± 16.3 vs. 27.0 ± 13.3, p < 0.001) than those in the etomidate group. There were no significant differences in the first-pass success rate (90.7% vs. 90.1%, p > 0.999), final mortality (16.1% vs. 20.6, p = 0.348), length of stay in the intensive care unit (days) (8 [4, 15] (Interquartile range)), vs. 10 [4, 21], p = 0.998), ventilator days (4 [2, 10] vs. 5 [2, 13], p = 0.735), and hospital stay (days) (24.5 [10.25, 38.5] vs. 22 [8, 40], p = 0.322) in the 1:3 propensity score matching analysis. CONCLUSION: In this retrospective study of trauma resuscitation, those receiving intubation with ketamine had greater hemodynamic instability than those receiving etomidate. However, there was no significant difference in clinical outcomes between patients sedated with ketamine and those treated with etomidate.

An Evaluation of the Effect of Performance Improvement and Patient Safety Program Implemented in a New Regional Trauma Center of Korea.

BACKGROUND: This study examined the impact of the performance improvement and patient safety (PIPS) program implemented in 2015 on outcomes for trauma patients in a regional trauma center established by a government-led project for a national trauma system in Korea. METHODS: The PIPS program was based on guidelines by the World Health Organization and American College of Surgeons. The corrective strategies were proceeded according to the loop closure principle: data-gathering and monitoring, identification of preventable trauma deaths (PTDs), evaluation of preventable factors, analysis of findings, and corrective action plans. We established guidelines and protocols for trauma care, conducted targeted education and peer review presentations for problematic cases, and enhanced resources for improvement accordingly. A comparative analysis was performed on trauma outcomes over a four-year period (2015-2018) since implementing the PIPS program, including the number of trauma team activation and admissions, time factors related to resuscitation, ventilator duration, and the rate of PTDs. RESULTS: Human resources in the center significantly increased during the period; attending surgeons responsible for trauma resuscitation from 6 to 11 and trauma nurses from 85 to 218. Trauma admissions (from 2,166 to 2,786), trauma team activations (from 373 to 1,688), and severe cases (from 22.6 to 33.8%) significantly increased (all P < 0.001). Time to initial resuscitation and transfusion significantly decreased from 120 to 36 minutes (P < 0.001) and from 39 to 16 minutes (P < 0.001). Time to surgery for hemorrhage control and decompressive craniotomy improved from 99 to 54 minutes (P < 0.001) and 181 to 135 minutes (P = 0.042). Ventilator duration and rate of PTDs significantly decreased from 6 to 4 days (P = 0.001) and 22.2% to 8.4% (P = 0.008). CONCLUSION: Implementation of the PIPS program resulted in improvements in outcomes at a regional trauma center that has just been opened in Korea. Further establishment of the PIPS program is required for optimal care of trauma patients.

Effect of Coenzyme Q10 on Insulin Resistance in Korean Patients with Prediabetes: A Pilot Single-Center, Randomized, Double-Blind, Placebo-Controlled Study.

INTRODUCTION: This study aimed to examine whether administration of coenzyme Q10, an antioxidant, improves insulin resistance in patients with prediabetes. The study design was a pilot single-center, randomized, double-blind, placebo-controlled trial. METHODS: This pilot single-center, randomized, double-blind, placebo-controlled trial included a total of 80 adults (aged ≥20 years) with impaired glucose tolerance. After the initial screening visit, subjects were assigned to either the experimental (n = 40) or placebo (n = 40) group via simple randomization. Insulin resistance was represented as the insulin resistance index estimated by homeostasis model assessment (HOMA-IR). RESULTS: After the 8-week treatment period, the coenzyme group exhibited a significant decrease in the HOMA-IR (P < .001). The free oxygen radical and coenzyme Q10 concentrations were found to correlate significantly (P < .001). However, no significant changes in fasting blood glucose, insulin, and glycated hemoglobin levels were observed in either group. Additionally, no adverse events occurred in either group. CONCLUSION: Patients with prediabetes who were administered coenzyme Q10 showed a significant reduction in HOMA-IR values. Therefore, administration of coenzyme Q10 in patients with impaired glucose tolerance may slow the progression from prediabetes to overt diabetes.

Assessment of Normal Eyeball Protrusion Using Computed Tomographic Imaging and Three-Dimensional Reconstruction in Korean Adults.

PURPOSE: The aim of the present study was to assess normal eyeball protrusion from the orbital rim using two- and three-dimensional images and demonstrate the better suitability of CT images for assessment of exophthalmos. METHODS: The facial computed tomographic (CT) images of Korean adults were acquired in sagittal and transverse views. The CT images were used in reconstructing three-dimensional volume of faces using computer software. The protrusion distances from orbital rims and the diameters of eyeballs were measured in the two views of the CT image and three-dimensional volume of the face. Relative exophthalmometry was calculated by the difference in protrusion distance between the right and left sides. RESULTS: The eyeball protrusion was 4.9 and 12.5 mm in sagittal and transverse views, respectively. The protrusion distances were 2.9 mm in the three-dimensional volume of face. There were no significant differences between right and left sides in the degree of protrusion, and the difference was within 2 mm in more than 90% of the subjects. CONCLUSIONS: The results of the present study will provide reliable criteria for precise diagnosis and postoperative monitoring using CT imaging of diseases such as thyroid-associated ophthalmopathy and orbital tumors.

Anatomical study of the nerve regeneration after selective neurectomy in the rabbit: clinical application for esthetic calf reduction.

The purposes of this study were therefore to characterize the degeneration and regeneration of nerves to the calf muscles after selective neurectomy, both macroscopically and microscopically, and to determine the incidence of such regeneration in a rabbit model. Seventy four New Zealand white rabbits were used. Selective neurectomy to the triceps surae muscles was performed, and the muscles were subsequently harvested and weighed 1-4 months postneurectomy. The gastrocnemius muscles were stained with Sihler's solution to enable the macroscopic observation of any nerve regeneration that may have occurred subsequent to neurectomy. The change in triceps surae muscle weight was measured along the time course of the experiment. After neurectomy, nerve degeneration was followed by regeneration in all cases. The weight of the triceps surae muscle decreased dramatically between completion of the neurectomy and 1 month postneurectomy, but increased thereafter. The nerve branches were weakly stained with Sihler's solution until 2 months postneurectomy, and then strongly stained after 3 months. The number of myelinated axons was decreased at 2 month after neurectomy compared to nonneurectomized controls, but then gradually increased thereafter. Although there are currently no reports on the incidence of recovery after calf reduction, it may be a very common occurrence in the clinical field based on our findings. The findings of this study provide fundamental anatomical and surgical information to aid planning and practice in calf-reduction surgery.

Topographic relationships between the transverse facial artery, branches of the facial nerve, and the parotid duct in the lateral midface in a Korean population.

BACKGROUND: The aims of the present study were to clarify the topographic relationships between various structures in the lateral midface and to provide important anatomical information pertinent to face lifting or treatment of damage to the midface structure. METHODS: Thirty-two fixed cadavers were dissected (23 males and 9 females; mean age, 66.8 years) and 55 sides of midface were used. The transverse facial artery (TFA), zygomatic branch (Zb) and buccal branch (Bb) of the facial nerve, and the parotid duct (PD) were identified. The structures of the lateral midface were measured relative to the zygion and tragion. The vertical average distances from the zygion to each structure increased in the following order: ZB of the facial nerve, TFA, first Bb of the facial nerve, and PD. The horizontal average distance from the tragion to the point of emergence from anterior border of the parotid gland was also measured. RESULTS: The TFA was the closest and the third Bb of the facial nerve was the farthest away. The angles between the horizontal line and ZB of the facial nerve, TFA, PD, and first Bb of the facial nerve were +10.4, -2.3, -18.5, and -27.1 degrees, respectively. CONCLUSIONS: These results may be used to establish the precise locations and the courses of the important midface structures, and represent valuable data that may help to prevent complications during surgery for face lifting and reconstruction of the facial nerve and PD.

Anatomical characteristics of the nasal cartilages for successful rhinoplasty in Koreans.

BACKGROUNDS: The aims of the present study were to determine the exact level of separation of the upper lateral cartilage from the septal cartilage, and to classify the patterns of connection between the upper lateral cartilage and the lower lateral cartilage. METHODS: We dissected and photographed 60 sides of noses; 18 specimens were sectioned and stained with Masson's trichrome. RESULTS: The mean length of the connection between the upper lateral cartilage and septal cartilage was 16.1 mm. The mean level for separation of the upper lateral cartilage was 7.5 mm from the nasal bone. The pattern of connection between the upper lateral cartilage and lower lateral cartilage could be classified into five types: disconnection, end-to-end, overlap, scroll, and reverse scroll. CONCLUSIONS: The results of the present study will be helpful for surgical procedures such as nasal hump reduction and nasal cartilage work and also provide information for the anthropometric study of the nose.

Quantitative analysis of the cochlea using three-dimensional reconstruction based on microcomputed tomographic images.

The aim of this study was to provide data on various dimensions of the normal cochlea using three-dimensional reconstruction based on high-resolution micro-CT images. The petrous parts of 39 temporal bones were scanned by micro-computed tomography (CT) with a slice thickness of 35 µm. The micro-CT images were used in reconstructing three-dimensional volumes of the bony labyrinth using computer software. The volumes were used to measure 12 dimensions of the cochlea, and statistical analysis was carried out. The dimensions of cochleae varied widely between different specimens. The mean height and length of the cochlea were 3.8 and 9.7 mm, respectively. The angle between the basal and middle turns was slightly larger in males than in females, while none of the other 11 dimensions differed significantly between males and females. The cochlear accessory canals were observed in about half of the cases (51.3%). Correlation analysis among measured items revealed positive correlations among several of the measured dimensions. The present study could investigate the detailed anatomy of the normal cochlea using high-resolution imaging technologies. The results of the present study could be helpful for the precise diagnosis of congenital cochlear malformations and for producing optimized cochlear implants.

Centralization or decentralization of facial structures in Korean young adults.

It is well known that facial beauty is dictated by facial type, and harmony between the eyes, nose, and mouth. Furthermore, facial impression is judged according to the overall facial contour and the relationship between the facial structures. The aims of the present study were to determine the optimal criteria for the assessment of gathering or separation of the facial structures and to define standardized ratios for centralization or decentralization of the facial structures.Four different lengths were measured, and 2 indexes were calculated from standardized photographs of 551 volunteers. Centralization and decentralization were assessed using the width index (interpupillary distance / facial width) and height index (eyes-mouth distance / facial height). The mean ranges of the width index and height index were 42.0 to 45.0 and 36.0 to 39.0, respectively. The width index did not differ with sex, but males had more decentralized faces, and females had more centralized faces, vertically. The incidence rate of decentralized faces among the men was 30.3%, and that of centralized faces among the women was 25.2%.The mean ranges in width and height indexes have been determined in a Korean population. Faces with width and height index scores under and over the median ranges are determined to be "centralized" and "decentralized," respectively.

A morphometric study of the semicircular canals using micro-CT images in three-dimensional reconstruction.

It is generally accepted that the three semicircular canals are set at right angles to each other and the lateral semicircular canal is smaller than the anterior and posterior semicircular canals. Precise knowledge of the size and spatial relationships of the semicircular canals is vital, and so the 40 petrous parts of the temporal bones were scanned by micro-CT at a slice thickness of 35 µm. The micro-CT images were used in reconstructing three-dimensional models of the bony labyrinth using computer software. Various dimensions of the semicircular canals were measured using the software, and statistical analysis was performed. The anterior semicircular canal was slightly wider than the posterior semicircular canal, and their heights were similar. The radius of curvature of the lateral semicircular canal was 20% smaller than those of the anterior and posterior semicircular canals. The angles between the three canals were not exactly 90 degrees: they were 92.1, 84.4, and 86.2 degrees between the anterior and posterior, anterior and lateral, and posterior and lateral semicircular canals, respectively. We obtained high-resolution images of the semicircular canals using three-dimensional reconstruction software, and these were used to precisely measure the angles between the semicircular canals and the area of the distorted circle formed by each semicircular canal.

Microanatomy of the infraorbital canal and its connecting canals in the maxilla using 3-D reconstruction of microcomputed tomographic images.

The current study investigated the anatomy of the infraorbital canal (IOC) and its related small canals in the maxilla. Twenty-eight hemimaxillae from human cadavers were studied. The samples were scanned using microcomputed tomography, and then images were three-dimensionally reconstructed using computer software. The branch point of the canal into the anterior superior alveolar nerve from the IOC occurred at about one third along the length of the IOC in the anterior direction. Just over half of the cases had 1 canal. The branch arose either laterally (21/28) or inferiorly (7/28) from the IOC. There was a canal located at the inferior lateral border of the piriform aperture in all cases. The distribution of the canals in the maxilla is represented indirectly by the course and distribution of the nerve and blood vessels therein. This distribution could explain various phenomena encountered in the clinical field.

A mechanism of rat vibrissal movement based on actual morphology of the intrinsic muscle using three-dimensional reconstruction.

The vibrissal capsular muscle (VCM) of the rat is known to differ from the arrector pili muscle. The purpose of the present study was to characterize the rat VCM morphologically using three-dimensional reconstruction. The rat snout skin was fixed, processed with routine histological methods, sectioned serially at a thickness of 10 µm, and then stained with Masson's trichrome. The sectioned images were reconstructed three-dimensionally using 'Reconstruct' software. The findings confirmed that the VCM is a skeletal muscle attached to the vibrissal follicle such that the latter is rooted within the former. The VCM encircles the follicle almost entirely, from base to apex, and hooks around the follicle caudally. Each one of these capsular muscles is connected to two adjacent follicles in the same row. They overlap each other in the lower part, as the rostral follicular muscle that surrounds the caudal follicle. The present findings suggest that the vibrissae are able to move more freely (under voluntary control) than other general arrector pili muscles, in line with their sensory function.

The morphology and origin of the skeletal muscle bundles associated with the human mustache.

The arrector pili muscle is a smooth muscle bundle that attaches to the bulge region of the hair follicle and extends to its superior attachment in the upper dermis or epidermis. However, the morphology and origin of the muscle associated with the human mustache is different, having a general smooth arrector pili muscle. The purpose of the present study was to identify the morphology of the muscle associated with the human mustache using three-dimensional reconstruction. The skin of the superior part of the upper lip region from human cadavers were fixed, processed using routine histological methods, serially sectioned at a thickness of 10 µm, and then stained with Masson's trichrome. The serial sections were reconstructed three-dimensionally using 'Reconstruct' software. The present study confirmed skeletal muscle fibers in this area, but they did not attach to the follicle of the human mustache. Although the follicle of the mustache was surrounded with some muscle fibers, they just ran obliquely to the skin surface from the deeper orbicularis oris muscle regardless of the follicle. There was no muscle associated with the human mustache. The voluntary or involuntary mobility of the human mustache has been lost evolutionally forever.

Topographic anatomy of the masseter muscle focusing on the tendinous digitation.

The masseter muscle has superficial tendons that interdigitate like a saw (tendinous digitations), but a detailed description of these tendons is lacking in anatomic textbooks and atlases. The aim of the present study was to elucidate the topographic anatomy of the masseter muscle, focusing on its tendinous digitation. Sixty-five adult faces (113 sides) were dissected. Five parameters, including the lengths, widths, and thickness of the muscle, were measured. The number and morphology of tendinous digitations were also investigated. The length and width of the masseter muscle were longer and wider in male specimens than in female specimens. The number of masseter muscle tendinous digitations was predominantly two in males and three in females. The length of the tendinous digitations tended to be about three-quarters of that of the muscle. The second tendinous digitation was the longest in male specimens, while the first tendinous digitation was the longest in females. Based on our results, the external morphology of the masseter muscle does not match that described in anatomical atlases and textbooks. These findings may be helpful as a basic reference and in the treatment of masseter muscle hypertrophy and masseter tenomyositis.