In Sik Shin

Purpose: Fournier gangrene (FG) is a life-threatening condition characterized by rapid tissue necrosis in the perineal and genital regions. Early identification of risk factors is essential for improving prognosis and reducing mortality rates. This study aimed to identify predictive factors associated with mortality in patients with FG.Methods: A multi-institutional retrospective study was conducted across four tertiary care centers in Korea, including patients diagnosed with FG between January 2014 and December 2023. Data on demographic characteristics, laboratory findings, and clinical outcomes were collected. Independent risk factors for mortality were identified using multivariate logistic regression analysis, and optimal cutoff values for these predictors were determined.Results: A total of 133 patients were included. The findings showed that age, initial lactate level, hemoglobin level, platelet count, and albumin level were significant predictors of mortality. Age was associated with an odds ratio of 1.105 (95% confidence interval [CI], 1.038–1.177; P=0.0018), while initial lactate level exhibited an odds ratio of 1.820 (95% CI, 1.335–2.480; P=0.0002). The optimal cutoff values identified were 64.5 years for age, 3.15 mmol/L for lactate, 8.65 g/dL for hemoglobin, 208×109/L for platelet count, and 3.05 g/dL for albumin, with varying sensitivity and specificity.Conclusion: The study concluded that age, and initial levels of lactate, hemoglobin, albumin, and platelet count are independently predictive of mortality in patients with FG. These findings underscore the importance of aggressive management for patients presenting with abnormal serum values at admission to improve clinical outcomes. Further research is warranted to validate these results and to refine management strategies for FG.

Background: Multi-organ distress syndrome (MODS) causes morbidity in patients with trauma. This study evaluates the effectiveness of interleukin-33 (IL-33), which reflects tissue damage and the inflammatory response, as a MODS indicator in patients with trauma.Methods: Patients with trauma admitted to our trauma center between July 2022 and July 2023 were included. IL-33 levels were measured in blood samples for 4 days. Correlations with clinical and laboratory indicators, including initial IL-33 levels, were analyzed to identify independent predictors of MODS.Results: Among the 87 patients enrolled, 20 developed MODS. Initial IL-33 levels were elevated in the MODS group, compared with the non-MODS group. In the non-MODS group, IL-33 levels increased on day 1 and then declined, whereas in the MODS group, IL-33 levels were highest at admission (day 0) and decreased continuously through day 3. In patients with detectable initial IL-33 levels, the measured levels correlated with higher Abbreviated Injury Scale 5 scores and the Injury Severity Score (ISS). A logistic regression analysis revealed the ISS and delta neutrophil index as factors contributing to MODS progression.Conclusions: The findings suggest that initial IL-33 levels are elevated in the MODS group, compared with non-MODS group, and exhibit a rapidly declining trend, showing an initial association with MODS that was not maintained in a multivariate analysis. These findings suggest that IL-33 might have relevance in assessing trauma severity; however, further validation is required before it can be considered a biomarker for MODS.

Background and Objectives: Acute kidney injury (AKI) is a common complication in patients with trauma and is associated with increased morbidity and mortality rates. Early identification of patients at risk of AKI may enable timely intervention and improved outcomes. Biomarkers such as urinary mitochondrial DNA copy number (mtDNAcn) may play a role in predicting AKI. However, its role as a predictor of AKI has rarely been studied in patients with trauma. Therefore, the aim of this study was to evaluate the utility of mtDNA for early detection of AKI in this patient population. Materials and Methods: This single-center prospective observational study included patients with trauma admitted to a regional trauma center between July 2022 and July 2023. Serum and urine samples were collected at baseline and at 24, 48, and 72 h to measure mtDNAcn using real-time polymerase chain reaction test. Clinical variables, including hemoglobin (Hb) levels, were also recorded. Results: Among 65 enrolled patients, 25 (38.5%) developed AKI. Patients with AKI showed significantly lower Hb levels and higher urinary mtDNAcn at admission. Multivariate logistic regression analysis identified low Hb and elevated urinary mtDNAcn as independent predictors of AKI. The optimal cutoff value was 10.95 g/dL for Hb and 738.0 copies/μL for urinary mtDNAcn. However, no significant temporal differences in serum mtDNAcn were observed between the AKI and no-AKI groups. Conclusions: Both Hb and urinary mtDNAcn may serve as independent biomarkers for early identification of AKI in patients with trauma. Future studies are warranted to determine optimal targets and validate these findings in larger multicenter cohorts.

Ultraviolet radiation (UVR) is essential for vitamin D synthesis and influences various biological processes. This study examined the effects of controlled UV exposure on vitamin D synthesis and skin inflammation in healthy adults. In a randomized clinical trial, 24 volunteers received four 5-min standardized UV exposures (UVB: 1.34 mW/cm²; UVA: 27.7 mW/cm²) on representative skin areas. Blood samples were collected before exposure and after every two sessions to assess serum vitamin D, inflammatory markers, vitamin D-related markers, and oxidative stress indicators. Serum vitamin D concentration significantly increased after four exposures (p < 0.001), while calcium, phosphorus, and parathyroid hormone (PTH) significantly decreased (p < 0.05). Reactive oxygen species (ROS) significantly increased (p < 0.001), but no significant changes were observed in nitric oxide (NO) or myeloperoxidase (MPO) levels. Similarly, inflammatory markers such as C-reactive protein (CRP), MPO, and antioxidant enzymes (glutathione peroxidase [GPx] and catalase [CAT], showed no significant alterations. Among the inflammatory cytokines assessed, interleukin (IL)-1β levels showed a slight increase without reaching significance, and the levels of other cytokines such as IL-6, IL-10, tumor necrosis factor-alpha (TNF-α), and interferon-gamma (IFN-γ) showed no marked alterations. In addition, post-exposure skin assessment revealed no adverse effects. Our findings demonstrate that UVR exposure can enhance vitamin D synthesis in healthy adults without significant inflammatory responses or adverse effects, providing a basis for optimizing UV-based interventions to improve vitamin D status through risk management.

Background: The use of biomarkers to predict patient outcomes may be crucial for patients admitted to the intensive care unit (ICU) following surgery because biomarkers guide clinicians in tailoring treatment plans accordingly. Therefore, we aimed to identify potential biomarkers to predict the prognosis of patients with Fournier’s gangrene (FG) admitted to the ICU after surgery.Methods: We enrolled patients with FG admitted to our Hospital between January 2013 and December 2022. We retrospectively analyzed patient characteristics, factors related to management, scores known to be associated with the prognosis of FG, and laboratory data.Results: The study population included 28 survivors and 13 nonsurvivors. The initial serum lactate level taken in the emergency department; white blood cell, neutrophil, and platelet counts; delta neutrophil index and international normalized ratio; albumin, glucose, HCO3, and postoperative lactate levels; and the laboratory risk indicator for necrotizing fasciitis differed between survivors and nonsurvivors. Postoperative lactate and initial albumin levels were independent predictors of mortality in patients with FG. In the receiver operating characteristic curve analysis, the postoperative lactate level was the best indicator of mortality (area under the curve, 0.877; 95% confidence interval, 0.711–1.000). The optimal cutoff postoperative lactate level for predicting mortality was 3.0 mmol/L (sensitivity, 80.0%; specificity, 95.0%).Conclusions: Postoperative lactate and initial albumin levels could be potential predictors of mortality in patients with FG admitted to the ICU after surgery, and the optimal cutoff postoperative lactate and initial albumin levels to predict mortality were 3.0 mmol/L and 3.05 g/dl, respectively. Large-scale multicenter prospective studies are required to confirm our results.

Background and Objectives: Critically ill surgical patients are susceptible to various postoperative complications, including acute kidney injury (AKI) and multiorgan distress syndrome (MODS). These complications intensify patient suffering and significantly increase morbidity and mortality rates. This study aimed to identify the biomarkers for predicting AKI and MODS in critically ill surgical patients. Materials and Methods: We prospectively enrolled critically ill surgical patients admitted to the intensive care unit via the emergency department between July 2022 and July 2023. A total of 83 patients were recruited, and their data were used to analyze MODS. Three patients who showed decreased creatinine clearance at the initial presentation were excluded from the analysis for AKI. Patient characteristics and laboratory parameters including white blood cell (WBC) count, neutrophil count, delta neutrophil index, urine and serum β2-microglobulin, and urine serum mitochondrial DNA copy number (mtDNAcn) were analyzed to determine the reliable biomarker to predict AKI and MODS. Results: The following parameters were independently correlated with MODS: systolic blood pressure (SBP), initial neutrophil count, and platelet count, according to a logistic regression model. The optimal cut-off values for SBP, initial neutrophil count, and platelet count were 113 mmHg (sensitivity 66.7%; specificity 73.9%), 8.65 (X³) (10⁹/L) (sensitivity 72.2%; specificity 64.6%), and 195.0 (X³) (10⁹/L) (sensitivity 66.7%; specificity 81.5%), respectively. According to the logistic regression model, diastolic blood pressure (DBP) and initial urine mtDNAcn were independently correlated with AKI. The optimal cut-off value for DBP and initial urine mtDNAcn were 68.5 mmHg (sensitivity 61.1%; specificity 79.5%) and 1225.6 copies/μL (sensitivity 55.6%; specificity 95.5%), respectively. Conclusions: SBP, initial neutrophil count, and platelet count were independent predictors of MODS in critically ill patients undergoing surgery. DBP and initial urine mtDNAcn levels were independent predictors of AKI in critically ill surgical patients. Large-scale multicenter prospective studies are needed to confirm our results.

The aim of this study was to compare the outcomes of preperitoneal pelvic packing (PPP) and angioembolization (AE) for patients with equivocal vital signs after initial resuscitation. This single-centered retrospective study included information from the database of a regional trauma center from April 2014 to December 2022 for patients with pelvic fractures with a systolic blood pressure of 80–100 mmHg after initial fluid resuscitation. The patients’ characteristics, outcomes, and details of AE after resuscitative endovascular balloon occlusion of the aorta (REBOA) placed in zone III were collected. The follow-up duration was from hospital admission to discharge. A total of 65 patients were enrolled in this study. Their mean age was 59.2 ± 18.1 years, and 40 were males. We divided the enrolled patients into PPP (n = 43) and AE (n = 22) groups. The median time from emergency department (ED) to procedure and the median duration of ED stay were significantly longer in the AE group than in the PPP group (p ≤ 0.001 for both). The median mechanical ventilation (MV) duration was significantly shorter (p = 0.046) in the AE group. The number of patients with complications, overall mortality, and mortality due to hemorrhage did not differ between the two groups. Three patients (13.6%) were successfully treated with AE after REBOA. AE may be beneficial for patients with hemodynamically unstable pelvic fractures who show equivocal vital signs after initial fluid resuscitation in terms of reducing the MV duration and incidence of infectious complications.

Pediatric trauma patients are increasing, and trauma is the leading cause of death in children. Pancreatic injury is known as the fourth most common solid organ injury, but the diagnosis of pancreatic injury is often delayed due to the retroperitoneal location of the pancreas and the low sensitivity and specificity of diagnostic tests. Endoscopic retrograde cholangiopancreatography (ERCP) is an important test for the diagnosis and treatment of various biliary tract and pancreatic diseases. However, cases of performing ERCP in traumatic pancreatic injury in children have been rarely reported. Thus, we aimed to evaluate the usefulness of ERCP in traumatic pancreatic injury in children. Between January 1983 and December 2022, pediatric patients under the age of 18 who were treated for traumatic pancreatic injury at a single institution were recruited and retrospectively analyzed. Patient characteristics and clinical outcomes were assessed. Thirty-one patients were enrolled in this study. Among them, 15 (48.4%) patients underwent ERCP. The time to diet was significantly longer in the ERCP group. There were no statistically significant differences in other characteristics between the ERCP and the non-ERCP group. In nine (60%) patients of the ERCP group, ERCP was used for therapeutic intervention or as a decision-making tool for surgery, and was used to resolve pancreas-related complications. ERCP may be useful for the diagnosis and treatment of traumatic pancreatic injury in children. In addition, ERCP can be safely applied in children, and complications related to ERCP also may not increase. When obscure pancreatic injury is suspected, it is necessary to consider performing ERCP.

Objectives: The delta neutrophil index represents the fraction of circulating immature granulocytes and is a marker of infection and sepsis. Our study aimed to evaluate the usefulness of the delta neutrophil index in predicting mortality in patients with Fournier's gangrene.Methods: We enrolled patients with Fournier's gangrene who were admitted to the Wonju Severance Christian Hospital (Wonju, Korea) between September 2010 and December 2021. We retrospectively analyzed the patients' characteristics, factors related to management, scoring systems such as the Fournier's Gangrene Severity Index, and laboratory data measured at initial presentation.Results: There were 58 (68.2%) survivors and 27 (31.8%) non‐survivors. The initial levels of serum lactate, hemoglobin, delta neutrophil index, albumin, international normalized ratio, creatinine, Fournier's Gangrene Severity Index, Uludag Fournier's Gangrene Severity Index, and prognostic nutritional index differed between survivors and non‐survivors. Age, international normalized ratio, and delta neutrophil index were independent predictors of mortality in Fournier's gangrene. In receiver operating characteristic curve analysis, delta neutrophil index on the day of admission was the best indicator of mortality (area under the curve, 0.804; 95% confidence interval [0.679–0.929]). The optimal cutoff for delta neutrophil index in predicting mortality was 11.25% (sensitivity, 74.1%; specificity, 91.4%). The initial delta neutrophil index was the best indicator of mortality (area under the curve, 0.804; 95% confidence interval 0.679–0.929).Conclusion: The delta neutrophil index can be useful for predicting mortality in patients with Fournier's gangrene. A delta neutrophil index >11.25% at initial presentation is a reliable predictor of Fournier's gangrene.

Ha G, et al. Ann Surg Treat Res. 2021 Jul;101(1):49-57. https://doi.org/10.4174/astr.2021.101.1.49