Hepatobiliary and pancreatic cancers are associated with poor prognosis owing to their high level of tumor invasiveness, recurrence, hematogenous and lymphatic metastasis, resistance to firstline chemotherapy, and lack of effective target therapy [1,2]. Evidence in the literature suggests that hepatobiliary and pancreatic cancers develop through the accumulation of genetic and epigenetic alterations, which is influenced by host immune state, food, and environmental and microbial exposures [1-4]. The human microbiota is the collection of microorganisms exists in the human being, and the relationships with microorganisms and host can be considered to maintain a wide range of the spectrum, from mutualism to pathogen [5]. Abrupt changes in the microbiota of various human body areas associate with diverse localized or systemic human diseases. The human gastrointestinal tract is one of the biggest storing spaces of microbes in the body and contains both commensal and pathogenic microbial species [6]. Research on intestinal microbiota has shown that inflammatory bowel disease is originated from the varied composition of microbial composition and abnormal and overflowing mucosal immune response [7]. Numerous pathogens can promote cancer through well-identified mechanisms [8]. Although most studies are confined to specific bacterial pathogens and viruses, the link between human cancer and bacterial microbiota has recently been studied actively by using next-generation sequencing technology for microbiome profiling [9]. There is an increasing interest in understanding the role of microbiome as a microenvironment for cancer development, particularly in the area of hepatobiliary and pancreatic cancers [10]. The liver, biliary tract, and pancreas are located in very close Review
Patients undergoing hepatobiliary and pancreatic (HBP) surgery often need to be transfused, despite advances in surgical skills and perioperative care. However, many studies have indicated that cancer patients who are transfused have higher rates of perioperative mortality and cancer recurrence, and poorer prognoses [1]. Moreover, viral or bacterial infections, immunologic reactions, and increased postoperative morbidity are other adverse consequences of allogeneic transfusions. Furthermore, since there are not enough blood donors in Korea to supply the demand, new treatment strategies for HBP patients are needed. Patient blood management (PBM) programs, medical care without allogeneic blood transfusion, have traditionally been applied in various clinical situations, e.g., when patients refuse to be transfused for religious reasons, when there is no blood to transfuse, and when safe blood is not available [2]. Although PBM is a relatively new technology in the field of HBP surgery, its general concepts are very similar to those of traditional PBM. The basic concepts of PBM applicable to the perioperative and intraoperative method have recently been described. Erythropoietin, ferritin, vitamin B12, or volume expanders and preoperative autologous blood donation (PAD) are used in perioperative PBM. Intraoperative management includes acute normovolemic hemodilution (ANH), cell salvage (Cell Saver®), and hypotensive anesthesia. Although the disadvantages of transfusion and the advantages of PBM are widely recognized, few studies have evaluated the beneficial effects of PBM in HBP surgery. Although the use of PBM in HBP operations without transfusion (including pancreaticoduodenectomy for periampullary lesions, living donor liver transplantation, and major hepatectomy) has been reported in the past few years, it is inherently challenging to carry out researches on transfusion-related issues because reasons and sequelae of transfusion are multifactorial [3-6]. The goal of this article is to review the current status of PBM programs in HBP surgery. Review
Allogeneic blood transfusion is often restricted due to its adverse effects, a lack of blood supply, and religious or cultural constraints. As a result, patient blood management (PBM) has been gaining attention. PBM is an evidence-based, patient-centered bundle of technologies that manages perioperative anemia and reduces bleeding during surgery. PBM improves the postoperative prognoses. Perioperative anemia is the main concern in PBM; therefore, to diagnose and treat it is important. This review focuses on the perioperative use of oral or intravenous iron and erythropoietin (EPO), in relevant fields such as cardiac surgery, orthopedics, and neurosurgery. IV administration of iron has been controversial due to safety concerns, such as increased risk of infection. However, using IV iron appropriately is beneficial in most surgical settings. Although recombinant human EPO may increase thromboembolic risks, this can be mitigated through various methods including limiting the target Hb level, using it in combination with IV iron, or prophylaxis for deep venous thrombosis. EPO is recommended in patients undergoing cardiac or orthopedic surgery. As PBM becomes globally implemented, the blood management methods, including tranexamic acid, hemostatic agents, and cell salvage have become more variable as well. Among them, administration of iron and EPO would be the most common pharmacologic choices based on current practice. However, controversy still exists. Therefore, further studies on iron and EPO are needed to ensure better and safer patient care.
Atopic dermatitis (AD) is a representative allergic disease that is accompanied with high disease prevalence and considerable socioeconomic burden. While the pathophysiology is largely unknown, the role of microbes in health and diseases has drawn attention. The development of metagenomics that is a recent advance in analyzing microbiome has enabled us to research how microbiome impacts the development and aggravation of AD. Skin microbiome and intestinal microbiome are assumed to affect the AD. Research has shown a difference in skin and intestinal microbial composition between AD patients and normal controls. Based on the findings of microbial impacts on the AD, efforts to use probiotics for the treatment or prevention of AD have been made. However, further research is needed until the firm conclusion is reached.
Ever since mankind has had blood, efforts to stop bleeding have never ceased and so numerous methods for hemostasis have been developed. In recent decades, minimally invasive surgical techniques have led patients to less-bleeding surgery but, hemostatic agents, devices and techniques still play an important role in medical side. A number of hemostatic agents and devices have been developed and they can be classified by their mechanism of action. That classification of the coagulants includes mechanisms with physical, caustic, bio-physical, biologic actions. Hemostatic devices are divided into categories such as dressings, glue, clips, electrocoagulations and so on. Based on the concept of minimally invasive surgical procedures, variously developed surgical techniques are divided by the number of ports used and auxiliary instruments. However, there are advantages and disadvantages to each of the hemostatic agents and minimally invasive methods, and the belief in the classical method also prevents the application of new hemostatic methods. The knowledge and understanding of the benefits and costs of these newly developed hemostatic methods will make it easier for medical personnel to manage patient's blood.
Carbapenem-resistant Enterobacteriaceae (CRE) has emerged as a major problem of public health. By various resistance mechanisms including carbapenemase, there are few antibiotics to treat CRE infection. Therefore, an infection caused by CRE is associated with a higher mortality rate than those caused by other causative agents. By horizontal transmission of the carbapenemase-producing gene, resistance to carbapenem spreads to other organisms and multi-drug resistance could be induced. The incidence of CRE has increased, and many countries have been troubled with CRE outbreaks. The best way to manage and treat CRE is infection control and prevention against CRE. The aim of this paper is to describe the current status of CRE and clinical implication of CRE infection in Korea. The mechanism which induces resistance to carbapenem as well as carbapenemase-producing gene (a gene that could be transferred to other organisms and then induces resistance to carbapenem) make it difficult to treat CRE infection.
Increasingly, autologous blood transfusion has been arousing concern owing to awareness of adverse effects of allogenic blood transfusion, blood shortage and patients, having religious or personal issues. With the development of medicine, Cell Salvage and Acute normovolemic hemodilution (ANH) has been proposed as an alternative to allogenic blood transfusion. This review looked at the use of ANH and cell salvage and evaluated the benefits and usefulness based on the strengths and indications. Although not consistent with all cases of ANH, there were benefits in the amount of hemorrhage and transfusion, and no supplementary plasma or platelet transfusion was needed after surgery when employing ANH. But, it showed a cutoff value only for massive bleeding surgery (at least 500 mL). In the case of cell salvage, the amount of blood transfusion was reduced in most cases and platelet or plasma transfusion was not required in most cases. When the Leukoreduction filter (LDF) was utilized, it showed the effect of removing bacterial infection or tumor cells. Nonetheless, the effectiveness and benefits for patients in certain condition of cell salvage and ANH is ambiguous with discrepancies among studies or patients. Therefore, the aim of this study is to provide clinical knowledge relative to the procedure, measure the efficacy and usefulness of peri-operative blood management mentioned above and discuss the forthcoming prospects and challenges.
Preoperative anemia should be diagnosed and treated before surgery, because anemia is associated with increased postoperative mortality and morbidity. Even if iron deficiency is not detected, the possibility of functional iron deficiency should be considered. During surgery, patients should be managed to avoid hypothermia, acidosis, and hypocalcemia, while maintaining adequate blood pressure and preventing dilutional coagulopathy. It is currently recommended to start transfusion when hemoglobin is under 7–8 g/dL in patients without cardiac problems, using restrictive strategy rather than liberal, due to dangers of complications from transfusion. For those who refuse transfusion, or when transfusion is difficult due to multiple antibodies, or when attempting to reduce allogeneic transfusion, preoperative autologous blood donation (PAD), intraoperative acute normovolemic hemodilution (ANH), intraoperative blood salvage, or postoperative blood salvage can be used. For patients with trauma or massive bleeding, damage control resuscitation of permissive hypotension, restriction of crystalloid infusion, transfusion of blood product in a ratio similar to whole blood (1:1:1 of FFP, platelets, PRBC) must be actively carried out.
With the introduction of synthetic antibiotics, many lives including humans and animals have been saved against bacterial infection. An increasing level of antibiotics use, however, raises serious problems of multi-drug resistance and transferring of resistance genes across different environments and countries. Advances in high-throughput sequencing technology and efficient bioinformatics methods allow us to perform a large-scale screening and analysis of resistomes in the human and environmental microbiomes. Recent studies on human microbiomes have revealed a diverse distribution of resistance genes and their transferring activities in the communities. This review discusses recent progresses in metagenomic approaches to identify resistance genes in the human microbiome, including genomic sequence search and functional metagenomics methods. Using Rifampicin ADP-ribosyltransferase as an example, an integrative approach that analyzes the sequences and three-dimensional structures of the proteins derived from resistance genes is also introduced.
C. striatum is part of the normal skin and mucous membrane flora in humans and is widely disseminated in the environment. Traditionally, these strains have been considered contaminants. However, C. striatum has been linked to respiratory infection, bacteremia, and endocarditis; and it is strongly related to nosocomial outbreaks. At present, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF) is the most accurate routine identification method. Many C. striatum strains are multi-drug resistant, being susceptible only to vancomycin and linezolid. We should survey the antimicrobial susceptibility results regularly to monitor its resistance and consider it a possible pathogen.
Obstetricians and gynecologists frequently deal with hemorrhage so they should be familiar with management of patient blood management (PBM). We will review to summarize the alternative measures and interventions used in bloodless surgery in the field of obstetrics and gynecology. In the obstetric field, PBM has been developed as an evolving evidence-based approach with a number of key goals: (i) to identify, evaluate, and manage anemia; (ii) reduce iatrogenic blood loss; (iii) optimize hemostasis; and (iv) establish decision thresholds for transfusion. Transfusion, mechanical method including balloon tamponade and uterine artery embolization, and intraoperative cell salvage were introduced for PBM. In the gynecologic field, PBM is not significantly different from that in the obstetric field. Preoperative managements include iron supplement, erythropoietin administration, autologous blood donation, and uterine artery embolization. Meticulous hemostasis, short operative time, hypotensive anesthetic techniques, hemodilution during operation, blood salvage and pharmacological agents were introduced to intraoperative management. Postoperative measures include meticulous postoperative monitoring of the patient, early detection of blood loss, reduction of blood sampling, appropriate use of hemopoiesis, normalization of cardio-pulmonary function and minimization of oxygen consumption. In conclusion, each obstetrician and gynecologist should be aware about the appropriate method for blood conservation and use in practice. A comprehensive approach to coordinating all members of the bloodless agent and surgical team is essential.
Blood transfusion is an essential medical procedure that can save a patient's life. But, in the near future, it is anticipated that blood transfusion products will be lacking in Korea. Patient Blood Management (PBM) is an evidence-based, mult-idisciplinary approach to optimizing the care of patients who might need transfusion. This goal is fulfilled by clinically managing or preserving the patient's own blood instead of imprudently resorting to allogeneic blood. It can be said that Korea just begun the journey toward the PBM implementation. However, strong support from the government and endeavors from professional societies will make rapid and substantial success in implementation of PBM in Korea.
Pathology has a long history of artificial intelligence (AI) as much as any other field of medicine, and has used AI algorithms continuously. However, in Korea, pathology AI is unfamiliar even to the pathologists. In this article, I will summarize the terms and definitions, the basic elements of pathology AI, and the future direction. Digital pathology is a system or environment that digitizes glass slides into binary files, observes them through a monitor or any digital devices, interprets it, analyzes it, and maintains it. Computational pathology is a comprehensive concept of diagnosis support or research system that deals with image, text and omics data. Virtual microscopy is a method or technology that allows pathologists to view and share glass slides images from whole slide scanners. Image analysis is a technique or method that processes various digital images and quantifies features. The basic elements of pathology AI are as follows: environmental factors called digital pathology and technical elements such as AI, machine learning, and deep learning. Digital pathology workflow consists of three elements; acquisition or collection of data, data processing and data storage. The basic process of image analysis consists of preprocessing of image, identification of region of interest, and feature extraction. There is enormous potential for improvement of patient care through digital pathology and/or AI, and a harmonized discussion about activation of Korean digital pathology among government, academia and industry will be mandatory for future medicine and healthcare in Korea.
Gestational diabetes mellitus (GDM) is a frequent medical problem during pregnancy. It is associated with an increased risk of complications for GDM mother and the offspring. There is increasing evidence that GDM may increase the risk of future type 2 diabetes and cardiovascular disease in mothers, and may also increase the risk of obesity and diabetes in children. Therefore GDM affects health for a lifetime. The International Association of Diabetes and Pregnancy Study Groups (IADPSG) proposed a new screening approach for pre-diagnosed diabetes at the first prenatal visit and diagnostic criteria for GDM in accordance with perinatal outcomes. Nonetheless, controversies still exist about these issues. There is a positive linear association between increasing maternal glucose at oral glucose tolerance testing and risk of important perinatal outcomes. In managing the GDM patients, an individualized medical approach is essential. If maternal glucose levels have increased, insulin can be used to achieve glycemic targets. Postpartum screening for diagnosing of diabetes is essential for women with previous GDM.
Central serous chorioretinopathy (CSC) is an eye disease that causes serous retinal detachment in the posterior pole of the retina. The pathogenesis of CSC is not fully understood and various systemic factors have been reported to be associated with CSC. Recently, with the advent of advanced imaging techniques, novel imaging findings for CSC have been reported and the understanding of CSC has increased further. Moreover, in addition to conventional treatment for CSC, new treatment modalities such as photodynamic therapy, anti-vascular endothelial growth factor or subthreshold laser therapy, have emerged. In this article, an overall review and update of CSC, particularly focusing on new imaging findings and treatments, will be discussed.
Recent rapid advances in artificial intelligence (AI), especially in deep learning methods, have produced meaningful results in many areas. However, to achieve meaningful results for healthcare through AI, it is important to understand the meaning and characteristics of data in that area. For medical AI, a simple approach that accumulates massive amounts of data based on existing big data concepts cannot provide meaningful results in the healthcare field. We need well-curated data as opposed to a simple aggregation of data. The purpose of this study is to present the types and characteristics of healthcare data and future directions for the successful combination of AI and medical care.
