Association between the extent of diffusion restriction on brain diffusion-weighted imaging and neurological outcomes after an out-of-hospital cardiac arrest

BACKGROUND

This study evaluated the association between the extent of diffusion restriction on brain diffusion-weighted imaging (DWI) and neurological outcomes in patients who underwent targeted temperature management (TTM) after an out-of-hospital cardiac arrest (OHCA).

METHODS

Patients who underwent brain magnetic resonance imaging within 10 days of OHCA between 2012 and 2021 were analysed. The extent of diffusion restriction was described according to the modified DWI Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS). The 35 predefined brain regions were assigned a score if diffuse signal changes were concordantly present in DWI scans and apparent diffusion coefficient maps. The primary outcome was an unfavourable neurological outcome at 6 months. The sensitivity, specificity, and receiver operating characteristic (ROC) curves for the measured parameters were analysed. Cut-off values were determined to predict the primary outcome. The predictive cut-off DWI-ASPECTS was internally validated using five-fold cross-validation.

RESULTS

Of the 301 patients, 108 (35.9%) had 6-month favourable neurological outcomes. Patients with unfavourable outcomes had higher whole-brain DWI-ASPECTS (median, 31 [26-33] vs. 0 [0-1], P < 0.001) than those with favourable outcomes. The area under the ROC curve (AUROC) of whole-brain DWI-ASPECTS was 0.957 (95% confidence interval [CI] 0.928-0.977). A cut-off value of ≥8 for unfavourable neurological outcomes had specificity and sensitivity of 100% (95% CI 96.6-100) and 89.6% (95% CI 84.4-93.6), respectively. The mean AUROC was 0.956.

CONCLUSION

More extensive diffusion restriction on DWI-ASPECTS in patients with OHCA who underwent TTM was associated with 6-month unfavourable neurological outcomes. Running title: Diffusion restriction and neurological outcomes after cardiac arrest.

The Effects of Extracorporeal Cardiopulmonary Resuscitation According to Covariate Adjustment

This study compared the effects of extracorporeal cardiopulmonary resuscitation (ECPR) using propensity-score matching (PSM) analyses. A nationwide registry of out-of-hospital cardiac arrest (OHCA) patients in Korea between 2013 and 2016 was used. Patients with OHCA aged ≥15 years with cardiac etiology and resuscitation time >30 minutes were enrolled. Resuscitation-related variables before the initiation of ECPR were included. Two PSM analyses were performed separately, with and without post-ECPR variables. The primary outcome (PO) was a favorable neurologic outcome at hospital discharge. The rate of PO was 8.1% (13/161) in the ECPR group and 1.5% (247/16,489) in the conventional CPR (CCPR) group. In the matched cohort with post-ECPR variables, there was no significant difference in the rate of PO between the ECPR and CCPR groups (7.9% vs. 7.9%; p = 0.982). In the matched cohort without post-ECPR variables, the rate of PO was higher in the ECPR group than that in the CCPR group (8.3% vs. 3.6%; p = 0.012). PSM analysis without post-ECPR variables compared outcomes of all patients experiencing OHCA and treated with ECPR versus CCPR, which showed better neurologic outcomes for ECPR. PSM analysis with post-ECPR variables compared outcomes between ECPR survivors and CCPR survivors, which exhibited similar neurologic outcomes.

Cerebral venous thrombosis after ChAdOx1 nCoV-19 vaccination: a systematic review

OBJECTIVE

To perform a systematic review of case reports or case series regarding thrombosis with thrombocytopenia syndrome (TTS) and cerebral venous thrombosis (CVT) related to ChAdOx1 nCoV-19 vaccination to address the clinical features, laboratory findings, treatment modalities, and prognosis related with CVT.

SUBJECTS AND METHODS

We included 64 TTS patients from 19 articles, 6 case series and 13 case reports, in which thrombosis occurred after the first dose of ChAdOx1 nCoV-19 vaccination published up to 30 June 2021 in Embase, ePubs, Medline/PubMed, Scopus, and Web of Science databases.

RESULTS

Of the 64 TTS patients, 38 (59.3%) had CVT. Patients with CVT were younger (median 36.5 vs. 52.5 years, p<0.001), had lower fibrinogen levels (130 vs. 245 mg/dL, p=0.008), had more frequent history of intracerebral hemorrhage (ICH), and had higher mortality rate (48.6% vs. 19.2%, p=0.020) than that of patients without CVT. In multivariable analysis, the possibility of presence of CVT was higher in younger age groups [odd ratio (OR): 0.91, 95% confidence interval (CI): (0.86-0.97, p<0.001)] and those with accompanying intracerebral hemorrhage (ICH) (OR: 13.60, 95% CI (1.28-144.12, p=0.045).

CONCLUSIONS

Our study demonstrated that CVT related to ChAdOx1 nCoV-19 vaccination was associated with younger age, low levels of fibrinogen, presence of ICH and more frequent mortality compared to those of non-CVT. If TTS occurs after ChAdOx1 nCoV-19 vaccination, the presence of CVT in patients with young age or ICH should be considered.

Analysis of Disaster Medical Response: The Sejong Hospital Fire

This paper provides a field report on a fire that broke out on January 26, 2018 at Sejong Hospital in Miryang, South Korea, engendering the establishment of a committee to investigate the hospital fire response. This field report analyzes the disaster medical response. The official records of the disaster response from each institution were examined. On-site surveys were conducted through interviews with government officials and other health care workers regarding communication during the disaster response without using a separate questionnaire. All medical records were abstracted from hospital charts. There were 192 casualties: 47 victims died, seven were seriously injured, and 121 suffered minor injuries. Emergency Medical Services (EMS) arrived three minutes after the fire started, while news of the fire reached the National Emergency Medicine Operation Center based in Seoul in 12 minutes. The first disaster medical assistance team (DMAT) was dispatched 63 minutes after the National Emergency Medicine Operation Center was notified. The disaster response was generally conducted in accordance with disaster medical support manuals; however, these response manuals need to be improved. Close cooperation among various institutions, including nearby community public health centers, hospitals, fire departments, and DMATs, is necessary. The response manuals should be revised for back-up institutions, as the relevant information is currently incomplete.

Relationship between cooling time and neurological outcomes in targeted temperature management

OBJECTIVES

The relationship between cooling time (CT) variables and neurological outcomes is controversial. We evaluated the relationship between CT and neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM).

METHODS

We conducted a multicenter, prospective, and registry-based study of OHCA survivors treated with TTM. CT was defined as the time from restoration of spontaneous circulation to achievement of the target temperature. The primary outcome was a favorable neurological outcome at 6 months. Multilevel logistic regression analysis was performed to test the relationship between CT and the primary outcome.

RESULTS

Overall, the favorable neurological outcome rates at 6 months were 29.8% in 937 patients. When CT was stratified into categories of 0-3, 3.1-6, 6.1-9, 9.1-12, and >12 h, according to 3-h intervals, the primary outcome rates were 8.2%, 22.7%, 35.5%, 44.7%, and 44.5%, respectively (p < 0.001). Significant differences were not found in multilevel logistic regression analysis; the adjusted odds ratios (95% confidence interval) of each category for the primary outcome compared to the 0-3-h group were 0.81 (0.32 to 2.04), 0.77 (0.30 to 2.01), 1.26 (0.43 to 3.68), and 1.06 (0.37 to 3.06).

CONCLUSIONS

We did not find a relationship between CT and neurological outcomes at 6 months.

Association between Cardiac Arrest Time and Favorable Neurological Outcomes in Witnessed Out-of-Hospital Cardiac Arrest Patients Treated with Targeted Temperature Management

BACKGROUND

Patients who achieve a return of spontaneous circulation (ROSC) with prolonged cardiac arrest have been recognized to have a poor prognosis. This might lead to reluctance in the provision of post-resuscitation care. Hence, we evaluated the impact of cardiac arrest time on neurologic outcomes in out-of-hospital cardiac arrest (OHCA) patients.

METHODS

This cross-sectional study used a hospital-based nationwide registry of OHCAs in Korea between 2012 and 2016. All witnessed OHCA patients aged ≥ 15 years and treated with targeted temperature management were included. We collected the time from collapse to sustained ROSC, which was defined as the downtime. The primary outcome was a favorable neurological outcome at hospital discharge. A multiple logistic regression analysis was conducted to determine independent factors for primary outcome in patients with downtime > 30 minutes.

RESULTS

Overall, neurologically favorable outcome rates were 30.5% in 1,963 patients. When the downtime was stratified into categories of 0-10, 11-20, 21-30, 31-40, 41-50, 51-60, and > 60 minutes according to 10-minute intervals, neurologically favorable outcome rates were 58.2%, 52.3%, 37.3%, 24.6%, 14.1%, 17.4%, and 16.7%, respectively (P < 0.001). In patients with downtime > 30 minutes, age 51-70 years (odds ratio [OR], 5.35; 95% confidence interval [CI], 2.50-11.49), age ≤ 50 years (OR, 13.16; 95% CI, 6.06-28.57), shockable rhythm (OR, 3.92; 95% CI, 2.71-5.68), bystander resuscitation (OR, 1.80; 95% CI, 1.27-2.55), cardiac cause (OR, 3.50; 95% CI, 1.69-7.25), percutaneous coronary intervention (OR, 1.82; 95% CI, 1.18-2.81), and downtime ≤ 40 minutes (OR, 2.02; 95% CI, 1.42-2.88) were associated with favorable neurological outcomes.

CONCLUSION

In patients with prolonged downtime, predicting favorable neurologic outcome may be multifactorial. The cutoff value for downtime is not the only determining factor to provide post-resuscitation care.

Video-enhanced follow-up training improves basic life support skills retention in laypersons: A prospective randomized controlled trial

Background:

Retraining and retention for basic life support skills after initial basic life support education are important for high-quality basic life support performance at the scene.

Objectives:

We investigated whether delivery of a personal-training video clip reduced basic life support skill degradation in laypersons.

Methods:

After a basic life support layperson training course, the participants were randomized to the video group and control group. The layperson learners in the video group were provided with a video clip of themselves during basic life support education course and a follow-up text message every 3 months after initial basic life support course. The control group only received a follow-up text message every 3 months, without a video clip. The performances of all participants were reviewed initially and after 12 months in each group.

Results:

The total number of participants was 186. Among them, 22 in the video group and 29 in the control group completed the follow-up and final basic life support skill tests. In the control group, basic life support skill level of the participants was at 60.1% after 12 months compared with the initial test and 79.8% in the video group. The performance differences in each basic life support skill score between the initial and follow-up test at 12 months were significantly different between the video group and control group: non-compression, 0.0 (0.0–1.0) versus 1.0 (1.0–2.0); compression, 1.0 (0.0–1.3) versus 1.0 (0.0–4.0); automated external defibrillator, 2.0 (1.0–3.0) versus 3.0 (2.0–4.5) and total score, 4.0 (2.0–5.0) versus 6.0 (3.0–9.5), respectively (all p-values < 0.05).

Conclusion:

Delivery of a basic life support personal-training video clip to laypersons who received basic life support training can reduce performance degradation at 12 months.

Changes in Relative Importance of the 5-Level Triage System, Korean Triage and Acuity Scale, for the Disposition of Emergency Patients Induced by Forced Reduction in Its Level Number: a Multi-Center Registry-based Retrospective Cohort Study

BACKGROUND

The 5-level triage tool, the Korean Triage and Acuity Scale (KTAS), was developed based on the Canadian Triage and Acuity Scale and has been used for triage in all emergency medical institutions in Korea since 2016. This study evaluated the association between the decrease in level number and the change in its relative importance for disposition in the emergency department (ED).

METHODS

Using the registry of the National Emergency Department Information System (NEDIS) ver. 3.1, data regarding consecutive emergency patients from March 2017 to October 2017 were reviewed retrospectively. Reconfiguring KTAS levels, a total of 15 multinomial logistic regression models (KTAS_0 to KTAS_14), including the KTAS, its variants, and covariates were constructed to determine significant factors affecting ED disposition. The relative importance of each model was obtained using a dominance analysis.

RESULTS

A total of 79,771 patients were included in the analysis. In the model KTAS_0, the KTAS and 8 covariates were found to be significantly related to ED disposition. The KTAS and the decision maker of each ED visit, whether it was the physician or others, had the largest relative importance, 34.8% and 31.4%, respectively (P < 0.001). In other models of KTAS variants, including 4-level, 3-level and 2-level, the rates of the KTAS decreased to 31.8% (interquartile range [IQR], 28.9-34.2), 26.4% (IQR, 23.2-31.0), and 18.7% (IQR, 7.5-24.9), respectively (P = 0.016). On the other hand, the rates for covariates tended to be larger for smaller triage levels and so there was a significant interaction effect between the KTAS and the covariates according to the triage level (P < 0.001).

CONCLUSION

The 5-level triage tool, the KTAS, had the largest relative importance among the predictors affecting ED disposition only at its original level. Therefore, it is recommended that no attempt should be made to reduce the number of levels in the triage tool.

Accuracy of objective parameters in acute epiglottitis diagnosis: A case-control study

Lateral neck radiography is often used as a screening tool in emergency departments for suspected acute epiglottitis. The qualitative radiographic signs have been mainly used. The aim of this study was to evaluate the accuracy of objective radiographic parameters to aid diagnosis of acute epiglottitis.Patients who were diagnosed with acute epiglottitis from January 2006 to December 2016 were included in this case-control study. Control subjects with normal lateral neck radiograph findings were included at a 1:4 ratio during the same period. The clinical findings of the patients were assessed from electronic medical records and radiographs were interpreted by a board-certified radiologist and a board-certified emergency medicine physician. The widths of the 3rd cervical vertebral body, epiglottis base (EWB), epiglottis tip (EWT), aryepiglottic fold (AFW), and hypopharynx, as well as the dimensions of the retropharyngeal and retrotracheal soft tissues, were retrospectively measured. The sensitivity, specificity, and receiver operating characteristic (ROC) curves were analyzed for the measured parameters, and cutoff values were determined to predict acute epiglottitis. The predictive cutoff values of radiologic parameters were evaluated using 5-fold cross-validation.A total 260 epiglottitis patients and 1166 controls were included in the study. In the ROC curve analysis, the EWB had an area under the ROC curve (AUROC) of 0.99 for a cutoff value of 5.02 mm (sensitivity, 96.2%; specificity, 98.2%). The EWT had an AUROC of 0.97 for a cutoff value of 4.84 mm (sensitivity, 91.2%; specificity, 97.3%). The AFW had an AUROC of 0.88 for a cutoff value of 6.59 mm (sensitivity, 86.5%; specificity, 78.8%). The 5-fold cross-validation achieved AUROCs of 0.97 for EWB, 0.94 for EWT, and 0.83 for AFW.The objective radiographic parameters in lateral neck radiography may be useful in diagnosing acute epiglottitis. Further prospective studies may be warranted to evaluate the diagnostic performance in actual clinical practice.

Verification of the Optimal Chest Compression Depth for Children in the 2015 American Heart Association Guidelines: Computed Tomography Study

OBJECTIVE

The 2015 American Heart Association guidelines recommended pediatric rescue chest compressions of at least one-third the anteroposterior diameter of the chest, which equates to approximately 5 cm. This study evaluated the appropriateness of these two types by comparing their safeties in chest compression depth simulated by CT.

DESIGN

Retrospective study with data analysis conducted from January 2005 to June 2015 SETTING:: Regional emergency center in South Korea.

PATIENTS

Three hundred forty-nine pediatric patients 1-9 years old who had a chest CT scan.

INTERVENTIONS

Simulation of chest compression depths by CT.

MEASUREMENTS AND MAIN RESULTS

Internal and external anteroposterior diameter of the chest and residual internal anteroposterior diameter after simulation were measured from CT scans. The safe cutoff levels were differently applied according to age. One-third external anteroposterior diameters were compared with an upper limit of chest compression depth recommended for adults. Primary outcomes were the rates of overcompression to evaluate safety. Overcompression was defined as a negative value of residual internal anteroposterior diameter-age-specific cutoff level. Using a compression of 5-cm depth simulated by chest CT, 16% of all children (55/349) were affected by overcompression. Those 1-3 years old were affected more than those 4-9 years old (p < 0.001). Upon one-third compression of chest anteroposterior depth, only one subject (0.3%) was affected by overcompression. Rate of one-third external anteroposterior diameter greater than 6 cm in children 8 and 9 years old was 16.1% and 33.3%, respectively.

CONCLUSIONS

A chest compression depth of one-third anteroposterior might be more appropriate than the 5-cm depth chest compression for younger Korean children. But, one-third anteroposterior depth chest compression might induce deep compressions greater than an upper limit of compression depth for adults in older Korean children.

Initial blood pH during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients: a multicenter observational registry-based study

BACKGROUND

When an out-of-hospital cardiac arrest (OHCA) patient receives cardiopulmonary resuscitation (CPR) in the emergency department (ED), blood laboratory test results can be obtained by using point-of-care testing during CPR. In the present study, the relationship between blood laboratory test results during CPR and outcomes of OHCA patients was investigated.

METHODS

This study was a multicenter retrospective analysis of prospective registered data that included 2716 OHCA patients. Data from the EDs of three university hospitals in different areas were collected from January 2009 to December 2014. Univariate and multivariable analyses were conducted to elucidate the factors associated with survival to discharge and neurological outcomes. A final analysis was conducted by including patients who had no prehospital return of spontaneous circulation and those who underwent rapid blood laboratory examination during CPR.

RESULTS

Overall, 2229 OHCA patients were included in the final analysis. Among them, the rate of survival to discharge and a good Cerebral Performance Categories Scale score were 14% and 4.4%, respectively. The pH level was independently related to survival to hospital discharge (adjusted OR 6.287, 95% CI 2.601-15.197; p < 0.001) and good neurological recovery (adjusted OR 15.395, 95% CI 3.439-68.911; p < 0.001). None of the neurologically intact patients had low pH levels (< 6.8) or excessive potassium levels (> 8.5 mEq/L) during CPR.

CONCLUSIONS

Among the blood laboratory test results during CPR of OHCA patients, pH and potassium levels were observed as independent factors associated with survival to hospital discharge, and pH level was considered as an independent factor related to neurological recovery.

Metronome vs. Popular Song: A Comparison of Long-Term Retention of Chest Compression Skills after Layperson Training for Cardiopulmonary Resuscitation

Introduction

Long-term retention of cardiopulmonary resuscitation (CPR) skill is challenging for layperson trainees. This study compared the long-term retention of chest compression skills after either metronome-guided (MG) or popular song-guided (PG) CPR training.

Methods

This was a prospective randomised simulation trial. Untrained laypersons were randomly allocated to MG (n=61) or PG (n=68) groups at CPR training sessions. After CPR training, each participant performed 5-cycle CPR using a manikin with a Skill-Reporter™ immediately and six months afterwards.

Results

Immediately after training, the mean compression rate (MCR) was slightly higher in the PG than the MG group (107.4 vs. 102.2/min; p<0.0001), but there was no significant difference in the proportions of participants with an appropriate chest compression rate (100-120/min) (PSACCR) between the MG and PG (53/61 (86.9%) vs. 65/68 (95.6%); p=0.114). Six months later, MCR was faster in the MG than the PG (124.8 vs. 110.0/min; p<0.0001), and PSACCR in the PG was higher than that in the MG (62/68 (91.2%) vs. 25/61 (41.0%); p<0.0001). In both tests, there were no significant differences in other chest compression parameters of between the two groups, except for a minimal difference in incomplete chest release.

Conclusion

CPR training using a popular song is more effective than metronome-guided training in helping laypersons to maintain recommended compression rates after 6 months. (Hong Kong j.emerg.med. 2016;23:145-152)

Holiday Fast-Track Reduced Medical Cost and Length of Emergency Department Stay: Preliminary Report from a Single Secondary Care Hospital

Introduction

The aims of this study were to compare the effect of a Holiday Fast-Track (HFT) unit on medical costs and emergency department (ED) length of stay (LOS) associated with low acuity patients attended during the same timeframe in two consecutive years in a single secondary care hospital ED.

Methods

Two groups (non-HFT vs. HFT), before and after the fast-track unit was implemented, were compared. The HFT unit was operated to improve the flow of low acuity patients, which were defined as the patients classified as level 4 or 5 by the modified Canadian Triage and Acuity Scale. Data were collected from March 1 to April 30, 2011 for the non-HFT group and during the same period in 2012 for the HFT group.

Results

A total of 894 (431 for non-HFT period and 463 for HFT period) patients of acuity level 4 or 5 visited the ED during the study period. Compared to the non-HFT group, the ED LOS of the HFT group decreased by 27 min and 3.5 min in the patients with acuity levels 4 and 5, respectively (p=0.005 and p=0.003, respectively). Furthermore, total medical costs and laboratory fees were also reduced significantly in the HFT group (p<0.001, p=0.038). However, there was no difference in the other variables between those two groups.

Conclusions

The HFT system decreases the medical costs and LOS in low acuity patients visiting the ED of a secondary care hospital. (Hong Kong j.emerg.med. 2015;22:84-92)

Cucumber Plants Baited with Methyl Salicylate Accelerates Scymnus (Pullus) sodalis (Coleoptera: Coccinellidae) Visiting to Reduce Cotton Aphid (Hemiptera: Aphididae) Infestation

The cotton aphid, Aphis gossypii (Glover) (Hemiptera: Aphididae), is a major pest of many crops worldwide and a major cucumber plant pest in Taiwan. Because cotton aphids rapidly develop insecticide resistance and because of the insecticide residue problem, a safe and sustainable method is required to replace conventional chemical control methods. Methyl salicylate (MeSA), a herbivore-induced plant volatile, has been shown to affect aphids' behavior and attract the natural enemies of aphids for reducing their population. Therefore, this study examined the direct effects of MeSA on cotton aphids' settling preference, population development, and attractiveness to natural enemies. The efficiency of using MeSA and the commercial insecticide pymetrozine for reducing the cotton aphid population in laboratory and outdoor cucumber plant pot was also examined. The results showed no difference in winged aphids' settling preference and population development between the MeSA and blank treatments. Cucumber plants infested with cotton aphids and baited with 0.1% or 10% MeSA contained significantly higher numbers of the natural enemy of cotton aphids, namely Scymnus (Pullus) sodalis (Weise) (Coleoptera: Coccinellidae), and MeSA-treated cucumber plants contained a lower number of aphids. Significantly lower cotton aphid numbers were found on cucumber plants within a 10-m range of MeSA application. In addition, fruit yield showed no difference between the MeSA and pymetrozine treatments. According to our findings, 0.1% MeSA application can replace insecticides as a cotton aphid control tool. However, large-scale experiments are necessary to confirm its efficiency and related conservation biological control strategies before further use.

Effect of relative humidity on preeclampsia

PURPOSE OF INVESTIGATION

The authors aimed to determine the relationship between meteorological variables and hypertension in pregnancy by using data from a national weather database.

MATERIALS AND METHODS

For this population-based observational study, the database of the Korea National Health Insurance (KNHI) Claims of the Health Insurance Review and Assessment Service (HIRA) and Korea Meteorological Administration was used. The 48,275 women with preeclampsia among 2,495,383 women who gave birth were included. Monthly meteorological factors and preeclampsia prevalence for five years were statistically analyzed.

RESULTS

Among temperature, relative humidity, sunlight duration, and rainfall, only relative humidity had a significant inverse correlation with the preeclampsia prevalence (p < 0.001). The other meteorological factors were not associated with preeclampsia.

CONCLUSION

Relative humidity may be a significant factor for of the development of preeclampsia. Further monitoring of weather parameters during the entire pregnancy period may be the best method for verifying the present results in the development of preeclampsia.

A study of the dietary intakes by the pre-pregnancy body mass index in pregnant women

The authors analyzed the difference in weight gain and nutrition, according to the BMI before pregnancy. They divided 91 subjects into BMI group I (normal weight) and BMI group 2 (overweight) before pregnancy. In general, the BMI before pregnancy did not influence weight gain but, in the BMI group 2, the intakes of all of cholesterol, total fatty acids, vitamin B 12, iron, and copper were significantly higher. Neither group exhibited sufficient intake of vitamin B 1, vitamin B2, niacin, vitamin B6, folic acid, calcium, magnesium, iron, or zinc. Pre-pregnancy weight management and nutrition during pregnancy is very important.

Prognostic Factors in Emergency Department Patients with Glyphosate Surfactant Intoxication: Point-of-Care Lactate Testing

An increasing number of suicide attempts involve the ingestion of glyphosate surfactant; hence, clinical toxicologists may encounter severe cases of glyphosate surfactant intoxication. In several other clinical conditions, serum lactate is used to predict outcome. We investigated the relationship between lactate levels and 30-day mortality from glyphosate surfactant poisoning. This retrospective analysis involved 232 patients who were admitted to the emergency department after acute glyphosate surfactant poisoning between January 2004 and June 2014. We used a receiver operating characteristic (ROC) curve to define the optimal cut-off point for lactate levels. A Kaplan-Meier 30-day survival curve was then analysed in terms of the defined cut-off level. We used multi-variate Cox proportional hazards regression analysis to determine the risk factors for 30-day mortality. Of the 232 patients, 29 died, yielding a case fatality rate of 12.5%. Lactate was significantly higher in non-survivors (6.5 ± 3.1 mmol/L) than in survivors (3.3 ± 2.2 mmol/L; p < 0.001), and elevated lactate was significantly associated with 30-day mortality. The area under the ROC curve of lactate levels was 0.836 [95% confidence interval (CI): 0.716-0.869]. Lactate levels higher than 4.7 mmol/L were associated with increased mortality in multi-variable analysis (hazard ratio: 3.2; 95% CI: 1.1-8.7). Besides lactate, age >59 years, corrected QT interval >495 ms and potassium >5.5 mmol/L were independent risk factors for 30-day mortality. Lactate is an independent predictor of 30-day mortality in patients with glyphosate surfactant poisoning. Early measurement of lactate levels may be a simple and practical way to assess the severity of intoxication.

Effectiveness of the sequential organ failure assessment, acute physiology and chronic health evaluation II, and simplified acute physiology score II prognostic scoring systems in paraquat-poisoned patients in the intensive care unit

OBJECTIVE

This study was conducted to assess the ability of the sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation (APACHE) II scoring systems, as well as the simplified acute physiology score (SAPS) II method to predict group mortality in intensive care unit (ICU) patients who were poisoned with paraquat. This will assist physicians with risk stratification.

MATERIAL AND METHODS

The medical records of 244 paraquat-poisoned patients admitted to the ICU from January 2010 to April 2015 were examined retrospectively. The SOFA, APACHE II, and SAPS II scores were calculated based on initial laboratory data in the emergency department and during the first 24 h of ICU admission. The probability of death was calculated for each patient based on the SOFA score, APACHE II score, and SAPS II. The ability of the SOFA score, APACHE II score, and SAPS II method to predict group mortality was assessed using a receiver operating characteristic (ROC) curve and calibration analyses.

RESULTS

A total of 219 patients (mean age, 63 years) were enrolled. Sensitivities, specificities, and accuracies were 58.5%, 86.1%, and 64.0% for the SOFA, respectively; 75.1%, 86.1%, and 77.6% for the APACHE II scoring systems, respectively; and 76.1%, 79.1%, and 76.7% for the SAPS II, respectively. The areas under the curve in the ROC curve analysis for the SOFA score, APACHE II scoring system, and SAPS II were 0.716, 0.850, and 0.835, respectively.

CONCLUSION

The SOFA, APACHE II, and SAPS II had different capabilities to discriminate and estimate early in-hospital mortality of paraquat-poisoned patients. Our results show that although the SOFA and SAPS II are easier and more quickly calculated than APACHE II, the APACHE II is superior for predicting mortality. We recommend use of the APACHE II for outcome predictions and risk stratification in paraquat-poisoned patients in the ICU.

Use of vertebral body units to locate the cavoatrial junction for optimum central venous catheter tip positioning

BACKGROUND

Central venous catheter (CVC) placement plays an important role in clinical practice; however, optimal positioning of the CVC tip remains a controversial issue. The objective of this study was to evaluate the use of vertebral body unit (VBUs), to locate the cavoatrial junction (CAJ), for optimal CVC tip placement based on chest radiography (CXR) using the carina as a landmark.

METHODS

524 patients who underwent coronary computed tomographic angiography (CTA) and CXR were included. The position of the CAJ was identified using VBUs, and the efficacy of VBUs for locating the CAJ with the carina as a landmark was analysed using multiple regression analysis. A VBU was defined as the distance between two adjacent vertebral bodies, including the inter-vertebral disk space.

RESULTS

The mean (sd) distance from the carina to the superior CAJ was 54.3 (9.7) mm on CTA; the mean distance in VBUs at the level of the carina was 21.4 (1.7) mm on CTA and 22.6 (2.1) mm on CXR. The mean CAJ position was 2.5 VBUs below the carina on CTA and 2.4 VBUs below on CXR with 95% limits of agreement between -0.6 and +0.3.

CONCLUSIONS

The position of the CVC tip in relation to the carina can be described using the thoracic spine as an internal ruler, and the position of the CAJ in adults was reliably estimated to be 2.4 VBUs below the carina.

CLINICAL TRIAL REGISTRATION

KCT0001319.

Differences in Hands-off Time According to the Position of a Second Rescuer When Switching Compression in Pre-hospital Cardiopulmonary Resuscitation Provided by Two Bystanders: A Randomized, Controlled, Parallel Study

The change of compressing personnel will inevitably accompany hands off time when cardiopulmonary resuscitation (CPR) is performed by two or more rescuers. The present study assessed whether changing compression by a second rescuer located on the opposite side (OS) of the first rescuer can reduce hands-off time compared to CPR on the same side (SS) when CPR is performed by two rescuers. The scenario of this randomized, controlled, parallel simulation study was compression-only CPR by two laypersons in a pre-hospital situation. Considering sex ratio, 64 participants were matched up in 32 teams equally divided into two gender groups, i.e. , homogenous or heterogeneous. Each team was finally allocated to one of two study groups according to the position of changing compression (SS or OS). Every team performed chest compression for 8 min and 10 sec, with chest compression changed every 2 min. The primary endpoint was cumulative hands-off time. Cumulative hands-off time of the SS group was about 2 sec longer than the OS group, and was significant (6.6 ± 2.6 sec vs. 4.5 ± 1.5 sec, P = 0.005). The range of hands off time of the SS group was wider than for the OS group. The mean hands-off times of each rescuer turn significantly shortened with increasing number of turns (P = 0.005). A subgroup analysis in which cumulative hands-off time was divided into three subgroups in 5-sec intervals revealed that about 70% of the SS group was included in subgroups with delayed hands-off time ≥ 5 sec, with only 25% of the OS group included in these subgroups (P = 0.033). Changing compression at the OS of each rescuer reduced hands-off time compared to the SS in prehospital hands-only CPR provided by two bystanders.

Performance of intubation with 4 different airway devices by unskilled rescuers: manikin study

INTRODUCTION

This study was designed to compare the performances of 4 airway devices in achieving successful ventilation.

METHODS

A randomized crossover trial was conducted to evaluate 4 airway devices: laryngeal mask airway (LMA), i-gel (iGEL), PENTAX Airway Scope (AWS), and Macintosh laryngoscope (MCL). Thirty-eight unskilled rescuers performed intubation on a manikin during chest compressions in normal and difficult airway scenarios. The time to ventilation, intubation success rate, and difficulty of intubation were measured.

RESULTS

The time to ventilation of the airway devices in the normal scenario had a median value of 8.8 seconds (interquartile range, 7.3-10.5 seconds) for iGEL, 16.1 seconds (13.9-19.3 seconds) for LMA, 30.6 seconds (24.6-37.6 seconds) for AWS, and 35.0 seconds (29.5-45.9 seconds) for MCL. In the difficult airway scenario, the respective time to ventilation was 8.6 seconds (7.8-10.0 seconds), 15.3 seconds (14.3-20.2 seconds), 29.4 seconds (25.7-36.3 seconds) and 59.0 seconds (46.1-103.3 seconds). The success rates were 100% and 100% for LMA, 100% and 100% for iGEL, 97.4% and 94.7% for AWS, and 78.9% and 47.4% for MCL in the normal and difficult airway scenarios. The difficulties of intubation expressed as numerical rating scale were 2.0 and 2.0 (median values) for LMA, 1.0 and 2.0 for iGEL, 3.0 and 3.0 for AWS, and 4.0 and 5.0 for MCL in the normal and difficult airway scenarios, respectively.

CONCLUSION

With novice intubators who were unfamiliar with the airway devices, the LMA, iGEL, and AWS were superior to the MCL for establishing an airway without interruption of chest compressions in a manikin study. Intubation with the iGEL was faster and easier than with the other airway devices.

Comparison of CPR quality and rescuer fatigue between standard 30:2 CPR and chest compression-only CPR: a randomized crossover manikin trial

Objective

We aimed to compare rescuer fatigue and cardiopulmonary resuscitation (CPR) quality between standard 30:2 CPR (ST-CPR) and chest compression only CPR (CO-CPR) performed for 8 minutes on a realistic manikin by following the 2010 CPR guidelines.

Methods

All 36 volunteers (laypersons; 18 men and 18 women) were randomized to ST-CPR or CO-CPR at first, and then each CPR technique was performed for 8 minutes with a 3-hour rest interval. We measured the mean blood pressure (MBP) of the volunteers before and after performing each CPR technique, and continuously monitored the heart rate (HR) of the volunteers during each CPR technique using the MRx monitor. CPR quality measures included the depth of chest compression (CC) and the number of adequate CCs per minute.

Results

The adequate CC rate significantly differed between the 2 groups after 2 minutes, with it being higher in the ST-CPR group than in the CO-CPR group. Additionally, the adequate CC rate significantly differed between the 2 groups during 8 minutes for male volunteers (p =0.012). The number of adequate CCs was higher in the ST-CPR group than in the CO-CPR group after 3 minutes (p =0.001). The change in MBP before and after performing CPR did not differ between the 2 groups. However, the change in HR during 8 minutes of CPR was higher in the CO-CPR group than in the ST-CPR group (p =0.007).

Conclusions

The rate and number of adequate CCs were significantly lower with the CO-CPR than with the ST-CPR after 2 and 6 minutes, respectively, and performer fatigue was higher with the CO-CPR than with the ST-CPR during 8 minutes of CPR.

Feasibility of optic nerve sheath diameter measured on initial brain computed tomography as an early neurologic outcome predictor after cardiac arrest

OBJECTIVES

Few parameters are available to predict neurologic outcome of post-cardiac arrest patients in the early stage of treatment. Optic nerve sheath diameter (ONSD) has been used to indirectly assess intracranial pressure. This study evaluated whether ONSD, an additional parameter in initial brain computed tomography (CT) scans, can be an early predictor of neurologic outcome in post-cardiac arrest patients.

METHODS

A total of 112 cardiac arrest patients between November 2012 and October 2013 were identified. Ninety-eight comatose cardiac arrest patients were evaluated with brain CT. Of these patients, after exclusion of patients whose brain CT scans were done too late or with poor baseline neurology (Cerebral Performance Category [CPC] ≥ 3), 91 patients were included for this study. The parameters of initial brain CT, i.e., gray matter-to-white matter ratio (GWR) and ONSD, were measured after clinical care as part of a retrospective reanalysis of images. ONSD on brain CT was bilaterally measured 3 mm behind the eyeball at fixed window width and level and averaged to yield the mean value. The performance of ONSD to predict poor neurologic outcome (CPC = 3 to 5) was analyzed using multiple logistic regression analysis, receiver operating characteristic (ROC) curve analysis, and cross-tabulations.

RESULTS

Twenty-three patients showed good neurologic outcomes at hospital discharge. Mean (±SD) ONSD was 5.6 (±0.3) mm in the good outcome group versus 6.3 (±0.5) mm in the poor outcome group (p < 0.001). After basic clinical covariates were controlled for, i.e., age, Glasgow Coma Scale (GCS) score (3 vs. 4-15), and time from collapse to return of spontaneous circulation (ROSC), ONSD (odds ratio [OR] = 2.1; 95% confidence interval [CI] = 1.1 to 3.9) and GWR (OR = 0.6; 95% CI = 0.4 to 0.9) were found to be significant factors for predicting poor neurologic outcome. ROC curve analysis showed that ONSD and GWR had areas under the ROC curve of 0.931 (95% CI = 0.87 to 0.98) and 0.922 (95% CI = 0.86 to 0.97), respectively. Combining the cutoff values of ONSD (6.21 mm, sensitivity = 56%; 95% CI = 43% to 68%) and GWR (1.23, sensitivity = 84%; 95% CI = 73% to 92%) to have 100% specificities, the sensitivity was improved to 92% (95% CI = 84% to 98%). Intrarater and interrater intraclass correlation coefficients between the investigators measuring ONSD were 0.888 and 0.833, respectively.

CONCLUSIONS

Optic nerve sheath diameter on initial brain CT correlated closely with the neurologic outcome of hypoxic ischemic encephalopathy and had good reliability. Additional prospective work may be justified evaluating the standardization and diagnostic performance in real time use as a predictive tool for neurologic outcome following cardiac arrest.

Early hyperoxemia may not increase mortality after cardiac arrest: a pilot study

Objective

International Liaison Committee on Resuscitation guidelines advocate an arterial saturation of 94% to 96% after return of spontaneous circulation (ROSC). However, a few clinical trials have investigated the impact of postresuscitative O₂ therapy after cardiac arrest. We studied whether early hyperoxemia is associated with a poor post-ROSC outcome after in-hospital cardiac arrest.

Methods

We retrospectively reviewed patients who experienced an in-hospital cardiac arrest from January 2005 to January 2011. Based on the results of the first arterial blood gas analysis (ABGA) within 10 minutes and a second ABGA from 60 to 120 minutes after ROSC, patients were classified into three groups: hyperoxemia (PaO₂ ≥ 300 mmHg), normoxemia (300 mmHg > PaO₂ ≥ 60 mmHg), and hypoxemia (PaO₂ < 60 mmHg or ratio of PaO₂ to fraction of inspired oxygen < 300). We examined whether early hyperoxemia was associated with survival and neurological outcome.

Results

There were 792 patients who met the inclusion criteria: 638 (80.6%) in the hypoxemia group, 62 (7.8%) in the normoxemia group, and 92 (11.6%) in the hyperoxemia group. Multiple logistic regression analysis showed that hyperoxemia was not associated with survival (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.30 to 3.84) or neurological outcome (OR, 1.03; 95% CI, 0.31 to 3.40).

Conclusion

Postresuscitation hyperoxemia was not associated with survival or neurological outcome in patients with ROSC after in-hospital cardiac arrest.

Efficient production of transgenic melon via Agrobacterium-mediated transformation

Oriental melon (Cucumis melo L. var. makuwa) is an important fruit for human consumption. However, this plant species is one of the most recalcitrant to genetic transformation. The lack of an efficient in vitro system limits the development of a reproducible genetic transformation protocol for Oriental melon. In this study, an efficient transgenic production method for Agrobacterium-mediated transformation using cotyledon explants of Oriental melon was developed. Cotyledon explants were pre-cultivated for two days in the dark, and the optimal conditions for transformation of melon were determined to be a bacteria concentration of OD600 0.6, inoculation for 30 min, and two days of co-cultivation. Transgenic melon plants were produced from kanamycin-resistant shoots. A total of 11 independent transgenic plants were regenerated with a transformation efficiency of 0.8% of the inoculated explants. The transgenic plants were phenotypically normal and fully fertile, which might be a consequence of the co-cultivation time.

Heart rate-corrected QT interval predicts mortality in glyphosate-surfactant herbicide-poisoned patients

BACKGROUND

Glyphosate-surfactant herbicide is promoted by the manufacturer as having no risks to human health. Glyphosate surfactant has recently been used with increasing frequency in suicide attempts, so clinical toxicologists occasionally encounter cases of severe systemic toxicity. The purpose of this study was to identify the early predictive factors of patients at risk for mortality and the usefulness of the corrected QT interval (QTc interval) for predicting mortality from glyphosate-surfactant intoxication.

METHODS

This was a retrospective cohort study conducted from January 2005 to December 2012. A total of 153 patients with acute glyphosate-surfactant ingestion were included. To identify the predictive factors for mortality, objective variables easily assessed at presentation including previously reported predictive factors for mortality and severity were retrospectively analyzed for their association with mortality using univariate and multiple logistic analyses.

RESULTS

The average age of the patients was 56 years (range, 19-93 years). Of the 153 patients, 19 (12.4%) died. The most common abnormal electrocardiogram findings were prolonged QTc interval followed by intraventricular conduction delay and first-degree atrioventricular block. Nonsurvivors had a significantly more prolonged QTc interval when compared with that of survivors (survivors: 453.4 ± 33.6 milliseconds vs nonsurvivors: 542 ± 32.0 milliseconds, P < .001). Corrected QT interval and age were associated with a significantly increased risk of death in a multiple logistic regression. In a receiver operating curve analysis, the QTc interval had significant discriminatory power.

CONCLUSION

Prolonged QTc interval seems to be a useful prognostic factor for mortality in patients intoxicated with glyphosate-surfactant herbicide.

The most effective rescuer's position for cardiopulmonary resuscitation provided to patients on beds: a randomized, controlled, crossover mannequin study

BACKGROUND

The effectiveness of chest compressions for cardiopulmonary resuscitation (CPR) is affected by the rescuer's position with respect to the patient. In hospitals, chest compressions are typically performed while standing beside the patient, who is placed on a bed.

STUDY OBJECTIVES

To compare the effectiveness of chest compressions, performed on a bed during 2 min of CPR, among three different rescuer positions: standing, on a footstool, or kneeling on the bed.

METHODS

We performed a crossover randomized simulation trial. Participants were recruited from among students in the Department of Paramedics from July to August 2011. Thirty-eight participants were enrolled, and they performed chest compressions on a mannequin for 2 min in each of the three different positions, with a 1-week interval between each position.

RESULTS

The number of adequate compressions (depth > 50 mm) and the mean compression depth were significantly greater in the kneeling and footstool positions than in the standing position, but there was no significant difference between the kneeling and footstool positions. There were no significant differences in the compression rate, the percentage of correctly released compressions, and the percentage of compressions performed using the correct hand position among the three rescuer positions.

CONCLUSION

The mean compression depth and the number of adequate compressions were greater for both the kneeling and footstool positions than for the standing position during 2 min of CPR. We recommend kneeling on a bed or standing on a footstool as the rescuer positions during hospital CPR on a bed.

Use of antimicrobial agents in aquaculture

The aquaculture industry has grown dramatically, and plays an important role in the world's food supply chain. Antimicrobial resistance in bacteria associated with food animals receives much attention, and drug use in aquaculture is also an important issue. There are many differences between aquatic and terrestrial management systems, such as the methods used for administration of drugs. Unique problems are related to the application of drugs in aquatic environments. Residual drugs in fish products can affect people who consume them, and antimicrobials released into aquatic environments can select for resistant bacteria. Moreover, these antimicrobial-resistant bacteria, or their resistance genes, can be transferred to humans. To decrease the risks associated with the use of antimicrobials, various regulations have been developed. In addition, it is necessary to prevent bacterial diseases in aquatic animals by vaccination, to improve culture systems, and to monitor the amount of antimicrobial drugs used and the prevalence of antimicrobial-resistant bacteria.

Association of glypican-4 with body fat distribution, insulin resistance, and nonalcoholic fatty liver disease

CONTEXT AND OBJECTIVE

Glypican-4 was identified as a novel adipokine capable of enhancing insulin signaling and modulating adipocyte differentiation. We investigated associations between glypican-4 and body composition, insulin resistance, arterial stiffness, and nonalcoholic fatty liver disease (NAFLD) in nondiabetic Asian subjects.

DESIGN AND PARTICIPANTS

We analyzed baseline cross-sectional data from the Korean Sarcopenic Obesity Study, an ongoing prospective cohort study. NAFLD was diagnosed by unenhanced computed tomography using the liver attenuation index. We also examined the effects of a 3-month combined aerobic and resistance exercise program on glypican-4 levels and cardiometabolic risk factors.

RESULTS

Circulating glypican-4 levels were higher in men than in women (1.83 [1.19, 2.78] ng/mL vs 1.17 [0.66, 2.00] ng/mL, P < .001) and had a significant positive relationship with the waist-to-hip ratio (WHR) (r = 0.20, P = .014) and the ratio of visceral to sc fat area (r = 0.30, P < .001). Furthermore, glypican-4 levels in women were correlated with cardiometabolic risk factors, including insulin resistance and arterial stiffness, and were independently associated with NAFLD by multiple logistic regression analysis (P = .017, R² = 0.33). The 3-month combined exercise training program significantly improved several cardiometabolic parameters and reduced retinol binding protein-4 levels. Changes in glypican-4 levels after the exercise program were significantly different between subjects with an increased WHR compared with those with a decreased WHR (P = .034).

CONCLUSION

A gender-based difference in circulating glypican-4 levels was apparent as these were increased in women with NAFLD and related to body fat distribution, insulin resistance, and arterial stiffness.

Evaluation of antioxidant, rheological, physical and sensorial properties of wheat flour dough and cake containing turmeric powder

The effects of addition of turmeric powder (0%, 2%, 4%, 6% and 8%) were examined in order to obtain an antioxidant-enriched cake with good physico-chemical and sensorial properties. The rheological properties of doughs were evaluated using dynamic rheological measurements. Physical properties, curcumin content, radical scavenging activity (RSA-DPPH assay) and sensory analysis (hedonic test) of the supplemented cake were determined. Addition of turmeric powder up to 8% caused significant changes on dough characteristics and on cake rheological properties. The highest curcumin (203 mg/kg) and RSA-DPPH activity (45%) were achieved in the cake having the highest percentage of turmeric powder (8%); however, this sample showed the worst results regarding the rheological properties. Moreover, by sensory evaluation this cake sample was not acceptable. A 6% substitution of wheat flour with turmeric powder showed acceptable sensory scores which were comparable to those of 0-4% turmeric cakes. This indicated that up to 6% level of turmeric powder might be included in cake formulation.

Evaluation of Chest Compression Depth during Nine Minutes of Hands-Only Cardiopulmonary Resuscitation Performed by a Lone Rescuer and its Effect by Age Group: A Pilot Simulation Study Using a Manikin

Objective

There have been few studies on the use of long-standing hands-only cardiopulmonary resuscitation (CPR) by a lone rescuer. This study aimed to evaluate the long-standing (nine minutes) hands-only CPR by a lone rescuer, and the change of chest compression depth over time. The effect of age of rescuer on chest compression depth was also studied.

Methods

From a total of 404 adult lay-persons who participated in CPR training, 91 subjects were enrolled in the simulation trial of nine minutes of hands-only CPR using a manikin with a Skill-Reporter™. The quality of the chest compression over time and the effects of rescuer age were analysed.

Results

Of the 91 participants, 74 (81%) fully completed the nine minutes of CPR. No significant differences of incomplete CPR rate between each age group were observed. No significant differences in the degree of reduction in effective chest compressions were observed based on the time course among the different age groups. The total number of compressions decreased abruptly from the six-minute time point onwards (five minutes vs. six minutes, p=0.038).

Conclusions

Most trained lay-persons could complete the 9 minutes of hands-only CPR. The rate of chest compression shows a significant decrease after 6 minute. We do not find a significant difference in the decrease of adequate chest compressions over time among various age groups in this pilot simulation study.

Changes in Interhospital Transfer Patterns of Acute Ischemic Stroke Patients in the Regional Stroke Care System After Designation of a Cerebrovascular-specified Center

The Ministry of Health and Welfare of Korea recently designated cerebrovascularspecified centers (CSCs) to improve the regional stroke care system for acute ischemic stroke (AIS) patients. This study was performed to evaluate the changes in the flow of AIS patients between hospitals and to describe the role of the Emergency Medical Information Center (EMIC) after the designation of the CSCs. Data for coordination of interhospital transfers by the EMIC were reviewed for 6 months before and after designation of the CSCs. The data included the success or failure rate, the time used for coordination of interhospital transfer, and the changes in the interhospital transfer pattern between transfer-requesting and transfer-accepting hospitals. The total number of requests for interhospital transfer increased from 198 to 244 after designation of the CSCs. The median time used for coordination decreased from 8.0 minutes to 4.0 minutes (p<0.001). The success rate of coordination increased from 88.9% to 96.7% (p<0.001). The proportion of requests by CSCs decreased from 3.5% to 0.4% (p=0.017). However, the proportion of acceptance by non-CSC hospitals increased from 15.9% to 25.8% (p=0.015). With the designation of CSCs, the EMIC could coordinate interhospital transfers more quickly. However, AIS patients are more dispersed to CSC and non-CSC hospitals, which might be because the CSCs still do not have sufficient resources to cover the increasing volume of AIS patients and non-CSC hospitals have changed their policies. Further studies based on patients' outcome are needed to determine the adequate type of interhospital transfer for AIS patients.

Efficacy of metronome sound guidance via a phone speaker during dispatcher-assisted compression-only cardiopulmonary resuscitation by an untrained layperson: a randomised controlled simulation study using a manikin

AIM

Untrained laypersons should perform compression-only cardiopulmonary resuscitation (COCPR) under a dispatcher's guidance, but the quality of the chest compressions may be suboptimal. We hypothesised that providing metronome sounds via a phone speaker may improve the quality of chest compressions during dispatcher-assisted COCPR (DA-COCPR).

METHODS

Untrained laypersons were allocated to either the metronome sound-guided group (MG), who performed DA-COCPR with metronome sounds (110 ticks/min), or the control group (CG), who performed conventional DA-COCPR. The participants of each group performed DA-COCPR for 4 min using a manikin with Skill-Reporter, and the data regarding chest compression quality were collected.

RESULTS

The data from 33 cases of DA-COCPR in the MG and 34 cases in the CG were compared. The MG showed a faster compression rate than the CG (111.9 vs 96.7/min; p=0.018). A significantly higher proportion of subjects in the MG performed the DA-COCPR with an accurate chest compression rate (100-120/min) compared with the subjects in the CG (32/33 (97.0%) vs 5/34 (14.7%); p<0.0001). The mean compression depth was not different between the MG and the CG (45.9 vs 46.8 mm; p=0.692). However, a higher proportion of subjects in the MG performed shallow compressions (compression depth <38 mm) compared with subjects in the CG (median % was 69.2 vs 15.7; p=0.035).

CONCLUSIONS

Metronome sound guidance during DA-COCPR for the untrained bystanders improved the chest compression rates, but was associated more with shallow compressions than the conventional DA-COCPR in a manikin model.

Factors related to prehospital time delay in acute ST-segment elevation myocardial infarction

Despite recent successful efforts to shorten the door-to-balloon time in patients with acute ST-segment elevation myocardial infarction (STEMI), prehospital delay remains unaffected. Nonetheless, the factors associated with prehospital delay have not been clearly identified in Korea. We retrospectively evaluated 423 patients with STEMI. The mean symptom onset-to-door time was 255 ± 285 (median: 150) min. The patients were analyzed in two groups according to symptom onset-to-door time (short delay group: ≤ 180 min vs long delay group: > 180 min). Inhospital mortality was significantly higher in long delay group (6.9% vs 2.8%; P = 0.048). Among sociodemographic and clinical variables, diabetes, low educational level, triage via other hospital, use of private transport and night time onset were more prevalent in long delay group (21% vs 30%; P = 0.038, 47% vs 59%; P = 0.013, 72% vs 82%; P = 0.027, 25% vs 41%; P < 0.001 and 33% vs 48%; P = 0.002, respectively). In multivariate analysis, low educational level (1.66 [1.08-2.56]; P = 0.021), symptom onset during night time (1.97 [1.27-3.04]; P = 0.002), triage via other hospital (1.83 [1.58-5.10]; P = 0.001) and private transport were significantly associated with prehospital delay (3.02 [1.81-5.06]; P < 0.001). In conclusion, prehospital delay is more frequent in patients with low educational level, symptom onset during night time, triage via other hospitals, and private transport, and is associated with higher inhospital mortality.

Serum selenoprotein P levels in patients with type 2 diabetes and prediabetes: implications for insulin resistance, inflammation, and atherosclerosis

CONTEXT AND OBJECTIVE

The dysregulation of hepatokines may be associated with the pathogenesis of insulin resistance and type 2 diabetes. A recent study has suggested that selenoprotein P (SeP), a novel hepatokine, may play a role in the regulation of glucose metabolism and insulin sensitivity. We examined the relationship between circulating SeP levels and clinical parameters associated with insulin resistance in humans.

PARTICIPANTS AND METHODS

We compared serum SeP concentrations in 100 subjects with diverse glucose tolerance statuses. Furthermore, we evaluated the relationship between SeP and cardiometabolic risk factors including insulin resistance, high-sensitivity C-reactive protein, and carotid intima-media thickness.

RESULTS

Serum SeP concentrations were significantly higher in patients with type 2 diabetes or prediabetes than those with normal glucose tolerance (all P < 0.01) and decreased in a stepwise manner [1032.4 (495.9-2149.4) vs. 867.3 (516.3-1582.7) vs. 362.0 (252.5-694.5), P = 0.004]. In addition, overweight and obese subjects had significantly increased SeP levels compared with lean subjects (P = 0.002). Spearman's partial correlation analysis adjusted for age and gender showed a significant relationship between SeP and cardiometabolic factors including body mass index, waist circumference, systolic blood pressure, triglycerides, glucose, hemoglobin A1c, aspartate aminotransferase, and insulin resistance. Furthermore, in multiple regression analyses, SeP showed an independent association with carotid intima-media thickness as well as high-sensitivity C-reactive protein, even after adjustment for other confounding factors.

CONCLUSIONS

Circulating SeP concentrations were elevated in patients with glucose metabolism dysregulation and were related to various cardiometabolic parameters including insulin resistance, inflammation, and atherosclerosis.

Comparison of the Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II scoring system, and Trauma and Injury Severity Score method for predicting the outcomes of intensive care unit trauma patients

PURPOSE

The aim of this study was to assess the ability of the Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system, and Trauma and Injury Severity Score (TRISS) method to predict group mortality for intensive care unit (ICU) trauma patients.

METHODS

The medical records of 706 consecutive major trauma patients admitted to the ICU of Samsung Changwon Hospital from May 2006 to April 2010 were retrospectively examined. The SOFA and the APACHE II scores were calculated based on data from the first 24 hours of ICU admission, and the TRISS was calculated using initial laboratory data from the emergency department and operative data. The probability of death was calculated for each patient based on the SOFA score, APACHE II score, and TRISS equations. The ability to predict group mortality for the SOFA score, APACHE II score, and TRISS method was assessed by using 2-by-2 decision matrices and receiver operating characteristic curve analysis and calibration analysis.

RESULTS

In 2-by-2 decision matrices with a decision criterion of 0.5, the sensitivities, specificities, and accuracies were 74.1%, 97.1%, and 92.4%, respectively, for the SOFA score; 58.5%, 99.6%, and 91.1%, respectively, for the APACHE II scoring system; and 52.4%, 94.8%, and 86.0%, respectively, for the TRISS method. In the receiver operating characteristic curve analysis, the areas under the curve for the SOFA score, APACHE II scoring system, and TRISS method were 0.953, 0.950, and 0.922, respectively.

CONCLUSION

The results from the present study showed that the SOFA score was not different from APACHE II scoring system and TRISS in predicting the outcomes for ICU trauma patients. However, the method for calculating SOFA scores is easier and simpler than APACHE II and TRISS.

Decreased emergency department length of stay by application of a computerized consultation management system

OBJECTIVES

Consultation difficulty occurs in hospitals located in many countries, and it is understood that strategies to improve the emergency department (ED) consultation process are needed. The authors constructed a computerized consultation management system in the ED of a tertiary care teaching hospital to improve the consultation process and evaluate the influence of the consultation management system on ED length of stay (LOS) and the throughput process.

METHODS

Consultation management system software was developed and integrated into the hospital information system. The development process took place between June 2008 and May 2009. Before the development of the consultation system, ED personnel contacted on-call physicians of the specialty department, who are usually residents, by cellular phones. After the system had been developed, ED personnel selected the department and on-call physician in the specialty department using the consultation management software and activated the automatic consultation process when specialty consultation was necessary. If the treatment plan had not been registered for 3 hours, all of the residents in the specific department are notified of the delay in the treatment plan with a short message service (SMS) message. If an admission or discharge order had not been made in 6 hours, all of the residents and faculty staff in the specific department receive SMS messages stating the delay in disposition. ED patient data were collected from the hospital information system for 40 days before the system was developed (June 1, 2008, to July 10, 2008) and 40 days after the system was implemented (June 1, 2009, to July 10, 2009).

RESULTS

The median ED LOS decreased significantly, from 417.5 minutes (interquartile range [IQR] = 178.8-1,247.5 minutes) in the presystem period to 311.0 minutes (IQR = 128.0-817.3 minutes) in the postsystem period (p < 0.001). Also, the median time to disposition order decreased significantly, from 336.0 minutes (IQR = 145.0-943.0 minutes) to 235.0 minutes (IQR = 103.0-21.5; p = 0.001). No significant reduction was observed in the interval between the time of disposition decision and the time when the patients left the ED. Significant reductions of ED LOS were observed after implementing the system (p < 0.001) regardless of whether the visit occurred during the weekday daytime (09:00-17:00 hours), holiday and weekend daytime (09:00-17:00 hours), or nighttime (17:00-09:00 hours next day).

CONCLUSIONS

This study found decreased ED LOS by implementation of a computerized consultation management system in a tertiary care teaching hospital. The automated consultation and monitoring process formalized communication between physicians providing ED patient care in the academic ED with high consultation and admission rates.

Hormonal responses upon return of spontaneous circulation after cardiac arrest: a retrospective cohort study

INTRODUCTION

Cardiac arrest is often fatal and can be extremely stressful to patients, even if spontaneous rhythm is returned. The purpose of this study was to analyze the hormonal response after return of spontaneous circulation (ROSC).

METHODS

This is a retrospective review of the chart and laboratory findings in a single medical facility. The patients admitted to the intensive care unit after successful resuscitation after out-of-hospital cardiac arrest were retrospectively identified and evaluated. Patients with hormonal diseases, patients who received cortisol treatment, those experiencing trauma, and pregnant women were excluded. Serum cortisol, adrenocorticotropic hormone (ACTH), and anti-diuretic hormone (ADH (vasopressin)) were analyzed and a corticotropin-stimulation test was performed. Mortality at one week and one month after admission, and neurologic outcome (cerebral performance category (CPC)) one month after admission were evaluated.

RESULTS

A total of 117 patients, including 84 males (71.8%), were evaluated in this study. One week and one month after admission, 87 (74.4%) and 65 patients (55.6%) survived, respectively. Relative adrenal insufficiency, and higher plasma ACTH and ADH levels were associated with shock-related mortality (P = 0.046, 0.005, and 0.037, respectively), and ACTH and ADH levels were also associated with late mortality (P = 0.002 and 0.004, respectively). Patients with relative adrenal insufficiency, ACTH ≧5 pg/mL, and ADH ≧30 pg/mL, had a two-fold increased risk of a poor outcome (shock-related mortality): (odds ratio (OR), 2.601 and 95% confidence interval (CI), 1.015 to 6.664; OR, 2.759 and 95% CI, 1.060 to 7.185; OR, 2.576 and 95% CI, 1.051 to 6.313, respectively). Thirty-five patients (29.9%) had a good CPC (1 to 2), and 82 patients (70.1%) had a bad CPC (3 to 5). Age ≧50 years and an ADH ≧30 pg/mL were associated with a bad CPC (OR, 4.564 and 95% CI, 1.794 to 11.612; OR, 6.568 and 95% CI, 1.918 to 22.483, respectively).

CONCLUSIONS

The patients with relative adrenal insufficiency and higher blood levels of ACTH and ADH upon ROSC after cardiac arrest had a poor outcome. The effectiveness of administration of cortisol and ADH to patients upon ROSC after cardiac arrest is uncertain and additional studies are needed.

Ministry of Health clinical practice guidelines: Management of Rhinosinusitis and Allergic Rhinitis

The Ministry of Health publishes national clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the Ministry of Health clinical practice guidelines on Management of Rhinosinusitis and Allergic Rhinitis, for the information of readers of the Singapore Medical Journal. Chapters, page and figure numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=24046). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

The value of initial ionized calcium as a predictor of mortality and triage tool in adult trauma patients

Ionized hypocalcemia is a common finding in critically ill patients, but the relationship between ionized hypocalcemia and mortality risk in trauma patients has not been well established. The aim of this study was to assess the usefulness of initial ionized calcium (iCa) in predicting mortality in the trauma population, and evaluate its superiority over the three other triage tools: base deficit, systemic inflammatory response syndrome (SIRS) score, and triage-revised trauma score (t-RTS). A pro-and retrospective study was performed on 255 consecutive trauma patients admitted to our Emergency Medical Center from January to December, 2005, who underwent arterial blood gas analysis. Multivariate logistic regression analysis confirmed iCa (<or=0.88 mM/L), low Glasgow coma scale score, and a large transfusion amount to be significant risk factors associated with mortality (p<0.05). The sensitivities of iCa, base deficit, SIRS score, and t-RTS were 82.9%, 76.4%, 67.1%, and 74.5%, and their specificities were 41.0%, 64.1%, 64.1%, and 87.2%, respectively. Receiver operating characteristic curve analysis determined the areas under the curves of these parameters to be 0.607+/-0.062, 0.736+/-0.056, 0.694+/-0.059, and 0.875+/-0.043, respectively (95% confidence interval). Although initial iCa (<or=0.88 mM/L) was confirmed as a significant risk factor associated with mortality, it exhibited a poorer discriminative power for mortality prediction than other predictors, especially t-RTS.

Prognostic determinants in patients with traumatic pancreatic injuries

The aim of this study was to identify factors that predict morbidity and mortality in patients with traumatic pancreatic injuries. A retrospective review was performed on 75 consecutive patients with traumatic pancreatic injuries admitted to the Emergency Medical Center at Masan Samsung Hospital and subsequently underwent laparotomy during the period January 2000 to December 2005. Overall mortality and morbidity rates were 13.3% and 49.3%, respectively. A multivariate regression analysis revealed that greater than 12 blood transfusions and an initial base deficit of less than -11 mM/L were the most important predictors of mortality (p<0.05). On the other hand, the most important predictors of morbidity were surgical complexity and an initial base deficit of less than -5.8 mM/L (p<0.01). These data suggests that early efforts to prevent shock and rapidly control of bleeding are most likely to improve the outcome in patients with traumatic pancreatic injuries. The severity of pancreatic injury per se influenced only morbidity.