Changes and their prognostic implications of the National Early Warning Score (NEWS) in interhospital transferred critically ill patients

Objective@#This study aimed to investigate the association between the change in the National Early Warning Score (NEWS) before and after interhospital transport and the survival of critically ill patients transported by critical care transport. @*Methods@#A retrospective analysis of SMICU (Seoul Mobile Intensive Care Unit) transfer records and the National Emergency Department Information System (NEDIS) was conducted. Adult patients who used SMICU from 2016 to 2018 were included. Trauma patients and post-cardiac arrest patients were excluded. The NEWS before departure from the transferring hospital and the NEWS before the arrival at the receiving hospital were extracted, and the difference between both NEWS (△ NEWS) was calculated. The △ NEWS was categorized into three groups: -2 or less, -1 to 1, and 2 or more. The primary outcome was 24-hour post-transport mortality. Multivariable logistic regression was applied to calculate the adjusted odds ratio (AOR) and 95% confidence interval (CI) for the outcomes. @*Results@#Of the total number of 1,837 patients, 1,065 patients were included. △ NEWS were -2 or less in 131 (12.3%), -1 to 1 in 805 (75.6%), and 2 or more in 129 (12.1%) of the patients. The 24-hour mortality rate was 3.1%, 2.9%, and 7.0% in the △ NEWS≤-2, -1≤△ NEWS≤1, and △ NEWS≥2 groups, respectively. Relative to -1≤△ NEWS≤1, the AORs for the 24-hour mortality were 1.11 (95% CI, 0.38-3.29) in △ NEWS≤-2 and 2.56 (95% CI, 1.15-5.70) in △ NEWS≥2. @*Conclusion@#The changes in NEWS in critical care interhospital transport are associated with patient prognosis.

Effect of prehospital patient consciousness level on prehospital stroke screening by emergency medical service provider of stroke patient

Objective@#Stroke detection at the prehospital stage is critically important for the provision of rapid treatment to stroke patients. This study aimed to evaluate the effect of patient consciousness level on prehospital stroke screening (PSS) by the emergency medical service (EMS) provider. @*Methods@#This retrospective cross-sectional study was conducted using data collected from a linked database of NEDIS (National Emergency Department Information System) and the EMS database in three hospitals. Adult stroke patients who were admitted into the emergency department (ED) using 119 EMS ambulances from 2014 to 2018 were included. The prehospital level of consciousness of patients was evaluated by the EMS provider, and they were divided into two treatment groups: an alert group and a non-alert group (verbal, painful, and unresponsive). The study outcomes were positive results of PSS: the Los Angeles Prehospital Stroke Scale (LAPSS) and Cincinnati Prehospital Stroke Scale (CPSS). Logistic regression analysis was conducted to evaluate the effect of prehospital consciousness level on the PSS result. @*Results@#A total number of 3,422 stroke patients were included. The positive rate of LAPSS was 17.0% in the alert group and 8.8% in the non-alert group. The positive rate of CPSS was 35.7% in the alert group and 21.3% in the non-alert group. In the adjusted logistic regression model, in the non-alert group, the adjusted odds ratio (AOR) for LAPSS was 0.47 (95% confidence interval [CI], 0.38-0.59) and the AOR for positive CPSS was 0.49 (95% CI, 0.42-0.57). @*Conclusion@#Low consciousness level patients had lower detection of stroke by the EMS provider. EMS provider employees need additional training to achieve more effective detection of stroke in low consciousness level patients.

Prehospital intravenous catheter insertion, scene time interval, and their association with fatality in severe trauma patients with hypotension

Objective@#To investigate the association between prehospital intravenous (IV) catheter insertion, scene time interval (STI), and fatality in severe trauma patients with hypotension. @*Methods@#This study used a 2018 nationwide emergency medical services (EMS)-based trauma database. Adult severe trauma patients whose injury severity score was above or equal to 16 and whose initial systolic blood pressure was under 90 mmHg were included. Patients were divided into four groups based on whether a prehospital IV catheter was inserted and STI was within 10 minutes-group 1, IV catheter (+) and STI <10 minutes; group 2, IV catheter (+) and STI ≥10 minutes; group 3, IV catheter (-) and STI <10 minutes; and group 4, IV catheter (-) and STI ≥10 minutes. W-score (additional survivor expected for every 100 patients) was used as the outcome index. @*Results@#Among the 30,034 EMS-treated severe trauma patients, 550 patients were analyzed. Group 1 comprised 289 patients (53%), group 2, 159 (29%), group 3, 65 (12%), and group 4, 37 (6.7%). The case fatality rate was 104 (36%) in group 1, 38 (25%) in group 2, 23 (35%) in group 3, and 11 (30%) in group 4. The W-score (95% confidence interval) was 2.42 (2.38 to 2.99) in group 1, 1.89 (1.83 to 2.90) in group 2, -4.62 (-4.70 to -2.94) in group 3, and -5.41 (-5.52 to -3.03) in group 4. @*Conclusion@#Prehospital IV catheter insertion in severe trauma patients with hypotension is beneficial for survival, and the positive effect was prominent when STI was short.

The Impact of the COVID-19 Outbreak on Emergency Medical Service:An Analysis of Patient Transportations and Time Intervals

Background@#This study aimed to investigate the impact of the coronavirus disease 2019 (COVID-19) outbreak on the Emergency Medical Service (EMS) system in South Korea. The study focused on the differences in EMS time intervals following the COVID-19 outbreak, particularly for patients with fever. @*Methods@#A retrospective analysis of EMS patient transportation data from 2017 to 2022 was conducted using the national EMS database. @*Results@#Starting from the year 2020, coinciding with the COVID-19 outbreak, all EMS time intervals experienced an increase. For the years 2017 to 2022, the mean response time interval values were 8.6, 8.6, 8.6, 10.2, 12.8, and 11.4 minutes, and the mean scene time interval values were 7.1, 7.2, 7.4, 9.0, 9.8, and 10.9 minutes. The mean transport time interval (TTI) values were 12.1, 12.3, 12.4, 14.2, 16.9, and 16.2 minutes, and the mean turnaround time interval values were 27.6, 27.9, 28.7, 35.2, 42.0, and 43.1 minutes. Fever (≥ 37.5°C) patients experienced more pronounced prolongations in EMS time intervals compared to non-fever patients and had a higher probability of being non-transported. The mean differences in TTI between fever and non-fever patients were 0.8, 0.8, 0.8, 4.3, 4.8, and 3.2 minutes, respectively, from 2017 to 2022. Furthermore, the odds ratios for fever patients being transported to the emergency department were 2.7, 2.9, 2.8, 1.1, 0.8, and 0.7, respectively, from 2017 to 2022. @*Conclusion@#The study findings highlight the significant impact of the COVID-19 outbreak on the EMS system and emphasize the importance of ongoing monitoring to evaluate the burden on the EMS system.

Impact of Awareness Time Interval on the Effect of Bystander Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arrest: A Nationwide Study

Purpose@#The awareness time interval (ATI), the time from the witnessed event to emergency medical service (EMS) activation, is an important factor influencing out-of-hospital cardiac arrest (OHCA) outcomes. Since bystander cardiopulmonary resuscitation (BCPR) is provided after cardiac arrest is recognized, the effect of BCPR may vary depending on ATI delay. We aimed to investigate whether ATI modifies the effect of BCPR on OHCA outcomes. @*Materials and Methods@#A population-based observational study was conducted with EMS-treated witnessed adult (≥18 years) OHCAs between 2013 and 2018. The exposure variable was provision of BCPR. The primary outcome was a good neurological outcome defined as cerebral performance category scale 1or 2 (good CPC). Multivariable logistic regression analysis was conducted using the ATI group (–1, 1–5, 5– min) as the interaction term. @*Results@#Of 34366 eligible OHCAs, 65.5% received BCPR. EMS was activated within 1 min in 45.9%, within 1–5 min in 29.2%, and after 5 min in 24.9% cases. In the adjusted interaction model, compared with no BCPR, a longer ATI resulted in smaller adjusted odds ratios for good CPC in the BCPR group [5.33 (4.17–6.82) for ATI ≤1 min, 5.14 (4.00–6.60) for 1–5 min, and 2.14 (1.63–2.81) for ATI >5 min]. @*Conclusion@#The effect of BCPR on improving the chances for a good neurological outcome decreased as time from collapse to EMS activation increased. The importance of early recognition of OHCA and EMS activation should be emphasized in BCPR training.

Beta-Meta: a meta-analysis application considering heterogeneity among genome-wide association studies

Many packages for a meta-analysis of genome-wide association studies (GWAS) have beendeveloped to discover genetic variants. Although variations across studies must be considered, there are not many currently-accessible packages that estimate between-study heterogeneity. Thus, we propose a python based application called Beta-Meta which can easilyprocess a meta-analysis by automatically selecting between a fixed effects and a randomeffects model based on heterogeneity. Beta-Meta implements flexible input data manipulation to allow multiple meta-analyses of different genotype-phenotype associations in asingle process. It provides a step-by-step meta-analysis of GWAS for each association inthe following order: heterogeneity test, two different calculations of an effect size and ap-value based on heterogeneity, and the Benjamini-Hochberg p-value adjustment. Thesemethods enable users to validate the results of individual studies with greater statisticalpower and better estimation precision. We elaborate on these and illustrate them with examples from several studies of infertility-related disorders.

Prevalence of deep vein thrombosis and its clinical significance in patients with acute symptomatic pulmonary embolism

Objective@#The aims of this study were to determine the prevalence of deep vein thrombosis (DVT) and assess the association of concomitant DVT and unfavorable outcomes in patients with acute symptomatic pulmonary embolism (PE). @*Methods@#We conducted a retrospective analysis of patients with acute symptomatic PE by a computed tomography angiography. Study patients were divided into two groups, including unfavorable and favorable outcome groups. Baseline characteristics and radiologic findings were compared between the two groups. Then, binary logistic regression analysis using the unfavorable outcome as a dependent variable was performed to assess whether concomitant DVT was associated with unfavorable outcomes. @*Results@#Of the 128 patients, 67.2% (86 of 128) had concomitant DVT, and 20.3% (26 of 128) had an unfavorable outcome. The median age was 75.0 years (interquartile range, 63.0-82.0 years), and 76 (59.4%) patients were female. Concomitant DVT and proximal DVT were associated with unfavorable outcomes (P<0.05). In multivariate analysis, proximal DVT (adjusted odds ratio, 7.03; 95% confidence interval, 1.01-49.12) was an independent risk factor of unfavorable outcome. @*Conclusion@#In patients with acute symptomatic PE, about two-thirds of patients had DVT. This study suggests that proximal DVT is significantly associated with unfavorable outcomes.

Modification and Validation of a Complaint-Oriented Emergency Department Triage System:A Multicenter Observational Study

Purpose@#The objective of this study was to modify and validate an emergency department (ED) triage system with improved prediction performance on hospital outcomes by modifying the Korean Triage and Acuity Scale (KTAS). @*Materials and Methods@#We performed a retrospective observational study at three academic universities in South Korea. The KTAS code, determined by the chief complaint and the selected modifier of a patient, was used to derive the Modified KTAS (MKTAS). We calculated the area under the receiver operating characteristics curve (AUC) and the test characteristics to evaluate the performance of MKTAS to predict hospital mortality, critical outcome, and admission. @*Results@#A total of 272402 and 128831 ED visits were used for the derivation and validation of MKTAS, respectively. Compared to KTAS, MKTAS had significantly higher AUC values for the prediction of hospital mortality [MKTAS 0.826 (0.818–0.835) vs. KTAS 0.794 (0.784–0.803)], critical outcome [MKTAS 0.836 (0.830–0.841) vs. 0.798 (0.792–0.804)], and admission [MKTAS 0.725 (0.723– 0.728) vs. KTAS 0.685 (0.682–0.688)]. The sensitivity for predicting hospital mortality and critical outcome, as well as the specificity for predicting admission, were significantly improved. @*Conclusion@#MKTAS was derived by modifying the KTAS, and then validated. Compared with KTAS, MKTAS showed better discriminating ability to predict hospital outcomes. Continuous efforts to evaluate and modify widely used triage systems are required to improve their performance.

Low serum cholesterol level as a risk factor for out-of-hospital cardiac arrest: a case-control study

Objective@#We aimed to identify the association between low serum total cholesterol levels and the risk of out-of-hospital cardiac arrest (OHCA). @*Methods@#This case-control study was performed using datasets from the Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES) project and the Korea National Health and Nutrition Examination Survey (KNHANES). Cases were defined as emergency medical service-treated adult patients who experienced OHCA with a presumed cardiac etiology from the CAPTURES project dataset. Four controls from the KNHANES dataset were matched to each case based on age, sex, and county. Multivariable conditional logistic regression analysis was conducted to evaluate the effect of total cholesterol levels on OHCA. @*Results@#A total of 607 matched case-control pairs were analyzed. We classified total cholesterol levels into six categories (<148, 148-166.9, 167-189.9, 190-215.9, 216.237.9, and ≥238 mg/dL) according to the distribution of total cholesterol levels in the KNHANES dataset. Subjects with a total cholesterol level of 167-189.9 mg/dL (25th.49th percentile of the KNHANES dataset) were used as the reference group. In both the adjusted models and sensitivity analysis, a total cholesterol level of <148 mg/dL was significantly associated with OHCA (adjusted odds ratio [95% confidence interval], 6.53 [4.47.9.56]). @*Conclusion@#We identified an association between very-low total cholesterol levels and an increased risk of OHCA in a large, community-based population. Future prospective studies are needed to better understand how a low lipid profile is associated with OHCA.

Neurological outcomes and survival rate of out-of-hospital cardiac arrest patients with return of spontaneous circulation after percutaneous coronary intervention across age groups: a cross-sectional study

Objective@#Little is known about percutaneous coronary intervention (PCI) and its benefits in elderly patients with out-of-hospital cardiac arrest (OHCA). This study compared the survival to discharge and the neurological outcomes across the age groups of patients with OHCA. @*Methods@#Using the national cardiac arrest registry, OHCA patients with a return of spontaneous circulation from 2013 to 2017 were included in this study. The PCI history of the patients was obtained from their medical records. The outcomes were cerebral performance category (CPC) 1 and 2 and survival to discharge. Multivariable logistic regression analysis was performed, and an interaction term was evaluated to compare the effects of PCI across the age groups. @*Results@#This study included 22,320 patients. In the interaction term, the adjusted odds ratio (AOR) (95% confidence interval [CI]) for a good CPC was 2.84 (2.43-3.32) for the age group of 18-64 years, 3.26 (2.53-4.21) for the age group of 65-74 years, 3.37 (2.33-4.88) for the age group of 75-84 years, and 2.54 (0.92-7.01) for the age group of 85-106 years. The AOR (95% CI) for survival to hospital discharge was 3.31 (2.82-3.88) for the age group of 18-64 years, 2.65 (2.09-3.35) for the age group of 65-74 years, 2.20 (1.61-3.02) for the age group of 75-84 years, and 1.64 (0.73-3.67) for the age group of 85-106 years. @*Conclusion@#In the OHCA patients, the PCI group had more good outcomes (good CPC, survival to discharge) than the non-PCI group, but this benefit was not shown in those aged over 85 years. On the other hand, it could not explain why PCI should not be performed in the elderly, suggesting that age alone should not be used to make decisions regarding early invasive strategies.

The Implication of Cardiac Injury Score on In-hospital Mortality of Coronavirus Disease 2019

Background@#s: The severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) has spread worldwide. Cardiac injury after SARS-CoV-2 infection is a major concern. The present study investigated impact of the biomarkers indicating cardiac injury in coronavirus disease 2019 (COVID-19) on patients' outcomes. @*Methods@#This study enrolled patients who were confirmed to have COVID-19 and admitted at a tertiary university referral hospital between February 19, 2020 and March 15, 2020. Cardiac injury was defined as an abnormality in one of the following result markers: 1) myocardial damage marker (creatine kinase-MB or troponin-I), 2) heart failure marker (N-terminal-pro B-type natriuretic peptide), and 3) electrical abnormality marker (electrocardiography). The relationship between each cardiac injury marker and mortality was evaluated. Survival analysis of mortality according to the scoring by numbers of cardiac injury markers was also performed. @*Results@#A total of 38 patients with COVID-19 were enrolled. Twenty-two patients (57.9%) had at least one of cardiac injury markers. The patients with cardiac injuries were older (69.6 ± 14.9 vs. 58.6 ± 13.9 years old, P = 0.026), and were more male (59.1% vs. 18.8%, P = 0.013).They showed lower initial oxygen saturation (92.8 vs. 97.1%, P = 0.002) and a trend toward higher mortality (27.3 vs. 6.3%, P = 0.099). The increased number of cardiac injury markers was significantly related to a higher incidence of in-hospital mortality which was also evidenced by Kaplan-Meier survival analysis (P = 0.008). @*Conclusion@#The increased number of cardiac injury markers is related to in-hospital mortality in patients with COVID-19.

Development of a modified trauma and injury severity score to predict disability in acute trauma patients

Objective@#The Trauma and Injury Severity Score (TRISS) has been used to predict trauma patient mortality and to assess the quality of trauma care systems. The goal of this investigation was to develop a modified trauma-related injury severity score (termed the TRISS-D) for predicting disability in acute trauma patients. @*Methods@#We used data collected by emergency medical services and entered into the Korea Centers for Disease Control and Prevention severe trauma database. The TRISS-D was based on age category (0–14, 15–54, ≥55 years), the Revised Trauma Score, and the Injury Severity Score. The outcome measures were severe disability and worsening disability. Worsening disability was defined as a lower Glasgow Outcome Scale score at hospital discharge than before the traumatic incident. Two types of cases were examined: those with penetrating or blunt injuries (group 1) and those with severe head injuries (group 2). We assessed the discriminatory power of the TRISS-D by calculating the area under a receiver operating characteristic curve (AUROC). @*Results@#The database comprised 14,791 patients; overall, 3,757 (25%) had severe disability and 6,018 (41%) had worsening disability. For severe disability, the AUROC (95% confidence interval) for the TRISS-D was 0.948 (0.944–0.952) in group 1 and 0.950 (0.946–0.954) in group 2. The corresponding values for worsening disability were 0.810 (0.803–0.817) and 0.816 (0.809–0.823), respectively. @*Conclusion@#The TRISS-D showed excellent discriminatory power for severe disability and very good discriminatory power for worsening disability.

Development of a modified trauma and injury severity score to predict disability in acute trauma patients

Objective@#The Trauma and Injury Severity Score (TRISS) has been used to predict trauma patient mortality and to assess the quality of trauma care systems. The goal of this investigation was to develop a modified trauma-related injury severity score (termed the TRISS-D) for predicting disability in acute trauma patients. @*Methods@#We used data collected by emergency medical services and entered into the Korea Centers for Disease Control and Prevention severe trauma database. The TRISS-D was based on age category (0–14, 15–54, ≥55 years), the Revised Trauma Score, and the Injury Severity Score. The outcome measures were severe disability and worsening disability. Worsening disability was defined as a lower Glasgow Outcome Scale score at hospital discharge than before the traumatic incident. Two types of cases were examined: those with penetrating or blunt injuries (group 1) and those with severe head injuries (group 2). We assessed the discriminatory power of the TRISS-D by calculating the area under a receiver operating characteristic curve (AUROC). @*Results@#The database comprised 14,791 patients; overall, 3,757 (25%) had severe disability and 6,018 (41%) had worsening disability. For severe disability, the AUROC (95% confidence interval) for the TRISS-D was 0.948 (0.944–0.952) in group 1 and 0.950 (0.946–0.954) in group 2. The corresponding values for worsening disability were 0.810 (0.803–0.817) and 0.816 (0.809–0.823), respectively. @*Conclusion@#The TRISS-D showed excellent discriminatory power for severe disability and very good discriminatory power for worsening disability.

Quantitative autonomic function test in differentiation of multiple system atrophy from idiopathic Parkinson disease / 中华医学杂志(英文版)

BACKGROUND@#Differential diagnosis of idiopathic Parkinson disease (IPD) and multiple system atrophy-Parkinson type (MSA-P) is challenging since they share clinical features with parkinsonism and autonomic dysfunction. To distinguish MSA-P from IPD when the symptoms are relatively mild, we investigated the usefulness of the quantitative fractionalized autonomic indexes and evaluated the correlations of autonomic test indexes and functional status.@*METHODS@#Thirty-six patients with parkinsonism (22 with IPD and 14 with MSA-P) in Soonchunhyang University Bucheon Hospital from February 2014 to June 2015 were prospectively enrolled in the study. We compared fractionalized autonomic indexes and composite autonomic scoring scale between patients with IPD and MSA-P with Hoehn and Yahr (H&Y) score ≤3. Parasympathetic indexes included expiratory/inspiratory ratio during deep breathing, Valsalva ratio (VR), and regression slope of systolic blood pressure (BP) in early phase II (vagal baroreflex sensitivity) during Valsalva maneuver. Sympathetic adrenergic indexes were pressure recovery time (PRT) and adrenergic baroreflex sensitivity (BRSa) (BP decrement associated with phase 3 divided by the PRT), sympathetic index 1, sympathetic index 3, early phase II mean BP drop, and pulse pressure reduction rate. Additionally, we compared the unified multiple system atrophy rating scale (UMSARS) and H&Y scores and the autonomic indexes in all patients.@*RESULTS@#PRT was significantly different between the IPD and MSA-P groups (P = 0.004) despite the similar BP drop during tilt. Cut-off value of PRT was 5.5 s (sensitivity, 71.4%; specificity, 72.7%). VR (r = -0.455, P = 0.009) and BRSa (r = -0.356, P = 0.036) demonstrated a significant correlation with UMSARS and H&Y scores.@*CONCLUSIONS@#Among the cardiovascular autonomic indexes, PRT can be a useful parameter in differentiating the early stage of MSA-P from that of IPD. Moreover, VR, and BRSa may be the optimal indexes in determining functional symptom severity.

New prehospital scoring system for traumatic brain injury to predict mortality and severe disability using motor Glasgow Coma Scale, hypotension, and hypoxia: a nationwide observational study

OBJECTIVE: Assessing the severity of injury and predicting outcomes are essential in traumatic brain injury (TBI). However, the respiratory rate and Glasgow Coma Scale (GCS) of the Revised Trauma Score (RTS) are difficult to use in the prehospital setting. This investigation aimed to develop a new prehospital trauma score for TBI (NTS-TBI) to predict mortality and disability.METHODS: We used a nationwide trauma database on severe trauma cases transported by fire departments across Korea in 2013 and 2015. NTS-TBI model 1 used systolic blood pressure < 90 mmHg, peripheral capillary oxygen saturation < 90% measured via pulse oximeter, and motor component of GCS. Model 2 comprised variables of model 1 and age >65 years. We assessed discriminative power via area under the curve (AUC) value for in-hospital mortality and disability defined according to the Glasgow Outcome Scale with scores of 2 or 3. We then compared AUC values of NTS-TBI with those of RTS.RESULTS: In total, 3,642 patients were enrolled. AUC values of NTS-TBI models 1 and 2 for mortality were 0.833 (95% confidence interval [CI], 0.815 to 0.852) and 0.852 (95% CI, 0.835 to 0.869), respectively, while AUC values for disability were 0.772 (95% CI, 0.749 to 0.796) and 0.784 (95% CI, 0.761 to 0.807), respectively. AUC values of NTS-TBI model 2 for mortality and disability were higher than those of RTS (0.819 and 0.761, respectively) (P < 0.01).CONCLUSION: Our NTS-TBI model using systolic blood pressure, motor component of GCS, oxygen saturation, and age was feasible for prehospital care and showed outstanding discriminative power for mortality.

Assessment of serum biomarkers and coagulation/fibrinolysis markers for prediction of neurological outcomes of out of cardiac arrest patients treated with therapeutic hypothermia

OBJECTIVE: Despite increased survival in patients with cardiac arrest, it remains difficult to determine patient prognosis at the early stage. This study evaluated the prognosis of cardiac arrest patients using brain injury, inflammation, cardiovascular ischemic events, and coagulation/fibrinolysis markers collected 24, 48, and 72 hours after return of spontaneous circulation (ROSC).METHODS: From January 2011 to December 2016, we retrospectively observed patients who underwent therapeutic hypothermia. Blood samples were collected immediately and 24, 48, and 72 hours after ROSC. Neuron-specific enolase (NSE), S100-B protein, procalcitonin, troponin I, creatine kinase-MB, pro-brain natriuretic protein, D-dimer, fibrin degradation product, antithrombin-III, fibrinogen, and lactate levels were measured. Prognosis was evaluated using Glasgow-Pittsburgh cerebral performance categories and the predictive accuracy of each marker was evaluated. The secondary outcome was whether the presence of multiple markers improved prediction accuracy.RESULTS: A total of 102 patients were included in the study: 39 with good neurologic outcomes and 63 with poor neurologic outcomes. The mean NSE level of good outcomes measured 72 hours after ROSC was 18.50 ng/mL. The area under the curve calculated on receiver operating characteristic analysis was 0.92, which showed the best predictive power among all markers included in the study analysis. The relative integrated discrimination improvement and category-free net reclassification improvement models showed no improvement in prognostic value when combined with all other markers and NSE (72 hours).CONCLUSION: Although biomarker combinations did not improve prognostic accuracy, NSE (72 hours) showed the best predictive power for neurological prognosis in patients who received therapeutic hypothermia.

The Effect of Transport Time Interval on Neurological Recovery after Out-of-Hospital Cardiac Arrest in Patients without a Prehospital Return of Spontaneous Circulation

BACKGROUND: Longer transport adversely affects outcomes in out-of-hospital cardiac arrest (OHCA) patients who do not return to spontaneous circulation (ROSC). The aim of this study was to determine the association between the transport time interval (TTI) and neurological outcomes in OHCA patients without ROSC. METHODS: We analyzed adult OHCA patients with presumed cardiac etiology and without prehospital ROSC from 2012 to 2015. The study population was divided into 2 groups according to STI (short STI [1–5 minutes] and long STI [≥ 6 minutes]). The primary exposure was TTI, which was categorized as short (1–5 minutes), intermediate (6–10 minutes), or long (≥ 11 minutes). The primary outcome was a good neurological recovery at discharge. Multiple logistic regression analysis was used in each STI group. RESULTS: Among 57,822 patients, 23,043 (40%), 20,985 (36%), and 13,794 (24%) were classified as short, intermediate, and long TTI group. A good neurological recovery occurred in 1.0%, 0.6%, and 0.3% of the patients in the short, intermediate and long TTI group, respectively. Among 12,652 patients with short STI, a good neurological recovery occurred in 2.2%, 1.0%, and 0.4% of the patients in the short, intermediate and long TTI group, respectively. Among 45,570 patients with long STI, a good neurological recovery occurred in 0.7%, 0.5%, and 0.3% of the patients in the short, intermediate and long TTI group, respectively. When short TTI was used as a reference, the adjusted odds ratios (AOR) of TTI for good neurological recovery was different between short STI group and long STI group (AOR [95% confidence interval, 0.46 [0.32–0.67] vs. 0.72 [0.59–0.89], respectively, for intermediate TTI and 0.31 [0.17–0.55] vs. 0.49 [0.37–0.65], respectively, for long TTI). CONCLUSION: A longer TTI adversely affected the likelihood of a good neurological recovery in OHCA patients without prehospital ROSC. This negative effect was more prominent in short STI group.

Epidemiology and Outcomes of Sports-Related Traumatic Brain Injury in Children

BACKGROUND: Traumatic brain injury (TBI) is one of the leading causes of pediatric disability that results in many emergency department visits. The risk of TBI is high while playing sports. The aim of this study was to examine the demographics and clinical characteristics of sports-related TBI. METHODS: We performed a multicenter observational study using the Emergency Department–Based Injury In-Depth Surveillance database in Korea. Patients aged 5 to 18 years old, who sustained unintentional, sports-related head injuries between January 2011 and December 2016 were included. The type of sports was the main variable of interest, and it was classified into 6 categories. The primary outcome was TBI, and the secondary outcome was intracranial injury and hospital admission. A multivariable logistic regression analysis was performed to calculate the adjusted odds ratios (aORs) with 95% confidence intervals for the outcomes by sports type. RESULTS: Of the 1,537,617 injured patients, 10,717 (0.7%) patients were included in the study. Most of the patients were male (87.5%), and the most prevalent sports type was field sports (51.2%). The proportion of TBI, intracranial injury, and admission were 15.7%, 1.2%, and 3.5%, respectively. The aORs of TBI, intracranial injury, and admission in bicycle and street sports compared to field sports were 1.77 (1.37–2.28), 4.99 (2.62–9.50), and 2.27 (1.42–3.61) respectively. CONCLUSION: This is the first nationwide epidemiologic study of pediatric sports-related TBI in Korea. The ratios of TBI, intracranial injury and admission were highest in bicycle and street sports. Prevention strategies for pediatric sports-related TBI can be developed according to sports types.

Re-transmissibility of mouse-adapted ME7 scrapie strain to ovine PrP transgenic mice

Scrapie is a mammalian transmissible spongiform encephalopathy or prion disease that predominantly affects sheep and goats. Scrapie has been shown to overcome the species barrier via experimental infection of other rodents. To confirm the re-transmissibility of the mouse-adapted ME7 scrapie strain to ovine prion protein (PrP) transgenic mice, mice of an ovinized transgenic mouse line carrying the Suffolk sheep PrP gene that contained the A₁₃₆ R₁₅₄ Q₁₇₁/ARQ allele were intracerebrally inoculated with brain homogenates obtained from terminally ill ME7-infected C57BL/6J mice. Herein, we report that the mouse-adapted ME7 scrapie strain was successfully re-transmitted to the transgenic mice expressing ovine PrP. In addition, we observed changes in the incubation period, glycoform profile, and pattern of scrapie PrP (PrP(Sc)) deposition in the affected brains. PrP(Sc) deposition in the hippocampal region of the brain of 2nd-passaged ovine PrP transgenic mice was accompanied by plaque formation. These results reveal that the mouse-adapted ME7 scrapie strain has the capacity to act as a template for the conversion of ovine normal monomeric precursors into a pathogenic form in ovine PrP transgenic mice. The change in glycoform pattern and the deposition of plaques in the hippocampal region of the brain of the 2nd-passaged PrP transgenic mice are most likely cellular PrP species dependent rather than being ME7 scrapie strain encoded.

Delphi study to evaluate the emergency medical system operation fund support projects

OBJECTIVE: This study aimed to achieve expert consensus for the evaluation of Emergency medical system operation fund (EMSOF) support projects using the Delphi method in Korea. METHODS: The Delphi study was performed in June 2018. Experts who are members of the policy committee of the Korean Society of Emergency Medicine (KSEM) participated in the study. Respondents were asked to express their level of agreement of appropriateness for the following 6 categories for 21 projects: project contents, amount of support, indicators, performance, overall evaluation, and need to maintain. With a possible score of 9 points, the project categories were classified into 3 groups, inappropriate, moderate and appropriate, based on the median score of the respondents' ratings in each question. RESULTS: Sixteen of the 18 policy committee members participated in the survey. Their average professional work years were 8.2 years. All 21 projects were evaluated as appropriate for content. Amount of support and indicators were evaluated as moderate. Only 5 out of the 21 projects were evaluated as having appropriate indicators. No projects were evaluated as ineffective. Comprehensive evaluation of the projects was evaluated as moderate, and no project was evaluated as inappropriate in fund support. CONCLUSION: Overall, the contents of the EMSOF assistance project were rated high; however, there was a disagreement on the amount of support and evaluation indicators for each project. The results of this study are expected to be used as basic data to improve the use of EMSOF.