Characteristics and impacts from assault against emergency medical technicians in the emergency room

Objective@#Assault in the emergency room can lead to a decrease in the quality of the entire emergency medical system due to the functional deterioration and increased fatigue of the medical staff. This research tried to identify and analyze the characteristics of assault against emergency medical technicians (EMTs) working in the emergency room and establish the factors related to poor post-assault-exposure response. @*Methods@#In this multicenter study, we conducted a survey of EMTs working in the emergency rooms. Response after assault was measured by Likert 5-point scale; the data of the participants were divided based on the median score. The demographic characteristics, hospital preparedness, and the characteristics of the assault were analyzed. Afterwards, the data of the risk factors for poor post-assault-exposure response were subjected to multivariable logistic analysis. @*Results@#Of the 141 study participants, 84 (59.6%) were women. Most of them had experienced verbal violence (n=137, 97.2%) and physical threats (n=137, 92.2%), and 96 (68.0%) had experienced physical assault in the past year. The results of the multivariable logistic regression analysis revealed that female sex (adjusted odds ratio [aOR], 6.152; 95% confidence interval [CI], 2.687-14.120) and the increase in the number of physical assaults (aOR, 1.160; 95% CI, 1.036- 1.298) were associated with a poor response. @*Conclusion@#Considering the importance of the EMTs in the emergency medical system and the potential adverse effects on the status of their health and services, the provision of appropriate support to female EMTs and the active intervention for attenuation of physical assault escalation in case of aggressive situations is needed. Our present results can be used for the identification and resolution of the underlying causes of these problems.

Clinical Characteristics and Risk Factors for Mortality in Critical COVID-19 Patients Aged 50 Years or Younger During Omicron Wave in Korea:Comparison With Patients Older Than 50 Years of Age

Background@#The coronavirus disease 2019 (COVID-19) pandemic has caused the death of thousands of patients worldwide. Although age is known to be a risk factor for morbidity and mortality in COVID-19 patients, critical illness or death is occurring even in the younger age group as the epidemic spreads. In early 2022, omicron became the dominant variant of the COVID-19 virus in South Korea, and the epidemic proceeded on a large scale. Accordingly, this study aimed to determine whether young adults (aged ≤ 50 years) with critical COVID-19 infection during the omicron period had different characteristics from older patients and to determine the risk factors for mortality in this specific age group. @*Methods@#We evaluated 213 critical adult patients (high flow nasal cannula or higher respiratory support) hospitalized for polymerase chain reaction-confirmed COVID-19 in nine hospitals in South Korea between February 1, 2022 and April 30, 2022. Demographic characteristics, including body mass index (BMI) and vaccination status; underlying diseases; clinical features and laboratory findings; clinical course; treatment received; and outcomes were collected from electronic medical records (EMRs) and analyzed according to age and mortality. @*Results@#Overall, 71 critically ill patients aged ≤ 50 years were enrolled, and 142 critically ill patients aged over 50 years were selected through 1:2 matching based on the date of diagnosis. The most frequent underlying diseases among those aged ≤ 50 years were diabetes and hypertension, and all 14 patients who died had either a BMI ≥ 25 kg/m 2 or an underlying disease. The total case fatality rate among severe patients (S-CFR) was 31.0%, and the S-CFR differed according to age and was higher than that during the delta period. The S-CFR was 19.7% for those aged ≤ 50 years, 36.6% for those aged > 50 years, and 38.1% for those aged ≥ 65 years. In multivariate analysis, age (odds ratio [OR], 1.084; 95% confidence interval [CI], 1.043–1.127), initial low-density lipoprotein > 600 IU/L (OR, 4.782; 95% CI, 1.584–14.434), initial C-reactive protein > 8 mg/dL (OR, 2.940; 95% CI, 1.042–8.293), highest aspartate aminotransferase > 200 IU/L (OR, 12.931; 95% CI, 1.691–98.908), and mechanical ventilation implementation (OR, 3.671; 95% CI, 1.294–10.420) were significant independent predictors of mortality in critical COVID-19 patients during the omicron wave. A similar pattern was shown when analyzing the data by age group, but most had no statistical significance owing to the small number of deaths in the young critical group. Although the vaccination completion rate of all the patients (31.0%) was higher than that in the delta wave period (13.6%), it was still lower than that of the general population. Further, only 15 (21.1%) critically ill patients aged ≤ 50 years were fully vaccinated. Overall, the severity of hospitalized critical patients was significantly higher than that in the delta period, indicating that it was difficult to find common risk factors in the two periods only with a simple comparison. @*Conclusion@#Overall, the S-CFR of critically ill COVID-19 patients in the omicron period was higher than that in the delta period, especially in those aged ≤ 50 years. All of the patients who died had an underlying disease or obesity. In the same population, the vaccination rate was very low compared to that in the delta wave, indicating that non-vaccination significantly affected the progression to critical illness. Notably, there was a lack of prescription for Paxlovid for these patients although they satisfied the prescription criteria. Early diagnosis and active initial treatment was necessary, along with the proven methods of vaccination and personal hygiene. Further studies are needed to determine how each variant affects critically ill patients.

Loss of Neutralizing Activity of Tixagevimab/Cilgavimab (Evusheld™) Against Omicron BN.1, a Dominant Circulating Strain Following BA.5During the Seventh Domestic Outbreak in Korea in Early 2023

Tixagevimab/cilgavimab is a monoclonal antibody used to prevent coronavirus disease 2019 among immunocompromised hosts and maintained neutralizing activity against early omicron variants. Omicron BN.1 became a dominant circulating strain in Korea early 2023, but its susceptibility to tixagevimab/cilgavimab is unclear. We conducted plaque reduction neutralization test (PRNT) against BN.1 in a prospective cohort (14 patients and 30 specimens). BN.1 PRNT was conducted for one- and three-months after tixagevimab/ cilgavimab administration and the average PRNT ND 50 of each point was lower than the positive cut-off value of 20 (12.9 ± 4.5 and 13.2 ± 4.2, respectively, P = 0.825). In the paired analyses, tixagevimab/cilgavimab-administered sera could not actively neutralize BN.1 (PRNT ND 50 11.5 ± 2.9, P = 0.001), compared with the reserved activity against BA.5 (ND 50 310.5 ± 180.4). Unlike virus-like particle assay, tixagevimab/cilgavimab was not active against BN.1 in neutralizing assay, and would not be effective in the present predominance of BA.2.75 sublineages.

Severity-Adjusted Dexamethasone Dosing and Tocilizumab Combination for Severe COVID-19

Purpose@#Real-world experience with tocilizumab in combination with dexamethasone in patients with severe coronavirus disease (COVID-19) needs to be investigated. @*Materials and Methods@#A retrospective cohort study was conducted to evaluate the effect of severity-adjusted dosing of dexamethasone in combination with tocilizumab for severe COVID-19 from August 2020 to August 2021. The primary endpoint was 30-day clinical recovery, which was defined as no oxygen requirement or referral after recovery. @*Results@#A total of 66 patients were evaluated, including 33 patients in the dexamethasone (Dexa) group and 33 patients in the dexamethasone plus tocilizumab (DexaToci) group. The DexaToci group showed a statistically significant benefit in 30-day clinical recovery, compared to the Dexa group (p=0.024). In multivariable analyses, peak FiO2 within 3 days and tocilizumab combination were consistently significant for 30-day recovery (all p<0.05). The DexaToci group showed a significantly steeper decrease in FiO2 (-4.2±2.6) than the Dexa group (−2.7±2.6; p=0.021) by hospital day 15. The duration of oxygen requirement was significantly shorter in the DexaToci group than the Dexa group (median, 10.0 days vs. 17.0 days; p=0.006). Infectious complications and cellular and humoral immune responses against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the convalescence stage were not different between the two groups. @*Conclusion@#A combination of severity-adjusted dexamethasone and tocilizumab for the treatment of severe COVID-19 improved clinical recovery without increasing infectious complications or hindering the immune response against SARS-CoV-2.

Genetic–pathologic characterization of myeloproliferative neoplasms

Myeloproliferative neoplasms (MPNs) are clonal hematopoietic stem cell disorders characterized by the proliferation of one or more myeloid lineages. The current study demonstrates that three driver mutations were detected in 82.6% of 407 MPNs with a mutation distribution of JAK2 in 275 (67.6%), CALR in 55 (13.5%) and MPL in 6 (1.5%). The mutations were mutually exclusive in principle except in one patient with both CALR and MPL mutations. The driver mutation directed the pathologic features of MPNs, including lineage hyperplasia, laboratory findings and clinical presentation. JAK2-mutated MPN showed erythroid, granulocytic and/or megakaryocytic hyperplasia whereas CALR- and MPL-mutated MPNs displayed granulocytic and/or megakaryocytic hyperplasia. The lineage hyperplasia was closely associated with a higher mutant allele burden and peripheral cytosis. These findings corroborated that the lineage hyperplasia consisted of clonal proliferation of each hematopoietic lineage acquiring driver mutations. Our study has also demonstrated that bone marrow (BM) fibrosis was associated with disease progression. Patients with overt fibrosis (grade ⩾2) presented an increased mutant allele burden (P<0.001), an increase in chromosomal abnormalities (P<0.001) and a poor prognosis (P<0.001). Moreover, among patients with overt fibrosis, all patients with wild-type JAK2/CALR/MPL (triple-negative) showed genomic alterations by genome-wide microarray study and revealed the poorest overall survival, followed by JAK2-mutated MPNs. The genetic–pathologic characteristics provided the information for understanding disease pathogenesis and the progression of MPNs. The prognostic significance of the driver mutation and BM fibrosis suggests the necessity of a prospective therapeutic strategy to improve the clinical outcome.

A Case of Plasmodium malariae Infection Imported from Guinea

Recently, the number of Korean travelers and workers to malaria-endemic regions has increased, and the number of patients with imported malaria cases has increased as well. In Korea, most cases of imported malaria infections are caused by Plasmodium falciparum and P. vivax. Only one report of imported P. malariae infection has been published thus far. Here, we describe a case of imported P. malariae infection that was confirmed by peripheral blood smear and nested PCR targeting the small subunit ribosomal RNA (SSU rRNA) gene. A 53-yr-old man, who had stayed in the Republic of Guinea in tropical West Africa for about 40 days, experienced fever and headache for 3 days before admission. The results of rapid malaria test using the SD Malaria Antigen/Antibody Kit (Standard Diagnostics, Korea) were negative, but Wright-Giemsa stained peripheral blood smear revealed Plasmodium. To identify the Plasmodium species and to examine if the patient had a mixed infection, we performed nested PCR targeting the SSU rRNA gene. P. malariae single infection was confirmed by nested PCR. Sequence analysis of the SSU rRNA gene of P. malariae showed that the isolated P. malariae was P. malariae type 2. Thus, our findings suggest that when cases of imported malaria infection are suspected, infection with P. malariae as well as P. falciparum and P. vivax should be considered. For the accurate diagnosis and treatment of imported malaria cases, we should confirm infection with Plasmodium species by PCR as well as peripheral blood smear and rapid malaria antigen test.

A Case of Plasmodium ovale Malaria Imported from West Africa

Malaria is a parasitic infection caused by Plasmodium species. Most of the imported malaria in Korea are due to Plasmodium vivax and Plasmodium falciparum, and Plasmodium ovale infections are very rare. Here, we report a case of a 24-year-old American woman who acquired P. ovale while staying in Ghana, West Africa for 5 months in 2010. The patient was diagnosed with P. ovale malaria based on a Wright-Giemsa stained peripheral blood smear, Plasmodium genus-specific real-time PCR, Plasmodium species-specific nested PCR, and sequencing targeting 18S rRNA gene. The strain identified had a very long incubation period of 19-24 months. Blood donors who have malaria with a very long incubation period could be a potential danger for propagating malaria. Therefore, we should identify imported P. ovale infections not only by morphological findings but also by molecular methods for preventing propagation and appropriate treatment.

Evaluation of HUBI-QUANPRO Point-of-Care Testing for Cardiac Markers / 임상검사와정도관리

BACKGROUND: Recently, quantitative point-of-care testing (POCT) for cardiac markers using colloidal gold particles was developed in Korea. We evaluated the analytical performance of the HUBI-QUANPRO (Humasis, Korea) assay in comparison with two other assays. METHODS: We evaluated the analytical precision and linearity of HUBI-QUANPRO creatine kinase (CK)-MB, cardiac troponin I (cTnI), and B-type natriuretic peptides (BNP). HUBI-QUANPRO assay was compared with ADVIA Centaur (Siemens, Germany) and Triage (Biosite Diagnostics, USA) assays by using 100 blood samples. In addition, we evaluated the interference of hemoglobin on the HUBI-QUANPRO assay. RESULTS: The coefficients of variation of HUBI-QUANPRO CK-MB, cTnI, and BNP were 7.5-9.7%, 12.0-17.4%, and 14.7-15.7%, respectively. The linearity ranges of HUBI-QUANPRO CK-MB, cTnI, and BNP were 4.7-27.8 ng/mL, 0.76-6.51 ng/mL, and 76.2-762.2 ng/mL, respectively. The comparison study showed no significant difference among them. When 0.5% hemolysis occurred, remarkable hemoglobin interference was found in the three markers resulting in underestimation of the concentrations. CONCLUSIONS: HUBI-QUANPRO CK-MB and BNP showed good analytical performances compared with the other two assays. Hemoglobin interference was noted in the HUBI-QUANPRO assay, especially more in BNP. Although the linearity range of cTnI was narrow, its agreement rate with ADVIA Centaur was good, thus the HUBI-QUANPRO assay could be useful as a quantitative POCT for cardiac markers in the emergency department.

Comparison of Nine Different Qualitative HBsAg Assay Kits / 대한진단검사의학회지

BACKGROUND: Qualitative hepatitis B surface antigen (HBsAg) assay kits are still commonly used in Korea where hepatitis B virus (HBV) infection is endemic. The accurate determination of HBsAg plays a crucial role in the diagnosis and prevention of HBV infection, especially in endemic areas. The aim of this study was to compare the detection sensitivities of 9 qualitative HBsAg assay kits. METHODS: Seven pooled sera with HBsAg concentration ranging from 0.14 IU/mL to 29.96 IU/mL were prepared. The HBsAg concentration of each pooled serum was determined by a quantitative HBsAg assay, Architect HBsAg (Abbott Laboratories, Ireland). The fully automated immunoassay kits included Elecsys HBsAg (Roche Diagnostics, Germany) and Immulite 2000 HBsAg (DPC, USA) and the rapid tests included 5 immunochromatographic assay (ICA) kits and 2 reverse passive hemagglutination assay (RPHA) kits. RESULTS: Elecsys HBsAg (Roche Diagnostics) showed positive result in pooled serum with HBsAg concentration of 0.14 IU/mL, but Immulite 2000 HBsAg (DPC) showed negative result in the same concentration. Although ICA kits showed variable results among different assay kits, all of them showed negative results in pooled sera with HBsAg concentration of < or =1.89 IU/mL. Two RPHA kits showed negative results in pooled sera with HBsAg concentration of < or =7.98 IU/mL. CONCLUSIONS: Although ICAs were more sensitive than RPHAs, they had variable sensitivities for HBsAg and were less sensitive than the automated immunoassay kits. Therefore, ICAs and RPHAs should be used with caution in the screening tests for HBsAg and their sensitivities need to be improved.