Out-of-hospital cardiac arrest: incidence, patient characteristics, outcomes, and trends over time between 2012 and 2018 in an urban city

Objective@#This study aimed to determine the incidence, characteristics, and outcomes of out-of-hospital cardiac arrests (OHCA) and to investigate the trends for the same in Changwon city, South Korea between 2012 and 2018. @*Methods@#We analyzed a list of adult cardiac arrest cases occurring between 2012 and 2018 from the OHCA surveillance registry and the Changwon Fire Department’s emergency medical services database. The trends in the incidence and resuscitation-related characteristics were assessed using nonparametric tests for trends across ordered groups. The predictors of the primary outcome were investigated using multivariable logistic regression. The primary outcome was a good neurological outcome at hospital discharge. @*Results@#A total of 2,951 OHCAs were attended by the emergency medical services and of these, 2,834 were included in this study. Overall, the proportion of patients discharged with a good neurologic outcome was 4.7% (133/2,834). Both OHCA survival and good neurologic outcomes improved significantly over time, from 4.9% and 2.1%, respectively, in 2012 to 10.3% and 7.4% in 2018 (P<0.001). The Utstein comparator (bystander-witnessed arrests presenting with initial shockable rhythm) increased over the study period (P-for-trend<0.001). Age, response time, scene time, in-hospital cardiopulmonary resuscitation (CPR) time, witness presence, cardiac origin, and shockable rhythm were associated with good neurologic outcomes. @*Conclusion@#With the gradual increase in the proportion of patients with witnessed cardiac arrests, bystander CPR, and initial shockable rhythm, the rate of survival and a good neurologic outcome at discharge also increased annually.

Deep Learning Approach Using Diffusion-Weighted Imaging to Estimate the Severity of Aphasia in Stroke Patients / 대한뇌졸중학회지

Background@#and Purpose This study aimed to investigate the applicability of deep learning (DL) model using diffusion-weighted imaging (DWI) data to predict the severity of aphasia at an early stage in acute stroke patients. @*Methods@#We retrospectively analyzed consecutive patients with aphasia caused by acute ischemic stroke in the left middle cerebral artery territory, who visited Asan Medical Center between 2011 and 2013. To implement the DL model to predict the severity of post-stroke aphasia, we designed a deep feed-forward network and utilized the lesion occupying ratio from DWI data and established clinical variables to estimate the aphasia quotient (AQ) score (range, 0 to 100) of the Korean version of the Western Aphasia Battery. To evaluate the performance of the DL model, we analyzed Cohen’s weighted kappa with linear weights for the categorized AQ score (0–25, very severe; 26–50, severe; 51–75, moderate; ≥76, mild) and Pearson’s correlation coefficient for continuous values. @*Results@#We identified 225 post-stroke aphasia patients, of whom 176 were included and analyzed. For the categorized AQ score, Cohen’s weighted kappa coefficient was 0.59 (95% confidence interval [CI], 0.42 to 0.76; P<0.001). For continuous AQ score, the correlation coefficient between true AQ scores and model-estimated values was 0.72 (95% CI, 0.55 to 0.83; P<0.001). @*Conclusions@#DL approaches using DWI data may be feasible and useful for estimating the severity of aphasia in the early stage of stroke.

Pediatric out-of-hospital cardiac arrest: incidence and outcomes in an urban city

Objective@#The aim of this study was to examine the incidence and outcomes of pediatric out-of-hospital cardiac arrests (OHCA) in Changwon city, South Korea. @*Methods@#From the Out-of-Hospital Cardiac Arrest Surveillance registry and the Changwon Fire Department’s Emergency Medical Services data, we obtained a list of 119 assessed pediatric OHCAs occurred between January 2012 and December 2018. We analyzed basic demographic variables, the location of cardiac arrest, witnessed status, bystander cardiopulmonary resuscitation (CPR), time variables for CPR, dispatcher-assisted CPR, initial cardiac rhythm, automated defibrillator use, and clinical outcomes at hospital discharge. @*Results@#A total of 2,954 OHCAs occurred during the study period, of which 72 were pediatric OHCAs. The rate of witnessed cardiac arrest was 30.6% (22/72), and bystander CPR was performed in 29 patients (40.3%). The rate of cardiac arrest occurring in public places was 16.7% (12/72). The rate of shockable rhythm in the initial electrocardiogram rhythm was 8.3% (6/72). Twelve patients (16.7%) survived to admission. The proportion of survivors discharged was 4.3% (3/70), and the rate of discharge with a good prognosis was 2.8% (2/70). @*Conclusion@#The incidence rate of pediatric OHCA was low in Changwon city. The survival rate was also low. Thus, studies with larger sample sizes and continuous monitoring in the community are needed.

The Prognosis of Glyphosate herbicide intoxicated patients according to their salt types

Purpose@#Glyphosate herbicide (GH) is a widely used herbicide and has been associated with significant mortality as poisoned cases increases. One of the reasons for high toxicity is thought to be toxic effect of its ingredient with glyphosate. This study was designed to determine differences in the clinical course with the salt-type contained in GH. @*Methods@#This was a retrospective study conducted at a single hospital between January 2013 and December 2017. We enrolled GH-poisoned patients visited the emergency department. According to salt-type, patients were divided into 4 groups: isopropylamine (IPA), ammonium (Am), potassium (Po), and mixed salts (Mi) groups. The demographics, laboratory variables, complications, and their mortality were analyzed to determine clinical differences associated with each salt-type. Addtionally, we subdivided patients into survivor and non-survivor groups for investigating predictive factors for the mortality. @*Results@#Total of 348 GH-poisoned patients were divided as follows: IPA 248, Am 41, Po 10, and Mi 49 patients. There was no difference in demographic or underlying disease history, but systolic blood pressure (SBP) was low in Po group. The ratio of intentional ingestion was higher in Po and Mi groups. Metabolic acidosis and relatively high lactate level were presented in Po group.As the primary outcome, the mortality rates were as follows: IPA, 26 (10.5%); Am, 2 (4.9%); Po, 1 (10%); and Mi, 1 (2%). There was no statistically significant difference in the mortality and the incidence of complications. Additionally, age, low SBP, low pH, corrected QT (QTc) prolongation, and respiratory failure requiring mechanical ventilation were analyzed as independent predictors for mortality in a regression analysis. @*Conclusion@#There was no statistical difference in their complications and the mortality across the GH-salt groups in this study.

The Comparison of Emergency Medical Service Responses to and Outcomes of Out-of-hospital Cardiac Arrest before and during the COVID-19 Pandemic in an Area of Korea

Background@#Since the declaration of the coronavirus disease 2019 (COVID-19) pandemic, COVID-19 has affected the responses of emergency medical service (EMS) systems to cases of out-of-hospital cardiac arrest (OHCA). The purpose of this study was to identify the impact of the COVID-19 pandemic on EMS responses to and outcomes of adult OHCA in an area of South Korea. @*Methods@#This was a retrospective observational study of adult OHCA patients attended by EMS providers comparing the EMS responses to and outcomes of adult OHCA during the COVID-19 pandemic to those during the pre-COVID-19 period. Propensity score matching was used to compare the survival rates, and logistic regression analysis was used to assess the impact of the COVID-19 pandemic on the survival of OHCA patients. @*Results@#A total of 891 patients in the pre-COVID-19 group and 1,063 patients in the COVID-19 group were included in the final analysis. During the COVID-19 period, the EMS call time was shifted to a later time period (16:00–24:00, P < 0.001), and the presence of an initial shockable rhythm was increased (pre-COVID-19 vs. COVID-19, 7.97% vs. 11.95%, P = 0.004). The number of tracheal intubations decreased (5.27% vs. 1.22%, P < 0.001), and the use of mechanical chest compression devices (30.53% vs. 44.59%, P < 0.001) and EMS response time (median [quartile 1-quartile 3], 7 [5–10] vs. 8 [6–11], P < 0.001) increased. After propensity score matching, the survival at admission rate (22.52% vs. 18.24%, P = 0.025), survival to discharge rate (7.77% vs. 5.52%, P = 0.056), and favorable neurological outcome (5.97% vs. 3.49%, P < 0.001) decreased. In the propensity score matching analysis of the impact of COVID-19, odds ratios of 0.768 (95% confidence interval [CI], 0.592–0.995) for survival at admission and 0.693 (95% CI, 0.446–1.077) for survival to discharge were found. @*Conclusion@#During the COVID-19 period, there were significant changes in the EMS responses to OHCA. These changes are considered to be partly due to social distancing measures. As a result, the proportion of patients with an initial shockable rhythm in the COVID-19 period was greater than that in the pre-COVID-19 period, but the final survival rate and favorable neurological outcome were lower.

The Comparison of Emergency Medical Service Responses to and Outcomes of Out-of-hospital Cardiac Arrest before and during the COVID-19 Pandemic in an Area of Korea

Background@#Since the declaration of the coronavirus disease 2019 (COVID-19) pandemic, COVID-19 has affected the responses of emergency medical service (EMS) systems to cases of out-of-hospital cardiac arrest (OHCA). The purpose of this study was to identify the impact of the COVID-19 pandemic on EMS responses to and outcomes of adult OHCA in an area of South Korea. @*Methods@#This was a retrospective observational study of adult OHCA patients attended by EMS providers comparing the EMS responses to and outcomes of adult OHCA during the COVID-19 pandemic to those during the pre-COVID-19 period. Propensity score matching was used to compare the survival rates, and logistic regression analysis was used to assess the impact of the COVID-19 pandemic on the survival of OHCA patients. @*Results@#A total of 891 patients in the pre-COVID-19 group and 1,063 patients in the COVID-19 group were included in the final analysis. During the COVID-19 period, the EMS call time was shifted to a later time period (16:00–24:00, P < 0.001), and the presence of an initial shockable rhythm was increased (pre-COVID-19 vs. COVID-19, 7.97% vs. 11.95%, P = 0.004). The number of tracheal intubations decreased (5.27% vs. 1.22%, P < 0.001), and the use of mechanical chest compression devices (30.53% vs. 44.59%, P < 0.001) and EMS response time (median [quartile 1-quartile 3], 7 [5–10] vs. 8 [6–11], P < 0.001) increased. After propensity score matching, the survival at admission rate (22.52% vs. 18.24%, P = 0.025), survival to discharge rate (7.77% vs. 5.52%, P = 0.056), and favorable neurological outcome (5.97% vs. 3.49%, P < 0.001) decreased. In the propensity score matching analysis of the impact of COVID-19, odds ratios of 0.768 (95% confidence interval [CI], 0.592–0.995) for survival at admission and 0.693 (95% CI, 0.446–1.077) for survival to discharge were found. @*Conclusion@#During the COVID-19 period, there were significant changes in the EMS responses to OHCA. These changes are considered to be partly due to social distancing measures. As a result, the proportion of patients with an initial shockable rhythm in the COVID-19 period was greater than that in the pre-COVID-19 period, but the final survival rate and favorable neurological outcome were lower.

Neurologic Prognostication by QEEG in Post Cardiac Arrest Patients with Therapeutic Hypothermia

Background@#Post-cardiac arrest syndrome (PCAS) is one of the critical conditions which can result in a more serious brain injury. Early and accurate prognostication is crucial for deciding the patient’s therapeutic plan and setting the treatment goal. This study aimed to establish the prognostication values of quantitative electroencephalography (QEEG) in PCAS patients. @*Methods@#We recruited 183 PCAS patients treated with therapeutic hypothermia. Electroencephalography (EEG) data within 72 hours after cardiac arrest (CA) and clinical data were collected. QEEG analysis including power spectral density (PSD) and connectivity analysis of default mode network (DMN) with imaginary coherence were performed. @*Results@#There were significantly different patterns of PSD between neurologic good and poor outcome groups; absolute and relative power of the alpha 2 and beta 1 frequency (10-15 Hz) bands were increased in all brain regions of good outcome group. However, the relative power of the delta band and higher frequency bands over fast alpha (beta 3 and gamma bands over 20 Hz) were poor outcome markers. We found out that connectivity of DMN were significantly decreased in the poor outcome group compared with the good outcome group. @*Conclusions@#These findings suggest that QEEG analysis could quantify and automate the interpretation of EEG. Furthermore, they can improve the prognostic values for neurologic outcomes relatively accurately and objectively in PCAS patients treated with hypothermia compared with traditional visual grading.

Vasospasm-related Sudden Cardiac Death Has Outcomes Comparable with Coronary Stenosis in Out-of-Hospital Cardiac Arrest

Background@#Characteristics of coronary vasospasm-related sudden cardiac death are not well understood. We aimed to compare the characteristics and clinical outcomes between coronary vasospasm and stenosis, in out-of-hospital cardiac arrest (OHCA) survivors, who underwent coronary angiogram (CAG). @*Methods@#We conducted a multicenter retrospective observational registry-based study at 8 Korean tertiary care centers. Data of OHCA survivors undergoing CAG between 2010 and 2015 were extracted. Patients were divided into vasospasm and stenosis (stenosis > 50%) groups based on CAG findings. The primary and the secondary outcomes were survival and a good neurologic outcome at 30 days after OHCA. Patients in the vasospasm and stenosis groups were propensity score matched. @*Results@#Of the 413 included patients, vasospasm and stenosis groups comprised 87 and 326 patients, respectively. There were 279 (66.7%) survivors and 206 (49.3%) patients with good neurologic outcomes. The vasospasm group had better clinical characteristics for outcome (younger age, less diabetes and hypertension, more prehospital restoration of spontaneous circulation, higher Glasgow Coma Scale, less ST segment elevation, and less requirement of circulatory support). The vasospasm group had better survival (75/87 vs. 204/326, P < 0.001) and good neurologic outcomes (62/87 vs. 144/326, P < 0.001). However, vasospasm was not independently associated with survival (odds ratio [OR], 0.980; 95% confidence interval [CI], 0.400–2.406) or neurologic outcomes (OR, 0.870; 95% CI, 0.359–2.108) after adjustment and vasospasm was not associated with survival and neurologic outcome in propensity score-matched cohorts. @*Conclusion@#Our analysis of propensity score-matched cohorts finds that vasospasm OHCA survivors have survival and neurologic outcomes comparable with those of stenotic OHCA survivors.

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 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.

Comparison of tracheal intubation with direct laryngoscope using an assistive technique for novice: a manikin study

Objective@#Tracheal intubation is an essential procedure in many emergencies. Direct laryngoscopy is the best method of intubation, but its success is not assured in a difficult airway. This study was designed to compare the performance of two intubation-assisted maneuvers that can help an unskilled person to perform a successful intubation. @*Methods@#A randomized crossover trial for intubation was conducted in three airway scenarios: normal airway, tongue edema (TE) and cervical immobilization (CI). Sixty paramedic students performed intubation on a manikin using single operator intubation (SM), external laryngeal manipulation (ELM), and colleague assisted laryngoscopic maneuver (CALM). The degree of the visual field, intubation success rate, time to ventilation (TTV), tooth fracture, and difficulty of intubation were measured. @*Results@#There was no statistically significant difference in success rates between the three intubation methods, except in CI, where CALM had a significantly higher success rate (91.7%) as compared to ELM (78.3%) and SM (71.7%). There was no significant difference in TTV between the three intubation methods in all scenarios. However, with an improvement in the degree of visual field with ELM and CALM, evaluated using the Cormack-Lehane classification system, there was a statistically significant improvement in both TE and CI. Tooth fractures were lowest when CALM was used. The degree of difficulty felt by operators during intubation also tended to be lower in CALM than other methods, particularly, in CI. @*Conclusion@#For a novice, intubation using CALM was on par or better than ELM in the manikin study. And CALM was a more effective assistive method, specifically in CI cases.

Outcome and status of postcardiac arrest care in Korea: results from the Korean Hypothermia Network prospective registry

Objective@#High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry. @*Methods@#We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months. @*Results@#Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours. @*Conclusion@#The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.

Comparison of tracheal intubation with direct laryngoscope using an assistive technique for novice: a manikin study

Objective@#Tracheal intubation is an essential procedure in many emergencies. Direct laryngoscopy is the best method of intubation, but its success is not assured in a difficult airway. This study was designed to compare the performance of two intubation-assisted maneuvers that can help an unskilled person to perform a successful intubation. @*Methods@#A randomized crossover trial for intubation was conducted in three airway scenarios: normal airway, tongue edema (TE) and cervical immobilization (CI). Sixty paramedic students performed intubation on a manikin using single operator intubation (SM), external laryngeal manipulation (ELM), and colleague assisted laryngoscopic maneuver (CALM). The degree of the visual field, intubation success rate, time to ventilation (TTV), tooth fracture, and difficulty of intubation were measured. @*Results@#There was no statistically significant difference in success rates between the three intubation methods, except in CI, where CALM had a significantly higher success rate (91.7%) as compared to ELM (78.3%) and SM (71.7%). There was no significant difference in TTV between the three intubation methods in all scenarios. However, with an improvement in the degree of visual field with ELM and CALM, evaluated using the Cormack-Lehane classification system, there was a statistically significant improvement in both TE and CI. Tooth fractures were lowest when CALM was used. The degree of difficulty felt by operators during intubation also tended to be lower in CALM than other methods, particularly, in CI. @*Conclusion@#For a novice, intubation using CALM was on par or better than ELM in the manikin study. And CALM was a more effective assistive method, specifically in CI cases.

Outcome and status of postcardiac arrest care in Korea: results from the Korean Hypothermia Network prospective registry

Objective@#High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry. @*Methods@#We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months. @*Results@#Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours. @*Conclusion@#The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.

Early Functional Connectivity Predicts Recovery from Visual Field Defects after Stroke / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: We aimed to assess whether early resting-state functional connectivity (RSFC) changes measured via functional magnetic resonance imaging (fMRI) could predict recovery from visual field defect (VFD) in acute stroke patients. METHODS: Patients with VFD due to acute ischemic stroke in the visual cortex and age-matched healthy controls were prospectively enrolled. Serial resting-state (RS)-fMRI and Humphrey visual field (VF) tests were performed within 1 week and at 1 and 3 months (additional VF test at 6 months) after stroke onset in the patient group. The control group also underwent RS-fMRI and a Humphrey VF test. The changes in RSFCs and VF scores (VFSs) over time and their correlations were investigated. RESULTS: In 32 patients (65±10 years, 25 men), the VFSs were lower and the interhemispheric RSFC in the visual cortices was decreased compared to the control group (n=15, 62±6 years, seven men). The VFSs and interhemispheric RSFC in the visual cortex increased mainly within the first month after stroke onset. The interhemispheric RSFC and VFSs were positively correlated at 1 month after stroke onset. Moreover, the interhemispheric RSFCs in the visual cortex within 1 week were positively correlated with the follow-up VFSs. CONCLUSIONS: Interhemispheric RSFCs in the visual cortices within 1 week after stroke onset may be a useful biomarker to predict long-term VFD recovery.

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.

Utility of white matter to gray matter signal intensity ratio in comatose patients treated by targeted temperature management after cardiac arrest: a preliminary study

OBJECTIVE: This study examined the efficacy of the white matter (WM) to gray matter (GM) signal intensity ratio (SIR) in predicting the clinical prognosis of cardiac arrest patients. METHODS: Thirty-one patients who were resuscitated from cardiac arrest and underwent brain magnetic resonance imaging (MRI) were investigated retrospectively. Thirty one subjects with normal brain MRI findings served as the controls. The signal intensities (SI) were measured on T2-weighted image (T2WI). The circular regions of measurement (2–10 mm²) were placed over the regions of interest, and the average signals in GM and WM were recorded in the caudate nucleus (CN), putamen, anterior limb of the internal capsule, corpus callosum (CC), and in the cortex and WM of the frontal lobe. Cerebral performance category (CPC) 1–2 were classified as a good prognosis, and CPC 3–5 were classified as a poor prognosis. RESULTS: Most combinations of the SIR of WM to GM and most SIs of GM, except the frontal cortex, were significantly different between the two groups. On the other hand, the SI of WM was insignificant between both groups. In receiver operating characteristic (ROC) curve analysis, the SIR of the CC to CN had an area under the ROC curve (AUROC) of 1.00 for a cut-off value of 1.59 (sensitivity, 100%; specificity, 100%), the SIR of the CC to putamen had also an AUROC of 1.00 for a cut-off value of 1.43 (sensitivity, 100%; specificity, 100%). CONCLUSION: The SIR of WM to GM measured on a T2WI is related to the neurological outcome after a cardiac arrest.

The Therapeutic Effect of Human Embryonic Stem Cell-Derived Multipotent Mesenchymal Stem Cells on Chemical-Induced Cystitis in Rats / 대한배뇨장애요실금학회지

PURPOSE: To evaluate the therapeutic effect of human embryonic stem cell (hESC)-derived multipotent mesenchymal stem cells (M-MSCs) on ketamine-induced cystitis (KC) in rats. METHODS: To induce KC, 10-week-old female rats were injected with 25-mg/kg ketamine hydrochloride twice weekly for 12 weeks. In the sham group, phosphate buffered saline (PBS) was injected instead of ketamine. One week after the final injection of ketamine, the indicated doses (0.25, 0.5, and 1×106 cells) of M-MSCs (KC+M-MSC group) or PBS vehicle (KC group) were directly injected into the bladder wall. One week after M-MSC injection, the therapeutic outcomes were evaluated via cystometry, histological analyses, and measurement of gene expression. Next, we compared the efficacy of M-MSCs at a low dose (1×105 cells) to that of an identical dose of adult bone marrow (BM)-derived MSCs. RESULTS: Rats in the KC group exhibited increased voiding frequency and reduced bladder capacity compared to rats of the sham group. However, these parameters recovered after transplantation of M-MSCs at all doses tested. KC bladders exhibited markedly increased mast cell infiltration, apoptosis, and tissue fibrosis. Administration of M-MSCs significantly reversed these characteristic histological alterations. Gene expression analyses indicated that several genes associated with tissue fibrosis were markedly upregulated in KC bladders. However the expression of these genes was significantly suppressed by the administration of M-MSCs. Importantly, M-MSCs ameliorated bladder deterioration in KC rats after injection of a low dose (1×105) of cells, at which point BM-derived MSCs did not substantially improve bladder function. CONCLUSIONS: This study demonstrates for the first time the therapeutic efficacy of hESC-derived M-MSCs on KC in rats. M-MSCs restored bladder function more effectively than did BM-derived MSCs, protecting against abnormal changes including mast cell infiltration, apoptosis and fibrotic damage.

Relationships of Serum Iron Parameters and Hemoglobin with Forced Expiratory Volume in 1 Second in Patients with Chronic Obstructive Pulmonary Disease / 가정의학회지

BACKGROUND: Although chronic obstructive pulmonary disease is a known cause of secondary polycythemia with elevated erythropoietic demands in response to hypoxemia, anemia is relatively common in patients with chronic obstructive pulmonary disease and is related to increased mortality. However, little is currently known about the relationship between various iron parameters and disease severity in chronic obstructive pulmonary disease patients. METHODS: Data from the fifth Korean National Health and Nutrition Examination Survey, a population-based epidemiologic survey conducted in 2010–2012, were used. A total of 1,129 patients with chronic obstructive pulmonary disease were examined to reveal the associations between the forced expiratory volume in 1 second (FEV1) and hemoglobin and iron parameters, including serum iron, ferritin, total iron binding capacity, and transferrin saturation, using Spearman correlations and multiple linear regression analyses. RESULTS: The FEV1 was positively correlated with serum hemoglobin (γ=0.37, P < 0.001), iron (γ=0.20, P < 0.001), transferrin saturation (γ=0.19, P < 0.001), and ferritin (γ=0.22, P < 0.001), and negatively correlated with age (γ=−0.40, P < 0.001) and lower in female patients (γ=−0.56, P < 0.001) in the Spearman correlation. The FEV1 was independently associated with serum iron (β=0.049, P=0.035) and transferrin saturation (β=0.049, P=0.035) after adjusting for age, sex, and body mass index in the multiple linear regression analyses. CONCLUSION: The serum iron and transferrin saturation levels were independently associated with FEV1 as a marker of chronic obstructive pulmonary disease severity.

Utility of Susceptibility-Weighted Imaging in Comatose Patients after Cardiac Arrest: A Preliminary Study

PURPOSE: This study was conducted to examine the efficacies of susceptibility weighted images (SWI) for predicting the clinical prognosis of comatose patients following cardiac arrest. METHODS: Thirty-two patients who were resuscitated from cardiac arrest and underwent brain magnetic resonance imaging (MRI) were retrospectively investigated and compared to 32 subjects with normal brain MRI findings who served as controls. The SWI readings were divided into three categories: prominent, diminished, and normal. Comatose patients were divided into two groups: those with a Glasgow-Pittsburgh cerebral performance category (CPC) of 1-2 (good outcome group) and those with a CPC of 3-5 (poor outcome group). RESULTS: Of the 32 patients, 17 (53.1%) showed good neurological outcomes upon hospital discharge. Normal patterns on SWI were mainly seen in the good outcome group (15 patients, 88.2%), while diminished patterns and prominent patterns were frequently found in the poor outcome group (13 patients, 88.7%). The combination of diminished pattern and prominent pattern predicted poor outcome with 86.7% sensitivity (95% confidence interval, 69.5%-100%) and 88.2% specificity (95% confidence interval, 72.9%-100%). CONCLUSION: The SWI findings correlate with the outcome of hypoxic-ischemic encephalopathy and may be a useful adjunct of vegetative state or death in comatose patients after cardiac arrest.

Prognosis of Acute Pancreatitis in Glyphosate Surfactant Herbicide-intoxicated Patients

PURPOSE: Glyphosate herbicides (GHs) are widely used and increasingly associated with poisoning cases. Acute pancreatitis (AP) is among the many complications associated with the toxicity of GHs. We investigated the relationship between incidence of AP and its prognosis in patients with GH poisoning. METHODS: This was a retrospective cohort study conducted at a single tertiary hospital between January 2004 and December 2014. We enrolled all patients presented to the emergency department with GH poisoning. The Clinical and laboratory variables were analyzed to investigate the relationship between GH intoxication and AP. RESULTS: We studied 245 patients. Incidence of AP after GH poisoning was 6.5%. Patients with AP (mean 66 years) were older than the non-AP group (56 years). Systolic blood pressure, Glasgow Coma Scale, and amount of ingested poison differed significantly between the two groups. In the blood tests, white blood cell count, alanine aminotransferase, glucose, potassium, amylase, and lipase showed significant differences. The pH, bicarbonate, and lactate levels also differed significantly. Patients with AP demonstrated higher incidence of respiratory failure, pneumonia, acute kidney injury, rhabdomyolysis, and intensive care unit stay time. Additionally, 30-day mortality (n=11, 68.8%) was significantly higher in the AP group. On multivariate analysis, adjusted age, amount of ingestion, and lactate correlated with occurrence of AP. CONCLUSION: The incidence of GH-induced AP was 6.5% with a 30-day mortality of 68.8%. The patient's age, ingested dosage, and lactate levels were associated with GH-induced AP.