Impact of Tocilizumab on Clinical Outcomes in COVID-19-Associated Cytokine Release Syndrome: A Single-Center Experience.

BACKGROUND: Tocilizumab is an interleukin-6 receptor antagonist hypothesized to blunt the uncontrolled immune response, cytokine release syndrome, in severe COVID-19 and prevent attributable morbidity and mortality. Objective: The objective of this study was to assess the impact of tocilizumab on clinical outcomes in COVID-19-associated cytokine release syndrome. METHODS: Single-center, retrospective cohort study assessing sixty-nine adult patients receiving tocilizumab for suspected COVID-19 cytokine release syndrome. The primary outcome was change in WHO clinical status scale on day seven post-dose analyzed using the Wilcoxon signed rank test. Secondary outcomes assessed impact of timing of administration on clinical outcome. Safety analyses included development of neutropenia, thrombocytopenia, transaminitis, and sepsis within 7 days post-dose. Statistical analyses were conducted using Microsoft Excel. RESULTS: No aggregate clinical change was found between day 0 and day 7. Eleven patients improved, twenty-seven worsened, and thirty-one showed no change. Clinical outcomes were weakly correlated with time from symptom onset (rs = 0.21; p = 0.08) or hospital admission (rs = -0.08; p = 0.49) to dose. In-hospital mortality was 63%. Sepsis was diagnosed in 21 patients, five of which were post-dose. Transaminitis, neutropenia, and thrombocytopenia occurred in seven, one, and six patients, respectively. CONCLUSION: Tocilizumab did not appear to influence clinical outcomes in our study population, irrespective of timing of administration. Adverse events were not considered drug-related.

Pyoderma Gangrenosum of the Hand: Unique Experience and Literature Review.

BACKGROUND: Pyoderma gangrenosum (PG) is a reactive, noninfectious, neutrophilic dermatosis. Diagnosis of PG is based on exclusion, due to lack of availability of a confirmatory test. PG is not caused by infection or gangrene. Misdiagnosis or delayed diagnosis of PG can lead to devastating results. CASE PRESENTATION: In this report, we present a patient with a delayed diagnosis of PG lesion on right hand. Despite initial surgical treatment, the wound was aggravated, and amputation was considered; however, it was eventually treated successfully with an autologous split thickness skin graft. CONCLUSIONS: Knowledge of the PG is essential to actively consider PG in early stage to help facilitate immediate treatment and avoid unnecessary interventions that may worsen the outcome.

Health literacy and health care experiences of migrant workers during the COVID-19 pandemic: a qualitative study.

BACKGROUND: Migrant workers are among the most vulnerable populations in society. This study explored the health-literacy experiences of migrant workers in South Korea and how the workers'daily lives have been affected by the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We conducted a series of semi-structured individual and focus-group interviews with 23 migrant workers (eight Cambodians, six Nepalese, four Sri Lankans, three Bangladeshis, and two Pakistanis) residing in the Daegu and Busan metropolitan areas of South Korea. All interviews were digitally recorded and transcribed verbatim. The data were analyzed using content analysis. RESULTS: Migrant workers had difficulty accessing and using health care services due, in large part, to linguistic barriers and a lack of an adequate support system. Four main themes were identified: difficulty understanding and using medical services, obtaining necessary health and safety information, the impact of COVID-19, and protecting oneself from becoming infected with COVID-19. Most workers depended on information from social networking services (SNS) and co-workers. CONCLUSIONS: Migrant workers' difficulty with health care access was exacerbated during the COVID-19 pandemic. The findings suggest the necessity of enhancing migrant workers' health literacy, along with the use of SNS as a viable pathway for sharing health information and resources.

Impact of the Acceptance of Disability on Self-Esteem among Adults with Disabilities: A Four-Year Follow-Up Study.

This study identified the acceptance of disability's impact on self-esteem among adults with disabilities in South Korea. This is a four-year follow-up study that obtained data from the Panel Survey of Employment for Persons with Disabilities from 2017 to 2020. In total, 3329 individuals participated. Logistic regression examined the acceptance of disability's effect on self-esteem. These variables were categorized based on the acceptance of disability (high→high, low→high, high→low, and low→low) and self-esteem (low and not low). Compared to the participants with a consistently high acceptance of disability, those with constantly low acceptance were 2.35 times (95% CI 1.81-3.04) more likely to have low self-esteem. When the acceptance of disability was low→high and high→low, the low self-esteem probability was 1.23 and 1.66 times, respectively. Low self-esteem was prominent for the following: men, 50-64-year olds, married, urban, economic activists, the mid-low household income category, and those with sensory disability. Acceptance of disability can adversely affect self-esteem when it is consistently low or changes from high to low. Among socio-economic factors, there were several risk factors that could make individuals more vulnerable to low self-esteem. Therefore, it is necessary to help people accept their disabilities to maintain healthy self-esteem levels.

Intravenous N-Acetylcysteine in Management of COVID-19: A Case Series.

A novel coronavirus, severe acute respiratory syndrome coronavirus-2, was isolated from patients' lower respiratory tracts in December 2019. As of May 19, 2021, there were over 33 million reported infections and almost 600,000 deaths in the United States. The infection, coronavirus disease-19 (COVID-19), can lead to cytokine storm, with elevations in interleukin-6 (IL-6), IL-10, tumor necrosis factor-α, nuclear factor-kappaB (NF-kappaB), and glutathione reductase. NF-kappaB activation is necessary for further transcription of other pro-inflammatory markers. Glutathione may play a role in modulation of NF-kappaB activation and elevated glutathione reductase may indicate glutathione depletion. Administration of N-acetylcysteine (NAC) may replenish spent glutathione and attenuate over-activation of NF-kappaB. This retrospective case series included 10 patients who were COVID-19 positive and received intravenous NAC in an attempt to attenuate the cytokine storm. Patients' outcomes were graded based on the World Health Organization symptom severity scale from 0, no evidence of infection, to 8, death. Overall, the median WHO Scale prior to NAC was 6.5, and increased by day seven, which indicated clinical worsening. This retrospective case series showed no benefit of NAC; however, further studies are needed to elucidate if differences in drug regimens would lead to positive results.

Impact of Insurance Benefits and Education on Point-of-Care Ultrasound Use in a Single Emergency Department: An Interrupted Time Series Analysis.

Background and Objectives: Point-of-care ultrasound (POCUS) is a useful tool that helps clinicians properly treat patients in emergency department (ED). This study aimed to evaluate the impact of specific interventions on the use of POCUS in the ED. Materials and Methods: This retrospective study used an interrupted time series analysis to assess how interventions changed the use of POCUS in the emergency department of a tertiary medical institute in South Korea from October 2016 to February 2021. We chose two main interventions-expansion of benefit coverage of the National Health Insurance (NHI) for emergency ultrasound (EUS) and annual ultrasound educational workshops. The primary variable was the EUS rate, defined as the number of EUS scans per 1000 eligible patients per month. We compared the level and slope of EUS rates before and after interventions. Results: A total of 5188 scanned records were included. Before interventions, the EUS rate had increased gradually. After interventions, except for the first workshop, the EUS rate immediately increased significantly (p < 0.05). The difference in the EUS rate according to the expansion of the NHI was estimated to be the largest (p < 0.001). However, the change in slope significantly decreased after the third workshop during the coronavirus disease 2019 pandemic (p = 0.004). The EUS rate increased significantly in the presence of physicians participating in intensive POCUS training (p < 0.001). Conclusion: This study found that expansion of insurance coverage for EUS and ultrasound education led to a significant and immediate increase in the use of POCUS, suggesting that POCUS use can be increased by improving education and insurance benefits.

Adverse events and preventive measures related to COVID-19 vaccines.

The coronavirus disease 2019 (COVID-19) vaccines are categorized according to the manufacturing technique, including mRNA vaccines and adenovirus vector vaccines. According to previous studies, the reported efficacy of the COVID-19 vaccine is excellent regardless of the type of vaccine, and the majority of studies have shown similar results for safety. Most of the adverse reactions after vaccination were mild or moderate grade, and severe reactions were reported in a very small proportion. However, the adverse reactions that might occur after nationwide vaccinations can contribute to crowding of emergency departments, and this can further lead to significant obstacles to providing necessary treatment for life-threatening conditions. Therefore, as emergency physicians, we would like to present some concerns and suggestions to prevent these predictable problems.

Comparison of emergency department utilization trends between the COVID-19 pandemic and control period.

ABSTRACT: Infectious disease pandemics has a great impact on the use of medical facilities. The purpose of this study was to analyze the effects of coronavirus disease 2019 (COVID-19) on the use of emergency medical facilities in the Republic of Korea. This single-center, retrospective observational study was conducted in a tertiary teaching hospital located in Incheon Metropolitan City, Republic of Korea. We set the pandemic period as February 19, 2020 to April 18, 2020, and the control period was set to the same period in 2018 and 2019. All consecutive patients who visited the emergency department (ED) during the study period were included. Patients were divided into 3 groups according to age (pediatric patients, younger adult patients and older adult patients). The total number, demographics, clinical data, and diagnostic codes of ED patients were analyzed. The total number of ED patients in the pandemic period was lower than that in the control period, which was particularly pronounced for pediatric patients. The proportion of patients who used the 119 ambulances increased in all 3 groups (P  = .002, P < .001, and P = .001), whereas the proportion of patients who visited on foot was decreased (P  = .006, P < .001, and P = .027). In terms of diagnostic codes, a significant decrease was observed in the proportion of certain infectious or parasitic diseases (A00-B99), and respiratory diseases (J00-J99) in the pediatric and younger adult patient groups (P < .001 and P < .001, respectively). The COVID-19 pandemic reduced the number of ED patients; however, the proportion of patients using ambulances increased. In particular, the proportion of patients with diagnostic codes for infectious and respiratory diseases significantly decreased during the pandemic period.

Respiratory Protection Effect of Ear-loop-type KF94 Masks according to the Wearing Method in COVID-19 Pandemic: a Randomized, Open-label Study.

BACKGROUND: Ear-loop-type Korean Filter 94 masks (KF94 masks, equivalent to the N95 and FFP2) are broadly used in health care settings in Korea for the coronavirus disease 2019 pandemic. METHODS: A prospective randomized open-label study was designed to identify differences in the fitting performance between mask wearing methods in three different types of KF94 mask with ear loops between January to March 2021. General-fitting involved wearing an ear-loop-type KF94 mask, and tight-fitting involved wearing a mask aided by a clip connecting the ear loops. Each of the 30 participants wore three types of masks according to a randomly assigned order in both methods and performed a total of six quantitative fit tests (QNFTs) according to the occupational safety and health administration protocol. RESULTS: All fit factors (FFs) measured by the QNFT were significantly higher for tight-fitting method with the clip in all KF94 masks (P < 0.001). However, the total FFs were very low, with a median (interquartile range) of 6 (3-23) and 29 (9-116) for general-fitting and tight-fitting, respectively. When wearing tightly, the horizontal 3-fold type mask with adjustable ear-loop length had the highest FF, with a median of 125, and the QNFT pass rate (FF ≥ 100) increased significantly from 4 (13%) to 18 (60%). CONCLUSION: Even with sufficient filter efficiency, ear-loop-type-KF94 masks do not provide adequate protection. However, in relatively low-risk environments, wearing a face-seal adjustable KF94 mask and tight wearing with a clip can improve respiratory protection for healthcare workers. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04794556.

Impact of the COVID-19 Outbreak on Emergency Care Utilization in Patients with Acute Myocardial Infarction: a Nationwide Population-based Study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted various aspects of daily living and has influenced the life of every individual in a unique way. Acute myocardial infarction (AMI) is associated with high morbidity and mortality; thus, timely treatment is crucial to prevent poor prognosis. Therefore, an immediate emergency department (ED) visit is required; however, no domestic studies have reported the effect of COVID-19 on ED visits by patients with AMI. Therefore, this study aimed to assess the changes in the pattern of ED visits by patients with AMI by comparing visits during the COVID-19 outbreak period to those during two control periods. METHODS: This nationwide, retrospective study used registry data of the National Emergency Department Information System. The 'outbreak period' was defined as the period between February 21, 2020 and April 1, 2020, while the 'control period' was defined as the same time period in the preceding two years (2018 and 2019). The primary outcome of our study was the number of patients admitted to the ED owing to AMI during the outbreak and control periods. Secondary outcomes were time from symptom onset to ED visit, length of ED stay, and 30-day mortality following admission. RESULTS: During the outbreak period, 401,378 patients visited the ED; this number was lower than that during the control periods (2018: 577,548; 2019: 598,514). The number of patients with AMI visiting the ED was lower during the outbreak period (2,221) than during 2018 (2,437) and 2019 (2,591). CONCLUSION: The COVID-19 pandemic has caused a reduction in ED visits by patients with AMI. We assume that this could likely be caused by misinterpretation of AMI symptoms as symptoms of respiratory infection, fear of contracting severe acute respiratory syndrome coronavirus 2, and restrictions in accessing emergency medical care owing to overburdened healthcare facilities. This study sheds light on the fact that healthcare and emergency medical staff members must work towards eliminating hurdles due to this pandemic for patients to receive timely emergency care, which in turn will help curb the growing burden of mortality.