Over-triage occurs when considering the patient's pain in Korean Triage and Acuity Scale (KTAS).

BACKGROUND: The Korean Triage and Acuity Scale (KTAS) was developed based on the Canadian Emergency Department Triage and Acuity Scale. In patients with pain, to determine the KTAS level, the pain scale is considered; however, since the degree of pain is subjective, this may affect the accuracy of KTAS. The purpose of this study was to evaluate the accuracy of KTAS in predicting patient's severity with the degree of pain used as a modifier. METHOD: A retrospective observational cohort study was conducted in an urban tertiary hospital emergency department (ED). We investigated patients over 16 years old from January to June 2016. The patients were divided into the pain and non-pain groups according to whether the degree of pain was used as a modifier or not. We compared the predictive power of KTAS on the urgency of patients between the two groups. Acute area registration in the ED, emergency procedure, emergency operation, hospitalization, intensive care unit admission, and 7-day mortality were used as markers to determine urgent patients. RESULTS: Overall, 24,253 patients were included in the study, with 9,175 (37.8%) in the pain group. The proportions of patients with KTAS 1-3 were 61.4% in the pain and 75.6% in the non-pain groups. Among patients with KTAS 2-3, the proportion of urgent patients was higher in the non-pain group than the pain group (p<0.001). The odds ratios for urgent patients at each KTAS level revealed a more evident discriminatory power of KTAS for urgent patients in the non-pain group. The predictability of KTAS for urgent patients was higher in the non-pain group than the pain group (area under the curve; 0.736 vs. 0.765, p-value <0.001). CONCLUSIONS: Considering the degree of pain with KTAS led to overestimation of patient severity and had a negative impact on the predictability of KTAS for urgent patients.

Effects of an emergency transfer coordination center on secondary overtriage in an emergency department.

BACKGROUND: Patients who cannot be stabilized at a lower-level emergency department (ED) should be transferred to an upper-level ED by emergency medical services. However, some patients are subsequently discharged after transfer without any intervention or admission, and this secondary overtriage (SO) wastes the limited resources of upper-level EDs. This study aimed to investigate whether an emergency transfer coordination center (ETCC) could reduce the risk of SO among patients who were transferred to a tertiary ED by emergency medical services. METHODS: This retrospective observational study evaluated data from a prospective registry at an urban tertiary ED in Korea (January 2017 to May 2017). The exposure of interest was defined as ETCC approval prior to transfer and the primary outcome was SO. Univariate analyses were used to identify statistically significant variables, which were used for a multivariate logistic regression analysis to estimate the effects of ETCC approval on SO. RESULTS: During the study period, 1270 patients were considered eligible for this study. A total of 291 transfers were approved by the center's ETCC, and the remaining patients were transferred without approval. Compared to cases without ETCC approval, cases with transfer after ETCC approval had a significantly lower risk of SO (odds ratio: 0.624, 95% confidence interval: 0.413-0.944). CONCLUSION: Transfers that were evaluated by an ETCC had a lower risk of SO, which may improve the appropriateness of transfer. Thus, tertiary EDs that have high proportions of transferred patients should have a transfer coordination system that is similar to an ETCC.

Risk score to predict false-positive ST-segment elevation myocardial infarction in the emergency department: a retrospective analysis.

BACKGROUND: The best treatment approach for ST-segment elevation myocardial infarction (STEMI) is prompt primary percutaneous coronary intervention (PCI). However, some patients show ST elevation on electrocardiography (ECG), but do not have myocardial infarction. We sought to identify the frequency of and to develop a prediction model for false-positive STEMI. METHODS: This study was conducted in the emergency departments (EDs) of two hospitals using the same critical pathway (CP) protocol to treat STEMI patients with primary PCI. The prediction model was developed in a derivation cohort and validated in internal and external validation cohorts. RESULTS: Of the CP-activated patients, those for whom ST elevation did not meet the ECG criteria were excluded. Among the patients with appropriate ECG patterns, the incidence of false-positive STEMI in the entire cohort was 16.3%. Independent predictors extracted from the derivation cohort for false-positive STEMI were age < 65 years (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.35-4.89), no chest pain (OR, 12.04; 95% CI, 5.92-25.63), atypical chest pain (OR, 7.40; 95% CI, 3.27-17.14), no reciprocal change (OR, 4.80; 95% CI, 2.54-9.51), and concave-morphology ST elevation (OR, 14.54; 95% CI, 6.87-34.37). Based on the regression coefficients, we established a simplified risk score. In the internal and external validation cohorts, the areas under the receiver operating characteristic curves for our risk score were 0.839 (95% CI, 0.724-0.954) and 0.820 (95% CI, 0.727-0.913), respectively; the positive predictive values were 40.9% and 22.0%, respectively; and the negative predictive values were 94.9% and 96.7%, respectively. DISCUSSION: Our prediction model would help them make rapid decisions with better rationale. CONCLUSION: We devised a model to predict false-positive STEMI. Larger-scale validation studies are needed to validate our model, and a prospective study to determine whether this model is effective in reducing improper primary PCI in actual clinical practice should be performed.

[Prognostic value of preoperative positron emission tomography-computed tomography in surgically resected gastric cancer].

BACKGROUND/AIMS: The diagnostic value of PET-CT, in gastric cancer is well known, but the prognostic value of pretreatment PET-CT has not been adequately evaluated. This study aimed to investigate the preoperative prognostic value of PET-CT in gastric cancer patients. METHODS: A total of 107 patients underwent surgical treatment for gastric cancer from April 2007 to December 2010 at Dong-A University Medical Center after confirming the presence of F-18 fluorodeoxyglucose (FDG) uptake on preoperative PET-CT. Among these patients, the following subjects were excluded: follow-up loss (13), palliative resection (5), neoadjuvant chemotherapy (1), and unrelated death (1). The remaining 87 patients were included in this study and data were collected by retrospectively reviewing the medical records. The median follow-up duration, defined as the period from operation to last imaging study date, was 34.2±14.8 months. FDG uptake values were represented by maximal standardized uptake value (SUVmax). In order to assess the correlation between SUVmax and recurrence, Kaplan-Meier's survival analysis with log-rank test and cox proportional hazard model were performed. Receiver operating characteristic (ROC) curve was employed to determine the optimal cutoff value of SUVmax. RESULTS: The result of Kaplan-Meier's survival analysis with log-rank test were significantly different between high SUVmax group and low SUVmax group (p=0.035), the cutoff value of which was 5.6. However, in multivariate analysis with cox proportional hazard model, T-staging, N-staging and SUVmax did not show statistical significance (p=0.190, p=0.307, and p=0.436, respectively). CONCLUSIONS: High SUVmax on PET-CT in gastric cancer can be a useful prognostic factor.

Performance of reperfusion therapy and hospital mortality in ST-elevation myocardial infarction patients with non-chest pain complaints.

PURPOSE: ST-elevation myocardial infarction (STEMI) patients may visit the emergency department (ED) complaining of sensations of pain other than the chest. We investigated our performance of reperfusion therapy for STEMI patients presenting with non-chest pains. MATERIALS AND METHODS: This was a retrospective observational cohort study. STEMI patients who underwent primary percutaneous coronary intervention (PCI) were divided into a chest pain group and a non-chest pain group. Clinical differences between the two groups and the influence of presenting with non-chest pains on door-to-electrocardiograms (ECG) time, door-to-balloon time, and hospital mortality were evaluated. RESULTS: Of the 513 patients diagnosed with STEMI, 93 patients presented with non-chest pains. Patients in the non-chest pain group were older, more often female, and had a longer symptom onset to ED arrival time and higher Killip class than patients in the chest pain group. There was a statistically significant delay in door-to-ECG time (median, 2.0 min vs. 5.0 min; p<0.001) and door-to-balloon time (median, 57.5 min vs. 65.0 min; p<0.001) in patients without chest pain. In multivariate analysis, presenting with non-chest pains was an independent predictor for hospital mortality (odds ratio, 2.3; 95% confidence interval, 1.1-4.7). However, door-to-ECG time and door-to-balloon time were not factors related to hospital mortality. CONCLUSION: STEMI patients presenting without chest pain showed higher baseline risk and hospital mortality than patients presenting with chest pain. ECG acquisition and primary PCI was delayed for patients presenting with non-chest pains, but not influencing hospital mortality. Efforts to reduce pre-hospital time delay for these patients are necessary.

Characteristics of intentional fall injuries in the ED.

INTRODUCTION: This study was conducted to examine the characteristics of intentional fall injuries and the factors associated with their prognosis. METHODS: The study included 8992 patients with unintentional falls from a height (nonintentional group) and 144 patients with intentional falls from a height (intentional group). General and clinical characteristics were compared between the 2 groups. Intentional fall cases were divided into severe and nonsevere groups, and the factors associated with severe injury were evaluated by comparing these groups. RESULTS: The most common age group was younger than 14 years in the nonintentional group and between 30 and 44 years old in the intentional group. For the nonintentional group, 65% of the patients were male, and 48% were male in the intentional group. Fall heights of more than 4 m were most common in the intentional group. Discharge was the most common result in the nonintentional group; however, death before arrival at the emergency department (ED) or during ED treatment occurred in 54.9% of patients in the intentional group. In the severe injury group within the intentional group, patients were older, and the height of the fall was higher. Factors associated with severe injury in the intentional group included being a high school graduate rather than a college graduate and greater fall height. CONCLUSION: The risk of severe injury increased with fall height in the intentional group, and a high school level of education rather than a college level of education was associated with more severe injury.

Development of emergency department load relief area--gauging benefits in empirical terms.

INTRODUCTION: The primary goal of this investigation was to develop a simulation model to evaluate the various internal and external factors affecting patient flow and crowding in the emergency department (ED). In addition, a few recommendations are proposed to reconfigure the patient flow to improve ED capacity while maintaining service quality. METHODS: In this research, we present a simulation study conducted in the ED at the "S Hospital" located in Seoul. Based on patient flow data and process analysis, a simulation model of patient throughput in the ED has been developed. We evaluated simulations of diverting the specific patient load in the light of our proposed recommendations to a separately managed area named as the ED load relief area (ED-LRA) and analyzing potential effects on overall length of stay (LOS) and waiting time (WT). RESULTS: What-if analyses have been proposed to identify key issues and investigate the improvements as per our proposed recommendations. The simulation results suggest that specific patient load diversion is needed to ensure desired outcomes. With the diversion of specific patient load to ED-LRA, there is a reduction of 40.60% in mean LOS and 42.5% in WT with improved resource utilization. As a result, opening of an ED-LRA is justified. CONCLUSIONS: Real-world systems are often too intricate for analytical models and often too expensive to trial with directly. Simulation models allow the modeling of this intricacy and enable experimentation to make inferences about how the actual system might perform. Our simulation study modeled that diverting the specific patient load to ED-LRA produced an improvement in overall ED's LOS and WT.

Compostimonas suwonensis gen. nov., sp. nov., isolated from spent mushroom compost.

A Gram-positive, aerobic, non-motile, short rod, designated SMC46(T), was isolated from a spent mushroom compost sample collected in the Suwon region, South Korea. 16S rRNA gene sequence analysis revealed that strain SMC46(T) was a member of the family Microbacteriaceae; however, the isolate formed a branch separate from other genera within the family. Sequence similarity between strain SMC46(T) and other members of the family Microbacteriaceae was ≤97 %, the highest sequence similarity being with Frigoribacterium faeni 801(T) and Frondihabitans australicus E1HC-02(T) (both 97.0 %). Some chemotaxonomic properties of strain SMC46(T) were consistent with those of the family Microbacteriaceae: MK-11 and MK-12 as the predominant menaquinones, anteiso-C(15 : 0), iso-C(16 : 0) and anteiso-C(17 : 0) as the major cellular fatty acids and diphosphatidylglycerol, phosphatidylglycerol and an unidentified glycolipid as the polar lipids. However, strain SMC46(T) contained a B-type peptidoglycan not previously found in the family Microbacteriaceae. The DNA G+C content was 68 mol%. On the basis of phenotypic, chemotaxonomic and phylogenetic distinctiveness, strain SMC46(T) was considered to represent a novel genus and species in the family Microbacteriaceae, for which the name Compostimonas suwonensis gen. nov., sp. nov. is proposed. The type strain of the type species is SMC46(T) ( = KACC 13354(T)  = NBRC 106304(T)).

Rapid discrimination of potato scab-causing Streptomyces species based on the RNase P RNA gene sequences.

Scab disease significantly damages potatoes and other root crops. Some Streptomyces species have been reported as potato-scab pathogens. Identification of the phytopathogenic Streptomyces is mainly done on the basis of the 16S rRNA gene, but use of this gene has some limitations for discriminating these strains because they share high similarities of 16S rRNA gene sequences. We tested the RNase P RNA (rnpB) gene as a taxonomic marker to clarify the relationship among closely related scab-causing Streptomyces strains. The rnpB genes were analyzed for 41 strains including 9 isolates from Jeju, Korea. There were 4 highly variable regions including nucleotide gaps in the rnpB genes. Interspecies similarity of the rnpB gene in tested Streptomyces strains was lower than about 97%, while the intraspecies similarity was higher than about 98%. Phylogenetic analysis demonstrated that the rnpB tree has similar topology to the 16S rRNA gene tree, but produces a more divergent phyletic lineage. These results revealed that the rnpB gene could be used as a powerful taxonomic tool for rapid differentiation of closely related Streptomyces species. In addition, it was also suggested that the variable regions marked as α, ß, γ, and δ in the rnpB gene could be useful markers for the detection of specific Streptomyces species.

Analyses of bacterial communities in meju, a Korean traditional fermented soybean bricks, by cultivation-based and pyrosequencing methods.

Despite the importance of meju as a raw material used to make Korean soy sauce (ganjang) and soybean paste (doenjang), little is known about the bacterial diversity of Korean meju. In this study, the bacterial communities in meju were examined using both culture-dependent and independent methods in order to evaluate the diversity of the bacterial population. Analyses of the 16S rRNA gene sequences of the bacterial strains isolated from meju samples showed that the dominant species were related to members of the genera Bacillus, Enterococcus, and Pediococcus. The community DNAs extracted from nine different meju samples were analyzed by barcoded pyrosequencing method targeting of the V1 to V3 hypervariable regions of the 16S rRNA gene. In total, 132,374 sequences, with an average read length of 468 bp, were assigned to several phyla, with Firmicutes (93.6%) representing the predominant phylum, followed by Proteobacteria (4.5%) and Bacteroidetes (0.8%). Other phyla accounted for less than 1% of the total bacterial sequences. Most of the Firmicutes were Bacillus and lactic acid bacteria, mainly represented by members of the genera Enterococcus, Lactococcus, and Leuconostoc, whose ratio varied among different samples. In conclusion, this study indicated that the bacterial communities in meju were very diverse and a complex microbial consortium containing various microorganisms got involved in meju fermentation than we expected before.

Pedobacter rhizosphaerae sp. nov. and Pedobacter soli sp. nov., isolated from rhizosphere soil of Chinese cabbage (Brassica campestris).

Two bacterial strains, 01-96(T) and 15-51(T), isolated from rhizosphere soil of Chinese cabbage (Brassica campestris) were characterized by using a polyphasic approach. 16S rRNA gene sequence analysis showed that strain 01-96(T) was phylogenetically related most closely to Pedobacter suwonensis 15-52(T) and Pedobacter roseus CL-GP80(T) (96.7 and 96.7% similarity, respectively), and strain 15-51(T) to Pedobacter borealis G-1(T) and P. suwonensis 15-52(T) (97.2 and 97.1%, respectively). However, levels of DNA-DNA relatedness between strain 15-51(T) and P. borealis KACC 14287(T) and P. suwonensis KACC 11317(T) were low (<50%). The G+C content of the genomic DNA was 37.8 mol% for strain 01-96(T) and 38.6 mol% for strain 15-51(T). The major fatty acids of the two strains were iso-C(17:0) 3-OH, iso-C(15:0) and summed feature 3 (iso-C(15:0) 2-OH and/or C(16:1)ω7c). The results of DNA-DNA hybridization and phenotypic data showed that strains 01-96(T) and 15-51(T) could be distinguished from their closest phylogenetic relatives, and that these strains represented two novel species of the genus Pedobacter, for which the names Pedobacter rhizosphaerae sp. nov. (type strain 01-96(T) =KACC 14938(T) =NBRC 107690(T)) and Pedobacter soli sp. nov. (type strain 15-51(T) =KACC 14939(T) =NBRC 107691(T)) are proposed.

Performance of an automated external defibrillator during simulated rotor-wing critical care transports.

OBJECTIVE: This study aimed to evaluate whether an automated external defibrillator (AED) was accurate enough to analyze the heart rhythm during a simulated rotor wing critical care transport. We hypothesized that AED analysis of the simulated rhythms during a helicopter flight would result in significant errors (i.e., inappropriate shocks, analysis delay). METHODS: Three commercial AEDs were tested for analyzing the heart rhythm in a helicopter using a manikin and a human volunteer. Ventricular fibrillation (VF), sinus rhythm, and asystole were simulated by using an arrhythmia simulator of the manikin. The intervals from analysis to shock recommendation were collected on a stationary and in-motion helicopter. Sensitivity and specificity of three AEDs were also calculated. Vibration intensities were measured with a digital vibration meter placed on the chest of the manikin/human volunteer both on the stretcher and on the floor of the helicopter. RESULTS: All AEDs correctly recommended shock delivery for the cardiac rhythms of the manikin. Sensitivity for VF was 100.0% (95% CI 91.2-100.0) and specificity for sinus rhythm and asystole were 100.0% (95% CI 91.2-100.0). Although the recorded ECG rhythms of the volunteer in an in-motion helicopter showed baseline artifacts, all AEDs analyzed the cardiac rhythm of the volunteer correctly and did not recommend shock delivery. On the floor of the helicopter, the median measured vibration intensity was 6.6 m/s(2) (IQR 5.5-7.7 m/s(2)) with significantly less vibrations transmitted to the manikin/human volunteer chest (manikin median 3.1 m/s(2), IQR 2.2-4.0 m/s(2); human volunteer median 0.95 m/s(2), IQR 0.65-1.25 m/s(2)). CONCLUSION: This study suggested that current AEDs could analyze the heart rhythm correctly during simulated helicopter transport. Further studies using an animal model would be needed before applying to patients.

Species belonging to genus protodaedalea in Korea.

One rare and interesting species collected from Seorak-san, Inje-gun; Yeonyeop-san, Hongcheon-gun; Daeam-san, Yanggu-gun, Gangwon-do; Pocheon-gun, Gyeonggi-do; Songni-san, Boeun-gun; Joryeong-san, Goesan-gun, Chungcheongbuk-do and Sobaeksan, Yeongju-si, Gyeongsangbuk-do is described and illustrated in detail. The species "Protodaedalea hispida Imazeki" and genus "Protodaedalea Iamzeki" has not been previously recorded in Korean fungal flora. The specimens have been deposited in the Herbarium Conservation Center of the National Academy of Agricultural Sciences.

Tectella patellaris from Korea.

One rare and interesting species collected from Gyeryong-san, Chungnam Province is described and illustrated in detail. The species "Tectella patellaris (Fr.) Murr." and genus "Tectella Earle" is a first record for Korean fungal flora. Specimens cited here have been deposited in the Herbarium Conservation Center of National Academy of Agricultural Sciences.

Nevskia terrae sp. nov., isolated from soil.

A Gram-negative bacterium, designated KIS13-15(T), was isolated from soil in Korea. Cells were strictly aerobic rods and were motile with 1-3 subpolar flagella. 16S rRNA gene sequence analysis revealed that strain KIS13-15(T) belonged to the order Xanthomonadales of the class Gammaproteobacteria and was closely related to Nevskia soli GR15-1(T) (97.9 % 16S rRNA gene sequence similarity) and Nevskia ramosa Soe1(T) (96.8 %). Strain KIS13-15(T) exhibited 38 and 29 % DNA-DNA relatedness with N. soli KACC 11703(T) and N. ramosa DSM 11499(T), respectively. The major fatty acids (>10 % of the total) were C(18 : 1)ω7c (40.6 %) and C(16 : 0) (12.4 %). The major isoprenoid quinone was ubiquinone 8. DNA G+C content was 67.3 mol%. The phenotypic characterization combined with 16S rRNA gene sequence analysis and DNA-DNA hybridization clearly classified strain KIS13-15(T) in a novel species of the genus Nevskia, for which the name Nevskia terrae sp. nov. is proposed. The type strain is KIS13-15(T) ( = KACC 12736(T)  = JCM 15425(T)).

Re-identification of Aspergillus fumigatus sensu lato based on a new concept of species delimitation.

The species concept of Aspergillus fumigatus sensu stricto has recently been defined by polyphasic taxonomy. Based on the new concept of species delimitations, 146 worldwide strains of Aspergillus fumigatus sensu lato were re-identified. Of those 146 strains, 140 (95.8%) could be identified as A. fumigatus sensu stricto, 3 (2.1%) as A. lentulus, and the remaining 3 strains as A. viridinutans complex, Neosartorya udagawae, and N. cf. nishimurae. Of 98 clinical strains, only 1 from dolphin nostril was identified as A. lentulus and not A. fumigatus sensu stricto. Random amplification of polymorphic DNA-polymerase chain reaction (RAPD-PCR) with primers PELF and URP1F produced nearly the same band patterns among 136 strains of A. fumigatus sensu stricto while discriminated the species from its related species. We also discussed about identification of several atypical A. fumigatus strains from clinical environments.

Kaistia terrae sp. nov., isolated from a wetland in Korea.

An ivory-coloured bacterium, designated strain 5YN7-3(T), was isolated from a wetland, Yongneup, Korea. Cells of the strain were aerobic, Gram-stain-negative, non-motile and short rods. 16S rRNA gene sequence analysis demonstrated that strain 5YN7-3(T) belongs to the order Rhizobiales of the class Alphaproteobacteria and is closely related to Kaistia soli 5YN9-8(T) (97.8 %), Kaistia granuli Ko04(T) (97.6 %) and Kaistia adipata Chj404(T) (97.4 %). Strain 5YN7-3(T) showed DNA-DNA hybridization values of 28, 22 and 35 % with K. granuli Ko04(T), K. soli 5YN9-8(T) and K. adipata Chj404(T), respectively. The major fatty acids were C(18 : 1)omega7c (51.2 %), C(19 : 0) cyclo omega8c (25.0 %), C(18 : 0) (12.9 %) and C(16 : 0) (10.8 %) (>10 % of total fatty acids). Ubiquinone-10 was the major isoprenoid quinone and the DNA G+C content was 66.5 mol%. The phenotypic characteristics in combination with 16S rRNA gene sequence analysis and DNA-DNA hybridization data clearly define strain 5YN7-3(T) as a novel species of the genus Kaistia, for which the name Kaistia terrae sp. nov. is proposed. The type strain is 5YN7-3(T) (=KACC 12910(T) =DSM 21341(T)).

Isolation and identification of Aspergillus section fumigati strains from arable soil in Korea.

63 strains of Aspergillus section Fumigati were isolated from 17 samples of arable soil in a central province of Korea. Based on the results of genotypic and phenotypic analyses, they were identified as Aspergillus fumigatus, A. lentulus, Neosartorya coreana, N. fennelliae, N. fischeri, N. glabra, N. hiratsukae, N. laciniosa, N. pseudofischeri, N. quadricincta, N. spinosa and N. udagawae. Among these, N. fennelliae, N. hiratsukae, N. quadricincta, and N. udagawae had not been previously recorded in Korea. The diversity of Aspergillus section Fumigati species from arable soil in Korea is also addressed.

Notes on some new species of psathyrella.

This study contains descriptions and illustrations of three new and noteworthy taxa of the genus Psathyrella from Korea. Among them, Psathyrella pervelatoid, P. koreana, and P. utriformcystis are new to science. All collections cited here are deposited in the Herbarium Conservation Center of National Academy of Agricultural Sciences.

A mobile telemedicine system for remote consultation in cases of acute stroke.

A mobile telemedicine system, capable of transmitting video and audio simultaneously, was designed for consulting acute stroke patients remotely. It could use a wireless local area network (e.g. inside the hospital) or a mobile phone network (e.g. outside the hospital). When initiating a call, the sending unit chose a suitable encoding profile based on the measured data throughput, in order to allocate appropriate bit rates for video and audio transmission. The system was tested using a portable digital assistant (PDA) type phone and smart phone as receiving units. Video and audio recordings were made from five patients (two normal and three stroke patients) and then transmitted at different rates. Subjectively, both video and audio qualities improved as the data throughput increased. The physical findings, including facial droop, arm drift and abnormal speech, were observed remotely by four specialists according to the Cincinnati Pre-hospital Stroke Scale guideline. A comparison between the face-to-face method and the mobile telemedicine method showed that there were no discrepancies at bit rates of more than 400 kbit/s. We conclude that specialists could generally conduct remote consultations for stroke patients either using a public mobile network or a wireless LAN.