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BackgroundThe effects of the body mass index (BMI) on outcomes of patients resuscitated from cardiac arrest are controversial. Therefore, the current study investigated the association between the BMI and the favourable neurologic outcomes and survival to discharge of patients resuscitated from out-of-hospital cardiac arrest (OHCA).MethodsThis multicentre, prospective, nationwide OHCA registry-based study was conducted using data from the Korean Cardiac Arrest Resuscitation Consortium (KoCARC). We enrolled hospitals willing to collect patient height and weight and included patients who survived to the hospital between October 2015 and June 2018. The included patients were categorised into the underweight (2), normal weight (≥18.5 to 2), overweight (≥25 to 2), and obese groups (≥30 kg/m2) according to the BMI per the World Health Organization (WHO) criteria. The primary outcome was a favourable neurologic outcome; the secondary outcome was survival to discharge. Univariate and multivariate analyses were performed to investigate the association between BMI and outcomes.ResultsNine hospitals were enrolled; finally, 605 patients were included in our analysis and categorised per the WHO BMI classification. Favourable neurologic outcomes were less frequent in the underweight BMI group than in the other groups (p = 0.002); survival to discharge was not significantly different among the BMI groups (p = 0.110). However, the BMI classification was not associated with favourable neurologic outcomes or survival to discharge after adjustment in the multivariate model.ConclusionThe BMI was not independently associated with favourable neurologic and survival outcomes of patients surviving from OHCA.

Prompt diagnosis and timely treatment are important for reducing morbidity and mortality from pyogenic liver abscess (PLA). The purpose of this study was to investigate the importance of the delta neutrophil index (DNI) reflecting the fraction of immature granulocytes as a predictor of the development of in-hospital hypotension in initially stable patients with PLA. We retrospectively identified 308 consecutive patients (>18 years) who were hemodynamically stable at presentation and diagnosed with PLA in the emergency department (ED) between January 2011 and September 2017. The outcome of interest was in-hospital hypotension 1–24 hours after admission to the ED. A high DNI at ED admission was an independent predictor of the development of in-hospital hypotension in initially stable patients with PLA (odds ratio [OR]: 1.44, 95.0% confidence interval [CI]: 1.06–1.95; P = 0.02). A DNI > 3.3% was associated with in-hospital hypotension at ED admission (OR: 5.37, 95.0% CI: 2.91–9.92; P P

This study evaluated whether the grey-white matter ratio (GWR) assessed via early brain computed tomography (CT) within 2 h after the return of spontaneous circulation (ROSC) following cardiac arrest is associated with poor neurological outcomes after 6 months in post-cardiac arrest patients treated with targeted temperature management (TTM).This study used data from the Korean Hypothermia Network prospective registry obtained from November 2015 to October 2017 to assess patients with out-of-hospital cardiac arrest (OHCA) who underwent brain CT within 2 h following the ROSC. The primary endpoint was the neurological outcome 6 months post-cardiac arrest (cerebral performance category; CPC). The GWR was measured using early brain CT images. The subgroup analysis examined the difference in GWRs obtained from early and repeated brain CT.Five-hundred-twelve patients were enrolled. Good (CPC 1-2) and poor (CPC 3-5) neurological outcomes were observed in 162 (31.6%) and 350 (68.4%) patients, respectively. The multivariate logistic regression analysis revealed that the GWR measured using early brain CT was a statistically nonsignificant predictor of poor neurologic outcomes (p = 0.727). In patients with poor outcomes, the mean GWR obtained from early and repeated CT images were 1.171 ± 0.058 and 1.091 ± 0.133, respectively (p 0.001); there was no statistically significant difference between the GWRs in patients with good outcomes.The GWR assessed via early brain CT alone is not an independent factor predictive of poor neurologic outcomes but could be useful when used with repeated CT data.

Background An accurate disease severity score that can quickly predict the prognosis of patients with sepsis in the emergency department (ED) can aid clinicians in distributing resources appropriately or making decisions for active resuscitation measures. This study aimed to compare the prognostic performance of quick sequential organ failure assessment (qSOFA) with that of other disease severity scores in patients with septic shock presenting to an ED. Methods We performed a prospective, observational, registry-based study. The discriminative ability of each disease severity score to predict 28-day mortality was evaluated in the overall cohort (which included patients who fulfilled previously defined criteria for septic shock), the newly defined sepsis subgroup, and the newly defined septic shock subgroup. Results A total of 991 patients were included. All disease severity scores had poor discriminative ability for 28-day mortality. The sequential organ failure assessment and acute physiology and chronic health evaluation II scores had the highest area under the receiver-operating characteristic curve (AUC) values, which were significantly higher than the AUC values of other disease severity scores in the overall cohort and the sepsis and septic shock subgroups. The discriminative ability of each disease severity score decreased as the mortality rate of each subgroup increased. Conclusions All disease severity scores, including qSOFA, did not display good discrimination for 28-day mortality in patients with serious infection and refractory hypotension or hypoperfusion; additionally, none of the included scoring tools in this study could consistently predict 28-day mortality in the newly defined sepsis and septic shock subgroups.

Sudden cardiac arrest leads to a significantly increased risk of severe neurological impairment and higher mortality rates in survivors due to global brain tissue injury caused by prolonged whole-body ischemia and reperfusion. The brain undergoes various deleterious cascading events. Among these damaging mechanisms, neuroinflammation plays an especially crucial role in the exacerbation of brain damage. Clinical guidelines indicate that 33 °C and 36 °C are both beneficial for targeted temperature management (TTM) after cardiac arrest. To clarify the mechanistic relationship between TTM and inflammation in transient global ischemia (TGI) and determine whether 36 °C produces a neuroprotective effect comparable to 33 °C, we performed an experiment using a rat model. We found that TTM at 36 °C and at 33 °C attenuated neuronal cell death and apoptosis, with significant improvements in behavioral function that lasted for up to 72 h. TTM at 33 °C and 36 °C suppressed the propagation of inflammation including the release of high mobility group box 1 from damaged cells, the activation and polarization of the microglia, and the excessive release of activated microglia-induced inflammatory cytokines. There were equal neuroprotective effects for TTM at 36 °C and 33 °C. In addition, hypothermic complications and should be considered safe and effective after 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., Graphical Abstract

Acute pulmonary embolism (PE), frequently seen in the emergency department (ED), is a leading cause of cardiovascular morbidity and mortality. The delta neutrophil index (DNI) reflects the fraction of circulating immature granulocytes as a component of the systemic inflammatory response syndrome criteria. The pathogenesis of acute PE is significantly associated with inflammation. The aim of the study was to investigate the clinical usefulness of the DNI as a marker of severity in patients with acute PE admitted to the ED.We retrospectively analyzed the data of patients who were diagnosed with acute PE at a single ED, admitted from January 1, 2011 to June 30, 2017. The diagnosis of acute pulmonary embolism was confirmed using clinical, laboratory, and radiological findings. The DNI was determined at presentation. The clinical outcome was all-cause mortality within 28 days of emergency department admission.We included 447 patients in this study. The multivariate Cox regression model demonstrated that higher DNI values on ED admission were significantly associated with short-term mortality (hazard ratio, 1.107; 95% confidence interval, 1.042-1.177). The optimal cut-off DNI value, measured on ED admission, was 3.0%; this value was associated with an increased hazard of 28-day mortality following PE (HR, 7.447; 95% CI, 4.183-13.366; P 0.001) CONCLUSION:: The DNI value, obtained as part of the complete blood count analysis, can be easily determined without additional burdens of cost or time. A high DNI is useful as a marker to predict 28-day mortality in patients with acute PE.

Background This is the first study to evaluate the association between the serially measured RDW values and clinical severity in patients surviving > 24 h after sustaining trauma. We evaluated the serial measurement and cut-off values of RDW to determine its significance as a prognostic marker of early mortality in patients with suspected severe trauma. Methods This study retrospectively analyzed prospective data of eligible adult patients who were admitted to the ED with suspected severe trauma. The RDW was determined on each day of hospitalization. The primary outcome was all-cause mortality within 28-days of ED admission. Results We included 305 patients who met our inclusion criteria. The multivariate Cox regression model demonstrated that higher RDW values on day 1 (hazard ratio [HR], 1.558; 95% confidence interval [CI], 1.09–2.227; p = 0.015) and day 2 (HR, 1.549; 95% CI, 1.046–2.294; p = 0.029) were strong independent predictors of short-term mortality among patients with suspected severe trauma. Considering the clinical course of severe trauma patients, the RDW is an important ancillary test for determining severity. Specifically, we found that RDW values > 14.4% on day 1 (HR, 4.227; 95% CI: 1.672–10.942; p 14.7% on day 2 (HR, 6.041; 95% CI: 2.361–15.458; p Conclusion An increased RDW value is an independent predictor of 28-day mortality in patients with suspected severe trauma. The RDW, routinely obtained as part of the complete blood count without added cost or time, can be serially measured as indicator of severity after trauma.

This study aimed to evaluate the association between the delta neutrophil index (DNI), which reflects immature granulocytes, and the severity of ST-elevation myocardial infarction (STEMI), as well as to determine the significance of the DNI as a prognostic marker for early mortality and other clinical outcomes in patients with STEMI who underwent reperfusion. This retrospective, observational cohort study was conducted using patients prospectively integrated in a critical pathway program for STEMI. We included 842 patients diagnosed with STEMI who underwent primary percutaneous coronary intervention (pPCI). Higher DNI values at time-I (within 2 h of pPCI; hazard ratio [HR], 1.075; 95% confidence interval [CI]: 1.046–1.108; p 2.5% at time-I (HR, 13.643; 95% CI: 8.13–22.897; p 2.9% at time-24 (HR, 12.752; 95% CI: 7.308–22.252; p

Objective Many studies have described constructing a prediction model for bacteremia in community-acquired pneumonia (CAP), but these studies were not validated in external heterogeneous groups. The objective of this study was to test the generalizability of a previous bacteremia prediction model for CAP by external validation. Methods This multicenter retrospective cohort analysis was performed in eight tertiary urban hospital emergency departments (ED). We reviewed adult patients who were hospitalized after presentation to the ED with CAP. We categorized the enrolled patients into three groups according to the bacteremia prediction model score and calculated the number of patients with or without a blood culture-positive result. We performed a multivariable analysis to identify significant predictors for bacteremia. Results Among the enrolled 2,001 patients, 1,592 (79.6%), 371 (18.5%), and 38 (1.9%) were stratified to a low, moderate, and high-risk group, respectively, and this proportion was similar with previous study. Each group had a bacteremia-positive rate as follows: 1.2% for the low-risk group, 7.2% for the moderate-risk group, and 31.5% for the high-risk group. The area under the receiver operating characteristic curve for the bacteremia model in the external validation cohort was 0.81, and there was no significant difference with that of the previous internal validation cohort (p = 0.246). Assuming that blood cultures were not performed in the low-risk patients, the sensitivity and specificity of this model were 0.68 and 0.81, respectively. Additionally, the positive predictive value and negative predictive value were 9.54% and 98.87%, respectively. A platelet count less than 130,000 cell/μL, albumin less than 3.3 mg/dL, and C-reactive protein (CRP) greater than 17 mg/dL were identified as significant predictors with a sensitivity and specificity of, 0.70 and 0.83, respectively. Conclusion The bacteremia prediction model was well validated in the general population and could help physicians make the decision to reduce the number of blood cultures in patients with CAP. This article is protected by copyright. All rights reserved.

The objective of this study was to evaluate the prognostic value of C-reactive protein (CRP), procalcitonin (PCT), and their combination for mortality in patients with septic shock. This multicenter, prospective, observational study was conducted between November 2015 and December 2017. A total of 1,772 septic shock patients were included, and the overall 28-day mortality was 20.7%. Although both CRP and PCT were elevated in the non-survivor group, only CRP had statistical significance (11.9 mg/dL vs. 14.7 mg/dL, p = 0.003, 6.4 ng/mL vs. 8.2 ng/mL, p = 0.508). Multivariate analysis showed that CRP and PCT were not independent prognostic markers. In the subgroup analysis of the CRP and PCT combination matrix using their optimal cut-off values (CRP 14.0 mg/dL, PCT 17.0 ng/dL), both CRP and PCT elevated showed significantly higher mortality (Odds ratio 1.552 [95% Confidence intervals 1.184–2.035]) than both CRP and PCT not elevated (p = 0.001) and only PCT elevated (p = 0.007). However, both CRP and PCT elevated was also not an independent predictor in multivariate analysis. Initial levels of CRP and PCT alone and their combinations in septic shock patients had a limitation to predict 28-day mortality. Future research is needed to determine new biomarkers for early prognostication in patients with septic shock.

BACKGROUND AND PURPOSE The early prediction of acute kidney injury (AKI) in sepsis and provision of timely treatment may improve outcomes. We investigated the efficacy of the delta neutrophil index (DNI)-which reflects the fraction of immature granulocytes-in predicting sepsis-induced AKI and 30-day mortality in cases of severe sepsis or septic shock. METHODS This retrospective, observational cohort study was performed with patients prospectively integrated in a critical pathway of early-goal-directed therapy /SEPSIS. We analyzed adult sepsis patients admitted to the emergency department with normal kidney function or stage 1 disease, based on the Acute Kidney Injury Network classification, between January 1, 2014 and September 30, 2017. The outcomes were the development of sepsis-induced severe AKI within 7 days and 30-day mortality. RESULTS A total of 346 patients were enrolled. An increase in the DNI values at Time-0 (odds ratio [OR], 1.060; P

Current guidelines recommend that rapid source control should be adopted in patients not6-12 h after sepsis is diagnosed. However, evidence level of this guideline is not specified, and there is no previous study on patients with septic shock visiting the emergency department (ED). Therefore, we aimed to assess the impact of rapid source control in patients with septic shock visiting the ED.In a prospective, observational, multicenter, registry-based study in 11 EDs, Cox proportional hazards model was used to assess the independent effect of source control and time to source control on 28-day mortality.Cox proportional hazard models revealed that 28-day mortality was significantly lower in patients who underwent source control (HR 0.538 (0.389-0.744), p .001). However, no significant association between the performance of source control after 6 h or 12 h from enrollment and 28-day mortality was noted.Patients with septic shock visiting the ED who underwent source control showed better outcomes than those who did not. We failed to demonstrate the performance of rapid source control reduced the 28-day mortality in septic shock patients. Further studies are required to determine the impact of rapid source control in sepsis and septic shock.

ObjectivesTo develop new nomograms by adding ECG changes (ST depression or tall T wave) and age to three conventional scoring systems, namely, World Federation of Neurosurgical Societies (WFNS) scale, Hunt and Hess (HH) system and Fisher scale, that can predict prognosis in patients with subarachnoid haemorrhage (SAH) using our preliminary research results and to perform external validation of the three new nomograms.DesignRetrospective, observational studySettingEmergency departments (ED) of two university-affiliated tertiary hospital between January 2009 and March 2015.ParticipantsAdult patients with SAH were enrolled. Exclusion criteria were age Primary outcome measuresThe 6 month prognosis was assessed using the Glasgow Outcome Scale (GOS). We defined a poor outcome as a GOS score of 1, 2 or 3.ResultsA total of 202 patients were included for analysis. From the preliminary study, age, ECG changes (ST depression or tall T wave), and three conventional scoring systems were selected to predict prognosis in patients with SAH using multi-variable logistic regression. We developed simplified nomograms using these variables. Discrimination of the developed nomograms including WFNS scale, HH system and Fisher scale was superior to those of WFNS scale, HH system and Fisher scale (0.912 vs 0.813; pConclusionsWe developed and externally validated new nomograms using only three independent variables. Our new nomograms were superior to the WFNS scale, HH systems, and Fisher scale in predicting prognosis and are readily available.

No studies have examined the role of delta neutrophil index (DNI) reflecting on immature granulocytes in determining the severity of multiple organ dysfunction (MODS) and short-term mortality. This study investigated the utility of the automatically calculated DNI as a prognostic marker of severity in trauma patients who were admitted to an intensive care unit (ICU). We retrospectively analysed prospective data of eligible patients. We investigated 366 patients. On multivariable logistic regression analysis, higher DNI values at 12 h (odds ratio [OR], 1.079; 95% confidence interval [CI]: 1.037–1.123; p p 3.25% at 12 h (OR, 12.7; 95% CI: 6.12–26.35; p 5.3% at 12 h was significantly associated with an increased risk of 30-day mortality (HR, 18.111; 95% CI, 6.988–46.935; p

Overcrowding in emergency departments is a serious public health issue. Recent studies have reported that overcrowding in emergency departments affects not only the quality of emergency care but also clinical decisions about admission. However, no studies have examined the characteristics of the patient groups whose admission rate is influenced by such overcrowding. This retrospective cohort study was conducted in a single emergency department between January 1 and December 31, 2018. Patients over 19 years old were enrolled and divided into three groups according to the degree of overcrowding—high, low, and non—based on the total number of patients in the emergency department. An emergency triage tool (the Korean Triage and Acuity Scale) was used, which categorizes patients into five different levels. We analyzed whether the degree of change in the admission rate according to the extent of overcrowding differed for each triage group. There were 73,776 patients in this study. In the analysis of all patient groups, the admission rate increased as the degree of overcrowding rose (the adjusted odds ratio for admission was 1.281 (1.225–1.339) in the high overcrowding group versus the non-overcrowding group). The analysis of the patients in each triage level showed an increase in the admission rate associated with the overcrowding, which was greater in the patient groups with a lower triage level (adjusted odds ratios for admission in the high overcrowding group versus non-overcrowding group: Korean Triage and Acuity Scale level 3 = 1.215 [1.120–1.317], level 4 = 1.294 [1.211–1.382], and level 5 = 1.954 [1.614–2.365]).

Current sepsis guidelines recommend administration of antibiotics within 1 hour of emergency department (ED) triage. However, the quality of the supporting evidence is moderate, and studies have shown mixed results regarding the association between antibiotic administration timing and outcomes in septic shock. We investigated to evaluate the association between antibiotic administration timing and in-hospital mortality in septic shock patients in the ED, using propensity score analysis.An observational study using a prospective, multicenter registry of septic shock, comprising data collected from 10 EDs, was conducted. Septic shock patients were included, and patients were divided into 4 groups by the interval from triage to first antibiotic administration: group 1 (≤1 hour; reference), 2 (1-2 hours), 3 (2-3 hours), and 4 (3 hours). The primary endpoint was in-hospital mortality. After inverse probability of treatment weighting, the outcomes of the groups were compared.A total of 2250 septic shock patients were included, and the median time to first antibiotic administration was 2.29 hours. The in-hospital mortality of groups 2 and 4 were significantly higher than those of group 1 (odds ratio [OR] 1.248; 95% confidence interval [CI], 1.053-1.478; P = .011; OR 1.419; 95% CI, 1.203-1.675; P.001, respectively), but those of group 3 was not (OR 1.186; 95% CI, 0.999-1.408; P = .052). Subgroup analyses of patients (n = 2043) with appropriate antibiotics presented similar results.In patients with septic shock, rapid administration of antibiotics was generally associated with a decrease in in-hospital mortality, but no "every hour delay" was seen.

Aim The optimal coronary angiography (CAG) timing in out-of-hospital cardiac arrest (OHCA) survivors without ST-segment elevation (STE) for good neurologic outcome remains unknown. This study aimed to evaluate whether immediate versus early CAG impacts neurological outcomes of OHCA survivors without STE. Methods This multicenter retrospective observational registry-based study was conducted at the emergency department (ED) of 8 Korean tertiary care hospitals. Data of adult non-traumatic OHCA patients with no obvious extra-cardiac cause, without STE, who were treated with targeted temperature management (TTM), and in whom CAG was performed within 24 h after return of spontaneous circulation between 2010 and 2015 were extracted. Patients in the immediate (≤2 h) and early (2–24 h) CAG groups were propensity score matched. The primary endpoint was 1-month good neurological outcomes. Results Among 346 patients with TTM and CAG, 119 who underwent CAG after 24 h were excluded, leaving 112 and 115 in the immediate and early CAG groups, respectively. Median time to CAG was 120.0 (70.0–224.0) minutes; 97 (42.7%) patients had significant coronary artery stenosis. Good neurological outcome was higher in the early versus immediate CAG group (50.4% vs. 31.3%, P = 0.003), but no significant intergroup difference persisted after matching. CAG timing was not associated with good neurological outcomes (odds ratio, 1.917; 95% confidence interval, 0.954–3.852; P = 0.07). Conclusions Coronary artery stenosis was found in 42.7% of TTM-treated non-STE OHCA patients with CAG within 24 h, but there was no clear neurological benefit of immediate versus early CAG.

Aim Since the introduction of targeted temperature management (TTM), the accuracy and timing of prognostic tests for post-cardiac arrest patients have changed. Although previous studies have demonstrated the effectiveness of a multimodal approach in assessing the prognosis of TTM patients, few studies have investigated an optimised strategy that sequentially combines different prognostic modalities. This study identified an optimal sequential combination of prognostic modalities to predict poor neurologic outcomes in patients undergoing TTM. Methods We performed a retrospective analysis using TTM management registry data. All patients underwent an identical sequence of prognostic tests at fixed timings. The sequence included brain computed tomography (CT), serum neuron-specific enolase (NSE), electrophysiological examination, neurologic examination, and diffusion-weighted imaging. We used hierarchical classification and regression tree analysis to find the optimal prognostic model. The primary measure was a poor neurologic outcome at one month after cardiac arrest. Results A total of 192 patients were included and 103 patients (53.6%) had poor neurologic outcomes. The final model consisted of brain CT, serum NSE, electroencephalogram, somatosensory-evoked potentials, and pupil light reflex. Our model predicted poor outcomes with a 0% false positive rate. Moreover, our model had an area under the receiver operating characteristic curve value of 0.911 (95% confidence interval, 0.872–0.950), which was significantly higher than that of each prognostic modality alone. Conclusions Our stepwise model showed excellent prognostic ability to predict poor outcomes at one month after cardiac arrest and may be used to minimise the risk of false pessimistic predictions in patients undergoing TTM.

Ischemia preconditioning (IPC) displays an important adaptation of the CNS to sub-lethal ischemia. In the present study, we examined the effect of IPC on immunoreactivities of VEGF-, and phospho-Flk-1 (pFlk-1) following transient cerebral ischemia in gerbils. The animals were randomly assigned to four groups (sham-operated-group, ischemia-operated-group, IPC plus (+) sham-operated-group, and IPC+ischemia-operated-group). IPC was induced by subjecting gerbils to 2 min of ischemia followed by 1 day of recovery. In the ischemia-operated-group, a significant loss of neurons was observed in the stratum pyramidale (SP) of the hippocampal CA1 region (CA1) alone 5 days after ischemia-reperfusion, however, in all the IPC+ischemia-operated-groups, pyramidal neurons in the SP were well protected. In immunohistochemical study, VEGF immunoreactivity in the ischemia-operated-group was increased in the SP at 1 day post-ischemia and decreased with time. Five days after ischemia-reperfusion, strong VEGF immunoreactivity was found in non-pyramidal cells, which were identified as pericytes, in the stratum oriens (SO) and radiatum (SR). In the IPC+sham-operated- and IPC+ischemia-operated-groups, VEGF immunoreactivity was significantly increased in the SP. pFlk-1 immunoreactivity in the sham-operated- and ischemia-operated-groups was hardly found in the SP, and, from 2 days post-ischemia, pFlk-1 immunoreactivity was strongly increased in non-pyramidal cells, which were identified as pericytes. In the IPC+sham-operated-group, pFlk-1 immunoreactivity was significantly increased in both pyramidal and non-pyramidal cells; in the IPC+ischemia-operated-groups, the similar pattern of VEGF immunoreactivity was found in the ischemic CA1, although the VEGF immunoreactivity was strong in non-pyramidal cells at 5 days post-ischemia. In brief, our findings show that IPC dramatically augmented the induction of VEGF and pFlk-1 immunoreactivity in the pyramidal cells of the CA1 after ischemia-reperfusion, and these findings suggest that the increases of VEGF and Flk-1 expressions may be necessary for neurons to survive from transient ischemic damage.

We assessed the usefulness of the delta neutrophil index (DNI), reflecting immature granulocytes, to stratify risk for developing contrast-induced nephropathy (CIN) in patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI) in a clinical setting.This study retrospectively analyzed prospective data of eligible adult patients admitted to the emergency department (ED) with STEMI followed by PCI. We determined DNI at multiple time points and analyzed the development of CIN and in-hospital mortality according to CIN incidence.Overall, 564 patients with STEMI followed by PCI were included. Of these, 58 patients (10.3%) had CIN. Areas under the curve for predictability of CIN using the DNI within 2 h after PCI (I) and 24 h on ED admission (24) among patients with CIN were 0.775 (P 0.001) and 0.751 (P 0.001), respectively. Multivariable logistic regression demonstrated that increased DNI values at time I (odds ratio [OR], 1.632; 95% confidence interval [CI], 1.357-1.964; P 0.001) and time 24 (OR, 1.503; 95% CI, 1.272-1.777; P 0.001) were strong independent factors for predicting CIN among patients with STEMI who underwent PCI. Increasing predictability of CIN was closely associated with DNI more than 1.8% on ED admission (OR, 12.494; 95% CI, 6.540-23.87; P 0.001) and more than 1.9% at time 24 (OR, 10.45; 95% CI, 5.769-18.928; P 0.001).The DNI is easily obtained as part of the complete blood count measurement without requiring additional cost or time. High DNI independently predicts the development of CIN in patients with acute STEMI followed by PCI.

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

PURPOSE The delta neutrophil index (DNI), reflecting the fraction of circulating immature granulocytes, is associated with increased mortality in patients with systemic inflammation. It is rapidly and easily measured while performing a complete blood count. This study aimed to determine whether the DNI can predict short-term mortality in patients presenting to the emergency department (ED) with upper gastrointestinal hemorrhage (UGIH). METHODS We retrospectively identified consecutive patients (>18 years old) with UGIH admitted to the ED from January 1, 2015 to February 28, 2016. The diagnosis of UGIH was confirmed using clinical, laboratory, and endoscopic findings. The DNI was determined on each day of hospitalization. The outcome of interest was 30-day mortality. RESULTS Overall, 432 patients with UGIH met our inclusion criteria. The multivariate Cox regression model demonstrated that higher DNI values on days 0 (hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.02-1.17; P = 0.012) and 1 (HR, 1.15; 95% CI, 1.06-1.24; P = 0.001) were strong independent predictors of short-term mortality. Further, a DNI >1% at ED admission was associated with an increased risk (HR, 40.9; 95% CI, 20.8-80.5; P

The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) recommend that chest compression be rotated every 2 min to prevent rescuer fatigue. However, the quality of chest compression using 2-min switched CPR tends to decrease rapidly due to rescuer fatigue. We aimed to compare the effectiveness of use of 2-min switched CPR and rescuer-limited CPR (the person performing compressions is allowed to switch with another rescuer prior to 2 min if feeling fatigued) in the setting of inhospital cardiac arrest.Using a randomised cross-over trial design, 90 medical students were grouped into pairs to perform four cycles of 2-min switched CPR and rescuer-limited CPR (495 s per technique). During each trial, the total number of compressions performed, mean depth of compression and proportion of effective compressions performed (compression depth5 mm) were recorded for identification of significant differences and changes in pulse rate and RR were measured to determine the extent of exhaustion.Compared with 2-min switched CPR, the mean compression was deeper (51 vs 47 mm, p0.001), total number of compressions greater (476 vs 397, p=0.003) and proportion of effective compressions greater (56% vs 47%, p=0.004) during rescuer-limited CPR. Subgroup analysis by 30-s unit showed more consistent compression quality during rescuer-limited CPR. No significant differences in change in pulse rate and RR were found between the two techniques.Rescuer-limited CPR yields a greater number of effective compressions and more consistent quality of CPR than 2-min switched CPR. Rescuer-limited CPR might be a suitable alternative for treating inhospital cardiac arrest.

BackgroundThe 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.MethodA 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.ResultsOverall, 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 (pConclusionsConsidering 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.

We aimed to analyze whether laser Doppler imaging (LDI) can lead to earlier decision-making regarding the need for surgery in adults with indeterminate burns.In a retrospective cohort study, we developed a prediction model for surgery in adults with indeterminate burns. Patient data (n=101) from January 2007 to December 2009 were used for model development, and those (n=40) from January 2010 to October 2010 for external validation.Between non-surgical and surgical groups, there were significant differences for mean age (p=0.009), % total body surface area burn (p=0.016), site of burn wound (p=0.033), and mean perfusion units (PU) (p0.001). Multiple logistic regression showed that only the mean PU differed significantly between the groups. The area under the curve (AUC) of the equation derived from multiple logistic regression was 0.938, which did not differ from that of the mean PU alone (0.931; p=0.453). Using a cut-off point of 154.7PU, the sensitivity of LDI was 78.3% and the specificity was 92.7%. This cut-off point also yielded a sensitivity of 77.8% and specificity of 95.5% in the external validation dataset.LDI can help make a decision for surgery in the early stages of care for adults with indeterminate burns.

We evaluated the mean platelet volume (MPV) to platelet ratio to determine its significance as a prognostic marker for early mortality in critically ill patients with suspected sepsis receiving early goal-directed therapy (EGDT).We retrospectively reviewed the records from a prospective EGDT registry and screened eligible adult patients who were admitted to the emergency department (ED) with severe sepsis and/or septic shock. The MPV/platelet ratio was estimated as the MPV value divided by the platelet count on each day of hospitalization. The clinical outcome was 28-day mortality.We included 120 patients receiving EGDT. In the multivariate Cox proportional hazard models, higher MPV/platelet ratios on admission (HR: 1.04; 95% CI: 1.015-1.066; P = 0.002) and at 24 h (HR: 1.032; 95% CI: 1.012-1.054; P = 0.002) were significant risk factors for mortality at 28 days. An increased trend for 28-day mortality was associated with a MPV/platelet ratio 3.71 on admission (HR: 4.274; 95% CI: 1.228-14.874; P = 0.023) and a higher MPV/platelet ratio (6.49) at 24 h (HR: 2.719; 95% CI: 1.048-7.051; P = 0.04) in patients with severe sepsis receiving EGDT.In our study, MPV or platelet count alone did not predict shock and 28-day mortality in patients with severe sepsis receiving EGDT. However, the MPV/platelet ratio at ED admission and on day 1 is a promising prognostic marker for 28-day mortality in patients with severe sepsis.

Objectives The purpose of this study was to investigate whether a multidisciplinary organised critical pathway (CP) for ST-segment elevation myocardial infarction (STEMI) management can significantly attenuate differences in the duration from emergency department (ED) arrival to evaluation and treatment, regardless of the arrival time, by eliminating off-hour and weekend effects. Design Retrospective observational cohort study. Setting 2 tertiary academic hospitals. Participants Consecutive patients in the Fast Interrogation Rule for STEMI (FIRST) program. Interventions A study was conducted on patients in the FIRST program, which uses a computerised physician order entry (CPOE) system. The patient demographics, time intervals and clinical outcomes were analysed based on the arrival time at the ED: group 1, normal working hours on weekdays; group 2, off-hours on weekdays; group 3, normal working hours on weekends; and group 4, off-hours on weekends. Primary and secondary outcome measures Clinical outcomes categorised according to 30-day mortality, in-hospital mortality and the length of stay. Results The duration from door-to-data or FIRST activation did not differ significantly among the 4 groups. The median duration between arrival and balloon placement during percutaneous coronary intervention did not significantly exceed 90 min, and the proportions (89.6–95.1%) of patients with door-to-balloon times within 90 min did not significantly differ among the 4 groups, regardless of the ED arrival time (p=0.147). Moreover, no differences in the 30-day (p=0.8173) and in-hospital mortality (p=0.9107) were observed in patients with STEMI. Conclusions A multidisciplinary CP for STEMI based on a CPOE system can effectively decrease disparities in the door-to-data duration and proportions of patients with door-to-balloon times within 90 min, regardless of the ED arrival time. The application of a multidisciplinary CP may also help attenuate off-hour and weekend effects in STEMI clinical outcomes.

OBJECTIVES The purpose of this study was to investigate the ability of sonography to identify acute epiglottitis in the emergency department. METHODS Fifteen patients with a final diagnosis of acute epiglottitis from indirect laryngoscopy by an otolaryngologist were enrolled in the study. To compare the normal epiglottis and acute epiglottitis, 15 healthy volunteers were assigned to a control group. The sonographic appearances of the epiglottitis and the pre-epiglottic space were recorded. The anteroposterior diameter of the epiglottis at the midpoint and both edges in a transverse view was measured in all participants. RESULTS A statistically significant difference (P < .001) was observed in the anteroposterior diameter of the epiglottis at the midpoint and both lateral edges between the patients and healthy volunteers. However, there was overlap in the ranges for the midpoint but no overlap in both lateral edges between groups. The upper-limit value for the healthy control group was 3.2 mm at both lateral edges, whereas the cutoff values of the right and left edges were 3.7 and 3.6 mm, respectively, according to the lower-limit value for the epiglottitis group. CONCLUSIONS The anteroposterior diameter of the epiglottis was significantly different between the patients with epiglottitis and the healthy volunteers. Because of this significant difference in the anteroposterior diameter of the epiglottis, sonography can be used as a rapid, noninvasive, and effective diagnostic tool for identifying cases of epiglottitis in the emergency department.

Introduction Various methods and devices have been described for cooling after cardiac arrest, but the ideal cooling method remains unclear. The aim of this study was to compare the neurological outcomes, efficacies and adverse events of surface and endovascular cooling techniques in cardiac arrest patients. Methods We performed a multicenter, retrospective, registry-based study of adult cardiac arrest patients treated with therapeutic hypothermia presenting to 24 hospitals across South Korea from 2007 to 2012. We included patients who received therapeutic hypothermia using overall surface or endovascular cooling devices and compared the neurological outcomes, efficacies and adverse events of both cooling techniques. To adjust for differences in the baseline characteristics of each cooling method, we performed one-to-one matching by the propensity score. Results In total, 803 patients were included in the analysis. Of these patients, 559 underwent surface cooling, and the remaining 244 patients underwent endovascular cooling. In the unmatched cohort, a greater number of adverse events occurred in the surface cooling group. Surface cooling was significantly associated with a poor neurological outcome (cerebral performance category 3–5) at hospital discharge (p = 0.01). After propensity score matching, surface cooling was not associated with poor neurological outcome and hospital mortality [odds ratio (OR): 1.26, 95% confidence interval (CI): 0.81-1.96, p = 0.31 and OR: 0.85, 95% CI: 0.55-1.30, p = 0.44, respectively]. Although surface cooling was associated with an increased incidence of adverse events (such as overcooling, rebound hyperthermia, rewarming related hypoglycemia and hypotension) compared with endovascular cooling, these complications were not associated with surface cooling using hydrogel pads. Conclusions In the overall matched cohort, no significant difference in neurological outcomes and hospital morality was observed between the surface and endovascular cooling methods.

Studies show that young children are vulnerable to burn injuries. We aimed to investigate the characteristics of thermal injuries in this population. We included children below 6 years of age who visited the emergency department (ED) after thermal injuries who were registered in the Korean Emergency Department-based Injury In-Depth Surveillance (2011-2016) database. Demographic characteristics, injury-related factors, and factors associated with ED treatment were gathered from the data. Then, we divided all children into two groups according to the ED discharge status: discharge versus admission (including cases transferred to other hospitals). The characteristics of the two groups were compared, and factors associated with admission were investigated. During the study period, 11,667 children with thermal injuries visited the ED. The number of boys was higher than the number of girls, and children aged 1 year accounted for the largest proportion. Most cases occurred in spring and indoors; the home was found to be the most common place. The most common type of burn was scald burns (69%), followed by contact burns (25.9%), and the most commonly burnt body area was the upper limbs (43.7%), followed by the lower limbs (16.8%). Most children (95.8%) were discharged home. The odds for hospital admission were lower for 2-3 and 4-5 year olds than for 0-1 year olds. The odds for hospital admission for contact burns were lower and those for electrical burns were higher than odds for hospital admission for scald burns. In summary, those aged 0-1 showed the largest incidence of thermal injuries and the most common burn mechanism was scald burns. Upper limbs were the most commonly affected body area, but their odds for requiring admission was lowest. Our results could be used as baseline data for prospective interventional studies investigating ways to reduce the incidence of childhood thermal injuries.

Objectives: The correct chest compression technique was emphasised to enhance the result of cardiopulmonary resuscitation in the 2005 guidelines. The present study compared the effects of different bed heights, including a bed at knee height, on the performance of chest compressions. Methods: Twenty-four healthcare providers participated in this study. Knee height was defined as the baseline bed height. Bed heights were adjusted to 10 and 20 cm above the baseline and 10 and 20 cm below the baseline. At the five bed heights, chest compressions were performed for 2 minutes, and the compression rate was maintained at 100 per minute, with audible feedback. Results: The mean compression depths (MCD) were 28.3 mm (SD 10.7; knee height +20 cm), 32.3 mm (SD 9.2; knee height +10 cm), 32.7 mm (SD 8.5; knee height), 32.3 mm (SD 9.0; knee height −10 cm) and 31.1 mm (SD 8.5; knee height −20 cm). The MCD was significantly lower at knee height plus 20 cm (p Conclusion: The performance of chest compressions decreased when the bed height was 20 cm higher than the knee height of the rescuer.

The purpose of this study was to assess the accuracy of a Web-based resuscitation recording program compared with the handwritten method.A Web site was developed to record in-hospital resuscitation events and a mock resuscitation was recorded using both the Web site and handwritten method by emergency nurses. Accurate recorded events and times were compared between the two methods through the use of a video clip. Paired t tests were used to compare differences in absolute timing error, the number of omitted events out of 11 reference events and total recorded events.Twenty-one emergency nurses recorded simulated resuscitation events using both the handwritten and Web-based computerised recording system. The mean absolute timing errors were significantly lower using the computerised recording program (37.3 s (SD 17.1) versus 8.3 s (SD 5.3), p0.001). The mean number of omissions for the computerised program was 1.8 (SD 0.8) compared with 1.4 (SD 1.1) for the handwritten method (p = 0.202). The mean number of total recorded events for the computerised program was 16.5 (SD 3.5) compared with 15.0 (SD 3.8) for the handwritten method (p = 0.063).This study suggests that a Web-based recording program decreased timing error while causing no differences in the number of recorded or omitted events in a laboratory setting.

Purpose We evaluated the ratio of delta neutrophil index (DNI) to albumin (A) in patients receiving early goal-directed therapy (EGDT) to determine the prognostic significance of the DNI/A ratio as a marker of early mortality in critically ill patients with suspected sepsis. Methods We retrospectively analyzed records from a prospective EGDT registry in an emergency department (ED) and screened eligible adult patients who were admitted to the ED with severe sepsis and/or septic shock. The new DNI/A ratio was calculated as the DNI value on each hospital day divided by the initial albumin level on ED admission. The clinical outcome was mortality after 28 days. Results A total of 120 patients receiving EGDT were included in this study. Multivariate Cox proportional-hazard models revealed that higher DNI/A ratios on day 1 (hazard ratio [HR], 1.068; 95% confidence interval [CI], 1.01-1.13; P = .0209) and the peak day (HR, 1.057; 95% CI, 1.001-1.116; P = .0456) were independent risk factors for mortality at 28 days. Our study demonstrated that the increased trend toward 28-day mortality was associated with a DNI/A ratio greater than 8.4 on day 1 (HR, 2.513; 95% CI, 0.950-6.64; P = .0528) and a higher DNI/A ratio (> 6.4) on the peak day (average, 4.2 days; HR, 2.953; 95% CI, 1.033-8.441; P Conclusion The ratio of DNI to serum albumin on ED admission is a promising prognostic marker of 28-day mortality in patients with severe sepsis receiving EGDT.

Background The post-resuscitation phase after out-of-hospital cardiac arrest (OHCA) is characterised by a systemic inflammatory response (e.g., severe sepsis), for which the immature granulocyte count is a diagnostic marker. In this study we evaluated the prognostic significance of the delta neutrophil index (DNI), which is the difference in leukocyte subfractions as assessed by an automated blood cell analyser, for early mortality after OHCA. Materials and Methods OHCA records from the emergency department cardiac arrest registry were retrospectively analysed. Patients who survived at least 24 h after return of spontaneous circulation were included in the analysis. We evaluated mortality and cerebral performance category scores at 30 days. Results A total of 83 patients with OHCA were included in the study. Our results showed that DNI >8.4% on day 1 (hazard ratio [HR], 3.227; 95% CI, 1.485–6.967; p = 0.001) and DNI >10.5% on day 2 (HR, 3.292; 95% CI, 1.662–6.519; p8.4% on day 1 (HR, 2.718; 95% CI, 1.508–4.899; p10.5% on day 2 (HR, 1.709; 95% CI, 1.051–2.778; p = 0.02) were associated with worse neurologic outcomes 30 days after OHCA. Conclusion A higher DNI is a promising prognostic marker for 30-day mortality and neurologic outcomes after OHCA. Our findings indicate that patients with elevated DNI values after OHCA might be closely monitored so that appropriate treatment strategies can be implemented.

Background The aim of this study was to assess the quality of chest compressions performed by inexperienced rescuers using three different techniques: two-hand, right one-hand, and left one-hand. Methods We performed a prospective, randomised, crossover study in a simulated 6-year-old paediatric manikin model. Each participant performed 2-minute continuous chest compressions, using three different techniques. Chest compression quality data, including compression rate, compression depth, and residual leaning was recorded by a Q-CPR™ compression sensor connected to HeartStart MRx (Philips Healthcare, Andover, MA, USA). To examine trends in chest compression performance over time, each 2-minute period was divided into six consecutive 20-second epochs. Results The 36 participants completed 108 two-minute trials, consisting of a total of 25,030 compressions. The mean compression rates [95% confidence interval] were as follows: two-hand, 116.8 [111.7–121.9]; left one-hand, 115.0 [109.9–120.1]; and right one-hand, 115.5 [110.4–120.6] (p = 0.565). The mean compression depth for two-hand was 38.7 mm (37.1–40.2), which was higher than for left one-hand (36.3 mm [34.8–37.9]) or right one-hand (35.4 mm [33.9-37.0]) (p 0.999). The residual leaning rate was higher with two-hand (40.7 [27.9–53.5]) than that for left one-hand (29.2 [16.4–42.0]) or right one-hand (25.8 [13.0–38.6]) (p = 0.021). Conclusions For paediatric cardiopulmonary resuscitation by inexperienced rescuers, the two-hand technique has the advantage of producing deeper compressions than the one-hand technique, but it is accompanied by more frequent residual leaning. For the one-hand techniques, the right and left hand produced chest compressions of similar quality.

Background Admission on weekends and off-hours has been associated with poor outcomes and mortality from acute stroke. The purpose of this study was to investigate whether an organized clinical pathway (CP) for ischemic stroke can effectively reduce the time from arrival to evaluation and treatment in the emergency department (ED) and improve outcomes, regardless of the time from arrival in the ED. Methods We conducted a retrospective analysis of all consecutive patients included in the prospective registry database in the Brain Salvage through Emergency Stroke Therapy program, which uses the computerized physician order entry (CPOE) system. Patients were classified based on their time of arrival in the ED: group 1, normal working hours on weekdays; group 2, off-hours on weekdays; group 3, normal working hours on weekends; and group 4, off-hours on weekends. Clinical outcomes were categorized according to 30 days in-hospital mortality, in-hospital mortality, and the modified Rankin score during a single length of stay (LOS). Results No time intervals differed significantly among the 4 patient groups who received intravenous administration of tissue plasminogen activator (IV-tPA). Use of IV-tPA ( P = .5110) was not affected by arrival in the ED on off-days or weekends. The overall mortality rate was 3.9%, and the median LOS was 7 days (Interquartile range (IQR), 5-10). By Kaplan-Meier analysis, the cumulative probability of mortality and survival did not differ significantly among the 4 groups over 30 days ( P = .1557). Conclusion An organized CP, based on CPOE, for ischemic stroke can effectively attenuate disparities in the time interval between ED arrival to evaluation and treatment regardless of ED arrival time. This pathway may also help to eliminate off-hour and weekend effects on outcomes from ischemic stroke.

The aim of this study is to evaluate the usefulness of the GlideScope video laryngoscope (GVL) as a tool to educate novice users in conventional tracheal intubation. 41 premedical students with no previous experience in tracheal intubation participated in this prospective, randomised and controlled study. Group M (n = 20) was instructed in tracheal intubation by using the Macintosh laryngoscope and group G (n = 21) was instructed by using both the GVL and the Macintosh laryngoscope. There was no significant difference in tracheal intubation performance using the Macintosh laryngoscope between the two groups. However, the GVL facilitates the education of tracheal intubation because it shows the same anatomical structure for both instructor and trainee simultaneously on a real-time basis. This aspect makes the trainee feel more comfortable learning the material with a high degree of satisfaction. Introducing GVL to conventional intubation education for novice users could increase the satisfaction of trainees during the procedure, especially as a way to understand critical anatomical structures.

The objective of this study was to compare the efficacy of ethyl chloride spray and ice cube for the control of pain induced by the antibiotic skin test.We performed a prospective, crossover, randomized study in which healthy adult volunteers received an intradermal skin test on both arms after different analgesic pretreatments. We assessed the pretreatment pain and discomfort after the intradermal skin injection using a 100-mm visual analogue scale.A total of 50 volunteers were enrolled in the study. The mean pain scores after the skin test were 32.4 +/- 17.6 and 54.7 +/- 22.4 mm, for the ice cube and vapocoolant spray pretreatment, respectively (P.0001). The mean discomfort scores during pretreatment were 20.0 +/- 15.2 mm for ice cube and 10.5 +/- 11.5 mm for vapocoolant spray (P.0001). Forty-five (90%) subjects preferred the ice cube pretreatment for the intradermal skin test.The ice cube application was significantly more effective than the vapocoolant spray in reducing the pain of the antibiotic skin test. Hence, the ice cube pretreatment is suggested for easy and fast pain reduction for the antibiotic skin test in the emergency department.

Objectives Long working hours can negatively impact a worker's health. The objective of this study was to examine the association between working hours and cardiovascular diseases (CVDs) and compare the degree of risk based on CVD subtypes in Korean workers. Methods This study was a case-control study of the patients registered in the Occupational Cardiovascular Diseases Surveillance 2010. The cases included 348 patients diagnosed with a CVD (123 cerebral infarction, 69 intracerebral hemorrhage, 57 subarachnoid hemorrhage, 99 acute myocardial infarction). Controls were 769 participants with no history of CVDs matched for gender, age, type of occupation, and region. Participants' working hours in the previous week and the average working hours over the past three months were assessed to examine short-term and long-term effects. Results After adjusting for confounding factors, the odds ratios (ORs) for CVDs in the short-term were 2.66 (95% Confidence interval (CI) :1.78-3.99) for working ≤40 hours, 1.85 (95% CI: 1.22-2.81) for working 50.1-60 hours and 4.23 (95% CI: 2.81-6.39) for working >60 hours compared with the 40.1-50-hour working group. The ORs in the long-term were 2.90 (95% CI: 1.86-4.52) for working ≤40 hours, 1.73 (95% CI: 1.03-2.90) for working 48.1-52 hours and 3.46 (95% CI: 2.38-5.03) for working >52 hours compared with the 40.1-48-hour working group. Conclusions Long working hours are related to an increased risk of CVDs, and the degree of risk differs based on CVD subtype. Short working hours are also related to an increased risk for CVDs. More prospective studies targeting specific disease risks are required.

Purpose The objective of this study was to develop a new nomogram that can predict 28-day mortality in severe sepsis and/or septic shock patients using a combination of several biomarkers that are inexpensive and readily available in most emergency departments, with and without scoring systems. Materials and methods We enrolled 561 patients who were admitted to an emergency department (ED) and received early goal-directed therapy for severe sepsis or septic shock. We collected demographic data, initial vital signs, and laboratory data sampled at the time of ED admission. Patients were randomly assigned to a training set or validation set. For the training set, we generated models using independent variables associated with 28-day mortality by multivariate analysis, and developed a new nomogram for the prediction of 28-day mortality. Thereafter, the diagnostic accuracy of the nomogram was tested using the validation set. Results The prediction model that included albumin, base excess, and respiratory rate demonstrated the largest area under the receiver operating characteristic curve (AUC) value of 0.8173 [95% confidence interval (CI), 0.7605-0.8741]. The logistic analysis revealed that a conventional scoring system was not associated with 28-day mortality. In the validation set, the discrimination of a newly developed nomogram was also good, with an AUC value of 0.7537 (95% CI, 0.6563-0.8512). Conclusion Our new nomogram is valuable in predicting the 28-day mortality of patients with severe sepsis and/or septic shock in the emergency department. Moreover, our readily available nomogram is superior to conventional scoring systems in predicting mortality.

Objective We aimed to compare the quality of chest compressions performed by inexperienced rescuers in different positions, notably supine and at a 30° inclined lateral position, to ascertain whether high-quality chest compression is feasible on a pregnant subject in cardiac arrest. Subjects and methods We performed a prospective, randomised crossover design study. Each participant performed 2-min chest compressions in two different positions on a mannequin: a supine position and a 30° left inclined lateral position. After 2 min of chest compression in one position, the participant took a rest for 10 min to minimise rescuer fatigue and then performed chest compression in the second position. Data on chest compression rate, mean chest compression depth, correct compression depth rate, correct recoil rate, and correct hand position rate were collected. To measure the angle between the rescuer's arm and the victim's chest surface, chest compressions were recorded with a video recorder. After each practice session, participants were asked to report the subjective difficulty of performing chest compressions using a visual analogue scale. Results All 32 participants successfully completed the study. The mean compression rate and depth were 121.0 per minute and 53.3 mm in the supine position and 118.8 per minute and 52.0 mm in the inclined lateral position, respectively ( p = 0.978 and p = 0.260, respectively). Also, there were no differences in the correct compression depth rate, the correct hand position rate, or the correct recoil rate ( p = 0.426, p = 0.467, and p = 0.260, respectively). However, the lowest and highest angles and the subjective difficulty of chest compression differed significantly ( p p p = 0.007, respectively). Conclusions Inexperienced rescuers appear to be capable of performing high-quality chest compressions in a 30° inclined lateral position on pregnant women in a simulated cardiac arrest state.

Introduction Traumatic chest injuries may occur following cardiopulmonary resuscitation (CPR). The aim of this study was to address the frequency of injuries, especially rib and sternal fractures, and also to identify factors that contribute to post-CPR trauma. Methods This study was a prospective cross-sectional study conducted in the emergency departments (ED) of eight academic tertiary care centers. To evaluate injuries secondary to CPR, we performed chest computed tomography (CT) in patients who were successfully resuscitated from cardiac arrest. Contributing factors that might be related to injuries were also investigated. Results We enrolled 71 patients between 1 January 2011 and 30 June 2011. Rib and sternal fractures were diagnosed in 22 and 3 patients, respectively. Females were more susceptible to rib fracture ( p =0.036). When non-physicians participated as chest compressors in the ED, more ribs were fractured ( p =0.048). The duration of CPR and number of compressors were not contributing factors to trauma secondary to CPR. There was a wide variation in the frequency of rib fractures from hospital to hospital (0–83.3%). In high-risk hospitals (in which more than 50% of patients had rib fractures), the average age of the patients was higher, and non-physicians took part in ED CPR more often than they did at low-risk hospitals. Conclusion The incidence of rib fracture following CPR was different in various hospitals. The presence of non-physician chest compressors in the ED was one of the contributing factors to rib fracture. Further studies on the influence of resuscitators and relation between quality of chest compression and CPR-induced injuries are warranted to reduce complications following CPR.

Specialty consultations and waiting for admission to a hospital bed are major contributors to increased length of stay and overcrowding in the emergency department. We implemented a computerized short messaging service to inform care providers of patient delay in order to reduce length of stay. The purpose of this study was to evaluate the effects of this strategy on length of stay in the emergency department.This was a before-and-after observational study. Prior to this study, we registered the mobile phone numbers of all board certified specialists into a computerized physician order entry database and developed an auto-sending short messaging program linked to consultation orders. The short message was transmitted at 2 and 4h after consultation, when a disposition was not yet established, and at 8h after the admission order if the patient was still waiting. The length of stay of consulted patients and intervals such as consultation time (registration-consultation), disposition time (consultation-admission decision), and boarding time (admission decision-hospitalization) of admitted patients were compared between the pre-implementation (September 2009) and post-implementation period (November 2009). Subgroup analyses of disposition time were performed according to time of consultation and the number of consultations.A total of 7518 patients visited the emergency department during the pre-periods and post-periods. Among them, 3335 patients required specialty consultations. The median length of stay of consulted patients decreased significantly after implementation of the messaging system (pre-207 min vs. post-193 min, p0.001). Among admitted patients, the median length of stay decreased by 36 min from 294 min to 258 min (p0.001). In the subgroup analysis, times for establishing patient dispositions decreased significantly when the consultation was performed at night and when there was only one department consulted. The numbers of patients with disposition times within 2 and 4h and boarding times within 8h were all increased after implementation of the short message service program.This study suggested that the computerized physician order entry-based short messaging service program, used to inform decision-makers of patient delay, could reduce the length of stay for consulted patients in the emergency department.

Background The purpose of this study is to compare the cardiopulmonary resuscitation (CPR) team dynamics and performance between a conventional simulation training group and a script-based training group. Methods This was a prospective randomised controlled trial of educational intervention for CPR team training. Fourteen teams, each consisting of five members, were recruited. The conventional group (C) received training using a didactic lecture and simulation with debriefing, while the script group (S) received training using a resuscitation script. The team activity was evaluated with checklists both before and after 1 week of training. The videotaped simulated resuscitation events were compared in terms of team dynamics and performance aspects. Results Both groups showed significantly higher leadership scores after training (C: 58.2±9.2 vs 67.2±9.5, p=0.007; S: 57.9±8.1 vs 65.4±12.1, p=0.034). However, there were no significant improvements in performance scores in either group after training. There were no differences in the score improvement after training between the two groups in dynamics (C: 9.1±12.6 vs S: 7.4±13.7, p=0.715), performance (C: 5.5±11.4 vs S: 4.7±9.6, p=0.838) and total scores (C: 14.6±20.1 vs S: 12.2±19.5, p=0.726). Conclusion Script-based CPR team training resulted in comparable improvements in team dynamics scores compared with conventional simulation training. Resuscitation scripts may be used as an adjunct for CPR team training.

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 6.6m/s 2 (IQR 5.5–7.7m/s 2 ) with significantly less vibrations transmitted to the manikin/human volunteer chest (manikin median 3.1m/s 2 , IQR 2.2–4.0m/s 2 ; human volunteer median 0.95m/s 2 , IQR 0.65–1.25m/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.

Objective There has been little investigation on the appropriateness of the hand position suggested by various guidelines in paediatric cardiopulmonary resuscitation (CPR). We aimed to identify anatomical structures underneath the chest compression landmarks and tried to find the proper hand position using computed tomography (CT) images for more effective paediatric CPR. Patients and methods This study included a total of 181 paediatric patients who were admitted to Severance Hospital and underwent CTs of chest. We studied structures located under the inter-nipple line and under the lower third of the sternum. The distances from the xiphoid process to the level of the left ventricular outflow tract (LVOT) were measured to find the ceiling on the proper hand position. Results The LVOT (42.0%) and the root of the aorta (21.5%) were more frequently located than the left ventricle under the inter-nipple line, and the liver was located under the lower third of the sternum in a significant number of patients (28.7%). The LVOT was placed 6.8±13.9mm below the nipple level, but there was no significant difference in the distance from the nipple level to the LVOT among the age groups ( p =0.517). Conclusions The hand position at the inter-nipple line might be too high and that at the lower third of the sternum might be too low as it can compress the liver. Further studies are needed to find the proper hand position for more effective chest compression during paediatric CPR.

We report a case of lumbosacral plexopathy caused by an isolated aneurysm in the common iliac artery. The patient presented with low back and buttock pain radiating to the right leg and numbness in the L5 and S1 dermatomes. A computed tomography scan showed an aneurysm of the right common iliac artery. This case serves to increase awareness of the possibility of lumbosacral plexopathy in patients with symptoms of a prolapsed intervertebral disc.

Meckel's diverticulum results from incomplete closure of the omphalomesenteric duct, and is the most common congenital anomaly of the small intestine. We present a case report of a 42-year-old patient who developed a strangulated intestinal obstruction as a complication of Meckel's diverticulum. The strangulated bowel obstruction was suggested by contrast-enhanced computed tomography. He recovered after a diverticulectomy and had no need for a small bowel resection.