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This study investigated the impact of intracerebral hemorrhage (ICH) on the cumulative mortality of patients with hyperacute ischemic stroke. This population-based retrospective cohort study used claims data from the National Health Insurance Service customized database of South Korea. The recruitment period was 2005–2018. The study population included patients with hyperacute ischemic stroke who had received intravenous thrombolysis. The primary endpoint was 12-month cumulative mortality, which was analyzed in both the ICH and no-ICH groups. Of the 50,550 patients included, 2567 (5.1%) and 47,983 (94.9%) belonged to the ICH and no-ICH groups, respectively. In the univariable analysis for 12-month mortality, ICH patients were substantially more prevalent among dead patients than among patients who survived (11.6% versus 3.6%; p < 0.001). The overall 12-month cumulative mortality rate was 18.8%. Mortality in the ICH group was higher than that in the no-ICH group (42.8% versus 17.5%; p < 0.001). In the multivariable analysis, the risk of 12-month cumulative mortality was 2.97 times higher in the ICH group than in the no-ICH group (95% confidence interval, 2.79–3.16). The risk of 12-month cumulative mortality in hyperacute ischemic stroke can increase approximately threefold after the occurrence of spontaneous ICH following intravenous thrombolysis.

Background and Objectives: This study assessed the prognostic value of underlying chronic kidney disease (CKD) and renal replacement therapy (RRT) on the clinical outcomes from out-of-hospital cardiac arrest (OHCA). Materials and Methods: This retrospective study was conducted utilizing the population-based OHCA data of South Korea between 2008 and 2018. Adult (>18 years) OHCA patients with a medical cause of cardiac arrest were included and classified into three categories based on the underlying CKD and RRT: (1) non-CKD group; (2) CKD without RRT group; and (3) CKD with RRT group. A total of 13,682 eligible patients were included (non-CKD, 9863; CKD without RRT, 1778; CKD with RRT, 2041). From the three comparison subgroups, data with propensity score matching were extracted. The influence of CKD and RRT on patient outcomes was assessed using propensity score matching and multivariate logistic regression analyses. The primary outcome was survival at hospital discharge and the secondary outcome was a good neurological outcome at hospital discharge. Results: The two CKD groups (CKD without RRT and CKD with RRT) showed no significant difference in survival at hospital discharge compared with the non-CKD group (CKD without RRT vs. non-CKD, p > 0.05; CKD with RRT vs. non-CKD, p > 0.05). The non-CKD group had a higher chance of having good neurological outcomes than the CKD groups (non-CKD vs. CKD without RRT, p < 0.05; non-CKD vs. CKD with RRT, p < 0.05) whereas there was no significant difference between the two CKD groups (CKD without RRT vs. CKD with RRT, p > 0.05). Conclusions: Compared with patients without CKD, the underlying cause of CKD—regardless of RRT—may be linked to poor neurological outcomes. Underlying CKD and RRT had no effect on the survival at hospital discharge.

OBJECTIVE To evaluate the prognostic factors associated with the sustained return of spontaneous circulation (ROSC) and survival to hospital discharge in traumatic out-of-hospital cardiac arrest (TOHCA) patients without prehospital ROSC. METHODS We analyzed Korean nationwide data from the Out-of-Hospital Cardiac Arrest Surveillance, and included adult TOHCA patients without prehospital ROSC from January 2012 to December 2016. The primary outcome was sustained ROSC (>20 minutes). The secondary outcome was survival to discharge. Multivariate analysis was performed to investigate factors associated with the outcomes of TOHCA patients. RESULTS Among 142,905 cases of OHCA, 8,326 TOHCA patients were investigated. In multivariate analysis, male sex (odds ratio [OR], 1.326; 95% confidence interval [CI], 1.103-1.594; P=0.003), and an initial shockable rhythm (OR, 1.956; 95% CI, 1.113-3.439; P=0.020) were significantly associated with sustained ROSC. Compared with traffic crash, collision (OR, 1.448; 95% CI, 1.086-1.930; P=0.012) was associated with sustained ROSC. Fall (OR, 0.723; 95% CI, 0.589- 0.888; P=0.002) was inversely associated with sustained ROSC. Male sex (OR, 1.457; 95% CI, 1.026-2.069; P=0.035) and an initial shockable rhythm (OR, 4.724; 95% CI, 2.451-9.106; P

We aimed to measure the diagnostic accuracy of the deep learning model (DLM) for ST-elevation myocardial infarction (STEMI) on a 12-lead electrocardiogram (ECG) according to culprit artery sorts. From January 2017 to December 2019, we recruited patients with STEMI who received more than one stent insertion for culprit artery occlusion. The DLM was trained with STEMI and normal sinus rhythm ECG for external validation. The primary outcome was the diagnostic accuracy of DLM for STEMI according to the three different culprit arteries. The outcomes were measured using the area under the receiver operating characteristic curve (AUROC), sensitivity (SEN), and specificity (SPE) using the Youden index. A total of 60,157 ECGs were obtained. These included 117 STEMI-ECGs and 60,040 normal sinus rhythm ECGs. When using DLM, the AUROC for overall STEMI was 0.998 (0.996–0.999) with SEN 97.4% (95.7–100) and SPE 99.2% (98.1–99.4). There were no significant differences in diagnostic accuracy within the three culprit arteries. The baseline wanders in false positive cases (83.7%, 345/412) significantly interfered with the accurate interpretation of ST elevation on an ECG. DLM showed high diagnostic accuracy for STEMI detection, regardless of the type of culprit artery. The baseline wanders of the ECGs could affect the misinterpretation of DLM.

(1) Background: Rapid and accurate negative discrimination enables efficient management of scarce isolated bed resources and adequate patient accommodation in the majority of areas experiencing an explosion of confirmed cases due to Omicron mutations. Until now, methods for artificial intelligence or deep learning to replace time-consuming RT-PCR have relied on CXR, chest CT, blood test results, or clinical information. (2) Methods: We proposed and compared five different types of deep learning algorithms (RNN, LSTM, Bi-LSTM, GRU, and transformer) for reducing the time required for RT-PCR diagnosis by learning the change in fluorescence value derived over time during the RT-PCR process. (3) Results: Among the five deep learning algorithms capable of training time series data, Bi-LSTM and GRU were shown to be able to decrease the time required for RT–PCR diagnosis by half or by 25% without significantly impairing the diagnostic performance of the COVID-19 RT–PCR test. (4) Conclusions: The diagnostic performance of the model developed in this study when 40 cycles of RT–PCR are used for diagnosis shows the possibility of nearly halving the time required for RT–PCR diagnosis.

Objective This study aimed to analyze the association between the culprit artery and the diagnostic accuracy of automatic electrocardiogram (ECG) interpretation in patients with ST-segment elevation myocardial infarction (STEMI).Methods This single-centered, retrospective cohort study included adult patients with STEMI who visited the emergency department between January 2017 and December 2020. The primary endpoint was the association between the culprit artery occlusion and the misinterpretation of ECG, evaluated by the chi-square test or Fisher exact test.Results The rate of misinterpretation of the automated ECG for patients with STEMI was 26.5% (31/117 patients). There was no significant correlation between the ST segment change in the four involved leads (anteroseptal, lateral, inferior, and aVR) and the misinterpretation of ECG (all P > 0.05). Single culprit artery occlusion significantly affected the misinterpretation of ECG compared with multiple culprit artery occlusion (single vs. multiple, 27/86 [31.3%] vs. 4/31 [12.9%], P = 0.045). There was no association between culprit artery and the misinterpretation of ECG (P = 0.132).Conclusion Single culprit artery occlusion might increase misinterpretation of ECG compared with multiple culprit artery occlusions in the automatic interpretation of STEMI.

Reducing the time to diagnose COVID-19 helps to manage insufficient isolation-bed resources and adequately accommodate critically ill patients in clinical fields. There is currently no alternative method to RT-PCR, which requires 40 cycles to diagnose COVID-19. We proposed a deep learning (DL) model to improve the speed of COVID-19 RT-PCR diagnosis. We developed and tested a DL model using the long-short term memory method with a dataset of fluorescence values measured in each cycle of 5,810 RT-PCR tests. Among the DL models developed here, the diagnostic performance of the 21st model showed an area under the receiver operating characteristic (AUROC), sensitivity, and specificity of 84.55%, 93.33%, and 75.72%, respectively. The diagnostic performance of the 24th model showed an AUROC sensitivity, and specificity of 91.27%, 90.00%, and 92.54%, respectively.

Reducing the time to diagnose COVID-19 helps to manage insufficient isolation-bed resources and adequately accommodate critically ill patients. There is currently no alternative method to real-time reverse transcriptase polymerase chain reaction (RT-PCR), which requires 40 cycles to diagnose COVID-19. We propose a deep learning (DL) model to improve the speed of COVID-19 RT-PCR diagnosis. We developed and tested a DL model using the long short-term memory method with a dataset of fluorescence values measured in each cycle of 5810 RT-PCR tests. Among the DL models developed here, the diagnostic performance of the 21st model showed an area under the receiver operating characteristic (AUROC), sensitivity, and specificity of 84.55%, 93.33%, and 75.72%, respectively. The diagnostic performance of the 24th model showed an AUROC, sensitivity, and specificity of 91.27%, 90.00%, and 92.54%, respectively.

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.

Background Few studies have investigated the prognostic value of cardiac implantable electronic device (CIED)-detection of sleep-disordered breathing (SDB) for risk stratification of cardiovascular events. In the Device-Detected CArdiac Tachyarrhythmic events and Sleep-disordered breathing (DEDiCATES) study, we aim to determine whether device-detected SDB events are associated with increased risk of cardiac arrhythmias or other cardiovascular outcomes. Methods and design Six-hundred patients (300 patients with low-voltage pacing devices and 300 with high-voltage defibrillator devices) who have dual chamber CIEDs with AP Scan™ function (Boston Scientific Inc., Marlborough, MA, USA) are planned to be enrolled in this study. AP Scan reports the average number of sleep disturbance events per hour per night in the form of a Respiratory Disturbance Index (RDI). The daily RDI values are to be used for quantitative measurement of the severity and burden of SDB. CIED-detected atrial high rate episodes (AHREs) and clinical atrial tachyarrhythmia will be assessed as the primary outcomes over a follow-up period of 2 years. Correlations between CIED-detected SDB and AHRE burdens will be analyzed. The secondary outcomes are CIED-detected or clinical ventricular arrhythmic events, stroke, heart failure hospitalization, mortality, and quality of life. Conclusion This study will determine the prognostic value of automated diagnostic function of CIED for SDB, which will help to improve the cardiovascular prognoses of CIED patients by enabling convenient and accurate assessments of SDB events.

Background: Nighttime hospital admission is often associated with increased mortality risk in various diseases. Following sepsis campaign implementation, this study investigated compliance rates with the Surviving Sepsis Campaign 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality. Methods: We conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the complete 3-hour treatment bundle according to the time of arrival in the ED. Mediation analysis was conducted to evaluate the proportion of the total effect that could be explained by hospital admission times.Results: A total of 2,247 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance for the administration of antibiotics within 3-h (adjusted odds ratio (AOR), 1.276; 95% confidence interval (95% CI), 1.050–1.550, p=0.014), vasopressor within 3-h (AOR, 1.235; 95% CI, 1.009–1.512; P=0.031) and for the administration of the complete 3-h bundle (AOR, 1.231; 95% CI, 1.004–1.501; P=0.046), likely as a result of the increased volume of patients admitted during daytime hours. Consequently, daytime hospital admission adversely affected in-hospital and 28-day mortality rates, mediated by decreased compliance with the complete 3-h bundle. Conclusions: Septic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Despite sepsis campaign implementation, factors that decrease bundle compliance should be reconsidered in patients with septic shock.

Background Nighttime hospital admission is often associated with increased mortality risk in various diseases. This study investigated compliance rates with the Surviving Sepsis Campaign (SSC) 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality in patients with septic shock. Methods We conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the SSC 3-h bundle according to the time of arrival in the ED. Results A total of 2049 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance with the administration of antibiotics within 3 h (adjusted odds ratio (adjOR), 1.326; 95% confidence interval (95% CI), 1.088–1.617, p = 0.005) and with the complete SSC bundle (adjOR, 1.368; 95% CI, 1.115–1.678; p = 0.003), likely to result from the increased volume of all patients and sepsis patients admitted during daytime hours. The hazard ratios of the completion of SSC bundle for 28-day mortality and in-hospital mortality were 0.750 (95% CI 0.590–0.952, p = 0.018) and 0.714 (95% CI 0.564–0.904, p = 0.005), respectively. Conclusion Septic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Both the higher number of admitted patients and the higher patients to medical staff ratio during daytime may be factors that are responsible for lowering the compliance.

Objectives The aim of this study was to evaluate the effect of ticagrelor versus clopidogrel on left ventricular (LV) remodeling after reperfusion of ST-segment elevation myocardial infarction (STEMI) in humans. Background Animal studies have demonstrated that ticagrelor compared with clopidogrel better protects myocardium against reperfusion injury and improves remodeling after myocardial infarction. Methods In this investigator-initiated, randomized, open-label, assessor-blinded trial performed at 10 centers in Korea, patients were enrolled if they had naive STEMI successfully treated with primary percutaneous coronary intervention (PCI) and at least 6-month planned duration of dual-antiplatelet treatment. The coprimary endpoints were LV remodeling index (LVRI) (a relative change of LV end-diastolic volume) measured on 3-dimensional echocardiography and N-terminal pro–B-type natriuretic peptide level at 6 months. Results Among initially enrolled patients with STEMI (n = 336), 139 in each group completed the study. LVRI at 6 months was numerically lower with ticagrelor versus clopidogrel (0.6 ± 18.6% vs. 4.5 ± 16.5%; p = 0.095). Ticagrelor significantly reduced the 6-month level of N-terminal pro–B-type natriuretic peptide (173 ± 141 pg/ml vs. 289 ± 585 pg/ml; p = 0.028). These differences were prominent in patients with pre-PCI TIMI (Thrombolysis In Myocardial Infarction) flow grade 0. By multivariate analysis, ticagrelor versus clopidogrel reduced the risk for positive LV remodeling (LVRI >0%) (odds ratio: 0.56; 95% confidence interval: 0.33 to 0.95; p = 0.030). The LV end-diastolic volume index remained unchanged during ticagrelor treatment (from 54.7 ± 12.2 to 54.2 ± 12.2 ml/m2; p = 0.629), but this value increased over time during clopidogrel treatment (from 54.6 ± 11.3 to 56.4 ± 13.9 ml/m2; p = 0.056) (difference −2.3 ml/m2; 95% confidence interval: −4.8 to 0.2 ml/m2; p = 0.073). Ticagrelor reduced LV end-systolic volume index (from 27.0 ± 8.5 to 24.7 ± 8.4 ml/m2; p Conclusions Ticagrelor was superior to clopidogrel for LV remodeling after reperfusion of STEMI with primary PCI. (High Platelet Inhibition With Ticagrelor to Improve Left Ventricular Remodeling in Patients With ST Segment Elevation Myocardial Infarction [HEALING-AMI]; NCT02224534 )

Background: The cervical collar has been used as a common device for the initial stabilization of the cervical spine. Although many cervical collars are commercially available, there is no consensus on which offers the greatest protection, with studies showing considerable variations in their ability to restrict cervical range of motion. The use of the XCollar (Emegear, Carpinteria, CA) has been known to decrease the risk of spinal cord injury by minimizing potential cervical spinal distraction. We compared XCollar with two other cervical collars commonly used for adult patients with cervical spine injury to evaluate the difference in effectiveness between the three cervical collars to restrict cervical range of motion. Objectives: This study aimed to evaluate the difference between the three cervical collars in their ability to restrict cervical range of motion. Method: A total of 30 healthy university students aged 21–25 years participated in this study. Participants with any cervical disease and symptoms were excluded. Three cervical collars were tested: Philadelphia® Collar, Stifneck® Select™ Collar, and XCollar. A digital camera and an image-analysis technique were used to evaluate cervical range of motion during flexion, extension, bilateral bending and bilateral axial rotation. Cervical range of motion was evaluated in both the unbraced and braced condition. Results: XCollar permitted less than a mean of 10° of movement during flexion, extension, bilateral bending and bilateral axial rotation. This was less than the movement permitted by the other two cervical collars. Conclusion: XCollar presented superior cervical immobilization compared to the other two commonly used cervical collars in this study. Thus, when cervical collar is considered for an adult patient with cervical spine injury, XCollar might be one of the considerate options as a cervical immobilization device.

Summary Background CT radiation is arguably carcinogenic. Results from single-centre studies, mostly retrospective, have advocated lowering the CT radiation dose for the diagnosis of appendicitis. However, adoption of low-dose CT has been slow. We aimed to assess the effectiveness of low-dose CT compared with standard-dose CT in the diagnosis of appendicitis in adolescents and young adults. Methods We did this pragmatic, multicentre, randomi s ed controlled non-inferiority trial at 20 South Korean teaching hospitals with little experience with low-dose CT. Patients aged 15–44 years with suspected appendicitis were randomly assigned (1:1), via computer-generated random assignments (permuted block sizes of two, four, six, and eight) concealed in sequentially numbered envelopes, to receive low-dose CT (2 mSv) or standard-dose CT (≤8 mSv). Randomisation was stratified by site. Group allocation was concealed from patients, outcome assessors, and adverse event adjudicators; care providers, site pathologists, and data collectors were aware of allocation. The primary endpoint was the negative (unnecessary) appendectomy rate among all appendectomies, with a non-interiority margin of 4·5% for low-dose versus standard-dose CT. Primary analy s is was by modified intention to treat, which included all patients who received an appendectomy in the group to which they were assigned. This trial is registered with ClinicalTrials.gov, number NCT01925014. Findings Between Dec 4, 2013, and Aug 18, 2016, we assigned 1535 patients to the low-dose CT group and 1539 patients to the standard-dose CT group. 22 (3·9%) of 559 patients had a negative appendectomy in the low-dose group versus 16 (2·7%) of 601 patients in the standard-dose group (difference 1·3%, 95% CI −0·8 to 3·3; p=0·0022 for the non-inferiority test). We recorded 43 adverse events in 43 (2·8%) of 1535 patients in the low-dose group and 41 adverse events in 40 (2·6%) of 1539 patients in the standard-dose group. One life-threatening adverse event of anaphylaxis caused by an iodinated contrast material occurred in the low-dose group. Interpretation Radiation dose of appendiceal CT for adolescents and young adults can be reduced to 2 mSv without impairing clinical outcomes. In view of the vast number of appendiceal CT examinations done worldwide, use of low-dose CT could prevent a sizeable number of radiation-associated cancers in the future. Funding Korea Health Industry Development Institute, Seoul National University Bundang Hospital, Dasol Life Science, and Bracco Imaging Korea.

Objective To evaluate the clinical characteristics, therapeutic interventions, and outcomes of patients with septic shock admitted to the emergency department (ED). Methods This study was a preliminary, descriptive analysis of a prospective, multi-center, observational registry of the EDs of 10 hospitals participating in the Korean Shock Society. Patients aged 19 years or older who had a suspected or confirmed infection and evidence of refractory hypotension or hypoperfusion were included. Results A total of 468 patients were enrolled (median age, 71.3 years; male, 55.1%; refractory hypotension, 82.9%; hyperlactatemia without hypotension, 17.1%). Respiratory infection was the most common source of infection (31.0%). The median Sepsis-related Organ Failure Assessment score was 7.5. The sepsis bundle compliance was 91.2% for lactate measurement, 70.3% for blood culture, 68.4% for antibiotic administration, 80.3% for fluid resuscitation, 97.8% for vasopressor application, 68.0% for central venous pressure measurement, 22.0% for central venous oxygen saturation measurement, and 59.2% for repeated lactate measurement. Among patients who underwent interventions for source control (n=117, 25.1%), 43 (36.8%) received interventions within 12 hours of ED arrival. The in-hospital, 28-day, and 90-day mortality rates were 22.9%, 21.8%, and 27.1%, respectively. The median ED and hospital lengths of stay were 6.8 hours and 12 days, respectively. Conclusion This preliminary report revealed a mortality of over 20% in patients with septic shock, which suggests that there are areas for improvement in terms of the quality of initial resuscitation and outcomes of septic shock patients in the ED.

Supplemental Digital Content is available in the text, This study aimed to investigate the prognostic difference between AUTOPULSE and LUCAS for out-of-hospital cardiac arrest (OHCA) adult patients. A retrospective observational study was performed nationwide. Adult OHCA patients after receiving in-hospital mechanical chest compression from 2012 to 2016 were included. The primary outcomes were sustained return of spontaneous circulation (ROSC) of more than 20 minutes and survival to discharge. Among 142,906 OHCA patients, 820 patients were finally included. In multivariate analysis, female (OR, 0.57; 95% CI, 0.33–0.99), witnessed arrest (OR, 2.10; 95% CI, 1.20–3.69), and arrest cause of non-cardiac origin (OR, 0.25; 95% CI, 0.10–0.62) were significantly associated with the increase in ROSC. LUCAS showed a lower survival than AUTOPULSE (OR, 0.23; 95% CI, 0.06–0.84), although it showed no significant association with ROSC. Percutaneous coronary intervention (OR, 6.30; 95% CI, 1.53–25.95) and target temperature management (TTM; OR, 7.30; 95% CI, 2.27–23.49) were the independent factors for survival. We categorized mechanical CPR recipients by witness to compare prognostic effectiveness of AUTOPULSE and LUCAS. In the witnessed subgroup, female (OR, 0.46; 95% CI, 0.24–0.89) was a prognostic factor for ROSC and shockable rhythm (OR, 5.04; 95% CI, 1.00–25.30), percutaneous coronary intervention (OR, 12.42; 95% CI, 2.04–75.53), and TTM (OR, 9.03; 95% CI, 1.86–43.78) for survival. In the unwitnessed subgroup, no prognostic factors were found for ROSC, and TTM (OR, 99.00; 95% CI, 8.9–1100.62) was found to be an independent factor for survival. LUCAS showed no significant increase in ROSC or survival in comparison with AUTOPULSE in both subgroups. The in-hospital use of LUCAS may have a deleterious effect for survival compared with AUTOPULSE.

ObjectivesHyperchloraemia is associated with poor clinical outcomes in sepsis patients; however, this association is not well studied for hypochloraemia. We investigated the prevalence of chloride imbalance and the association between hypochloraemia and 28-day mortality in ED patients with septic shock.MethodsA retrospective analysis of data from 11 multicentre EDs in the Republic of Korea prospectively collected from October 2015 to April 2018 was performed. Initial chloride levels were categorised as hypochloraemia, normochloraemia and hyperchloraemia, according to sodium chloride difference adjusted criteria. The primary outcome was 28-day mortality. A multivariate logistic regression model adjusting for age, sex, comorbidities, acid-base state, sepsis-related organ failure assessment (SOFA) score, lactate and albumin level was used to test the association between the three chloride categories and 28-day mortality.ResultsAmong 2037 enrolled patients, 394 (19.3%), 1582 (77.7%) and 61 (3.0%) patients had hypochloraemia, normochloraemia and hyperchloraemia, respectively. The unadjusted 28-day mortality rate in patients with hypochloraemia was 27.4% (95% CI, 23.1% to 32.1%), which was higher than in patients with normochloraemia (19.7%; 95% CI, 17.8% to 21.8%). Hypochloraemia was associated with an increase in the risk of 28-day mortality (adjusted OR (aOR), 1.36, 95% CI, 1.00 to 1.83) after adjusting for confounders. However, hyperchloraemia was not associated with 28-day mortality (aOR 1.35, 95% CI, 0.82 to 2.24).ConclusionHypochloraemia was more frequently observed than hyperchloraemia in ED patients with septic shock and it was associated with 28-day mortality.

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.

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.

OBJECTIVE This study aimed to compare intubation performance between blind intubation through supraglottic airway devices and direct laryngoscopy by novices under manikin simulation. We hypothesized that the intubation time by novices using supraglottic airway devices was superior to that with the Macintosh laryngoscope (MCL). METHODS A prospective, randomized crossover study was conducted with 95 participants, to evaluate i-gel, air-Q, LMA Fastrach, and MCL devices. Primary outcomes were the intubation time and the success rate for intubation. RESULTS The i-gel showed the shortest insertion and tube passing time among the four devices; the i-gel and air-Q also showed the shortest total intubation time (all P

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.

The aim of this study was to evaluate the clinical utility of the lactate/albumin (L/A) ratio as a predictive factor of 28-day mortality in critically ill sepsis patients.This is a retrospective observational study from a prospectively collected multicenter registry of 10 emergency departments (EDs) in teaching hospitals that participated in the Korean Shock Society. It enrolled patients who were 19 years of age or older who had a suspected or confirmed infection and evidence of refractory hypotension or hypoperfusion. The prognostic performance of the L/A ratio and lactate level for predicting 28-day mortality was assessed. Lactate and albumin levels were measured immediately after ED arrival.A total of 946 patients were included, with 22.5% overall 28-day mortality. The area under the receiver operating characteristic curve (AUROC) value of the L/A ratio (0.69, 95% confidence interval [CI] 0.64-0.73, P 0.01) was higher than that of lactate (0.65, 95% CI 0.61-0.70, P 0.01) for predicting 28-day mortality. The optimal cutoff of the L/A ratio was 1.32. The AUROC value of the L/A ratio was better than that of lactate regardless of lactate level (normal [2.0 mmol/L]: 0.68 vs. 0.55; intermediate [≥2.0, 4.0 mmol/L]: 0.65 vs. 0.50; high [≥4.0 mmol/L]: 0.66 vs. 0.62). In the subgroup with decreased lactate elimination, the AUROC value of the L/A ratio was also significantly higher than that of lactate (hepatic dysfunction: 0.70 vs. 0.66; renal dysfunction: 0.71 vs. 0.67). The L/A ratio cut-off and hypoalbminemia showed further discriminative value for 28-day mortality even in patients with normal or intermediate lactate levels.The prognostic performance of the L/A ratio was superior to that of a single lactate measurement for predicting 28-day mortality of critically ill sepsis patients. L/A ratio can be a useful prognostic factor regardless of initial lactate level and the presence of hepatic or renal dysfunction.

Background: We compared the clinical characteristics and outcomes between the new definition of sepsis-3 septic shock and the definition previously used from 1991 until recently. Methods: We conducted an observational study using a prospective, multi-center registry of septic shock from October 2015 to February 2017. Registry data were collected by 10 emergency departments (EDs) in tertiary hospitals that are members of the Korean Shock Society. Data on septic shock patients who met the previous septic shock definition were collected. The patients were divided into a sepsis-3 defined septic shock group, made up of those who met the new criteria for refractory hypotension with hyperlactatemia, and a group of those who met only the 1991 definition for septic shock. The primary outcome was 90-day mortality, and secondary outcomes were 28-day mortality and in-hospital mortality. Results: Of all 1,028 included patients, 574 (55.8%) met the septic shock criteria for sepsis-3, leaving 454 patients who met only the previous definition. Those who met the sepsis-3 criteria demonstrated higher comorbidity than those who met the previous definition (83.1% vs . 75.3%, P vs . 5.0±2.9, 9.3±3.8 vs . 6.6±3.4, and 20.0 (15.0–26.0) vs . 15.0 (10.0–20.3), respectively; P vs . 23.3%; P vs . 17.1% and 25.1% vs . 16.5%, respectively; P Conclusions: The new definition of septic shock successfully selected patients with greater severities and worse outcomes.

Background During cardiopulmonary resuscitation (CPR), chest tubes can hinder increases in intrathoracic pressure by venting the pressure during chest compressions, thus reducing the blood flow generated by the thoracic pump effect. The aim of the present study was to investigate the effects of chest tubes on hemodynamic efficacy during standard CPR in a swine model of cardiac arrest. Methods Twelve domestic male pigs weighing 39.6 ± 8.4 kg underwent bilateral tube thoracostomy and received a total of 12 min of standard manual CPR, which comprised of two 6-min courses of CPR after 2 min of electrically induced ventricular fibrillation. Each 6-min set consisted of 3 min of CPR with clamped chest tubes (CCT-CPR) and 3 min of CPR with unclamped chest tubes (UCT-CPR). The sequence of CCT-CPR and UCT-CPR was randomized. Results Hemodynamic parameters including aortic pressure, left ventricular pressure, right ventricular pressure, right atrial pressure, and minimal and maximal dp/dt did not differ significantly between CCT-CPR and UCT-CPR. No significant differences were noted in carotid blood flow, end-tidal CO2, or coronary perfusion pressure between CCT-CPR and UCT-CPR. Conclusions The presence of chest tubes did not affect the hemodynamic efficacy of standard CPR. There is no need to clamp chest tubes during standard CPR.

Objectives. Early airway management is very important for severely ill patients. This study aimed to investigate the efficacy of face to face intubation in four different types of laryngoscopes (Macintosh laryngoscope, Pentax airway scope (AWS), Glidescope video laryngoscope (GVL), and C-MAC video laryngoscope (C-MAC)).Method. Ninety-five nurses and emergency medical technicians were trained to use the AWS, C-MAC, GVL and Macintosh laryngoscope with standard airway trainer manikin and face to face intubation. We compared VCET (vocal cord exposure time), tube pass time, 1st ventilation time, VCET to tube pass time, tube pass time to 1st ventilation time, and POGO (percentage of glottis opening) score. In addition, we compared success rate according to the number of attempts and complications.Result. VCET was similar among all laryngoscopes and POGO score was higher in AWS. AWS and Macintosh blade were faster than GVL and C-MAC in total intubation time. Face to face intubation success rate was lower in GVL than other laryngoscopes.Conclusion. AWS and Macintosh were favorable laryngoscopes in face to face intubation. GVL had disadvantage performing face to face intubation.

Background Little is known about the clinical outcomes of patients with different types of coronary bifurcation lesions. We sought to compare long-term clinical outcomes of patients with true or non-true bifurcation lesions who underwent percutaneous coronary intervention. Methods and results We compared major adverse cardiac events (MACE: cardiac death, myocardial infarction [MI], or target lesion revascularization) between 1,502 patients with true bifurcation lesions (51.8%) and 1,395 with non-true bifurcation lesions (48.2%). True bifurcation lesions were defined as Medina classification (1.1.1), (1.0.1), or (0.1.1) lesions. During a median follow-up of 36 months, MACE occurred in 296 (10.2%) patients. Patients with true bifurcation lesions had a significantly higher risk of MACE than those with non-true bifurcation lesions (HR 1.39; 95% CI 1.08-1.80; P=0.01). Among true bifurcation lesions, Medina (1.1.1) and (0.1.1) were associated with a higher risk of cardiac death or MI than Medina (1.0.1) (HR 4.15; 95% CI 1.01-17.1; P=0.05). During the procedure, side branch occlusion occurred more frequently in Medina (1.1.1) and (1.0.1) than Medina (0.1.1) lesions (11.5% vs. 7.4%, P=0.03). Conclusions Patients with true bifurcation lesions had worse clinical outcomes than those with non-true bifurcation lesions. Procedural and long-term clinical outcomes differed according to the type of bifurcation lesion. These findings should be considered in future bifurcation studies.

Objective There are few data regarding clinical characteristics, laboratory parameters, electrocardiographic and echocardiographic findings in takotsubo cardiomyopathy patients presenting with QT prolongation. Aim of this study was to investigate the differences in these parameters between takotsubo cardiomyopathy patients presenting with and those without QT prolongation. Methods We performed an observational retrospective study. One hundred five patients were enrolled from the takotsubo cardiomyopathy registry database and divided according to the presence of QT prolongation. Fifty patients presented with QT prolongation (QT group) and 55 did not (NQT group). Statistical analysis was performed using Student's t-test or Mann-Whitney U test and chi-square test. Results QT group had higher prevalence of dyspnea (66 versus 40%, p=0.008) and cardiogenic shock (46 versus 24%, p=0.016) than NQT group. QT group had higher prevalence of ST elevation (82 versus 64%, p=0.036), T wave inversion (96 versus 58%, p=0.001), ventricular tachycardia/ventricular fibrillation (8 versus 0%, p=0.032) and classic ballooning pattern (92 versus 66%, p=0.003), but lower left ventricular ejection fraction (mean, 39.2 versus 43.5%, p=0.005). In addition, QT group had significant higher hs-C-reactive protein (median, 6.6 versus 1.7 mg/L, p=0.023), creatine kinase-MB (median, 18.6 versus 7.6 ng/mL, p=0.032) and NT-pro-brain natriuretic peptide levels (median, 3637 versus 2145 pg/mL, p=0.044). QT group required more frequent use of inotropics (46 versus 24%, p=0.016) and diuretics (58 versus 38%, p=0.042) than NQT group. Conclusion The clinical features of takotsubo cardiomyopathy are different according to the presence of QT prolongation. The QT group was lesser likely to have preserved cardiovascular reserve and more likely to require hemodynamic support than the NQT group despite the entire prognosis of takotsubo cardiomyopathy is excellent regardless of QT prolongation.

This study aimed to compare prognostic difference between intravascular cooling devices (ICDs) and surface cooling devices (SCDs) in targeted temperature management (TTM) recipients.Adult TTM recipients using ICD or SCD during 2012 to 2016 were included in this nationwide observational study. The outcome was survival to hospital discharge and good neurological outcome at hospital discharge.Among 142,905 out-of-hospital cardiac arrest patients, 1159 patients (SCD, n = 998; ICD, n = 161) were investigated. After propensity score matching for all patients, 161 matched pairs of patients were available for analysis (SCD, n = 161; ICD, n = 161). We observed no significant differences in the survival to hospital discharge (SCD, n = 144 [89.4%] vs ICD, n = 150 [93.2%], P = .32) and the good neurological outcomes (SCD, n = 86 [53.4%] vs ICD, n = 91 [56.5%], P = .65). TTM recipients were categorized by age groups (elderly [age >65 years] vs nonelderly [age ≤65 years]) to compare prognostic difference between ICD and SCD according to the age groups. In the nonelderly group, the use of ICD or SCD was not a significant factor for survival to hospital discharge or good neurologic outcome. Whereas, the use of ICD was significantly associated with good neurological outcome (odds ratio, 3.97; 95% confidence interval, 1.19 - 13.23, P = .02) compared with SCD in the elderly group.There were no significant differences in the survival to hospital discharge and the good neurological outcomes between SCD and ICD recipients. However, the use of ICD might be more beneficial than SCD in elderly patients.

Influenza epidemics occur annually with variations in size and severity. Hospital-based Influenza Morbidity & Mortality was established to monitor influenza epidemics and their severity, which is composed of two surveillance systems: emergency room-based and inpatient-based surveillance. Regarding emergency room-based surveillance, influenza-like illness index (influenza-like illness cases per 1,000 emergency room-visiting subjects), number of laboratory-confirmed cases and the distribution of influenza types were estimated weekly. Inpatient-based surveillance included monitoring for hospitalization, complications, and mortality. The emergency room influenza-like illness index correlated well with the number of laboratory-confirmed influenza cases, and showed a bimodal peak at Week 4 (179.2/1,000 emergency room visits) and Weeks 13-14 (169.6/1,000 emergency room visits) of 2012. Influenza A was the predominant strain during the first epidemic peak, while influenza B was isolated exclusively during the second peak. In 2011-2012 season, the mean admission rate of emergency room-visiting patients with influenza-like illness was 16.3% without any increase over the epidemic period. Among the hospitalized patients with influenza, 33.6% (41 out of 122 patients) were accompanied by complications, and pneumonia (28.7%, 35 out of 122 patients) was the most common. Most fatal cases were caused by influenza A (96.2%) after the first epidemic peak. In conclusion, Hospital-based Influenza Morbidity & Mortality was effective for monitoring the trends in circulating influenza activity concurrently with its severity. In the 2011-2012 season, the influenza epidemic persisted for a ≥ 5-month period, with a bimodal peak of influenza A and B in sequence. Overall, influenza A was more severe than influenza B.

Background There have been few data to review and analyze the temporal preference of the onset of Tako-tsubo cardiomyopathy (TTC). Aim of this study was to investigate chronobiological variations in the occurrence of TTC and changes of these variations according to age and gender. Methods One hundred and thirty-seven patients were enrolled from our TTC registry database from January 2004 to December 2010 in Korea. Results The median age of the entire study population was 59 years (inter-quartile range 53–72 years). The majority of patients were women ( n = 101, 74%). The onset of TTC differed as a function of season ( P = .001), with the peak in July and the nadir in March. Events were most frequent in summer ( n = 53%, 38.7%) and least so in winter ( n = 26, 19%, chi-square = 13.92, P = .003). TTC was most frequent in the morning ( n = 56, 40.9%) and least so at night ( n = 22, 16.1%, chi-square = 21.98, P = .001). Also, TTC was most frequent on Monday ( n = 34, 24.8%) and least so on Saturday ( n = 7, 5.1%, chi-square = 30.44, P = .001). Stressor pattern, age and gender do not influence these increases of occurrence in summer, on Monday, and in the morning of TTC. Conclusions TTC seems to exhibit a temporal variation of occurrence with preferred peaks during morning, Monday, and summer. Stressor pattern, age and gender do not influence these temporal patterns of the occurrence of TTC. Further studies are needed to investigate the potential link between chronobiological variations of TTC onset and underlying pathophysiologic mechanisms.