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Aims This study aimed to evaluate the effects of esmolol treatment for patients with refractory ventricular fibrillation (RVF) in out-of-hospital cardiac arrest (OHCA). Methods This single-centre retrospective pre-post study evaluated patients who were treated between January 2012 and December 2015. Some patients had received esmolol (loading dose: 500μg/kg, infusion: 0-100μg/kg/min) for RVF (≥3 defibrillation attempts), after obtaining consent from the patient's guardian. Results Twenty-five patients did not receive esmolol (the control group), and 16 patients received esmolol. Sustained return of spontaneous circulation (ROSC) was significantly more common in the esmolol group, compared to the control group (56% vs. 16%, p=0.007). Survival and good neurological outcomes at 30 days, 3 months and at 6 months were >2-fold better in the esmolol group, compared to the control group, although these increases were not statistically significant. Conclusions The findings of our study suggest that administration of esmolol may increase the rate of sustained ROSC and ICU survival among patients with RVF in OHCA. Further larger-scale, prospective studies are necessary to determine the effect of esmolol for RVF in OHCA.

Introduction Stroke recently became the second cause of death in Korea. Nevertheless, many studies have reported that the delay of emergency medical service (EMS) transportation in specific areas is a major obstacle to reduce the mortality and morbidity of stroke. The objective of this study was to assess geographic variation regarding this factor at the national level in Korea throughout a funnel plot. Setting Emergency departments. Methods Data were obtained from the “2010 Emergency Medicine Annual Report” published by the National Emergency Medical Centre of Korea. This report describes the general characteristics of eligible Emergency Departments (EDs) across Korea. Therefore, we were able to calculate retrospectively the percentage of stroke patients who reached an ED within 3 hours after the development of symptoms against the volume of total visiting patients according to area. Subsequently, we generated a correlation matrix between ratio of stroke patients who visited EDs within the therapeutic period and ratio of usage of EMS ambulances. Results We found that four areas out of 16 administrative divisions in Korea were located beyond the lower control limit and one area was between the lower warning and lower control limits, according to a funnel plot showing the percentage of patients within the therapeutic period of stroke against the total volume of patients according to area. The ratio of stroke patients who visited EDs within the therapeutic period was significantly correlated with the ratio of use of EMS ambulances to a moderately positive degree (r=0.51; pConclusions Encouraging the public in Korea to use an EMS ambulance in case of stroke may shorten the pre-hospital delay.

Introduction Horseracing-related injuries have not been studied before in Korea in any detail, although horseracing takes place very regularly in the country. The injury rate is understandably high, owing to the weight of the horses and the speed they can achieve. The purpose of this study was to identify the incidence and the injury patterns of severe equestrian trauma, as well as the associated risk factors. Methods All patients with equestrian injuries who visited the emergency department (ED) between June 2007 and May 2011 were reviewed retrospectively. Results During the study period, 288 patients presented to ED with horse-related injury. Two hundred and eighty patients were enrolled in this study. The most common cause of the injury was a fall (168, 60.0%). The most common region of the injury was the face (123, 43.9%). The intermediate value of NISS was 3 (1-75). Thirty-two patients (11.4%) were diagnosed as having moderate to severe injury. Thoracic injuries occurred less often in cases of a fall. Facial and thoracic injuries occurred more often, however abdominal and pelvic injuries were not very common in cases of a clash. When thoracic injuries were accompanied by injuries to other parts of the body, the incidence of moderate to severe injury was very high. Conclusions Horseracing is a much rougher sport than general horse-riding. Therefore, one recommendation from this study is that jockeys who participate in horseracing should wear additional protective equipment other than a helmet and boots. (Hong Kong j.emerg.med. 2014;21:387-391)

Objective There is no specific treatment for comatose patients after near-hanging or in those who recover from cardiac arrest (CA) caused by hanging. Since 2009, we have used therapeutic hypothermia (TH) to treat all comatose survivors of near-hanging and in patients who recovered from CA caused by hanging. The purpose of this study was to describe the outcomes in comatose patients after near-hanging. Design Case series. Setting Emergency departments of two regional hospitals. Methods We collected patient data from the Samsung Medical Center hypothermia database between November 2009 and November 2011. We included all patients presented with near-hanging or CA caused by hanging; who remained comatose and received TH after resuscitation for analysis. Clinical characteristics and outcome of patients were presented. Results During the study period, 26 patients were admitted to the emergency department after near-hanging or CA caused by hanging; 21 patients were enrolled in this study. Twelve patients with CA and 9 comatose patients without CA were treated with TH. Only 1 patient with CA had a good neurological outcome. By contrast, all near-hanging patients without CA had a good neurological outcome. Conclusions TH can be an effective therapeutic modality in cases of near-hanging without CA. However, the effectiveness of TH is questionable in patients who survive from CA caused by hanging. (Hong Kong j.emerg.med. 2014;21:316-321)

Background: The purpose of this study was to identify the factors that influence mortality in organophosphate intoxication and the differences between the elderly (≥65 years) and younger adults (18-64 years) looking at vital sign, length of admission, cholinesterase activity, complications, and prognosis. Methods: All patients visiting one Emergency Department (ED) with organophophate intoxication between January 2000 and December 2011 were reviewed retrospectively. We divided the patients into two groups, geriatric adults (≥ 65 years) and nongeriatric adults (18-64 years). Results: During the study period, 155 patients (45 patients, ≥65 years; 110 patients, 18-64 years) presented to the ED with organophosphate intoxication. Thirty-six elderly patients (80.0%) vs. 63 younger adult patients (57.3%) were intubated endotracheally, with the analysis showing a clear distinction between the two groups (p=0.026). Twenty-two elderly patients (48.9%) vs. 23 younger adult patients (20.9%) went into shock, displaying a significant gap (p=0.008). Thirtyfive elderly patients (81.4%) vs. 62 younger adult patients (59.0%) developed respiratory complications and 20 elderly patients (46.5%) vs. 19 younger adult patients (18.1%) developed central nervous system complications, with obvious differences seen in each of the comparison at (p=0.031) and (p=0.005), respectively. Comparing plasma cholinesterase levels at 1st, 3rd, 5th, 10th, 15th, and 20th days, the rate of increase was faster in the younger adults (p=0.022). Conclusion: With organophosphate intoxication, elderly patients tended to be intubated endotracheally, went into shock, developed central nervous system complications, were more severe, and showed a slower increase in cholinesterase level.

Bulimia nervosa is one of the eating disorders. Psychological manifestations of this disease, such as guilt or denial, may interfere with patient communication. The patients with bulimia nervosa are most commonly between ages of 17 and 25 years old, and often maintain normal body weight. It is not easy to screen out and diagnose bulimia nervosa patients at the emergency department. We reported two bulimia nervosa patients who visited our emergency department with abdominal distension, and one of them died of abdominal compartment syndrome. We confirmed collapse of the abdominal aorta and key arteries in enhanced abdominal computed tomography. Promptly, we performed gastrostomy for reduction of abdominal pressure, but she finally succumbed due to multiple organ failure 12 hours after the surgery.

Ischemic damage occurs well in vulnerable regions of the brain, including the hippocampus and striatum. In the present study, we examined neuronal damage/death and glial changes in the striatum 4 days after 5, 10, 15 and 20 min of transient cerebral ischemia using the gerbil. Spontaneous motor activity was increased with the duration time of ischemia-reperfusion (I-R). To examine neuronal damage, we used Fluoro-Jade B (F-J B, a marker for neuronal degeneration) histofluorescence staining. F-J B positive cells were detected only in the 20 min ischemia-group, not in the other groups. In addition, we examined gliosis of astrocytes and microglia using anti-glial fibrillary acidic protein (GFAP) and anti- ionized calcium-binding adapter molecule 1 (Iba-1), respectively. In the 5 min ischemia-group, GFAP-immunoreactive astrocytes were distinctively increased in number, and the immunoreactivity was stronger than that in the sham-group. In the 10, 15 and 20 min ischemia-groups, GFAP-immunoreactivity was more increased with the duration of I-R. On the other hand, the immunoreactivity and the number of Iba-1-immunoreactive microglia were distinctively increased in the 5 and 10 min ischemia-groups. In the 15 min ischemia-group, cell bodies of microglia were largest, and the immunoreactivity was highest; however, in the 20 min ischemia-group, the immunoreactivity was low compared to the 15 min ischemia-group. The results of western blotting for GFAP and Iba-1 were similar to the immunohistochemical data. In brief, these findings showed that neuronal death could be detected only in the 20 min ischemia-group 4 days after I-R, and the change pattern of astrocytes and microglia were apparently different according to the duration time of I-R.

Ubiquitin binds to short-lived proteins and denatured proteins produced by various forms of injury. The loss of ubiquitin leads to an accumulation of abnormal proteins and may affect cellular structure and function. The aim of the present study is to observe the chronological changes in ubiquitin naive form and its mutant form (ubiquitin+1) in the hippocampal CA1 region (CA1) after transient cerebral ischemia in gerbils. Delayed neuronal death in the CA1 was confirmed 4 days after ischemic insult with NeuN immunohistochemistry. Ubiquitin immunoreactivity and protein level in the CA1 were lowest at 12 h after ischemia/reperfusion; thereafter, they were increased with time. Ubiquitin+1 immunoreactivity and protein levels in the CA1 were slightly decreased at 3 h after ischemia/reperfusion, and they were significantly increased 1 day after ischemia/reperfusion. In addition, ubiquitin and ubiquitin+1 immunoreaction was expressed in astrocytes after delayed neuronal death in the ischemic CA1. To elucidate the protective effect of ubiquitin on ischemic damage, the animals were treated with ubiquitin (1.5 mg/kg body weight) intravenously via the femoral vein. Ubiquitin treatment significantly reduced ischemia-induced locomotor hyperactivity, neuronal death and reactive gliosis such as astrocytes and microglia. In addition, 5 days after ubiquitin treatment in the ischemic group, ubiquitin immunoreactivity was similar to that in the ubiquitin-treated sham group, however, ubiquitin+1 immunoreactivity was higher than that in the ubiquitin-treated sham group. These findings indicate that the depletion of ubiquitin and the accumulation of ubiquitin+1 in CA1 pyramidal neurons after transient cerebral ischemia may inhibit ubiquitin proteolytic pathway and this leads to delayed neuronal death of CA1 pyramidal neurons directly or indirectly after transient cerebral ischemia.

Organophosphate (OP) intoxication remains a serious worldwide health concern, and many patients with acute OP intoxication have also consumed alcohol. Therefore, we evaluated the association of blood alcohol concentration (BAC) with mortality among patients with OP intoxication. We retrospectively reviewed records from 135 patients who were admitted to an emergency department (ED) for OP intoxication between January 2000 and December 2012. Factors that were associated with patient survival were identified via receiver operating characteristic curve, multiple logistic regression, and Kaplan-Meier survival analyses. Among 135 patients with acute OP poisoning, 112 patients survived (overall mortality rate: 17 %). The non-survivors also exhibited a significantly higher BAC, compared to the survivors [non-survivors: 192 mg/dL, interquartile range (IQR) 97-263 mg/dL vs. survivors: 80 mg/dL, IQR 0-166.75 mg/dL; p 0.001]. A BAC cut-off value of 173 mg/dL provided an area under the curve of 0.744 [95 % confidence interval (CI) 0.661-0.815], a sensitivity of 65.2 %, and a specificity of 81.2 %. A BAC of 173 mg/dL was associated with a significantly increased risk of 6-month mortality in the multiple logistic regression model (odds ratio 4.92, 95 % CI 1.45-16.67, p = 0.001). The Cox proportional hazard model revealed that a BAC of 173 mg/dL provided a hazard ratio of 3.07 (95 % CI 1.19-7.96, p = 0.021). A BAC of 173 mg/dL is a risk factor for mortality among patients with OP intoxication.

Heat shock proteins act as molecular chaperones and are involved in protein folding, refolding, transport, and translocation. In the present study, we observed changes in heat shock protein 60 (HSP60) immunoreactivity and protein level in the gerbil hippocampal CA1 region after 5 min of transient forebrain ischemia and its neuroprotective effect against ischemic damage. HSP60 immunoreactivity in the CA1 region began to increase in the stratum pyramidale at 30 min after ischemia/reperfusion, and peaked 24 h after ischemia/reperfusion. Thereafter, HSP60 immunoreactivity was decreased in the CA1 region with time. Seven days after ischemia/reperfusion, HSP60 immunoreactivity was increased again in the CA1 region: at this time point after ischemia/reperfusion, HSP60 immunoreactivity was expressed in glial cells in the ischemic CA1 region. HSP60 immunoreactive glial cells were astrocytes containing glial fibrillar acidic protein. In contrast, change in HSP60 immunoreactivity in the ischemic CA2/3 region was not significant compared with that in the ischemic CA1 region. In Western blot study, HSP60 protein level in the CA1 region was increased after ischemia/reperfusion and highest 24 h after ischemia/reperfusion. Animals treated with recombinant adenoviruses expressing Hsp60 (Ad-Hsp60) showed the neuroprotection of CA1 pyramidal neurons from ischemic damage. These results suggest that HSP60 may be associated with delayed neuronal death of CA1 pyramidal neurons after transient ischemia, and the induction of HSP60 protects the neurons from ischemic damage.

Aims To determine whether the level of plasma neutrophil gelatinase-associated lipocalin (NGAL) can predict acute kidney injury (AKI) and clinical outcomes after recovery of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA). Methods We conducted a prospective observational study of consecutive admitted patients with ROSC after OHCA between January 2013 and March 2015. Plasma was collected within 4h of ROSC to determine the level of NGAL. Outcome variables were AKI, 30-day survival, and good neurological outcome (GNO). We evaluated the association between NGAL and outcomes. Results Fifty-four patients were included. AKI occurred in 26 (48.0%); 15 (27.7%) survived over 30 days and 8 had GNO (14.8%). NGAL was significantly lower in the group with non-AKI, 30-day survival, and GNO. To predict AKI, 30-day survival, and GNO, the area under the receiver operating characteristic curve for NGAL was 0.810, 0.728, and 0.875, respectively. In a logistic regression model, NGAL >189ngml −1 was strongly associated with AKI (odds ratio [OR] 7.01, 95% confidence interval [CI]: 1.89–26.01) in a multivariate model. A lower level of NGAL was strongly associated with 30-day survival (OR 6.12, 95% CI: 1.64–23.42 at NGAL −1 ) and GNO (OR 19.83, 95% CI: 2.21–178.32 at NGAL −1 ) in a univariate model, but was not significantly associated with outcomes in a multivariate model. Conclusions Plasma NGAL is a strong predictor of AKI in patients exhibiting OHCA at ICU admission. Lower levels of NGAL are associated with greater chance of 30-day survival and GNO.

Background Delta neutrophil index (DNI) is a new inflammatory marker and the present study aimed to evaluate the predictive value of the DNI for the presence of a perforation in elderly with acute appendicitis. Methods This retrospective observational study was conducted on 108 consecutive elderly patients (≥65 years old) with acute appendicitis treated over a 24-month period. Results Sixty-nine of the 108 patients (median, IQR: 72, 67-77 years) were allocated to the perforated appendicitis group (63.9%) and 39 to the non-perforated appendicitis group (36.1%). WBC, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and DNI were significantly higher in the perforated group. In multiple logistic regression analyses, initial DNI was the only independent marker that can significantly predict the presence of perforation in multiple regression [odds ratio 9.38, 95% confidence interval (2.51-35.00), P=.001]. Receiver operator characteristic curve analysis showed that DNI is a good predictor for the presence of appendiceal perforation at an optimal cut-off for DNI being 1.4% (sensitivity 67.7%, specificity 90.0%, AUC 0.807). Conclusion Clinicians can reliably differentiate acute perforated appendicitis from non-perforated appendicitis by DNI level of 1.4 or more in elderly patients.

Background: Since video-assisted thoracoscopic surgery (VATS) was introduced as a new treatment modality for empyema thoracis, numerous reports have suggested that VATS is a more effective treatment method than the traditional methods that mainly use antibiotics and drainage apparatus. However, no confirmative evidence of the superiority of VATS over the traditional method has been provided yet. Methods: We attempted to evaluate the efficacy of VATS for the treatment of empyema thoracis by reviewing past medical records and simple chest films. First, we divided the patients into two groups based on the treatment method: group A of 15 patients who were treated with the traditional method between January 2001 and December 2003, and group B of 9 patients who were treated with VATS between December 2003 and August 2006. The final outcomes used in this study were the number of days of hospital stay, chest tube duration, leukocytosis duration, febrile duration, and intravenous antibiotics usage duration. In addition, radiological improvements were compared. Results: The mean age(standard deviation) of 11 men and 4 women in group A was years, and of 9 men and 2 women in group B was years. Group B had a significantly shorter hospital stay ( vs. days; p=0.014), shorter chest tube duration ( vs. days; p=0.039), shorter leukocytosis duration ( vs. days; p=0.008), shorter febrile duration ( vs. days; p=0.004), and shorter duration of intravenous antibiotics usage ( vs. days; p=0.018). However, radiological improvements did not show any statistical differences. Conclusion: Early application of VATS for empyema thoracis treatment reduced hospital stay, thoracostomy tube duration, leukocytosis duration, febrile duration, and antibiotics usage duration in comparison with the traditional methods. The early performing of VATS might be an effective treatment modality for empyema thoracis.