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To verify the role of lactate dehydrogenase to albumin (LDH/ALB) ratio as an independent prognostic factor for mortality due to the lower respiratory tract infection (LRTI) in the emergency department (ED).We reviewed the electronic medical records of patients who were admitted to the ED for the management of LRTI between January 2018 and December 2020. Initial vital signs, laboratory data, and patient severity scores in the ED were collected. The LDH/ALB ratio was compared to other albumin-based ratios (blood urea nitrogen to albumin ratio, C-reactive protein to albumin ratio, and lactate to albumin ratio) and severity scales (pneumonia severity index, modified early warning score, CURB-65 scores), which are being used as prognostic factors for in-hospital mortality. Multivariable logistic regression was performed to identify independent risk factors.The LDH/ALB ratio was higher in the non-survivor group than in the survivor group (median [interquartile range]: 217.6 [160.3;312.0] vs. 126.4 [100.3;165.1], p 0.001). In the comparison of the area under the receiver operating characteristic curve (AUC) for predicting in-hospital mortality, the AUC of the LDH/ALB ratio (0.808, 95% confidence interval: 0.757-0.842, p 0.001) was wider than other albumin-based ratios and severity scales, except the blood urea nitrogen to albumin ratio. In the multivariable logistic regression analysis, the LDH/ALB ratio independently affected in-hospital mortality.The LDH/ALB ratio may serve as an independent prognostic factor for in-hospital mortality in patients with LRTI.

Background Surgical debridement is usually an essential step in treating complex facial lacerations (CFL). As the severity of CFL increases, conventional surgical debridement (CSD) of wound edges becomes difficult and may be insufficient to remove damaged tissues and create clean edges. Because the severity and shape of CFL are diverse and different, it is necessary to tailor the customized pre-excisional design, the tailored surgical debridement (TSD), for each case before performing surgical debridement. Applying TSD is expected to enable effective debridement in CFL with higher severity. This study compared cosmetic outcomes and complication incidence of CSD and TSD, according to CFL severity. Methods This was a retrospective observational study. Eligible patients with CFL who visited the emergency department between August 2020 and December 2021 were examined. CFL severity was graded to Grades I and II. CSD and TSD outcomes were compared using the Scar Cosmesis Assessment and Rating (SCAR) scale. Furthermore, a good cosmetic outcome was defined as a SCAR score of ≤ 2. The percentage of good cosmetic outcome between the two groups was compared. The SCAR score and percentage of good cosmetic outcomes between the two groups were compared overall and by severity. For comparison of complication incidence, asymmetry, infection, and dehiscence incidence were compared. Results In total, 252 patients were enrolled (121 [48.0%] CSD and 131 [52.0%] TSD). In CSD and TSD groups, the median SCAR scores were 3 (1–5) and 1 (0–2) in all enrolled patients (p

Background Surgical debridement is usually an essential step in treating complex facial lacerations (CFL). As the severity of CFL increases, conventional surgical debridement (CSD) of wound edges becomes difficult and may be insufficient to remove damaged tissues and create clean edges. Because the severity and shape of CFL are diverse and different, it is necessary to tailor the customized pre-excisional design, the tailored surgical debridement (TSD), for each case before performing surgical debridement. Applying TSD is expected to enable effective debridement in CFL with higher severity. This study compared cosmetic outcomes and complication incidence of CSD and TSD, according to CFL severity. Methods This was a retrospective observational study. Eligible patients with CFL who visited the emergency department between August 2020 and December 2021 were examined. CFL severity was graded to Grades I and II. CSD and TSD outcomes were compared using the Scar Cosmesis Assessment and Rating (SCAR) scale. Furthermore, a good cosmetic outcome was defined as a SCAR score of ≤ 2. The percentage of good cosmetic outcome between the two groups was compared. The SCAR score and percentage of good cosmetic outcomes between the two groups were compared overall and by severity. For comparison of complication incidence, asymmetry, infection, and dehiscence incidence were compared. Results In total, 252 patients were enrolled (121 [48.0%] CSD and 131 [52.0%] TSD). In CSD and TSD groups, the median SCAR scores were 3 (1–5) and 1 (0–2) in all enrolled patients (p

This study conducted to analyze and compare the epidemiological and clinical characteristics of hydrogen fluoride-exposed patients based on major burn criteria for the appropriate emergency department (ED) response to a mass casualty chemical spill. This retrospective cross-sectional study included the records of patients (n = 199) who visited the ED of Gumi City University Hospital from September 27, 2012, to October 20, 2012. Subjects were included in the major burn group (MBG) if they presented with wounds that required referral to a burn center according to the American Burn Association guidelines or in the nonmajor burn group (NMBG) if not. Males were predominant in both the MBG (n = 55, 48 males) and NMBG (n = 144, 84 males; P < .05). The most prevalent timeline for visiting the ED was the phase which included 9–32 hours post-leak of hydrogen fluoride, including 45 patients (81.8%) in the MBG and 122 patients (84.7%) in the NMBG (P < .001). The respiratory tract was the site of greatest damage in patients in both the MBG and NMBG (n = 47, 85.5% vs n = 142, 98.6%, P < .001). Regarding dispositions, all patients in the NMBG were discharged (n = 144, 100%); however, eight patients (14.5%) in the MBG underwent other dispositions (discharge against medical advice, five patients; admission, one patient; death, two patients, P < .05). Patient outcomes after major chemical contamination events should be characterized in future studies to maximize the quality of patient care.

Aim We presented the cut-off value of a diffusion-weighted image (DWI) scoring system to predict poor neurologic outcome using DWI taken 72−96 h after out-of-hospital cardiac arrest (OHCA) patients underwent target temperature management (TTM). Methods This was a prospective single-centre observational study, conducted from March 2018 to April 2020 in OHCA patients after TTM. Neurological status was assessed 6 months after return of spontaneous circulation (ROSC) using the Glasgow-Pittsburgh cerebral performance categories (CPC) scale. CPC of 1–2 demonstrated good neurologic outcomes whilst a CPC of 3–5 was related to poor neurologic outcomes. The receiver operating characteristic curves and DeLong method were used to evaluate the cut-off value of the DWI scoring system to predict poor neurologic outcome. Results The good and poor neurologic outcome groups consisted of 38 (54.3%) and 32 (45.7%) patients, respectively. The area under the receiver operating characteristic curve (AUROC) of the overall, cortex, deep grey nuclei, and cortex plus deep grey nuclei scores, white matter, brainstem, and cerebellum measured 72−96 h after ROSC were 0.96, 0.96, 0.97, 0.96, 0.95, 0.95, and 0.93 respectively. For 100.0% specificity to predict poor neurologic outcome, the overall scores of the DWI scoring system measured 72−96 h after ROSC with a cut-off value of 52 had a sensitivity of 81.3% (95% CI: 63.6–92.8). Conclusion This study demonstrated that the DWI scoring systems measured between 72 and 96 h after ROSC were valuable tools to predict poor neurologic outcome in post-OHCA patients treated with TTM.

We evaluated whether combining the serum albumin level and the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE) class could be a prognostic predictor in elderly patients with urinary tract infection (UTI).We retrospectively included adult patients (age ≥ 65 years) with UTI who were hospitalized in the emergency department (ED) between January 1, 2014 and December 31, 2018. We graded the serum albumin level and classified the PRACTICE score; the modified PRACTICE was defined as the sum of the albumin level grade and the PRACTICE class. We comparatively assessed the predictive value for in-hospital mortality and admission to the intensive care unit (ICU) in survivor and non-survivor groups.In total, the study analysis included 1159 patients, and in-hospital mortality was 3.4% (n = 39). The modified PRACTICE score (4.0 [1.4] vs 6.1 [1.2], p 0.001) was significantly increased in the non-survivor group. The area under the curve value of factors associated with in-hospital mortality were the Modified Early Warning Score (MEWS) 0.57 (95% CI 0.54-0.60), albumin 0.83 (95% CI 0.81-0.85), PRACTICE 0.71 (95% CI 0.69-0.74), and the modified PRACTICE 0.86 (95% CI 0.84-0.88). Factors associated with ICU admission were MEWS 0.65 (95% CI 0.62-0.68), albumin 0.66 (95% CI 0.64-0.69), PRACTICE 0.66 (95% CI 0.63-0.68), and the modified PRACTICE 0.72 (95% CI 0.69-0.74).The modified PRACTICE score can be a useful prognostic predictor in elderly patients with UTI.

Aim In a previous study, low and high-normal arterial carbon dioxide tension (PaCO2) were not associated with serum neuron-specific enolase (NSE) in cardiac arrest survivors. We assessed the effect of PaCO2 on NSE in cerebrospinal fluid (CSF) and serum. Methods This was a retrospective study. PaCO2 for the first 24 h was analysed in four means, qualitative exposure state (qES), time-weighted average (TWA), median, and minimum–maximum (Min–Max). These subgroups were divided into low (LCO2) and high PaCO2 (HCO2) groups defined as PaCO2 ≤ 35.3 and PaCO2 > 43.5 mmHg, respectively. NSE was measured at 24, 48, and 72 h (sNSE24,48,72 and cNSE24,48,72) from return of spontaneous circulation (ROSC). The primary outcome was the association between PaCO2 and the NSE measured at 24 h after ROSC. Results Forty-two subjects (male, 33; 78.6%) were included in total cohort. PaCO2 in TWA subgroup was associated with cNSE24,48,72, while PaCO2 in the other subgroup were only associated with cNSE24. PaCO2 and cNSE in qES subgroup showed good correlation (r = −0.61; p Conclusion Association was found between NSE and PaCO2 using CSF, despite including normocapnic ranges; TWA of PaCO2 may be most strongly associated with CSF NSE levels. A prospective, multi-centre study is required to confirm our results.

Aim This study examined whether the presence of cortical necrosis (CN) on ultra-early diffusion-weighted imaging (DWI) and the severity of cytotoxic oedema (CytE) with cerebral oedema (CbrE), measured using quantitative analysis of apparent diffusion coefficient (ADC), could predict neurological outcomes before targeted temperature management in out-of-hospital cardiac arrest survivors (OHCAs). Methods In this retrospective study, the first DWI with ADC scans was performed within 6 h; the second was obtained between 72 and 96 h after return of spontaneous circulation. The primary outcome was neurological outcomes at 6 months after OHCA. The % voxels of ADC value (PV) was calculated; CbrE and CytE values were > or Results Thirty-six patients were included. CN (area under receiver operating characteristic curve [AUC] = 0.800), thld-CytE (PV420; AUC = 0.730), and thld-CbrE (PV1090; AUC = 0.775) showed meaningful performance, and the combined score showed best performance for poor outcome prediction (AUC = 0.956). DWI findings of CN patients was worse at the second DWI. ΔPV significantly increased in the poor outcome group, CN patients, and the group including both, thld-CytE and thld-CbrE. Conclusions In OHCAs, ultra-early DWI with ADC could successfully predict poor neurological outcomes by combining scores of CN, thld-CytE, and thld-CbrE.

Studies on the prognostic performance of optic nerve sheath diameter (ONSD) in out-of-hospital cardiac arrest survivors (OHCA) have reported conflicting results. We aimed to investigate the usefulness of ONSD measured using magnetic resonance imaging (MRI) to estimate its association with intracranial pressure (ICP) and 6-month neurological outcomes in CA survivors treated with targeted temperature management (TTM).This retrospective study included 37 CA survivors who underwent TTM from January 2018 to December 2018. ICP was measured by lumbar catheter during TTM on Days 0, 1, 2, and 3. ONSD was measured using MRI on Days 0 and 3. The primary outcome was the correlation between ONSD and ICP associated with neurological outcomes obtained after 6 months.The median (interquartile range [IQR]) ONSD was not significantly different between the good and poor neurological outcome group on Day 0 (5.2 mm [4.8-5.8] vs 5.2 mm [4.8-5.6]; p = 0.948) and Day 3 (5.0 mm [4.8-5.2] vs 5.5 mm [4.4-5.9]; p = 0.105). ONSD and ICP had excellent correlation on Day 3 (r = 0.90, p 0.001). ONSD showed excellent correlation with increased ICP (IICP) defined as ICP above 20 mmHg (r = 0.89, p 0.001). ONSD cut-off of 5.99 mm was used with a sensitivity of 90.0% and specificity of 98.0% to identify IICP.The ONSD on Days 0 or 3 did not show differences in neurological outcomes in OHCA patients treated with TTM. However, ONSD had an excellent correlation with ICP on Day 3 and with IICP. Further studies are required to confirm our results.

This study was performed to verify whether lactate dehydrogenase to albumin (LDH/ALB) ratio could be used as an independent prognostic factor in patients with severe infection requiring intensive care. We reviewed electronic medical records of patients hospitalized to the intensive care unit via the emergency department with a diagnosis of infection between January 2014 and December 2019. From the collected data, ALB-based ratios (LDH/ALB, blood urea nitrogen to albumin, C-reactive protein to albumin, and lactate to albumin ratios) and some severity scores (modified early warning score, mortality in emergency department sepsis score [MEDS], and Acute Physiology And Chronic Health Evaluation II [APACHE II] score) were calculated. LDH/ALB ratio for predicting the in-hospital mortality was compared with other ALB-based ratios and severity scales by univariable and receiver-operating characteristics curve analysis. Modified severity scores by LDH/ALB ratio and multivariable logistic regression were used to verify the independence and usefulness of the LDH/ALB ratio. The median LDH/ALB ratio was higher in non-survivors than survivors (166.9 [interquartile range: 127.2–233.1] vs 214.7 [interquartile range: 160.2–309.7], P

Background: In patients with sepsis, early resuscitation and intensive care are associated with a lower mortality rate compared with late resuscitation. We evaluated the utility of the Korean Modified Early Warning Score (KMEWS), which combines the Modified Early Warning Score (MEWS) and the Korean Triage and Acuity Scale (KTAS), as a triage tool to screen for infection in patients visiting the emergency department (ED).Methods: We retrospectively reviewed data extracted from electronic medical records. Patients aged ≥18 years, with infection, who were admitted to hospital via the ED between January 1, 2018, and December 31, 2019 were eligible for inclusion. The MEWS, quick Sepsis-related Organ Failure Assessment (qSOFA), and Mortality in Emergency Department Sepsis (MEDS) of each patient were calculated. The KTAS score was 5, 4, 3, 2, and 1 point, for Levels 1, 2, 3, 4, and 5, respectively. The KMEWS was calculate as the sum of the KTAS score and the MEWS. In addition, the participants were assigned to a septic shock group and a non-septic group for intergroup comparisons.Results: The area under the curve (AUC) values for predicting septic shock were: KMEWS, 0.910 (95% confidence interval [CI], 0.902–0.918); MEWS, 0.896 (95% CI, 0.887–0.904); KTAS score, 0.809 (95% CI, 0.798–0.819); and the MEDS, 0.927 (95% CI, 0.919–0.934). The AUC values for predicting mortality were: KMEWS, 0.752 (95% CI, 0.740–0.764); MEWS, 0.717 (95% CI, 0.704–0.729); KTAS score, 0.764 (95% CI, 0.752–0.776); and the MEDS, 0.844 (95% CI, 0.834–0.854). The AUC values for predicting intensive care unit admission were: KMEWS, 0.826 (95% CI, 0.816–0.837); MEWS, 0.782 (95% CI, 0.770–0.793); KTAS score, 0.821 (95% CI, 0.810–0.831); and the MEDS, 0.839 (95% CI, 0.829–0.849).Conclusion: The KMEWS is a useful triage screening tool for determining clinical severity in ED patients with infection.

Incidences of brain death due to nicotine overdose by e-cigarettes have been increasing. In such cases, liver donation has been not reported because of the secondary damage to the liver due to metabolism of large amounts of nicotine. However, kidneys have been considered acceptable for transplant. Here, we present a successful case of liver transplant from a brain-dead donor due to intentional nicotine ingestion who did not have extensive steatosis. To the best of our knowledge, this is the first report of such a case.

Aim of the study No definitive experimental or clinical evidence exists whether brain hypothermia before, rather than during or after, resuscitation can reduce hypoxic-ischemic brain injury following cardiac arrest/cardiopulmonary resuscitation (CA/CPR) and improve outcomes. We examined the effects of moderate brain hypothermia before resuscitation on survival and histopathological and neurobehavioral outcomes in a mouse model. Methods Adult C57BL/6 male mice (age: 8–12 weeks) were subjected to 8-min CA followed by CPR. The animals were randomly divided into sham, normothermia (NT; brain temperature 37.5 °C), and extracranial hypothermia (HT; brain temperature 28–32 °C) groups. The hippocampal CA1 was assessed 7 day after resuscitation by histochemical staining. Neurobehavioral outcomes were evaluated by the Barnes maze (BMT), openfield (OFT), rotarod, and light/dark (LDT) tests. Cleaved caspase-3 and heat shock protein 60 (HSP70) levels were investigated by western blotting. Results The HT group exhibited higher survival and lower CA1 neuronal injury than did the NT group. HT mice showed improved spatial memory in the BMT compared with NT mice. NT mice travelled a shorter distance in the OFT and tended to spend more time in the light compartment in the LDT than did sham and HT mice. The levels of cleaved caspase-3 and HSP70 were non-significantly higher in the NT than in the sham and HT groups. Conclusions Moderate brain hypothermia before resuscitation improved survival and reduced histological neuronal injury, spatial memory impairment, and anxiety-like behaviours after CA/CPR in mice.

Aim We evaluated the optimal timing of optic nerve sheath diameter (ONSD) measurement to predict neurologic outcome in post-cardiac arrest patients treated with target temperature management (TTM). Methods This was a prospective single-centre observational study from April 2018 to March 2019. Good outcome was defined as the Glasgow-Pittsburgh cerebral performance categories (CPC) 1 or 2, and poor outcome as a CPC between 3 and 5. ONSD was measured initially after return of spontaneous circulation (ROSC) (ONSDinitial), at 24 h (ONSD24), 48 h (ONSD48), and 72 h (ONSD72) using ultrasonography. The receiver operating characteristic (ROC) curves and DeLong method were used to compare the values for predicting neurologic outcomes. Results Out of the 36 patients enrolled, 18 had a good outcome. ONSD24, ONSD48, and ONSD72 were higher in the poor outcome group. The area under ROC curve of ONSD24 was 0.91 (95% confidence interval 0.77–0.98) in predicting poor neurologic outcomes. With a cut off value of 4.90 mm, ONSD24 had a sensitivity of 83.3% and a specificity of 94.4% in predicting poor neurologic outcomes. Conclusion Our findings demonstrate ONSD24 as a valuable tool to predict the neurologic outcome in post-cardiac arrest patients treated with TTM. Therefore, we recommend performing ONSD measurement using ultrasonography at 24 h after ROSC, rather than immediately after ROSC, to predict neurologic outcome in post-cardiac arrest patients treated with TTM.

Background: Bystander cardiopulmonary resuscitation is a key component of life-saving after an out-of-hospital cardiac arrest. In the pre-arrival instructions for out-of-hospital cardiac arrest, it is recommended that the patient be laid on a flat floor. However, the most common reason for not performing cardiopulmonary resuscitation is that the bystander could not move the patient. Objectives: This study aim to investigate the effects of using a home-bed mattress on the quality of chest compression. Methods: In this prospective, randomized study, chest compression without ventilation was performed for 4 min on a Resusci Anne manikin placed on a flat floor or on three types of home-bed mattresses (hard, medium and soft). Chest compression depth, chest compression rate and chest recoil were measured from the manikin with the Laerdal PC Skill Reporting System, and changes in chest compression quality using the four different surfaces were compared. Results: Thirty participants were enrolled to perform chest compression. There was no significant difference in chest compression depth and depth accuracy between the four surfaces. The median chest compression rates were 108.1 ± 8.5, 107.0 ± 8.3, 103.3 ± 8.9 and 98.3 ± 7.9 compressions/min ( p Conclusion: Using a home-bed mattress did not decrease the chest compression quality, except chest compression rate of soft-firmness mattress. Thus, it may be effective to initiate chest compression on a home-bed mattress if the bystander cannot move the patient to the floor.

Purpose Brain swelling post-cardiac arrest may affect cerebrospinal fluid volume. We aimed to investigate the prognostic performance of the proportion of cerebrospinal fluid volume (pCSFV) using brain computed tomography (CT) in cardiac arrest survivors. Materials and Methods This retrospective multicentre study included adult comatose cardiac arrest survivors who underwent brain CT scan prior to target temperature management (TTM) from 2015 to 2016. Grey-to-white matter ratio (GWR) and pCSFV values were calculated. pCSFV analysis was performed using automated quantitative analysis programming. The primary outcome was a 6-month neurological outcome. Results Of 251 patients (median age, 57 years), 173 (68.9%) were male, 87 (34.7%) had a shockable rhythm, and 160 (63.7%) had unfavourable neurological outcomes. GWR but not pCSFV was significantly higher in terms of favourable neurological outcomes (p = .015). pCSFV prognostic performances were similar to GWR, and were poor overall, (0.521; 95% confidence interval [CI], 0.446–0.694 vs. 0.515; 95% CI, 0.441–0.589). After adjusting for covariates, pCSFV but not GWR was independently associated with neurological outcome 6 months following cardiac arrest (p = .049). Conclusion pCSFV was independently associated with neurological outcome 6 months following cardiac arrest, however prognostic performance was not good.

Aim We aimed to evaluate the onset of severe blood-brain barrier (BBB) disruption using cerebrospinal fluid/serum albumin quotient (Qa) in cardiac arrest patients treated with target temperature management (TTM). Methods This was a prospective single-centre observational cohort study from October 2017 to September 2018 with the primary endpoint being the onset of severe BBB disruption, determined based on Qa in cardiac arrest patients treated with TTM. Enrolled patients were grouped according to neurologically good and poor outcomes using the cerebral performance category (CPC) at 3 months after return of spontaneous circulation (ROSC). Severe BBB disruption was evaluated using Qa measured immediately (Qa0) and at 24 h (Qa24), 48 h (Qa48), 72 h (Qa72) after ROSC. Results Of 21 patients enrolled, poor outcome group had 10 patients. Qa0 was 0.019 (0.008∼0.024) in the poor outcome group and 0.006 (0.003∼0.008) in the good outcome group (p = 0.09). Qa24 was 0.045 (0.025∼0.115) in the poor outcome group and 0.006 (0.003∼0.006) in the good outcome group (p = 0.03). Qa48 was 0.055 (0.023∼0.276) in the poor outcome group and 0.006 (0.006∼0.009) in the good outcome group (p = 0.02). Qa72 was 0.047 (0.026∼0.431) in the poor outcome group and 0.007 (0.005∼0.011) in the good outcome group (p = 0.02). Conclusion Qa was significantly higher in the poor outcome group at 24 h, 48 h, and 72 h. Severe BBB disruption indicated by Qa ≥ 0.02 in poor outcome group treated with TTM occurred within the first 24 h after ROSC.

Rapid disease progression in neuroemergencies is associated with blood-brain barrier (BBB) disruption. We investigated a less invasive strategy for assessing BBB status by evaluating S100 calcium-binding protein B (S100B) and neuron-specific enolase (NSE) at early stages of the hypoxic-ischemic brain injury (HIBI) cascade.This retrospective study used prospectively collected data from patients with out-of-hospital cardiac arrest (August 2019-July 2021). Albumin specimens obtained from serum and cerebrospinal fluid via arterial catheter and lumbar puncture were used to measure the albumin quotient (Qa), which is widely accepted as the gold standard method for detecting BBB disruption. Serum S100B and NSE levels were measured simultaneously following the return of spontaneous circulation. We conducted linear regression to evaluate the relationship between S100B and Qa and the predictive performance of S100B for abnormal Qa. The primary study outcome was abnormal Qa (0.007).Forty-one patients were enrolled; 30 showed an abnormal Qa suggestive of BBB disruption. S100B levels were significantly higher than in those with a normal Qa (0.244 μg/L [interquartile range [IQR], 0.146-0.823 vs 0.754 μg/L [IQR, 0.317-2.228], P = .03). We report a positive correlation between serum S100B and Qa (R2 = 0.110; P = .04). The area under the receiver operating characteristics curve (AUROC) evaluating the predictive performance of S100B with respect to abnormal Qa was 0.718 (95% confidence interval, 0.556-0.847). The cutoff value for S100B (with respect to BBB disruption) in the total cohort was 0.283 μg/L (sensitivity, 80.0%; specificity, 72.7%). Subgroup analyses in patients with serum neuron-specific enolase (NSE) levels of40.8 ng/mL (excluding those with established neuronal cell injury) showed an improved correlation coefficient (R2 = 0.382; P.01) and predictive performance (AUROC, 0.836 [95% confidence interval, 0.629-0.954]) compared with the total cohort.Serum S100B obtained at an early stage of the HIBI cascade is associated with abnormal Qa, suggesting BBB disruption. The predictive performance of S100B and the correlation between serum S100B and Qa can be improved using a complementary strategy (i.e., evaluations of S100B and NSE levels) that combines considerations of cell damage in astrocytes and neurons.

Background This study analyzed the characteristics of hydrogen fluoride-exposed patients (HFEPs) treated in the emergency department (ED) of a local university hospital, and reviewed the hospital’s disaster response according to space, staff, supplies, and systems (4Ss). Methods This retrospective observational chart review and descriptive study included 199 HFEPs among 2588 total ED patients who visited a local university emergency medical center for treatment between September 27, 2012 and October 20, 2012, following a hydrofluoric acid leak at the Hube Globe factory in Gumi City, Republic of Korea. Descriptive results concerning the 4Ss were obtained by interviewing ED specialist staff physicians on duty during the study period. In accordance with American Burn Association criteria, patients requiring burn center referral were assigned to the major burn group (MBG) as severe condition. Results During the acute phase (within 8 h after leak initiation), there were 43 patients in the ED, which was staffed with 3 doctors and 3 nurses, without 4S resources. Of these 43 patients, there were 8 HFEPs (100%) in the MBG and 0 in the non-MBG (NMBG). During the subacute phase (24 h after the acute phase), there were 262 patients in the ED including 167 HFEPs, of whom 45 (26.95%) were in the MBG and 122 (73.05%) were in the NMBG. The ED was then staffed with 6 doctors (3 on day shift and 3 on night shift) and 10 nurses (3 on day shift, 4 on evening shift, and 3 on night shift), and no 4S resources were available. Throughout the study period, no 4Ss were available. First, there was no expansion of ED space or secured disaster reserve beds. Second, there was no increase in manpower with duty time adjustments or duty relocation for ED working personnel. Third, there was no logistics reinforcement (e.g., antidote or personal protective equipment). Fourth, there were no disaster-related measures for the administration department, decontamination zone setup, safety diagnostic testing, or designated disaster triage implementation. Conclusions The hospital’s disaster response was insufficient for all aspects of the 4Ss. Detailed guidance concerning a hospital disaster management plan is required.

Objective: This study aimed to analyze the characteristics of hydrogen fluoride–exposed patients (HFEPs) treated at an emergency department (ED) at a local university hospital, and to review the hospital's disaster response according to staff, stuff, space, and system (4Ss).Method: This is retrospective observational chart review and descriptive study included 199 HFEPs among 2628 of total ED patient who visited a local university emergency medical center for treatment between September 27 and October 20, 2012, following an HF leak at the Hub Globe factory in Gumi City, Republic of Korea. Descriptive results concerning 4Ss were obtained from interview with ED specialist staff physician on duty during the study period. According to the criteria of the American Burn Association, patients requiring burn center referral were assigned to the major burn group (MBG) as severe condition. Result: During the first 24 h after the accident, 161 (80.9%) HFEPs were treated in the ED. Among the 55 (27.6%) patients in the MBG, 8 (4% of the HFEPs) came to the ED during the acute phase (within the first 8 h after the leak began). During the acute phase, the ED was staffed with three doctors and three nurses. Among the total 2628 patients in the ED during the study period, 262 (9.97%) patients, including 167 (83.92%) of the 199 HFEPs, were there during the subacute phase, defined as the 24 h after the acute phase. During the subacute phase, the ED staff consisted of six doctors and 10 nurses. No concepts according to 4Ss that allowed for the expansion of ED space with securing disaster reserve beds or an increase in manpower with duty time adjustments or duty relocation for ED working personnel were in place as well as reinforcement of logistics such as antidote or PPE or disaster related measures of administration department or decontamination zone setup or decontamination or disaster related diagnostic testing measures or unification and management of the entrances and exits of hospital or implementation of previously designated disaster triage.Conclusion: Hospital disaster response was insufficient for all aspects of 4Ss. Detailed guidance for hospital disaster management plan establishment is required.

This retrospective cohort study aimed to compare the effectiveness of conventional treatment and ultra-early application of negative pressure wound therapy (NPWT) in patients with snakebites. Patients who visited the emergency department within 24 hours after a snakebite were assigned to the non- NPWT or NPWT group. Swelling resolution time and rates of necrosis, infection, and operations were compared between the 2 groups. The Stony Brook Scar Evaluation Scale was used to measure short- and long-term wound healing results. Among the included 61 patients, the swelling resolution time was significantly shorter in the NPWT group than in non- NPWT group (P = .010). The NPWT group showed lower necrosis (4.3% versus 36.8%; P = .003) and infection (13.2% and 4.3%; P = .258) rates than the non- NPWT group. The median Stony Brook Scar Evaluation Scale scores were higher in the NPWT group than in the non- NPWT group (P

Objective Hypoxic ischemia (HI) is a secondary insult that can cause fatal neurologic outcomes after traumatic brain injury (TBI), ranging from mild cognitive deficits to persistent vegetative states. We here aimed to unravel the underlying pathological mechanisms of HI injury in a TBI mouse model.Methods Neurobehavior, neuroinflammation, and oxidative stress were assessed in a mouse model of controlled cortical impact (CCI) injury followed by HI. Mice underwent CCI alone, CCI followed by HI, HI alone, or sham operation. HI was induced by one-vessel carotid ligation with 1 hour of 8% oxygen in nitrogen. Learning and memory were assessed using the novel object recognition test, contextual and cued fear conditioning, and Barnes maze test. Brain cytokine production and oxidative stress-related components were measured.Results Compared to TBI-only animals, TBI followed by HI mice exhibited significantly poorer survival and health scores, spatial learning and memory in the Barnes maze test, discrimination memory in the novel object recognition test, and fear memory following contextual and cued fear conditioning. Malondialdehyde levels were significantly lower, whereas glutathione peroxidase activity was significantly higher in TBI followed by HI mice compared to TBI-only and sham counterparts, respectively. Interleukin-6 levels were significantly higher in TBI followed by HI mice compared to both TBI-only and sham animals.Conclusion Post-traumatic HI aggravated deficits in spatial, fear, and discrimination memory in an experimental TBI mouse model. Our results suggest that increased neuroinflammation and oxidative stress contribute to HI-induced neurobehavioral impairments after TBI.

Background Serum interleukin-6 (IL-6) is a cytokine released in response to an inflammatory stimulus or tissue injury. IL-6 levels are known to increase in patients with brain injury. Objective We investigated the neurologic outcomes associated with serum IL-6 levels in out-of-hospital cardiac arrest (OHCA) survivors who underwent target temperature management (TTM). Methods This was a prospective single-center observational study from October 2018 to November 2019 in a cohort of 45 patients. Serum inflammatory markers (IL-6, C-reactive protein, white blood cells) were determined in samples obtained immediately and at 24, 48, and 72 h after the return of spontaneous circulation (ROSC). Poor neurologic outcome, defined as Cerebral Performance Category 3–5 at 3 months after cardiac arrest, was the primary outcome. Results Among 45 patients enrolled in this study, 25 (55.6%) patients showed a poor neurologic outcome. IL-6 levels were significantly higher in the poor neurologic outcome group immediately (IL-60) after ROSC. The area under the curve (AUC) value of IL-60 was the highest among those of serum IL-6, CRP, and WBC at each time point. The IL-6 levels for predicting poor neurologic outcome had a sensitivity of 75.0%, with 80% specificity at IL-60. The AUC of IL-60 was 0.810 (95% confidence interval 0.664–0.913), with a cutoff value of 346.7 pg mL−1. Conclusions Serum IL-6 level immediately after ROSC was a highly specific and sensitive marker for the 3-month poor neurologic outcome, and may be a useful early predictive marker of neurologic outcome in OHCA survivors treated with TTM.

Aim We evaluated the prognostic value of serum- and cerebrospinal fluid (CSF)-ubiquitin carboxyl-terminal esterase L1 protein (UCHL1) measurements in post- post-out of hospital cardiac arrest (OHCA) patients treated with target temperature management (TTM), to predict neurologic outcome. Methods This was a prospective single-centre observational cohort study, conducted from April 2018 to September 2019. Serum- and CSF-UCHL1 were obtained immediately (UCHL1initial), 24 h (UCHL124), 48 h (UCHL148), and 72 h (UCHL172) after return of spontaneous circulation (ROSC). The area under the receiver operating characteristic curves (AUROC) and Delong method were used to identify cut-off values of serum- and CSF-UCHL1initial, UCHL124, UCHL148, UCHL172 for predicting neurologic outcomes. Results Of 38 patients enrolled, 16 comprised the poor outcome group. The AUROCs for serum- and CSF-UCHL1initial were 0.71 and 0.93 in predicting poor neurological outcomes, respectively (p = 0.01). The AUROCs for serum- and CSF-UCHL124 were 0.85 and 0.91 (p = 0.24). The AUROCs for serum- and CSF-UCHL148 were 0.90 and 0.97 (p = 0.07). The AUROCs for serum- and CSF-UCHL172 were 0.94 and 0.98 (p = 0.25). Conclusion Findings of this study demonstrate that CSF-UCHL1 measured immediately, 24, 48, and 72 h after ROSC is a valuable predictor for evaluating neurologic outcomes, whereas serum-UCHL1 measured at 24, 48, and 72 h after ROSC showed a significant performance in the prognostication of poor outcomes in post-OHCA patients treated with TTM.

This study aimed to determine whether the blood urea nitrogen to serum albumin (B/A) ratio is a useful prognostic factor of mortality in patients with aspiration pneumonia.The study included patients with aspiration pneumonia who had been admitted to our hospital via the emergency department (ED) between January 1, 2014 and December 31, 2018. The 28-day mortality after the ED visits was the primary end point of this study. The data of the survivors and non-survivors were compared.A final diagnosis of aspiration pneumonia was made for 443 patients during the study period. Significant differences were observed in age, respiratory rate, albumin levels, total protein levels, blood urea nitrogen levels, C-reactive protein levels, glucose, and Charlson comorbidity index scores between the survivor and non-survivor groups. Moreover, the B/A ratio was significantly higher in the non-survivor group than that in the survivor group. The area under the curve for the B/A ratio was 0.70 [95% confidence interval (CI) 0.65-0.74], 0.71 for the PSI (95% CI 0.67-0.76), 0.64 for CURB-65 (95% CI 0.60-0.69), and 0.65 for albumin (95% CI 0.60-0.70) on the receiver operating characteristic curve for predicting mortality within 28 days of the ED visit. Multivariable logistic regression analysis revealed that the B/A ratio (7, OR 3.40, 95% CI 1.87-6.21, P 0.001) was associated with mortality within 28 days of the ED visit.The B/A ratio is a simple and potentially useful prognostic factor of mortality in aspiration pneumonia patients.

Background The purpose of this study was to present a systematic review and meta-analysis of the diagnostic accuracy of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis in pregnant women. Methods A literature search was conducted using the databases of PubMed, Ovid MEDLINE, EMBASE, and the Cochrane Library. The inclusion criteria were the use of MRI, as a diagnostic protocol for acute appendicitis in pregnant women, and the availability of diagnostic parameters, such as sensitivity and specificity. For each selected study, the basic demographic information and measures of diagnostic accuracy, such as sensitivity, specificity, and positive and negative predictive values, were extracted. Forest plots and summary receiver operating characteristic curves (SROC) were also obtained for diagnostic accuracy of MRI for acute appendicitis during pregnancy. Results A total of 22 studies and the data of 2392 patients were analyzed. Most studies had high sensitivity, with the exception of a few that had sensitivities of 0.18, 0.5, and 0.6. With respect to specificity, most results were close to 1.0, and the lowest result was 0.92. The SROC curves showed high levels of accuracy, as evidenced by an area under the curve value of 0.9922. Conclusion MRI showed overall high accuracy for diagnosing acute appendicitis in pregnant women. Therefore, it is a good diagnostic tool as a first-line imaging method for suspected appendicitis in pregnant women.

Aim The optimal time to measure serum albumin concentration (SAC) to predict prognosis in cardiac arrest (CA) survivors has not been elucidated. We aimed to compare the relationships between time-related SAC, optic nerve sheath diameter (ONSD), intracranial pressure (ICP), and neurological prognosis in CA survivors. Methods We undertook a retrospective study examining CA patients treated with target temperature management (TTM). ICP was measured using cerebrospinal fluid (CSF) pressure and ONSD was obtained before TTM. SAC was measured repeatedly at 4–6 h intervals from the hospital arrival time. We analysed CSF pressure, ONSD, and minimum SAC (MSAC) separately, or in combination, to predict poor neurological outcome. Results Of 83 patients enrolled, the good outcome group comprised 25 (34%) patients. MSAC at 24 h (MSAC24) had a higher area under the receiver operating characteristic curve (AUC) (0.687; 95% confidence interval (CI), 0.668–0.926) than other time points. CSF pressure showed a higher AUC (0.973; 95% CI, 0.911–0.996) than MSAC24 and ONSD (0.677; 95% CI, 0.565–0.776). In contrast to using MSAC24 and ONSD separately, the combination of both modalities resulted in a better AUC, thus improving the prediction of the neurological outcome (0.734; 95% CI, 0.626–0.825) and ICP (0.758; 95% CI, 0.651–0.845) after return of spontaneous circulation (ROSC) from CA. Conclusion A higher ICP was strongly associated with and seemed predictive of poor outcome. Furthermore, the MSAC24/ONSD combination may be a useful predictor of high ICP and poor neurological outcome. Prospective studies should be conducted to confirm these results.

Dear Editor,Zolpidem and flunitrazepam are commonly used for insomnia. Recently, cardiac safety concerns of zolpidem have been raised because of a case of long QT syndrome, complicated by Torsades ...

Dear editor,Certain shellfish commonly ingested by humans contain toxins and can cause systemic poisoning [1]. Although a few cases of tetramethylammonium (TMA) poisoning due to Neptunea ingestion ...

Purpose Cerebrospinal fluid (CSF) lactate dehydrogenase (LDH) levels increase in patients with brain injury. We investigated neurologic outcomes associated with CSF LDH levels in out-of-hospital cardiac arrest (OHCA) survivors who underwent target temperature management (TTM). Materials and methods This was a prospective single-centre observational study from April 2018 to May 2019 on a cohort of 41 patients. CSF and serum LDH samples were obtained immediately (LDH0) and at 24 (LDH24), 48 (LDH48), and 72 h (LDH72) after return of spontaneous circulation (ROSC). Neurologic outcomes were assessed at 3 months after ROSC using the Cerebral Performance Category scale. Results Twenty-one patients had a poor neurologic outcome. CSF LDH levels were significantly higher in the poor neurologic outcome group at each time point. The area under the curve (AUC) of CSF LDH48 was 0.941 (95% confidence interval [CI], 0.806–0.992). With a cut off value of 250 U/L, CSF LDH48 had a high sensitivity (94.1%; 95% CI, 71.3–99.9) at 100% specificity. Conclusions CSF LDH level at 48 h was a highly specific and sensitive marker for 3-month poor neurologic outcome. This may constitute a useful predictive marker for neurologic outcome in OHCA survivors treated with TTM.

We aimed to compare the relationship of mean arterial pressure (MAP) and intracranial pressure (ICP) to predict the neurological prognosis in cardiac arrest (CA) survivors. We retrospectively examined out-of-hospital CA patients treated with targeted temperature management. ICP was measured using cerebrospinal fluid (CSF) pressure, whereas MAP was measured as blood pressure monitored through the radial or femoral artery during CSF pressure measurement. Primary outcome was 6-month neurological outcome. Of 92 enrolled patients, the favorable outcome group comprised 31 (34%) patients. The median and interquartile range of MAP were significantly higher and ICP was significantly lower in patients with favorable neurological outcomes than in those with unfavorable neurological outcomes (94.3 mmHg [80.0-105.3] vs. 82.0 mmHg [65.3-96.3]

Aim Cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels increase ahead of serum NSE levels in patients with severe brain injury. We examined the prognostic performance between CSF NSE and serum NSE levels in out-of-cardiac arrest (OHCA) survivors who had undergone target temperature management (TTM). Methods This single-centre prospective observational study included OHCA patients who had undergone TTM. NSE levels were assessed in blood and CSF samples obtained immediately (Day 0), and at 24 h (Day 1), 48 h (Day 2), and 72 h (Day 3) after return of spontaneous circulation (ROSC). The primary outcome was the 6-month neurological outcome. Results We enrolled 34 patients (males, 24; 70.6%), and 16 (47.1%) had a poor neurologic outcome. CSF NSE and serum NSE values were significantly higher in the poor outcome group compared to the good outcome group at each time point, except for serum Day 0. CSF NSE and serum NSE had an area under curve (AUC) of 0.819–0.972 and 0.648–0.920, respectively. CSF NSE prognostic performances were significantly higher than serum NSE levels at Day 1 and showed excellent AUC values (0.969; 95% confidence interval [CI] 0.844–0.999) and high sensitivity (93.8%; 95% CI 69.8–99.8) at 100% specificity. Conclusion We found CSF NSE values were highly predictive and sensitive markers of 6-month poor neurological outcome in OHCA survivors treated with TTM at Day 1 after ROSC. Therefore, CSF NSE levels at day 1 after ROSC can be a useful early prognosticator in OHCA survivors.

Introduction This report describes changes in blood and urine concentrations of glyphosate potassium over time and their correlations with clinical symptoms in a patient with acute glyphosate potassium poisoning. Case report A 67-year-old man visited the emergency center after ingesting 250 mL of a glyphosate potassium-based herbicide 5 h before. He was alert but presented with nausea, vomiting, and bradyarrhythmia with atrial fibrillation (tall T waves). Laboratory findings revealed a serum potassium level of 6.52 mEq/L. After treatment with an injection of calcium gluconate, insulin with glucose, bicarbonate, and an enema with polystyrene sulfonate, the patient's serum potassium level normalized and the bradyarrhythmia converted to a normal sinus rhythm. During admission, the blood and urine concentration of glyphosate and urine aminomethylphosphonic acid (AMPA, a glyphosate metabolite) was measured at regular time intervals. The patient's glyphosate blood concentration on admission was 11.48 mg/L, and it had decreased rapidly by 16 h and maintained about 1mgl/L by 70 h after admission. Urine glyphosate and AMPA levels had also decreased rapidly by 6 h after admission. Discussion Glyphosate potassium poisoning causes hyperkalemia. Blood concentrations of glyphosate were decreased rapidly by 16 h after admission, and urine concentrations were also decreased by 6 h after admission.

Background Metformin is commonly used for the treatment of type 2 diabetes mellitus. Renal insufficiency is one of the contraindications for its use. Inadvertent prescription in patients with renal insufficiency may lead to metformin-associated lactic acidosis (MALA), which is associated with a high risk of mortality. Consequently, the early recognition and management of MALA is essential. Case Report We present the case of a 68-year-old man who had reversible blindness resulting from severe lactic acidosis. On presentation, he was alert, oriented, and had no complaints except mild abdominal discomfort and blindness. He denied any history of trauma or drug abuse. The results of the laboratory studies showed severe metabolic acidosis with a high anion gap and increased levels of serum creatinine. There were no predisposing ocular or neurologic lesions that could have induced the blindness. Although the blood levels of methanol, ethanol, and metformin were not estimated, correction of acidosis and hemodialysis led to a complete recovery. Why Should an Emergency Physician Be Aware of This? Rarely, transient blindness may occur in patients with fatal severe metabolic acidosis. Evaluation for the presence of metabolic acidosis and a detailed medical history are essential in the management of acute blindness in such patients.