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Breastfeeding is known to protect against febrile seizure (FS). Whether its impact continues throughout the childhood period is still controversial. Our objective was to investigate the protective effect of breastfeeding against FS stratified by age.We included children who participated in the National Health Screening Program for Infants and Children (NHSPIC) aged between four and six months between 2008 and 2014. Feeding type was confirmed based on the NHSPIC questionnaire, and data from the Korean National Health Insurance Service were used to determine FS cases during a five-year follow-up period.Among the 1,791,335 children, the most prevalent feeding type was exclusive breastfeeding (EB) (42.3%). FS occurred most frequently in the exclusive formula feeding (EF) group (12.2%), followed by the partial breastfeeding (PB) (11.3%) and EB groups (10.7%). Compared with the EF group, the adjusted odds ratio for FS was 0.87 (95% confidence interval, 0.86 to 0.88, P 0.001) and 0.93 (0.92 to 0.94, P 0.001) in the EB and PB groups, respectively. The protective effect by age 2.5 years was significant in both the EB (0.85; 0.84 to 0.86, P 0.001) and PB (0.92; 0.90 to 0.93, P 0.001) groups. In contrast, the protective effect was not significant in the PB group and inconsistent in the EB group after 2.5 years.Breastfeeding has a protective effect against FS in the most prevalent age period, from 0 to 2.5 years. Despite the limited effect after age 2.5 years, we support the current recommendation for prolonged breastfeeding to promote childhood health.

Coronary artery bypass grafting (CABG) is an important and viable option for patients with symptomatic or life-threatening ischemic heart disease. Few papers have explored whether socioeconomic status is a significantly important determinant in late outcomes of CABG, and individual-level socioeconomic data were particularly scarce. This study was conducted to explore the impact of individual income level on clinical outcomes after CABG.This nationwide longitudinal population-based study was conducted in South Korea using the National Health Insurance Service database. Overall, 29 810 adult patients who underwent first-time isolated CABG from 2005 to 2015 were included. The individual income level was stratified into 4 quartiles (Q1-Q4). The primary outcome was overall mortality.After adjustment for preoperative comorbidities, no significant difference in the in-hospital mortality rate was observed between the lowest (income Q1 group) and highest (income Q4 group) quartiles. The risk of overall mortality increased significantly with a reduction in income level, and having an income in the lowest quartile was a significant predictor of worse late mortality compared with the highest quartile (hazard ratio, 1.23; 95% CI, 1.17-1.30). Moreover, the overall incidence of stroke and myocardial infarction was significantly higher in the income Q1 group than in the income Q4 group. The median follow-up duration was 7.0 years (interquartile range, 4.1-10.2 years).Patients with a lower individual income level had an increased risk of the poorer long-term outcomes after CABG compared with the highest individual income level quartile.

Arterial blood gas analysis (ABGA) is one of the few tests performed during cardiopulmonary resuscitation (CPR). There have been some studies on the prediction of survival outcomes in adult out-of-hospital cardiac arrest (OHCA) patients during CPR using ABGA results. However, in pediatric OHCA patients, the prognosis of survival outcome based on ABGA results during CPR remains unclear. We retrospectively analyzed prospectively collected data from the Korean Cardiac Arrest Resuscitation Consortium (KoCARC) registry, a multicenter OHCA registry of Republic of Korea. We analyzed 108 pediatric (age < 19 years) OHCA patients between October 2015 and June 2022. Using multivariable logistic regression, an adjusted odds ratio (aOR) was obtained to validate the ABGA results of survival to hospital admission and survival to discharge. The variables associated with survival to hospital admission were non-comorbidities (aOR 3.03, 95% confidence interval (CI) 1.22–7.53, p = 0.017) and PaO2 > 45.750 mmHg (aOR 2.69, 95% CI 1.13–6.42, p = 0.026). There was no variable that was statistically significant association with survival to discharge. PaO2 > 47.750 mmHg and non-comorbidities may serve as an independent prognostic factor for survival to hospital admission in pediatric OHCA patients. However, the number of cases analyzed in our study was relatively small, and there have been few studies investigating the association between ABGA results during CPR and the survival outcome of pediatric OHCA patients. Therefore, further large-scale studies are needed.

Background and objective The benefits of green spaces are starting to be recognized, particularly after the emergence of COVID-19. However, only well-managed green spaces deliver positive benefits. To maintain green spaces, various assessment tools have been developed. The Green Flag Award (GFA), which is the UK’s national audit tool, is focused on the structure and criteria of green spaces assessment. However, we do not know about the changes that drive our understandings of well-managed green spaces, impacts of the GFA, or changes in other assessment tools. Therefore, the aim of this study is to understand the changes that drive the development of green space assessment tools, with a focus on the GFA, to deliver a framework for the long-term management of these spaces. Methods This study employed the Protocol and Reporting result with Search, Appraisal, Synthesis, and Analysis (PSALSAR) and Develop frameworks, as well as the assessment-focused place-keeping analytical framework. The PSALSAR framework was used to ensure accuracy, systematisation, exhaustiveness, and reproducibility. The assessment-focused place-keeping analytical framework was employed to understand the contribution of green space assessment tools in the long-term management of these spaces. Results First, well-managed green spaces (GS) were positively associated with quality of life, which is a widely known fact. However, the approach to managing GS in the long term is a key issue. Second, the GFA had great impacts on the ability to manage GS well by providing developed domains and reflecting contemporary GS issues. Third, drivers of GS assessment tools include the persistence and importance of conventional maintenance, emphasis on accessibility by expanding practical boundaries, the inevitability of enhancing community involvement, and diversity of involvement in the judging process. Lastly, assessment-focused, place-keeping analytical frameworks imply that approaches to long-term management should be contextualised based on policy, funding, governance, partnership, and maintenance. Conclusion Understanding changes that drive GS assessment and its association with GS management should be prioritised. This study concludes that approaches to GS assessment should be framed in the context of long-term management, underscored by understanding contemporary GS issues.

BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a major public health problem and a leading cause of death worldwide. Despite studies suggesting an association between socioeconomic status (SES) and the outcomes of OHCA survivors, the majority of such investigations have only focused on short-term outcomes. Therefore, the effect of SES on the long-term outcomes of OHCA survivors is unknown. OBJECTIVE The purpose of this study was to identify whether SES influenced the long-term outcomes of survivors after OHCA. METHODS Using health claims data obtained from the National Health Insurance (NHI) service in Korea, we included OHCA survivors who were hospitalized between January 2005 and December 2015 and survived for at least 30 days. The patients were divided into two groups, NHI and Medical Aid (MA) groups, with the MA group defined as having a low SES. Cumulative mortality was estimated using the Kaplan‒Meier method, and a Cox proportional hazards model was used to evaluate the impact of SES on long-term mortality. A subgroup analysis was performed based on whether cardiac procedures were performed. RESULTS We followed 4,933 OHCA survivors for up to 14 years (median of 3.3 years). The Kaplan‒Meier survival curve showed that the MA group had a significantly decreased long-term survival rate compared with the NHI group. With an adjusted hazard ratio (aHR) of 1.51 (95% confidence interval [CI] 1.34-1.71), low SES was associated with increased long-term mortality. The overall mortality rate of the patients who underwent cardiac procedures in the MA group was significantly higher than that of the NHI group (aHR 1.75, 95% CI 1.07-2.86). The overall mortality rate of patients without cardiac procedures was also increased in the MA group compared to the NHI group (aHR 1.38, 95% CI 1.22-1.57). CONCLUSIONS OHCA survivors with low SES had an increased risk of poor long-term outcomes compared with those with higher SES. OHCA survivors with low SES who have undergone cardiac procedures need considerable care for long-term survival.

Breaking of disposable blades during emergency endotracheal intubation has been reported. Breakage can cause serious injury and foreign body ingestion. We aimed to measure and analyze the strength characteristics of different disposable videolaryngoscope blades with the application of an upward-lifting force. We measured the strength of four disposable videolaryngoscope blades (C-Mac® S Video laryngoscope MAC #3, Glidescope GVL® 3 stat, Pentax AWS® PBlade TL type, and King Vision® aBlade #3) using the fracture test. The strength of 12 samples of each type of disposable videolaryngoscope blade was measured using an Instron 5,966 tensile tester by applying an upward-lifting force. After the fracture test using C-Mac, Glidescope GVL, Pentax AWS, and King Vision, the number of deformed blades were 0, 12, 3, and 7, respectively, and the number of broken blades were 12, 0, 9, and 5, respectively. The mean (standard deviation) maximum force strengths of Pentax AWS, C-Mac, King Vision, and Glidescope GVL blades were 408.4 (27.4) N, 325.8 (26.5) N, 291.8 (39.3) N, and 262.7 (3.8) N, respectively (P < 0.001). Clinicians should be aware of the varied strength characteristics of the four types of disposable videolaryngoscope blades when they are used in endotracheal intubation.

Background: Delayed neuropsychiatric sequelae (DNS) are a severe complication of carbon monoxide (CO) poisoning, and predicting DNS is difficult. This study aimed to investigate whether cardiac markers can be used as biomarkers to predict DNS occurrence following acute CO poisoning. Methods: This was a retrospective observational study that included patients with acute CO poisoning who visited two emergency medical centers in Korea from January 2008 to December 2020. The primary outcome was whether the occurrence of DNS was associated with laboratory results. Results: Of the 1327 patients with CO poisoning, 967 patients were included. Troponin I and BNP were significantly higher in the DNS group. As a result of multivariate logistic regression analysis, it was found that troponin I, mentality, creatine kinase, brain natriuretic peptide, and lactate levels independently influenced DNS occurrence in CO poisoning patients. The adjusted odds ratios for DNS occurrence were 2.12 (95% CI 1.31–3.47, p = 0.002) for troponin I and 2.80 (95% CI 1.81–3.47, p < 0.001) for BNP. Conclusion: Troponin I and BNP might be useful biomarkers for predicting the occurrence of DNS in patients with acute CO poisoning. This finding can help to identify high-risk patients who require close monitoring and early intervention to prevent DNS.

Introduction: The risk of venous thromboembolism increases after acute carbon monoxide poisoning. However, studies on the characteristics of patients who develop venous thromboembolism after carbon monoxide poisoning are rare. The aim of this study was to identify the risk factors for venous thromboembolism within 3 months after carbon monoxide poisoning. Methods: This is a population-based study that employed nationwide claims data from South Korea. Among the carbon monoxide poisoning patients (⩾18 years), the characteristics of the groups with and without venous thromboembolism (pulmonary embolism or deep vein thrombosis) were identified. All the significant variables in the univariable analysis were included in the multivariable logistic regression to determine the risk factors for venous thromboembolism occurrence. Results: Among the 24,232 carbon monoxide poisoning patients, 130 subjects developed venous thromboembolism within 90 days of their carbon monoxide poisoning diagnosis. The significant risk factors for venous thromboembolism in the multivariable analysis were age (adjusted odds ratio (aOR) = 1.01; 95% confidence interval (CI) = 1.003–1.03), intensive care unit admission (aOR = 3.80; 95% CI = 2.34–6.12), length of stay (aOR = 1.02; 95% CI = 1.0001–1.04), congestive heart failure (aOR = 2.17; 95% CI = 1.36–3.42), and cancer (aOR = 1.94; 95% CI = 1.10–3.22). The adjusted odds ratios for intensive care unit admission for patients with pulmonary embolism and deep vein thrombosis were 3.05 (95% CI = 1.61–5.61) and 5.60 (95% CI = 2.89–10.90), respectively. Conclusion: Patients with older age, intensive care unit admission, a longer length of stay, congestive heart failure, or cancer are at greater risk of developing venous thromboembolism after carbon monoxide poisoning. In particular, intensive care unit admission was the strongest risk factor for venous thromboembolism, pulmonary embolism, and deep vein thrombosis. Monitoring and administering prophylactic treatments to prevent venous thromboembolism would be helpful in high-risk in carbon monoxide poisoning patients.

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.

The rapid antigen test (RAT) has been adopted as a screening tool for SARS-CoV-2 infection in many emergency departments (EDs). We aimed to investigate the diagnostic value of the accuracy of the SARS-CoV-2 RAT as a screening tool in the ED. This retrospective observational study included patients who underwent both RAT and RT–PCR and visited the ED from 1 December 2021 to 15 March 2022. RAT and RT–PCR were performed by appropriately trained physicians. We performed detailed analyses using the E gene cyclic threshold (Ct) values of RT–PCR. Out of a total of 1875 patients, 348 (18.6%) had positive and 1527 (81.4%) had negative RT–PCR results. The overall sensitivity, specificity, positive predictive value, and negative predictive value of the RAT were 67.8%, 99.9%, 99.6%, and 93.2%, respectively. The E gene Ct value was significantly lower in the RAT-positive patients than in the RAT-negative patients (18.5 vs. 25.3, p < 0.001). When the E gene Ct cutoff was 30.0, 25.0, 20.0, and 15.0, the sensitivity of the RAT was 71.9%, 80.3%, 93.0%, and 97.8%, respectively. The sensitivity of the RAT could be considered high in patients with a high viral load, and the RAT could be used as a screening tool in the ED.

ImportanceThe recent American Heart Association guidelines added a sixth link in the chain of survival highlighting recovery and emphasized the importance of psychiatric outcome and recovery for survivors of out-of-hospital cardiac arrest (OHCA). The prevalence of psychiatric disorders among this population was higher than that in the general population.ObjectiveTo examine the prevalence of depression or anxiety and the association of these conditions with long-term mortality among individuals who survive OHCA.Design, Setting, and ParticipantsA longitudinal population-based cohort study was conducted to analyze long-term prognosis in patients hospitalized for OHCA between January 1, 2005, and December 31, 2015, who survived for 1 year or longer. Patients with cardiac arrest due to traumatic or nonmedical causes, such as injuries, poisoning, asphyxiation, burns, or anaphylaxis, were excluded. Data were extracted on depression or anxiety diagnoses in this population within 1 year from the database of the Korean National Health Insurance Service and analyzed April 7, 2022, and reanalyzed January 19 to 20, 2023.Main Outcomes and MeasuresFollow-up data were obtained for up to 14 years, and the primary outcome was long-term cumulative mortality. Long-term mortality among patients with and without a diagnosis of depression or anxiety were evaluated.ResultsThe analysis included 2373 patients; 1860 (78.4%) were male, and the median age was 53.0 (IQR, 44.0-62.0) years . A total of 397 (16.7%) patients were diagnosed with depression or anxiety, 251 (10.6%) were diagnosed with depression, and 227 (9.6%) were diagnosed with anxiety. The incidence of long-term mortality was significantly higher in the group diagnosed with depression or anxiety than in the group without depression or anxiety (141 of 397 [35.5%] vs 534 of 1976 [27.0%]; P = .001). With multivariate Cox proportional hazards regression analysis, the adjusted hazard ratio of long-term mortality for total patients with depression or anxiety was 1.41 (95% CI, 1.17-1.70); depression, 1.44 (95% CI, 1.16-1.79); and anxiety, 1.20 (95% CI, 0.94-1.53).Conclusions and RelevanceIn this study, among the patients who experienced OHCA, those diagnosed with depression or anxiety had higher long-term mortality rates than those without depression or anxiety. These findings suggest that psychological and neurologic rehabilitation intervention for survivors of OHCA may be needed to improve long-term survival.

Purpose: This study aimed to investigate the association between total serum cholesterol levels and outcomes upon discharge in patients after out-of-hospital cardiac arrest (OHCA). Methods: We performed a retrospective observational study using the Korean Cardiac Arrest Resuscitation Consortium (KoCARC) registry. Patients after OHCA whose total serum cholesterol levels were measured within 24 h after arriving at the emergency department were included in the analysis. The association between total serum cholesterol level and neurological outcomes upon discharge and survival to discharge was estimated. Results: Of the 12,321 patients after OHCA enrolled in the registry from October 2015 to June 2020, 689 patients were included. The poor neurologic outcome upon discharge group had a statistically significant lower total serum cholesterol level compared to the good neurologic outcome group (127.5 ± 45.1 mg/dL vs. 155.1 ± 48.9 mg/dL, p < 0.001). As a result of multivariate logistic regression analysis, the odds ratio for the neurologic outcome of total serum cholesterol levels was 2.00 (95% confidence interval [CI] 1.01–3.96, p = 0.045). The odds ratio for in-hospital death was 1.72 (95% CI 1.15–2.57, p = 0.009). Conclusions: Low total serum cholesterol levels could be associated with poor neurologic outcomes upon discharge and in-hospital death of patients hospitalized after OHCA.

Hospital environments are associated with a high risk of infection. As plasma-treated hydrogen peroxide mist disinfection has a higher disinfection efficacy, we tested the efficacy of plasma-treated hydrogen peroxide mist disinfection on several surfaces in various hospital environments. Disinfection was performed in 23 rooms across different hospital environments, including hospital wards, outpatient departments (OPDs), and emergency rooms. A total of 459 surfaces were swabbed before/after disinfection. Surfaces were also divided into plastic, metal, wood, leather, ceramic, silicone, and glass for further analyses. Only gram-positive bacteria were statistically analyzed because the number of gram-negative bacteria and mold was insufficient. Most colony-forming units (CFUs) of gram-positive bacteria were observed in OPDs and on leather materials before disinfection. The proportion of surfaces that showed a percentage decrease in CFU values of more than 90% after disinfection were as follows: OPDs (85%), hospital wards (99%), and emergency rooms (100%), plastic (97%), metal (83%), wood (84%), leather (81%), and others (87%). Plasma-treated hydrogen peroxide mist disinfection resulted in a significant decrease in the CFU values of gram-positive bacteria in various environments. Plasma-treated hydrogen peroxide mist disinfection is an effective and efficient method of disinfecting various hospital environments.

Background: The coronavirus disease 2019 (COVID-19) pandemic has caused deaths and shortages in medical resources worldwide, making the prediction of patient prognosis and the identification of risk factors very important. Increasing age is already known as one of the main risk factors for poor outcomes, but the effect of body mass index (BMI) on COVID-19 outcomes in older patients has not yet been investigated. Aim: We aimed to determine the effect of BMI on the severity and mortality of COVID-19 among older patients in South Korea. Methods: Data from 1272 COVID-19 patients (≥60 years old) were collected by the Korea Centers for Disease Control and Prevention. The odds ratios (ORs) of severe infection and death in the BMI groups were analyzed by logistic regression adjusted for covariates. Results: The underweight group (BMI

Background The purpose of this study was to identify the risk factors and causes of short-term mortality after emergency department (ED) discharge in older patients. Methods This population-based cohort study used nationwide health insurance claims data in Korea from 2008 to 2014. The causes of death and diagnoses of patients who died within 1 week after discharge from EDs (1-week ED death) were obtained. The risk factors for 1-week ED death were calculated using Cox proportional hazard regression analyses. Results The rate of 1-week ED death was 0.5% among 133,251 individuals aged ≥65 years discharged from EDs. In multivariate analysis, the top five ED discharge diagnoses associated with an increased risk of 1-week ED death were hypotension and vascular disease (adjusted hazard ratio [aHR]=5.11; 95% confidence interval [CI], 3.03–8.63), neoplasm (aHR=4.89; 95% CI, 3.77–6.35), coronary artery disease (aHR=3.83; 95% CI, 2.73–5.39), dyspnea (aHR=3.41; 95% CI, 2.48–4.68), and respiratory disease (aHR=2.25; 95% CI, 1.73–2.92). The most common causes of 1-week ED death were neoplasm (14.8%), senility (13.8%), and cerebrovascular disease (11.7%). Conclusion Neoplasm, coronary artery disease, and respiratory disease were the discharge diagnoses associated with an increased risk of short-term mortality after ED discharge. Neoplasm was the leading cause of short-term mortality after ED discharge in older patients.

Objectives To evaluate the separate and combined associations of socioeconomic status (SES) and depression with the incidences of acute myocardial infarction (AMI) and stroke. Methods We conducted a population-based cohort study using nationwide health insurance claims data collected from 2002 to 2016 in South Korea. A total of 2,705,090 subjects aged 20 years or older for whom had health screening data were collected between 2004 and 2005 were analyzed. The hazard ratios (HRs) for the incidences of AMI and stroke were calculated using Cox proportional regression analyses. Results After adjusting for cardiovascular risk factors, a low SES was associated with increased risks of AMI (HR, 1.16; 95% confidence interval (CI), 1.14–1.19) and stroke (HR, 1.13; 95% CI, 1.11–1.14) incidence. Depression was also associated with an increased incidence of AMI (HR, 1.26; 95% CI, 1.21–1.31) and stroke (HR, 1.24; 95% CI, 1.21–1.27). Patients with depression who had a low SES exhibited significantly increased risks of AMI (HR, 1.47; 95% CI, 1.36–1.60) and stroke (HR, 1.37; 95% CI, 1.30–1.44) compared to patients with a high SES who were not diagnosed with depression. Depression showed a positive effect modification of low and medium SES compared to high SES on the association with AMI but not with stroke. Conclusions Subjects with both a low SES and depression displayed the highest risk. Both SES and depression should be considered in cardiovascular risk assessments, particularly in individuals with depression who have a low SES.

Recent studies utilizing deep convolutional neural networks (CNN) have described the central venous catheter (CVC) on chest radiography images. However, there have been no studies for the classification of the CVC tip position with a definite criterion on the chest radiograph. This study aimed to develop an algorithm for the automatic classification of proper depth with the application of automatic segmentation of the trachea and the CVC on chest radiographs using a deep CNN. This was a retrospective study that used plain chest supine anteroposterior radiographs. The trachea and CVC were segmented on images and three labels (shallow, proper, and deep position) were assigned based on the vertical distance between the tracheal carina and CVC tip. We used a two-stage approach model for the automatic segmentation of the trachea and CVC with U-net++ and automatic classification of CVC placement with EfficientNet B4. The primary outcome was a successful three-label classification through five-fold validations with segmented images and a test with segmentation-free images. Of a total of 808 images, 207 images were manually segmented and the overall accuracy of the five-fold validation for the classification of three-class labels (mean (SD)) of five-fold validation was 0.76 (0.03). In the test for classification with 601 segmentation-free images, the average accuracy, precision, recall, and F1-score were 0.82, 0.73, 0.73, and 0.73, respectively. We achieved the highest accuracy value of 0.91 in the shallow position label, while the highest F1-score was 0.82 in the deep position label. A deep CNN can achieve a comparative performance in the classification of the CVC position based on the distance from the carina to the CVC tip as well as automatic segmentation of the trachea and CVC on plain chest radiographs.

The purpose of this study was to evaluate the diagnostic performance achieved by using fully-connected small artificial neural networks (ANNs) and a simple training process, the Kim-Monte Carlo algorithm, to detect the location of pneumothorax in chest X-rays. A total of 1,000 chest X-ray images with pneumothorax were taken randomly from NIH (the National Institutes of Health) public image database and used as the training and test sets. Each X-ray image with pneumothorax was divided into 49 boxes for pneumothorax localization. For each of the boxes in the chest X-ray images contained in the test set, the area under the receiver operating characteristic (ROC) curve (AUC) was 0.882, and the sensitivity and specificity were 80.6% and 83.0%, respectively. In addition, a common currently used deep-learning method for image recognition, the convolution neural network (CNN), was also applied to the same dataset for comparison purposes. The performance of the fully-connected small ANN was better than that of the CNN. Regarding the diagnostic performances of the CNN with different activation functions, the CNN with a sigmoid activation function for fully-connected hidden nodes was better than the CNN with the rectified linear unit (RELU) activation function. This study showed that our approach can accurately detect the location of pneumothorax in chest X-rays, significantly reduce the time delay incurred when diagnosing urgent diseases such as pneumothorax, and increase the effectiveness of clinical practice and patient care.

Objectives Neuron-specific enolase (NSE) is frequently used to predict neurological outcomes in patients with hypoxic brain injury. Hanging can cause hypoxic brain damage, and survivors can suffer from neurological deficits that may impair daily activities. Here, we investigated the utility of the initial serum NSE level as a predictor of neurological outcomes in near-hanging patients with decreased consciousness. Methods This retrospective multicenter study was conducted in patients who visited the emergency department due to near-hanging injury from October 2013 to February 2019 at three university hospitals in Korea. They were divided into two groups according to the presence of out-of-hospital cardiac arrest. The neurological outcome was determined using the Cerebral Performance Category (CPC) measured at the time of discharge. Multivariate analysis was performed to determine whether initial serum NSE is an independent predictor of neurological outcome. Results Of the 70 patients included in the study, 44 showed a poor neurological outcome (CPC score = 3–5). Among the 52 patients with cardiac arrest, only 10 (19.2%) were discharged with good neurological outcome (CPC score = 1–2). In the whole cohort, a high serum NSE level was a significant predictor of poor neurological outcome (odds ratio [OR], 1.343; 95% confidence interval [CI], 1.003–1.800, p = 0.048). Among the patients with cardiac arrest, a high serum NSE level was a significant predictor of poor neurological outcome (OR, 1.138; 95% CI, 1.009–1.284, p = 0.036). Conclusions In near-hanging patients, a high initial serum NSE level is an independent predictor of poor neurological outcome.

Supplemental material, sj-pdf-1-hkj-10.1177_1024907921994426 for Risk factors for venous thromboembolism after carbon monoxide poisoning: A nationwide population-based study by Yongil Cho, Tae Ho Lim, Byuk Sung Ko, Hyunggoo Kang, Jaehoon Oh and Heekyung Lee in Hong Kong Journal of Emergency Medicine

Background/Purpose An orthogonal neural network (ONN), a new deep-learning structure for medical image localization, is developed and presented in this paper. This method is simple, efficient, and completely different from a convolution neural network (CNN). Materials and methods The diagnostic performance of ONN for detecting the location of pneumothorax in chest X-rays was assessed and compared to that of CNN. In addition, ONN and CNN were applied to predict the location of the glottis in laryngeal images. Results An area under the receiver operating characteristic (ROC) curve (AUC) of 0.870, an accuracy of 85.3%, a sensitivity of 75.0%, and a specificity of 86.5% were achieved by applying ONN to detect the location of pneumothorax in chest X-rays; the ONN outperformed the CNN. By applying ONN to predict the location of the glottis in laryngeal images, we achieved the accurate prediction rate of 70.5% and the adjacent prediction rate of 20.5%. Conclusions This study demonstrated that an ONN can be used as a quick selection criterion to compare fully-connected small artificial neural network (ANN) models for image localization. The time it took to train an ONN was about 10% of the time using a CNN on images of a given input resolution. Our approach could accurately predict locations in medical images, reduce the time delay in diagnosing urgent diseases, and increase the effectiveness of clinical practice and patient care., Highlights • The purpose of this study was to develop and present an orthogonal neural network (ONN), a new deep-learning structure for medical image localization, for the first time in this paper. This method is simple, efficient, and completely different from a convolution neural network (CNN). • The diagnostic performance of ONN for detecting the location of pneumothorax in chest X-rays was assessed and compared to that of CNN. In addition, ONN and CNN were applied to predict the location of the glottis in laryngeal images. • An AUC of 0.870, an accuracy of 85.3%, a sensitivity of 75.0%, and a specificity of 86.5% were achieved by applying ONN to detect the location of pneumothorax in chest X-rays; the ONN outperformed the CNN. By applying ONN to predict the location of the glottis in laryngeal images, we achieved the accurate prediction rate of 70.5% and the adjacent prediction rate of 20.5%. The prediction accuracy of the ONN was compared favorably with that of the CNN. • This study demonstrated that an ONN can be used as a quick selection criterion to compare fully-connected small artificial neural network (ANN) models for image localization. The time it took to train an ONN was about 10% of the time using a CNN on images of a given input resolution. Our approach could accurately predict locations in medical images, reduce the time delay in diagnosing urgent diseases, and increase the effectiveness of clinical practice and patient care.

Background Aortic dissection (AD) is one of the most catastrophic diseases and is associated with high morbidity and mortality. The aim of this study is to investigate the hospital incidence and mortality rates of thoracic AD in Korea using a nationwide database. Methods We conducted a nationwide population-based study using the health claims data of the National Health Insurance Service in Korea. From 2005 to 2016, adult patients newly diagnosed with AD were included. All patients were divided into the following four subgroups by treatment: type A surgical repair (TASR), type B surgical repair (TBSR), thoracic endovascular aortic repair (TEVAR), and medical management (MM). The incidence rate, mortality rate, and risk factors of in-hospital mortality were evaluated. Results In total, 18,565 patients were newly diagnosed with AD (TASR, n = 4,319 [23.3%]; TBSR, n = 186 [1.0%]; TEVAR, n = 697 [3.8%]; MM, n = 13,363 [72.0%]). The overall AD incidence rate was 3.76 per 100,000 person-years and exhibited a gradual increase during the study period (3.29 to 4.82, P < 0.001). The overall in-hospital mortality rate was 10.84% and remained consistent (P = 0.57). However, the in-hospital mortality rate decreased in the TASR subgroup (18.23 to 11.27%, P = 0.046). An older age, the female sex, hypertension, and chronic kidney disease were independent risk factors for in-hospital mortality. Conclusion The incidence of thoracic AD has gradually increased in Korea. The in-hospital mortality in the TASR subgroup decreased over the decade, although the overall mortality of AD patients did not change., Graphical Abstract

Objective With trends in population aging an increasing number of older patients are visiting the emergency department (ED). This study aimed to identify the characteristics of ED utilization and risk factors for in-hospital mortality in older patients who visited EDs. Methods This nationwide observational study used National Emergency Department Information System data collected during a 2-year period from January 2016 to December 2017. The characteristics of older patients aged 70 years or older were compared with those of younger patients aged 20 to 69 years. Risk factors associated with in-hospital mortality were analyzed by multivariable logistic regression. Results A total of 6,596,423 younger patients and 1,737,799 older patients were included. In the medical and nonmedical older patient groups, significantly higher proportions of patients were transferred from another hospital, utilized emergency medical services, had Korean Triage and Acuity Scale scores of 1 and 2, required hospitalization, and required intensive care unit admission in the older patient group than in the younger patient group. ED and post-hospitalization mortality rates increased with age; in particular, older medical patients aged 90 or older had an in-hospital mortality rate of 9%. Older age, male sex, transfer from another hospital, emergency medical service utilization, a high Korean Triage and Acuity Scale score, systolic blood pressure 20/min, heart rate >100/min, body temperature

A novel deep-learning algorithm for artificial neural networks (ANNs) was developed and presented in this paper, which is intuitively understandable, simple, efficient, and completely different from the back-propagation method, i.e., randomly selecting weight factors and bias values of an ANN and adjusting their values by small random amounts during the training session where it does not need to calculate the gradients of the training error to adjust weight factors as does the back-propagation method. The algorithm was applied to predict the location of the glottis in airway images obtained using a video airway device. The glottic locations were marked in 1,200 airway images captured using GlideScope® and fiberoptic laryngoscopy. With the randomly selected 1,000 training set data, 84 ANN models were trained using the above algorithm. We sought an ANN model that minimized the average training error for all training set data by reducing the input image resolution. As the resolution was reduced, the average training error decreased to its lowest level at 30×30 pixels. Eventually, the 900-98-49 ANN model was selected as the prediction model for the location of the glottis; it was the model with the lowest training error, i.e., the highest learning rate. The selected prediction model was applied to the remaining 200 test set data to obtain the test accuracy, and we obtained that the accurate prediction and the adjacent prediction rates were 74.5% and 21.5%, respectively. Reducing the input image resolution to an appropriate level could yield better prediction of the glottic location in airway images. This ANN model can help clinicians perform intubation by presenting the predicted location of the glottis.

Background This study is aimed to identify the muscles that need to be trained for high-quality cardiopulmonary resuscitation by evaluating the muscles that are fatigued during chest compression in both kneeling and standing positions. Methods In this randomized crossover trial, 37 participants performed continuous chest compressions on a manikin for 5 min, alternating between kneeling and standing positions. The median frequency values of 16 muscles were determined from surface electromyography recordings. Results The median frequency values of the arm muscles (flexor carpi radialis, extensor carpi radialis, biceps brachii, triceps brachii) in both positions were significantly lower during the last 30 s than during the first 30 s, demonstrating muscle fatigue over time. The cervical erector spinae in the kneeling position and the external oblique abdominis in the standing position were also fatigued over time. In the deltoideus, quadriceps femoris, and biceps femoris muscles, the difference in median frequency between the last 30 s and the first 30 s was significantly different between the two positions, and muscles were more fatigued in the standing position than in the kneeling position. Conclusions Understanding patterns of muscle fatigue and training of these muscles would assist healthcare providers in performing high-quality chest compressions. ClinicalTrials.gov number: NCT02088879 .

Background This study aimed to investigate the relationship between body mass index ( BMI ) and sufficient chest compression depth (CCD) in obese patients by a mathematical model. Methods and Results This retrospective analysis was performed with chest computed tomography images conducted between 2006 and 2018. We classified the selected individuals into underweight (BMI (kg/m 2 ). We defined heart compression fraction ( HCF ) as and estimated under‐ HCF (the value of HCF HCF (the residual depth BMI groups. Of 30 342 individuals, 8856 were selected and classified into 4 BMI groups from a database. We randomly selected 100 individuals in each group and analyzed a total of 400 individuals’ cases. Higher BMI groups had a significantly decreased HCF with both 5 and 6 cm depth ( P HCF with both depths increased according to BMI group, whereas the proportion of over‐ HCF decreased except for the 5 cm depth ( P HCF , according to BMI group after adjustment of age and sex, was 7.325 (95% CI , 3.412–15.726; P CI , 2.353–47.001; P =0.002) with 6 cm depth, respectively. Conclusions The recommended chest compression depth of 5 to 6 cm in the current international guideline is unlikely to provide sufficient ejection fraction during cardiopulmonary resuscitation in obese patients.