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Background: The demand for organ transplants, both globally and in South Korea, substantially exceeds the supply, a situation that might have been aggravated by the enactment of the Life-Sustaining Treatment Decision Act (LSTDA) in February 2018. This legislation may influence emergency medical procedures and the availability of organs from brain-dead donors. This study aimed to assess LSTDA's impact, introduced in February 2018, on organ donation status in out-of-hospital cardiac arrest (OHCA) patients in a metropolitan city and identified related factors., Methods: We conducted a retrospective analysis of a regional cardiac arrest registry. This study included patients aged 16 or older with cardiac arrest and a cerebral performance category (CPC) score of 5 from January 2015 to December 2022. The exclusion criteria were CPC scores of 1-4, patients under 16 years, and patients declared dead or transferred from emergency departments. Logistic regression analysis was used to analyse factors affecting organ donation., Results: Of the 751 patients included in this study, 47 were organ donors, with a median age of 47 years. Before the LSTDA, there were 30 organ donations, which declined to 17 after its implementation. In the organ donation group, the causes of cardiac arrest included medical (34%), hanging (46.8%), and trauma (19.2%). The adjusted odds ratio for organ donation before the LSTDA implementation was 6.12 (95% CI 3.09-12.12), with non-medical aetiology as associated factors., Conclusion: The enactment of the LSTDA in 2018 in South Korea may be linked to reduced organ donations among patients with OHCA, underscoring the need to re-evaluate the medical and legal aspects of organ donation, especially considering end-of-life care decisions., (© 2024. The Author(s).)

Background: Fatigue and rotation time are key factors affecting the quality of cardiopulmonary resuscitation (CPR). This study aimed to investigate the effects of rotation time on CPR duration, and sex on chest compression quality., Methods: In this randomized crossover simulation study, we enrolled 100 paramedic students stratified by sex and randomly grouped into 28 male and 22 female pairs. In the 2- and 1-minute scenarios, 2 participants performed CPR for 20 minutes with a rotation cycle of 2 minutes and 1 minute, respectively. After taking a break, they changed over and performed CPR again for 20 minutes. The switching of roles was performed with the students positioned on opposite sides of the mannequin. For chest compression quality, a set was defined as CPR performed by 1 pair in a 2-minute scenario for 4 minutes. The quality of CPR in each set was compared between the 2 groups., Results: The 1-minute group showed significantly higher chest compression depth than the 2-minute group (54.0 [51.5-57.0] vs 52.5 [48.5-56.5] mm, P = .001, respectively). The female 2-minute group showed decreased chest compression depth over time, and the 1-minute group showed significantly increased chest compression depth during all sets except the 2nd set (54.0 [51.9-55.1] vs 50.5 [48.5-53.8] mm [P = .030], 52.3 [49.4-54.5] vs 50.8 [47.0-53.1] mm [P = .080], 52.8 [49.8-54.5] vs 48.8 [45.4-51.6] mm [P = .002], 51.5 [48.5-53.3] vs 48.3 [44.5-50.6] mm [P = .004], and 50.8 [48.9-54.1] vs 47.5 [44.6-50.1] mm [P = .001], respectively). The fatigue scores in the 2-minute group were significantly higher during sets 4 and 5 than those in the 1-minute group., Conclusion: When rescuer fatigue increases during prolonged CPR owing to their physical strength and skill levels, the rotation of rescuers every minute would be helpful in maintaining high-quality CPR., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: Since tobacco contains numerous harmful substances, besides nicotine, which is addictive, smoking cessation products and tobacco alternatives, such as electronic (e-) cigarettes, nicotine chewing gums, and patches, are being widely used. Nicotine gums are consumed orally. The nicotine from the gum is absorbed at a slower rate than that from e-cigarettes, and the former remains in the bloodstream for a longer period. In addition, the maximum number of daily doses is high, and it can be purchased without a doctor's prescription in many countries., Patient Concerns: A 29-year-old male patient consumed 5 2-mg nicotine gums at a time, twice a day, for 4 days (total amount: 70 mg). However, he visited the emergency unit with the chief complaint of involuntary limb movements after consuming an additional 15 gums 3 hour before the visit. At admission, his consciousness was clear, although 2 hour later, he experienced sudden loss of consciousness with worsening hypoxia and respiratory acidosis., Diagnosis: The patient's vital signs were stable at the time of admission, and blood test results showed no specific findings other than a white blood cell count of 14,800/µL, lactate level of 6.4 mmol/L, and prolactin level of 119.02 ng/mL. In addition, chest radiography and head computed tomography scans showed no acute phase abnormalities. Two hours later, he experienced loss of consciousness and respiratory failure, and the results of blood tests performed at this time showed that his blood cotinine level was 3491 ng/mL., Interventions: Supportive treatment, including endotracheal intubation followed by mechanical ventilation, was provided., Outcome: The patient's vital signs stabilized 3 days after treatment, and his consciousness and respiratory status had improved; therefore, mechanical ventilation was stopped. His condition was stable for the next 2 days, and he was discharged on the fifth day., Lessons: Acute respiratory exacerbation due to nicotine poisoning (from levels exceeding the lethal dose of 30-60 mg) was observed, although the gums were consumed over several days. Patients with nicotine poisoning may show acute respiratory failure and should be monitored carefully. Further studies are required to determine the toxic effects of nicotine replacement therapies., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Emergency departments (EDs) are on the frontline of the coronavirus disease (COVID-19) outbreak. To resolve the abrupt overloading of COVID-19-suspected patients in a community, each ED needs to respond in various ways. In our hospital, we increased the isolation beds through temporary remodeling and by performing in-hospital COVID-19 polymerase chain reaction testing rather than outsourcing them. The aim of this study was to verify the effects of our response to the newly developed viral outbreak.The medical records of patients who presented to an ED were analyzed retrospectively. We divided the study period into 3: pre-COVID-19, transition period of response (the period before fully implementing the response measures), and post-response (the period after complete response). We compared the parameters of the National Emergency Department Information System and information about isolation and COVID-19.The number of daily ED patients was 86.8 ± 15.4 in the pre-COVID-19, 36.3 ± 13.6 in the transition period, and 67.2 ± 10.0 in the post-response period (P < .001). The lengths of stay in the ED were significantly higher in transition period than in the other periods [pre-COVID-19 period, 219.0 (121.0-378.0) min; transition period, 301 (150.0-766.5) min; post-response period, 281.0 (114.0-575.0) min; P < .001]. The ratios of use of an isolation room and fever (≥37.5°C) were highest in the post-response period [use of isolation room: pre-COVID-19 period, 0.6 (0.7%); transition period, 1.2 (3.3%); post-response period, 16.1 (24.0%); P < .001; fever: pre-COVID-19 period, 14.8(17.3%); transition period, 6.8 (19.1%); post-response period, 14.5 (21.9%), P < .001].During an outbreak of a novel infectious disease, increasing the number of isolation rooms in the ED and applying a rapid confirmation test would enable the accommodation of more suspected patients, which could help reduce the risk posed to the community and thus prevent strain on the local emergency medical system., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: High-quality cardiopulmonary resuscitation with chest compression is important for good neurologic outcomes during out-of-hospital cardiac arrest (OHCA). Several types of mechanical chest compression devices have recently been implemented in Korean emergency medical services. This study aimed to identify the effect of prehospital mechanical chest compression device use on the outcomes of OHCA patients., Methods: We retrospectively analyzed data drawn from the regional cardiac arrest registry in Daegu, Korea. This registry prospectively collected data from January 2017 to December 2020. Patients aged 18 years or older who experienced cardiac arrest presumed to have a medical etiology were included. The exposure variable was the use of a prehospital mechanical device during transportation by emergency medical technicians. The outcomes measured were neurologic outcomes and survival to discharge. Logistic regression analysis was used., Results: Among 3,230 OHCA patients, 1,111 (34.4%) and 2,119 (65.6%) were managed with manual chest compression and with a mechanical chest compression device, respectively. The mechanical chest compression group showed poorer neurologic outcomes than the manual chest compression group (adjusted odds ratio, 0.12; 95% confidence interval, 0.04-0.33) and decreased survival to discharge (adjusted odds ratio, 0.39; 95% confidence interval, 0.19-0.82) after adjustment for confounding variables., Conclusion: Prehospital mechanical chest compression device use in OHCA was associated with poorer neurologic outcomes and survival to discharge compared to manual chest compression.

Backgruound: To prepare for future work stoppages in the medical industry, this study aimed to identify the effects of healthcare worker strikes on the mortality rate of patients visiting the emergency department (ED) at six training hospitals in Daegu, Korea., Methods: We used a retrospective, cross-sectional, multicenter design to analyze the medical records of patients who visited six training hospitals in Daegu (August 21-September 8, 2020). For comparison, control period 1 was set as the same period in the previous year (August 21-September 8, 2019) and control period 2 was set as July 1-19, 2020. Patient characteristics including age, sex, and time of ED visit were investigated along with mode of arrival, length of ED stay, and in-hospital mortality. The experimental and control groups were compared using t-tests, and Mann-Whitney U-test, chi-square test, and Fisher exact tests, as appropriate. Univariate logistic regression was performed to identify significant factors, followed by multivariate logistic regression analysis., Results: During the study period, 31,357 patients visited the ED, of which 7,749 belonged to the experimental group. Control periods 1 and 2 included 13,100 and 10,243 patients, respectively. No significant in-hospital mortality differences were found between study periods; however, the results showed statistically significant differences in the length of ED stay., Conclusion: The ED resident strike did not influence the mortality rate of patients who visited the EDs of six training hospitals in Daegu. Furthermore, the number of patients admitted and the length of ED stay decreased during the strike period.

Zoletil® (ZOL) is a combination drug of tiletamine, a dissociative anesthetic and zolazepam, a minor tranquilize, which has been used to induce short-term anesthesia in various animals. Depending on the administered dose, the effects of ZOL can range from sedation to anesthesia. Here, we aimed to determine the neurotoxicity of ZOL and elucidate its mechanism of action using BV-2 microglial cells. The results of MTT reduction assay and TUNEL staining revealed that ZOL induced neuronal toxicity and apoptosis in BV-2 cells. ZOL caused apoptosis via phosphorylation of c-Jun N-terminal kinase, increased ratio of Bax to Bcl-2, disruption of mitochondrial membrane potential, activation of caspase-3, and cleavage of poly (ADP-ribose) polymerase. Furthermore, reactive oxygen species were involved in ZOL-induced neuronal cell death as assessed by 2',7'-dichlorofluorescein diacetate staining. Moreover, BV-2 cells treated with ZOL exhibited increased expression of inflammatory enzymes, such as inducible nitric oxide synthase and cyclooxygenase-2, along with subsequent production of nitric oxide and prostaglandin E 2 . ZOL upregulated the expression of interleukin-1β, a proinflammatory cytokine. With respect to its molecular mechanism, ZOL increased the nuclear translocation and DNA binding of redox-sensitive transcription factor NF-κB, which seemed to be mediated by activation of extracellular signal-regulated kinase and p38 mitogen-activated protein kinase. These findings suggest that ZOL leads to apoptosis in BV-2 cells by inducing oxidative stress and inflammatory responses., (© The Author(s) 2022. Published by Oxford University Press.)

Background and Objectives : Frontline medical staff usually experience high levels of stress, which could greatly impact their work output. We conducted a survey to investigate the level of stress and its association with job types, work departments, and medical centers among COVID-19 pandemic frontline medical personnel. Materials and Methods : We conducted a cross-sectional survey using a self-administered questionnaire among 307 frontline medical staff who cared for COVID-19 patients in Daegu city. We used a 33-item questionnaire to assess respondents' general characteristics, job stress, personal effects associated with the COVID-19 pandemic, and their stress level. A general health questionnaire-12 (GHQ-12) was included in our questionnaire. Results : Majority (74.3%) of the respondents were in the stress group. The mean GHQ-12 score was 14.31 ± 4.96. More females (67.4%, p < 0.05) and nurses (73.3%, p = 0.001) were in the stress group compared to males and doctors. Medical staff in the general ward considered the severity of the COVID-19 pandemic situation higher. Nurses perceived work changes ( p < 0.05), work burden ( p < 0.05), and personal impact ( p < 0.05) more serious than doctors. Medical staff in Level 3 emergency department (ED) perceived a lack of real-time information ( p = 0.012), a lack of resources, and negative personal impacts associated with the pandemic as more serious than staff in Level 1 and Level 2 EDs. Medical staff in the intensive care unit perceived work changes ( p < 0.05), work burden ( p < 0.05), and lack of personal protective equipment ( p = 0.002) as more serious than staff in the ED and general ward. Conclusion : Providing real-time information and resources for reducing work burden and negative personal impact is central to maximizing the work output of the COVID-19 pandemic frontline medical staff. Supporting their mental health through regular programs and intervention is also imperative.

Objective: This study aimed to compare the outcomes of adult out-of-hospital cardiac arrest (OHCA) before and after the coronavirus disease 2019 (COVID-19) outbreak in a large metropolitan city., Methods: This before-and-after observational study used a prospective citywide OHCA registry. Adult patients with emergency medical service-treated OHCA, with presumed cardiac etiology, pre- and post-COVID-19 outbreak were enrolled. The study period spanned 2 months, starting from February 18, 2020. The control period was 2 months from February 18, 2019. The primary and secondary outcomes were good neurologic outcome and survival to hospital discharge, respectively. The association between the COVID-19 outbreak and OHCA outcomes was assessed using multivariable logistic regression analysis., Results: This study analyzed 297 OHCA patients (control period, 145; study period, 152). The bystander cardiopulmonary resuscitation rates were 64.8% and 60.5% during the control and study periods, respectively. Response and on-scene times increased by 2 minutes, supraglottic airway use increased by 35.6%, and mechanical chest compression device use increased by 13% post-COVID-19 outbreak. Good neurologic outcome was significantly lower during the study period in overall OHCAs (adjusted odds ratio, 0.23; 95% confidence interval, 0.05-0.98) and in witnessed OHCAs (adjusted odds ratio, 0.14; 95% confidence interval, 0.02-0.90). No significant difference was found in the survival to hospital discharge of OHCA patients between the two periods., Conclusion: During the COVID-19 pandemic, the response and on-scene times were longer, and good neurologic outcome was significantly lower than that in the control period.

Aim of the Study: We investigated whether controlled normothermia (CN) after the rewarming phase of targeted temperature management (TTM) is associated with preventing post-rewarming fever and outcomes 6 months after out-of-hospital cardiac arrest (OHCA)., Methods: This was an analysis of a prospective registry comprising OHCA patients treated with TTM at 22 academic hospitals between October 2015 and December 2018. We calculated the incremental area under the curve (iAUC) for body temperature greater than or equal to 37.5 °C for each patient during the first 24 h after the end of rewarming. The relationships among CN and iAUC, 6-month survival and good neurological outcome were analysed. To minimize differences in the baseline characteristics of the patients, we used propensity score-matched analysis., Results: In total, 1144 patients were enrolled. After propensity score matching, 646 patients (comprising 323 pairs) were obtained. In the unmatched cohort, post-rewarming CN was significantly associated with a lower iAUC (0.34 [1.38] vs. 1.19 [2.27]; p < 0.001) but not 6-month survival (adjusted odds ratio (OR): 1.121; 95% confidence interval (CI): 0.836-1.504; p = 0.446) and good neurological outcome (adjusted OR: 1.030; 95% CI: 0.734-1.446; p = 0.863). The results were similar in the propensity score-matched cohort (0.38 [1.56] vs. 1.03 [2.21], p < 0.001, OR: 1.347, 95% CI: 0.989-1.835, p = 0.059 and OR: 1.280, 95% CI 0.925-1.772, p = 0.137, respectively)., Conclusion: Post-rewarming CN prevents high fever in the normothermia phase of TTM. However, our data suggest the lack of association between CN and the patient's 6-month survival and good neurological outcome., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Timely treatment is important for patients with acute ischemic stroke (AIS). However, the coronavirus disease 2019 (COVID-19) outbreak may have caused delays in patient management. Therefore, we analyzed the prognosis and the time spent at the prehospital and hospital stages in managing patients diagnosed with AIS during the COVID-19 outbreak., Methods: This retrospective study evaluated patients diagnosed with AIS in the emergency department (ED) at five medical centers in Daegu city between February 18 and April 17 each year from 2018 to 2020. Data on the patients' clinical features and time spent on management were collected and compared according to COVID-19 and pre-COVID-19 summaries., Results: From a total of 533 patients diagnosed with AIS, 399 patients visited the ED before COVID-19 and 134 during the COVID-19 outbreak. During the COVID-19 outbreak, compared with pre-COVID-19, AIS patients had poor National Institute of Health Stroke Scale scores at the initial hospital visit (6 vs. 4, p =0.013) and discharge (3 vs. 2, p =0.001). During the COVID-19 outbreak, the proportion of direct visits to hospitals through public emergency medical services (EMS) increased, and the onset of symptoms-to-ED door time via the public EMS was delayed (87 min vs. 68 min, p =0.006)., Conclusions: The prognosis of AIS patients during the COVID-19 outbreak was worse than that of pre-COVID-19 patients with delays at the prehospital stage, despite the need for timely care., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2021 Sang-Hun Lee et al.)

Background: Cardiopulmonary resuscitation (CPR) performance depends on individual ability and training. Well-trained or professional rescuers can maintain high-quality CPR for longer than laypeople. This study aimed to examine the effects of reducing resting intervals on CPR performance, physiological parameters, and hemodynamic parameters during prolonged CPR in well-trained providers., Methods: The study enrolled 90 volunteers from the paramedic students of our institution. They were randomly divided into 3 groups: 2 minutes, 1 minute 45 seconds, and 1 minute 30 seconds rest groups. Each participant performed 5 cycles of chest compression only CPR (2 min/cycle) with different resting intervals according to grouping. CPR quality, physiological variations, and hemodynamic variations were measured for each cycle and compared across the groups., Results: Of the 90 volunteers, 79 well-trained providers were finally included. The variation of the average chest compression depth across the 5 cycles showed significant differences between the 3 groups: from cycle 1 to 2: 1.2 (3.1) mm, -0.8 (2.0) mm, and -2.0 (3.0) mm in the 2 minutes, 1 minute 45 seconds, and 1 minute 30 seconds groups, respectively (P < .001); from cycle 1 to 3: 0.0 (3.0) mm, -0.7 (3.2) mm, and -2.6 (3.9) mm, respectively (P = .030). However, all 3 groups maintained the recommended rate and chest compression depth for all 5 cycles. Physiological and hemodynamic parameters showed no significant differences between the groups., Conclusions: Well-trained providers were able to maintain high-quality CPR despite reducing rest intervals. Adjusting the rest interval may help maintain overall CPR quality in special situations or where layperson rescuers are involved., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

The first confirmed community transmission of coronavirus disease 2019 in Daegu Metropolitan City, South Korea, occurred on February 18, 2020. In the following 70-day period, approximately 6000 new cases occurred, severely impacting the medical service system. This study investigated the crisis-impact on the local emergency transport system.Emergency medical service activity reports were retrospectively reviewed to determine patient demographics and initial vital signs. Delay in reaching the patient, transporting the patient to the hospital, and returning to the fire station were assessed and categorized based on patients' initial vital signs. The study period was divided into 4 groups (1/1-2/18, 2/19-3/3, 3/4-3/31, and 4/1-04/30) and intergroup differences were analyzed.When compared to Period 1, the time-difference between the request to attend a scene and arrival at the scene was delayed in Periods 2, 3, and 4 by 4 minute 58 s, 3  minute 24 seconds, and 2 minute 20 seconds, respectively; that between arriving at the scene and at the hospital was delayed by 7  minute 43 seconds, 6 minutes 59 seconds, and 4 minutes 30 seconds, respectively; and that between arriving at the hospital and returning to the fire station was delayed by 29  minute 3 second, 25  minute 55 second, and 18  minute 44 second, respectively. In Period 2, for patients with symptoms of severe illness when compared to patients lacking such symptoms, the time-difference between the request to attend the scene and arrival at a hospital and between arrival at the hospital and returning to the fire station were 6 to 23 minute and 12 to 48 minute longer, respectively. Most of the delays impacted patients with a fever. In terms of condition, the statistical effect size for delay in transport time was from large to small: fever, hypoxia, abnormal respiratory rate, respiratory symptom, and hypotension.Outbreaks of infectious disease cause a paradoxical state in emergency medical transport systems, inducing delays in the transport of severely ill patients. Therefore, maintenance and improvement of the medical service system for both patients with infectious disease and those with other severe illnesses is required.

Objective: High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry., Methods: We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months., Results: Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours., Conclusion: The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.

Objective: Cardiopulmonary resuscitation (CPR) education with a feedback device is known to result in better CPR skills compared to one without the feedback device. However, its long-term benefits have not been established. The purpose of this study was to evaluate the long-term CPR skill retention after training using real-time visual manikins in comparison to that of non-feedback manikins., Methods: We recruited 120 general university students who were randomly divided into the real-time feedback group (RTFG) and the non-feedback group. Of them, 95 (RTFG, 48; non-feedback group, 47) attended basic life support and automated external defibrillation training for 1 hour. For comparison of retention of CPR skills, the two groups were evaluated based on 2-minute chest compression performed immediately after training and at 3, 6, and 9 months. The CPR parameters between the two groups were also compared using a generalized linear model., Results: At immediately after training, the performance of RTFG was better in terms of average chest compression depth (51.9±1.1 vs. 45.5±1.1, p<0.001) and a higher percentage of adequate chest compression depth (51.0±4.1 vs. 26.9±4.2, p<0.001). This significant difference was maintained until 6 months after training, but there was no difference at 9 months after training. However, there was no significant difference in the chest compression rate and the correct hand position at any time point., Conclusion: CPR training with a real-time visual feedback manikin improved skill acquisition in chest compression depth, but only until 6 months after the training. It could be a more effective educational method for basic life support training in laypersons.

This study evaluated whether inter-hospital transfer (IHT) after the return of spontaneous circulation (ROSC) was associated with poor neurological outcomes after 6 months in post-cardiac-arrest patients treated with targeted temperature management (TTM). We used data from the Korean Hypothermia Network prospective registry from November 2015 to December 2018. These out-of-hospital cardiac arrest (OHCA) patients had either received post-cardiac arrest syndrome (PCAS) care at the same hospital or had been transferred from another hospital after ROSC. The primary endpoint was the neurological outcome 6 months after cardiac arrest. Subgroup analyses were performed to determine differences in the time from ROSC to TTM induction according to the electrocardiography results after ROSC. We enrolled 1326 patients. There were no significant differences in neurological outcomes between the direct visit and IHT groups. In patients without ST elevation, the mean time to TTM was significantly shorter in the direct visit group than in the IHT group. IHT after achieving ROSC was not associated with neurologic outcomes after 6 months in post-OHCA patients treated with TTM, even though TTM induction was delayed in transferred patients.

Background: The effect of renal replacement therapy (RRT) on the outcomes of severe acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) is uncertain. This study aimed to evaluate the association of RRT with 6-month mortality in patients with severe AKI treated with targeted temperature management (TTM) after OHCA., Methods: This was a retrospective analysis of a prospectively collected multicentre observational cohort study that included adult OHCA patients treated with TTM across 22 hospitals in South Korea between October 2015 and December 2018. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. The primary outcome was 6-month mortality and the secondary outcome was cerebral performance category (CPC) at 6 months. Multivariate Cox regression analysis was performed to define the role of RRT in stage 3 AKI., Results: Among 10,426 patients with OHCA, 1373 were treated with TTM. After excluding those who died within 48 h of return of spontaneous circulation (ROSC) and those with pre-arrest chronic kidney disease, our study cohort comprised 1063 patients. AKI developed in 590 (55.5%) patients and 223 (21.0%) had stage 3 AKI. Among them, 115 (51.6%) were treated with RRT. The most common treatment modality among RRT patients was continuous renal replacement therapy (111 [96.5%]), followed by intermittent haemodialysis (4 [3.5%]). The distributions of CPC (1-5) at 6 months for the non-RRT vs. the RRT group were 3/108 (2.8%) vs. 12/115 (10.4%) for CPC 1, 0/108 (0.0%) vs. 1/115 (0.9%) for CPC 2, 1/108 (0.9%) vs. 3/115 (2.6%) for CPC 3, 6/108 (5.6%) vs. 6/115 (5.2%) for CPC 4, and 98/108 (90.7%) vs. 93/115 (80.9%) for CPC 5, respectively (P = 0.01). The RRT group had significantly lower 6-month mortality than the non-RRT group (93/115 [81%] vs. 98/108 [91%], P = 0.04). Multivariate Cox regression analyses showed that RRT was independently associated with a lower risk of death in patients with stage 3 AKI (hazard ratio, 0.569 [95% confidence interval, 0.377-0.857, P = 0.01])., Conclusion: Dialysis interventions were independently associated with a lower risk of death in patients with stage 3 AKI treated with TTM after OHCA.

Background: Heatstroke is one of the most serious heat-related illnesses. However, establishing public policies to prevent heatstroke remains a challenge. This study aimed to investigate the most relevant climate elements and their warning criteria to prevent outdoor heatstroke (OHS)., Methods: We investigated heatstroke patients from five major hospitals in Daegu metropolitan city, Korea, from June 1 to August 31, 2011 to 2016. We also collected the corresponding regional climate data from Korea Meteorological Administration. We analyzed the relationship between the climate elements and OHS occurrence by logistic regression., Results: Of 70 patients who had heatstroke, 45 (64.3%) experienced it while outdoors. Considering all climate elements, only mean heat index (MHI) was related with OHS occurrence ( p =0.019). Therefore, the higher the MHI, the higher the risk for OHS (adjusted odds ratio, 1.824; 95% confidence interval, 1.102-3.017). The most suitable cutoff point for MHI by Youden's index was 30.0°C (sensitivity, 77.4%; specificity, 73.7%)., Conclusion: Among the climate elements, MHI was significantly associated with OHS occurrence. The optimal MHI cutoff point for OHS prevention was 30.0°C., Competing Interests: No potential conflicts of interest relevant to this article was reported., (Copyright © 2019 Yeungnam University College of Medicine.)

Rationale: Clebopride is known as a dopamine antagonist used for alleviating emetic symptoms with minimal side effects. Herein, we report a case of acute dystonic reaction possibly caused by administration of clebopride in a young male., Patient Concerns: A 19-year-old with no special medical conditions, visited a local clinic complaining of abdominal discomfort, associated with nausea and vomiting. The patient was prescribed with tiropramide, clebopride, simethicone, and mosapride citrate, only to visit the emergency department for abrupt neck pain followed with dystonic reactions upon oral administration of the drugs. The patient suffered involuntary movements of the neck to the right, while maintaining voluntary motor controls of the neck to the left., Diagnosis: Vital signs and neurological exams showed no obscurity and the preliminary blood workup (a complete blood count and measurement of electrolytes, inflammatory marker levels, copper concentration, etc) were all within normal ranges. Additional imagery tests including brain computed tomography (CT), neck contrast-enhanced CT, and magnetic resonance imaging failed to prove any focal lesion pertinent to the condition. Drug screening was done and then clebopride was suspected to be the cause of the dystonic reactions., Interventions: Benztropine (1 mg) was administered orally., Outcomes: The patient's symptoms improved after 1 hour, and he was observed for 6 more hours for possible recurrences before he was discharged. The patient was referred to an outpatient neurology department for 1 month, during which he had no recurrence or other extrapyramidal symptoms., Lessons: Although it is uncommon to experience extrapyramidal symptoms by clebopride, its chemical closeness to metoclopramide may induce such symptoms under certain clinical situations. Therefore, physicians should take in consideration of this effect and dwell in caution upon prescribing the drug.

Carbon monoxide (CO) is well-known as toxic gas and intrinsic signaling molecule such as neurotransmitter and blood vessel relaxant. Recently, it has been reported that low concentration of CO exerts therapeutic actions under various pathological conditions including liver failure, heart failure, gastric cancer, and cardiac arrest. However, little has been known about the effect of CO in neurodegenerative diseases like Parkinson's disease (PD). To test whether CO could exert a beneficial action during oxidative cell death in PD, we examined the effects of CO on 6-hydroxydopamine (6-OHDA)-induced cell death in C6 glioma cells. Treatment of CO-releasing molecule-2 (CORM-2) significantly attenuated 6-OHDA-induced apoptotic cell death in a dose-dependent manner. CORM-2 treatment decreased Bax/Bcl2 ratio and caspase-3 activity, which had been increased by 6-OHDA. CORM-2 increased phosphorylation of NF-E2-related factor 2 (Nrf2) which is a transcription factor regulating antioxidant proteins. Subsequently, CORM-2 also increased the expression of heme oxygenase-1 and superoxide dismutases (CuZnSOD and MnSOD), which were antioxidant enzymes regulated by Nrf2. These results suggest that CO released by CORM-2 treatment may have protective effects against oxidative cell death in PD through the potentiation of cellular adaptive survival responses via activation of Nrf2 and upregulation of heme oxygenase-1, leading to increasing antioxidant defense capacity.

The purpose of this study was to investigate the molecular mechanism underlying oxidative and inflammatory neuronal cell death induced by endosulfan, a pesticide belonging to the chemical family of organochlorines. The cortical and hippocampal tissues derived from Sprague-Dawley (SD) rats treated with endosulfan exhibited increased intracellular accumulation of reactive oxygen species and oxidative damages to cellular macromolecules such as depletion of glutathione, lipid peroxidation, and protein carbonylation. Conversely, the expression of antioxidant enzymes including γ-glutamylcysteine ligase (GCL), superoxide dismutase (SOD), and heme oxygenase-1 (HO-1) was markedly reduced in the brain tissues exposed to endosulfan. Moreover, during endosulfan-induced neuronal cell death, mRNA expression of pro-inflammatory cytokines such as tumour necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) was elevated, which seemed to be mediated by the activation of nuclear factor-kappa B (NF-κB) by phosphorylation of p65 subunit. These results suggest a new molecular mechanism underlying the endosulfan-induced acute neurotoxicity via induction of oxidative stress and pro-inflammatory responses.

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

Background: Previous studies examining sex differences in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) have indicated that women have favorable outcomes; however, detailed evidence remains lacking. We aimed to investigate sex differences in the backgrounds and outcomes of patients undergoing ECPR for OHCA. Methods: This study was a secondary analysis of the registry from the SAVE-J II study, a retrospective multicenter study conducted in Japan from 2013 to 2018. Adult patients without external causes who underwent ECPR for OHCA were included. The primary outcome was a favorable neurological outcome (Cerebral Performance Status 1 or 2) at hospital discharge. We used multilevel logistic regression to evaluate the association of sex differences, adjusting for center-level (hospital) and individual-level variables (patient background, cardiac arrest situation, and in-hospital intervention factors). For sensitivity analyses, we performed three models of multilevel logistic regression when selecting confounders. Results: Among the 1819 patients, 1523 (83.7%) were men, and 296 (16.3%) were women. The median age (61.0 vs. 58.0 years), presence of a witness (78.8% vs. 79.2%), and occurrence of bystander CPR (57.5% vs. 61.6%) were similar between groups. Women were more likely to present with an initial non-shockable rhythm (31.7% vs. 49.7%), as well as a non-shockable rhythm at hospital arrival (52.1% vs. 61.5%) and at ECMO initiation (48.1% vs. 57.1%). The proportion of favorable neurological outcomes was 12.3% in males and 15.9% in females (p = 0.10). Multilevel logistic regression analysis showed that the female sex was significantly associated with a favorable neurologic outcome at discharge (adjusted odds ratio: 1.60 [95% confidence interval: 1.05–2.43]; p = 0.03). This advantage in women was consistently observed in the sensitivity analyses. Conclusions: The female sex is significantly associated with favorable neurological outcomes at hospital discharge in patients who received ECPR for OHCA. [ABSTRACT FROM AUTHOR]

Objective: Therapeutic hypothermia (TH) has become the standard strategy for reducing brain damage in the postresuscitation period. The aim of this study was to investigate current TH performance and outcomes in out-of-hospital cardiac arrest (OHCA) survivors using data from the Korean Hypothermia Network (KORHN) registry., Methods: We used the KORHN registry, a web-based multicenter registry that includes 24 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TH between 2007 and 2012 were included. The primary outcomes were neurological outcome at hospital discharge and in-hospital mortality. The secondary outcomes were TH performance and adverse events during TH., Results: A total of 930 patients were included, of whom 556 (59.8%) survived to discharge and 249 (26.8%) were discharged with good neurologic outcomes. The median time from return of spontaneous circulation (ROSC) to the start of TH was 101 minutes (interquartile range [IQR], 46 to 200 minutes). The induction, maintenance, and rewarming durations were 150 minutes (IQR, 80 to 267 minutes), 1,440 minutes (IQR, 1,290 to 1,440 minutes), and 708 minutes (IQR, 420 to 900 minutes), respectively. The time from the ROSC to coronary angiography was 1,045 hours (IQR, 121 to 12,051 hours). Hyperglycemia (46.3%) was the most frequent adverse event., Conclusion: More than one-quarter of the OHCA survivors (26.8%) were discharged with good neurologic outcomes. TH performance was appropriately managed in terms of the factors related to its timing, including cooling start time and rewarming duration., Competing Interests: No potential conflict of interest relevant to this article was reported.

Background: High-quality cardiopulmonary resuscitation (CPR) can restore spontaneous circulation (ROSC) and neurological function and save lives. We conducted an umbrella review, including previously published systematic reviews (SRs), that compared mechanical and manual CPR; after that, we performed a new SR of the original studies that were not included after the last published SR to provide a panoramic view of the existing evidence on the effectiveness of CPR methods. Methods: PubMed, EMBASE, and Medline were searched, including English in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) SRs, and comparing mechanical versus manual CPR. A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) and GRADE were used to assess the quality of included SRs/studies. We included both IHCA and OHCA, which compared mechanical and manual CPR. We analyzed at least one of the outcomes of interest, including ROSC, survival to hospital admission, survival to hospital discharge, 30-day survival, and survival to hospital discharge with good neurological function. Furthermore, subgroup analyses were performed for age, gender, initial rhythm, arrest location, and type of CPR devices. Results: We identified 249 potentially relevant records, of which 238 were excluded. Eleven SRs were analyzed in the Umbrella review (January 2014–March 2022). Furthermore, for a new, additional SR, we identified eight eligible studies (not included in any prior SR) for an in-depth analysis between April 1, 2021, and February 15, 2024. The higher chances of using mechanical CPR for male patients were significantly observed in three studies. Two studies showed that younger patients received more mechanical treatment than older patients. However, studies did not comment on the outcomes based on the patient's gender or age. Most SRs and studies were of low to moderate quality. The pooled findings did not show the superiority of mechanical compared to manual CPR except in a few selected subgroups. Conclusions: Given the significant heterogeneity and methodological limitations of the included studies and SRs, our findings do not provide definitive evidence to support the superiority of mechanical CPR over manual CPR. However, mechanical CPR can serve better where high-quality manual CPR cannot be performed in selected situations. [ABSTRACT FROM AUTHOR]

Background: Public health emergencies of international concern (PHEICs) as the COVID-19 pandemic and others that have occurred since the early 2000s put enormous pressure on health and care systems. This is being a context for protests by health and care workers (HCWs) because of additional workload, working conditions and effects on mental and physical health. In this paper, we intended to analyze the demands of HCWs associated with industrial actions, protests, strikes and lockouts (IAPSLs) which occurred during COVID-19 pandemic and other PHEICs; to identify the impact of these grievances; and describe the relevant interventions to address these IAPSLs. Methods: We included studies published between January 2000 and March 2022 in PubMed, Embase, Scopus, BVS/LILACS, WHO's COVID-19 Research Database, ILO, OECD, HSRM, and Google Scholar for grey literature. Eligibility criteria were HCWs as participants, IAPSLs as phenomenon of interest occurring in the context of COVID-19 and other PHEICs. GRADE CERQual was used to assess risk of bias and confidence of evidence. Results: 1656 records were retrieved, and 91 were selected for full-text screening. We included 18 publications. A system-wide approach, rather than a limited approach to institutions on strike, makes it possible to understand the full impact of the strike on health and care services. PHEICs tend to aggravate already adverse working conditions of HCWs, acting as drivers for HCWs strikes, leading to staff shortages, and financial issues, both in the North and in the Global South, particularly evident in Asia and Africa. In addition, issues related to deficiencies in leadership and governance in heath sector and lack of medical products and technologies (e.g., lack of personal protective equipment) were the main drivers of strikes, each contributing 25% of the total drivers identified. Conclusions: It is necessary to focus on the preparedness of health and care systems to respond adequately to PHEICs, and this includes being prepared for HCWs' IAPSLs, talked much in the context of COVID-19 pandemic. Evidence to assist policymakers in defining strategies to respond adequately to the health and care needs of the population during IAPSLs is crucial. The main impact of strikes is on the disruption of health care services' provision. Gender inequality being a major issue among HCWs, a proper understanding of the full impact of the strike on health and care services will only be possible if gender lens is combined with a systemic approach, rather than gender-undifferentiated approaches limited to the institutions on strike. [ABSTRACT FROM AUTHOR]

This study investigates the impact of the COVID-19 pandemic on pediatric out-of-hospital cardiac arrest (OHCA) outcomes in Japan, aiming to address a critical research gap. Analyzing data from the All-Japan Utstein registry covering pediatric OHCA cases from 2018 to 2021, the study observed no significant changes in one-month survival, neurological outcomes, or overall performance when comparing the pre-pandemic (2018–2019) and pandemic (2020–2021) periods among 6765 cases. However, a notable reduction in pre-hospital return of spontaneous circulation (ROSC) during the pandemic (15.1–13.1%, p =.020) was identified. Bystander-initiated chest compressions and rescue breaths declined (71.1–65.8%, 22.3–13.0%, respectively; both p <.001), while bystander-initiated automated external defibrillator (AED) use increased (3.7–4.9%, p =.029). Multivariate logistic regression analyses identified factors associated with reduced pre-hospital ROSC during the pandemic. Post-pandemic, there was no noticeable change in the one-month survival rate. The lack of significant change in survival may be attributed to the negative effects of reduced chest compressions and ventilation being offset by the positive impact of widespread AED availability in Japan. These findings underscore the importance of innovative tools and systems for safe bystander cardiopulmonary resuscitation during a pandemic, providing insights to optimize pediatric OHCA care. [ABSTRACT FROM AUTHOR]

Background: Interhospital transfer (IHT) is necessary for providing ultimate care in the current emergency care system, particularly for patients with severe trauma. However, studies on IHT during the pandemic were limited. Furthermore, evidence on the effects of the coronavirus disease 2019 (COVID-19) pandemic on IHT among patients with major trauma was lacking. Method: This retrospective cohort study was conducted in an urban trauma center (TC) of a tertiary academic affiliated hospital in Daegu, Korea. The COVID-19 period was defined as from February 1, 2020 to January 31, 2021, whereas the pre-COVID-19 period was defined as the same duration of preceding span. Clinical data collected in each period were compared. We hypothesized that the COVID-19 pandemic negatively impacted IHT. Results: A total of 2,100 individual patients were included for analysis. During the pandemic, the total number of IHTs decreased from 1,317 to 783 (− 40.5%). Patients were younger (median age, 63 [45–77] vs. 61[44–74] years, p = 0.038), and occupational injury was significantly higher during the pandemic (11.6% vs. 15.7%, p = 0.025). The trauma team activation (TTA) ratio was higher during the pandemic both on major trauma (57.3% vs. 69.6%, p = 0.006) and the total patient cohort (22.2% vs. 30.5%, p < 0.001). In the COVID-19 period, duration from incidence to the TC was longer (218 [158–480] vs. 263[180–674] minutes, p = 0.021), and secondary transfer was lower (2.5% vs. 0.0%, p = 0.025). Conclusion: We observed that the total number of IHTs to the TC was reduced during the COVID-19 pandemic. Overall, TTA was more frequent, particularly among patients with major trauma. Patients with severe injury experienced longer duration from incident to the TC and lesser secondary transfer from the TC during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Audience: This simulated automated chest compression device was designed for use in simulation cardiac arrest cases involving emergency medicine residents, but it would be applicable to other learners such as nurses, pharmacists, and medical students. Background: Automated chest compression devices (ACCD) are commonly utilized in cardiac arrest in the emergency department and by emergency medical services (EMS) as patients arrive in the ED. Prolonged simulated cardiac arrest can be challenging to maintain proper chest compression depth and technique. Resident learning may be enhanced during cardiac arrest in the simulation environment by implementing the use of a simulated ACCD. Educational Objectives: By the end of this educational session using a resuscitation trainer or high-fidelity manikin, learners should be able to: 1. Recognize appropriate application of simulated ACCD to an ongoing resuscitation case 2. Demonstrate proper positioning of simulated ACCD in manikin model 3. Integrate simulated ACCD to provide compressions appropriately throughout cardiac arrest scenario Educational Methods: We developed a cost-effective simulated ACCD for use in resuscitation simulation cases. An initial pilot session identified components of fidelity that were used to model the simulated ACCD after those utilized in clinical situations. Three simulated devices were created and then tested for efficacy during high-fidelity simulation with 25 emergency medicine residents. Research Methods: Visual analog scales were used to explore how the simulated ACCD affected perceived realism and stress level during the cardiac arrest simulation. Qualitative data were collected through open-ended learner feedback comments. The institutional review board at our institution reviewed this project and determined that it was exempt. Results: With inclusion of the simulated ACCD device, learners rated the simulation "more realistic" with an average rating of 74/100 and "less stressful" with an average rating of 69/100 on the visual analog scales. Learner comments noted that the use of the ACCD in simulation resulted in better resource availability and accurate environmental noise. Discussion: The simulated ACCD presented here was found to be effective, realistic, and practical for use by learners in a resuscitation curriculum. Our results suggest that implementating a cost-effective simulated ACCD ($98 for supplies) in high-fidelity simulation cardiac arrest cases enhances the perceived realism of the environment and offers physician learners a low-stress opportunity to practice the clinical application of ACCD in cardiac arrest resuscitation. Additionally, the use of the simulated ACCD, specifically in a prolonged resuscitation, eliminated the need for physically demanding manual chest compressions. Anecdotally, in simulated environments we have observed poor-quality manual chest compressions due to an understanding that the manikin is “not real,” leading to decreased psychological fidelity from the shared acceptance of the poor-quality compressions. Thus, the presence of a simulated clinical device providing chest compressions could have increased the feel of realism through improved psychological fidelity. Additionally, we note that the physical and psychological fidelity of this simulated device was sufficient for physicians to perceive clinical implementation, but may be suboptimal for assistive staff, who are focused on the specific functionality and may benefit from training on the physical device in clinical use. Finally, our simulated ACCD resembles the clinical device our department uses; we advise modifications as appropriate to allow a simulated ACCD created for other learners to also resemble their clinically used ACCD. [ABSTRACT FROM AUTHOR]

Purpose: Since identified in December 2019, the novel coronavirus disease 2019 (COVID-19) has had a global impact on medical resource use and costs for patients with cancer in South Korea. This study aimed to identify the medical use and costs among patients with cancer during the COVID-19 pandemic, to predict these patterns in South Korea in the future. Methods: We conducted a secondary claims data analysis using the National Health Insurance Service database for the calendar period of 2019–2020. Monthly relative percent changes in cancer incidence, medical use, and billing costs for medical care utilization by cancer type were calculated. Then, the medical use and costs after January 2020 were predicted using a time series model with data before the COVID-19 outbreak (2014–2019). Results: The incidence of cancer diagnoses has seen a notable decline since the outbreak of the COVID-19 in 2020 as compared to 2019. Despite the impact of COVID-19, there hasn't been a distinct decline in outpatient utilization when compared to inpatient utilization. While medical expenses for both inpatient and outpatient visits have slightly increased, the number of patients treated for cancer has decreased significantly compared to the previous year. In June 2020, overall outpatient costs experienced the highest increase (21.1%), while individual costs showed the most significant decrease (-4.9%) in June 2020. Finally, the number of hospitalisations and outpatient visits increased slightly from June–July in 2020, reducing the difference between the actual and predicted values. The decrease in the number of inpatient hospitalisations (-22~-6%) in 2020 was also high. Conclusions: The overall use of medical services by patients with cancer decreased in 2020 compared with that in the pre-COVID-19 pandemic period. In the future, the government should consider how to recover from the COVID-19 pandemic, and establish permanent health policies for patients with cancer. [ABSTRACT FROM AUTHOR]

Background: Prehospital factors play a vital role in out-of-hospital cardiac arrest (OHCA) survivability, and they vary between countries and regions. We investigated the prehospital factors associated with OHCA outcomes in a single metropolitan city in the Republic of Korea. Methods: This study included adult medical OHCA patients enrolled prospectively, using data from the citywide OHCA registry for patients registered between 2018 and 2021. The primary outcome was survival to hospital discharge. Multivariable logistic regression analysis was conducted to determine the factors associated with the study population's clinical outcomes, adjusting for covariates. We performed a sensitivity analysis for clinical outcomes only for patients without prehospital return of spontaneous circulation prior to emergency medical service departure from the scene. Results: In multivariable logistic regression analysis, older age (odds ratio [OR] 0.96; 95% confidence interval [CI] 0.95–0.97), endotracheal intubation (adjusted odds ratio [aOR] 0.29; 95% [CIs] 0.17–0.51), supraglottic airway (aOR 0.29; 95% CI 0.17–0.51), prehospital mechanical chest compression device use (OR 0.13; 95% CI 0.08–0.18), and longer scene time interval (OR 0.96; 95% CI 0.93–1.00) were negatively associated with survival. Shockable rhythm (OR 24.54; 95% CI 12.99–42.00), pulseless electrical activity (OR 3.11; 95% CI 1.74–5.67), and witnessed cardiac arrest (OR 1.59; 95% CI 1.07–2.38) were positively associated with survival. In the sensitivity analysis, endotracheal intubation, supraglottic airway, prehospital mechanical chest compression device use, and longer scene time intervals were associated with significantly lower survival to hospital discharge. Conclusions: Regional resuscitation protocol should be revised based on the results of this study, and modifiable prehospital factors associated with lower survival of OHCA should be improved. [ABSTRACT FROM AUTHOR]

Background: Although the ongoing epidemics of Coronavirus disease 2019 (COVID-19) may have affected the mortality trend of the nation, the national level assessment of excess mortality (changes in overall mortality in the entire population) is still scarce in Korea. Therefore, this study evaluated the excess mortality during the COVID-19 pandemic in Korea using the certified mortality data. Methods: Monthly mortality and population data from January 2013 to June 2022 was obtained from the National Health Insurance Service database and Statistics Korea. A quasi-Poisson interrupted time-series model adjusted for age structure, population, seasonality, and long-term trends was used to estimate the counterfactual projections (expected) of mortality during the COVID-19 pandemic (March 2020 to June 2022). The absolute difference (observed—expected) and ratio (observed / expected) of mortality were calculated. Stratified analysis based on pandemic years (years 2020, 2021, and 2022), sex, and age groups (aged 0–4, 5–19, 20–64, and ≥ 65 years) were conducted. Results: An 8.7% increase in mortality was observed during the COVID-19 pandemic [absolute difference: 61,277 persons; ratio (95% confidence interval (CI)): 1.087 (1.066, 1.107)]. The gap between observed and estimated mortality became wider with continuation of the pandemic [ratio (95% CI), year 2020: 1.021 (1.003, 1.040); year 2021: 1.060 (1.039, 1.080), year 2022: 1.244 (1.219, 1.270)]. Although excess mortality across sex was similar, the adult [aged 20–64, ratio (95% CI): 1.059 (1.043, 1.076)] and elderly [aged 65-, ratio (95% CI): 1.098 (1.062, 1.135)] population showed increased excess mortality during the pandemic. Conclusions: Despite Korea's successful quarantine policy response, the continued epidemic has led to an excess mortality. The estimated mortality exceeded the number of deaths from COVID-19 infection. Excess mortality should be monitored to estimate the overall impact of the pandemic on a nation. [ABSTRACT FROM AUTHOR]

Background: Serum neuron-specific enolase (NSE) is the only recommended biomarker for multimodal prognostication in postcardiac arrest patients, but low sensitivity of absolute NSE threshold limits its utility. This study aimed to evaluate the prognostic performance of serum NSE for poor neurologic outcome in out-of-hospital cardiac arrest (OHCA) survivors based on their initial rhythm and to determine the NSE cutoff values with false positive rate (FPR) < 1% for each group. Methods: This study included OHCA survivors who received targeted temperature management (TTM) and had serum NSE levels measured at 48 h after return of spontaneous circulation in the Korean Hypothermia Network, a prospective multicenter registry from 22 university-affiliated teaching hospitals in South Korea between October 2015 and December 2018. The primary outcome was poor outcome at 6 month, defined as a cerebral performance category of 3–5. Results: Of 623 patients who underwent TTM with NSE measured 48 h after the return of spontaneous circulation, 245 had an initial shockable rhythm. Median NSE level was significantly higher in the non-shockable group than in the shockable group (104.6 [40.6–228.4] vs. 25.9 [16.7–53.4] ng/mL, P < 0.001). Prognostic performance of NSE assessed by area under the receiver operating characteristic curve to predict poor outcome was significantly higher in the non-shockable group than in the shockable group (0.92 vs 0.86). NSE cutoff values with an FPR < 1% in the non-shockable and shockable groups were 69.3 (sensitivity of 42.1%) and 102.7 ng/mL (sensitivity of 76%), respectively. Conclusion: NSE prognostic performance and its cutoff values with FPR < 1% for predicting poor outcome in OHCA survivors who underwent TTM differed between shockable and non-shockable rhythms, suggesting postcardiac arrest survivor heterogeneity. Trial registration KORHN-PRO, NCT02827422. Registered 11 September 2016—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02827422 [ABSTRACT FROM AUTHOR]

Background: Frequent Emergency Department (ED) visitors are identified by the policymakers to reduce avoidable ED visits and lessen the financial and operational burden. This study aimed to identify the factors related to the frequent use of ED services. Methods: This nationwide, cross-sectional observational study was conducted using information obtained from the 2019 National Emergency Department Information System (NEDIS) database. Frequent ED users were defined as patients with four or more ED visits a year. We performed multiple logistic regression analyses to verify the relationship among sociodemographic characteristics, residential characteristics, clinical characteristics, and frequency of ED visits. Results: Among 4,063,640 selected patients, 137,608 patients visited the ED four or more times a year (total number of visits = 735,502 times), which accounted for 3.4% and 12.8% of the total number of ED users and ED visits, respectively. A high ED visit frequency was associated with male sex, age < 9 or ≥ 70 years, Medical Aid (based on the insurance type), lower number of medical institutions and beds compared with that of the national average, and conditions, such as cancer, diabetes, renal failure, and mental illness. A low ED-visit frequency was associated with residence in regions vulnerable to emergency medical care and regions with high income. The possibility of frequent ED visits was high for patients with level 5 severity (non-emergent) and those with an increased need for medical treatment, including older patients and patients with cancer or mental illness. The possibility of frequent ED visits was low for patients aged > 19 years with level 1 severity (resuscitation). Conclusions: Health service accessibility factors, including low income and medical resource imbalance, were associated with frequent ED visits. Future large-scale prospective cohort studies are warranted to establish an efficient emergency medical system. [ABSTRACT FROM AUTHOR]

BACKGROUND: Targeted temperature management (TTM), as a therapeutic temperature control strategy for cardiac arrest (CA), is recommended by guidelines. However, the relationship between postrewarming fever (PRF) and the prognosis of CA patients is unclear. Therefore, we aim to summarize the studies regarding the influence of PRF on patients with CA. METHODS: EMBASE, PubMed, and Cochrane Central databases were searched from inception to March 13, 2022. Randomized clinical trials (RCTs) and cohort studies on PRF in CA patients were included. According to the heterogeneity, the meta-analysis was performed using a random effects model or fixed effects model to calculate the pooled odds ratios (ORs) and corresponding 95% confidence intervals (CIs). The outcome data were unfavorable neurological outcome and mortality. RESULTS: The meta-analysis included 11 observational studies involving 3,246 patients. The results of the meta-analysis show that PRF (body temperature >38.0 °C) has no effect on the neurological outcome of CA patients (OR 0.71, 95% CI 0.43-1.17, I² 82%) and has a significant relationship with lower mortality (OR 0.63; 95% CI 0.49-0.80, I² 39%). However, PRF with a stricter definition (body temperature >38.5 °C) was associated with worse neurological outcome (OR 1.44, 95% CI 1.08-1.92, I² 45%) and higher mortality (OR 1.71, 95% CI 1.25-2.35, I² 47%). CONCLUSION: This study suggests that PRF >38.0 °C may not affect the neurological outcome and have a lower mortality in CA patients who completed TTM. However, PRF >38.5 °C is a potential prognostic factor for worse outcomes in CA patients. [ABSTRACT FROM AUTHOR]

Summary: Background: Drugs which can inhibit nausea/vomiting and/or increase gastric emptying are used to treat gastroparesis, mostly 'off‐label'. Within each category, they act at different targets and modulate different physiological mechanisms. Aims: Address the questions: In gastroparesis, why should blocking one pathway causing vomiting, be more appropriate than another? Why might increasing gastric emptying via one mechanism be more appropriate than another? Methods: Drugs used clinically were identified via consensus opinions and reviews, excluding the poorly characterised. Their pharmacology was defined, mapped to mechanisms influencing vomiting and gastric emptying, and rationale developed for therapeutic use. Results: Vomiting: Rationale for 5‐HT3, D2, H1 or muscarinic antagonists, and mirtazapine, amitriptyline, nortriptyline, are poor. Arguments for inhibiting central consequences of vagal afferent transmission by NK1 antagonism are complicated by doubts over effects on nausea. Gastric emptying: Confusion emerges because of side‐effects of drugs increasing gastric emptying: Metoclopramide (5‐HT4 agonist, D2 and 5‐HT3 antagonist; also blocks some emetic stimuli and causes tardive dyskinesia) and Erythromycin (high‐efficacy motilin agonist, requiring low doses to minimise side‐effects). Limited trials with selective 5‐HT4 agonists indicate variable efficacy. Conclusions: Several drug classes inhibiting vomiting have no scientific rationale. NK1 antagonism has rationale but complicated by limited efficacy against nausea. Studies must resolve variable efficacy of selective 5‐HT4 agonists and apparent superiority over motilin agonists. Overall, lack of robust activity indicates a need for novel approaches targeting nausea (e.g., modulating gastric pacemaker or vagal activity, use of receptor agonists or new targets such as GDF15) and objective assessments of nausea. [ABSTRACT FROM AUTHOR]

Cardiopulmonary resuscitation (CPR) education for the public may improve bystander intention to perform CPR on cardiac arrest patients. Studies have shown that different CPR education intervention methods can improve learning performance, with key indicators including attitude toward to CPR, intention to perform CPR, and degree of CPR knowledge and skills. The present study compared the traditional face-to-face method to hybrid and virtual reality (VR) methods to observe difference in learning performance and length of performance retention. This study adopted randomized controlled trial to compare CPR learning performance between traditional face-to-face, hybrid, and VR methods. Participants from each intervention group completed a pretest and 2 posttests. The measurement tools included an attitude and intention questionnaire, knowledge examination, and skill examination with a RESUSCI ANNE QCPR ® manikin. The performance among all participants in pretest showed no significant difference between the intervention groups, indicating no difference in their background attitude, knowledge, and skill level. Significant differences were observed in the average degree of intention to perform CPR between the hybrid and traditional groups in 1st and 2nd posttest. Compared to the pretest results, the posttests revealed significantly higher attitude toward CPR, intention to perform CPR, knowledge examination results, accuracy of overall chest compression, accuracy of CPR procedure, accuracy of AED usage, accuracy of chest compression rate, and accuracy of chest compression depth. The average time to reattending CPR learning and practice session was 11–12 weeks reported by participants. The hybrid and VR methods to CPR education resulted in the same level of improvement in learning performance as traditional face-to-face teaching. The suggested frequency for renewing CPR knowledge and skills is 12 weeks which may be considered in new strategies aimed at promoting CPR education and exposure to the public. [ABSTRACT FROM AUTHOR]

Background: A proper nutritional plan for resuscitated patients is important in intensive care; however, specific nutritional guidelines have not yet been established. This study aimed to determine the incidence of diet-related complications that were affected by the timing of enteral nutrition in resuscitated patients after cardiac arrest. Methods: This retrospective and 1:1 propensity score matching study involved patients who recovered after nontraumatic, out-of-hospital cardiac arrest at a tertiary hospital. Patients were divided into an early nutrition support (ENS) group and a delayed nutrition support (DNS) group according to the nutritional support time within 48 hours after admission. The incidence of major clinical complications was compared between the groups. Results: A total of 46 patients (ENS: 23, DNS: 23) were enrolled in the study. There were no differences in body mass index, comorbidity, and time of cardiopulmonary resuscitation between the two groups. There were 9 patients (ENS: 4, DNS: 5) with aspiration pneumonia; 4 patients (ENS: 2, DNS: 2) with regurgitation; 1 patient (ENS: 0, DNS: 1) with ileus; 21 patients (ENS: 10, DNS: 11) with fever; 13 patients (ENS: 8, DNS: 5) with hypoglycemia; and 20 patients (ENS: 11, DNS: 9) with hyperglycemia. The relative risk of each complication during post-resuscitation care was no different between groups. Conclusions: There was a similar incidence of diet-related complications during post cardiac arrest care according to the timing of enteral nutrition. [ABSTRACT FROM AUTHOR]

Background: Because virtual simulation promotes learning and cognitive skill development, it may be useful for teaching students to manage postpartum hemorrhage (PPH) and its complex decision algorithm. Objective: This study aimed to compare the satisfaction and effectiveness of virtual simulation with usual supervised work in producing knowledge and satisfaction. Methods: This two-center two-stage crossover randomized controlled trial included student midwives. One group underwent the virtual simulation intervention in the first period (January 2018) and the usual supervised classroom work in the second (May 2018); the other group followed the reverse chronology. Satisfaction was the primary outcome. The secondary outcome was knowledge of the PPH management algorithm, assessed by responses to a case vignette after each intervention session. Results: The virtual simulation -supervised work (VS-SW) chronology was allocated to 48 students, and its inverse (SW-VS) to 47; Satisfaction was significantly higher for the virtual simulation for its overall grade (6.8 vs. 6.1, P = 0.009), engagingness (very good 82.1% vs. 24.3%, P < 0.001), and ease of use (very good 77.9% vs. 46.1%, P < 0.001). Knowledge did not differ between the two groups (respectively, 89.5% versus 83.5%, P = 0.3). Conclusion: Satisfaction is higher with virtual simulation without lowering knowledge scores, which argues for the use of such innovative teaching strategies. This could lead to an increase in students' motivation to learn. [ABSTRACT FROM AUTHOR]

Background Unlike other countries, South Korea did not implement a large-scale lockdown or closure of businesses to manage the coronavirus disease 2019 (COVID-19) pandemic, but relied on changes in population behaviours and early isolation and treatment of patients. It is important to evaluate the effectiveness of such alternative strategies on the mortality of the general population. Methods Mortality and monthly population data from 2013 to 2020 were obtained. A quasi-Poisson regression model adjusting for age structure, seasonality and time was used to evaluate whether underlying trends for monthly mortality rate have changed with the pandemic. Stratification analyses based on sex and location of deaths (inside vs outside of medical facilities) were conducted. Results The risk estimates showed no changes in non-accidental mortality during the COVID-19 pandemic [relative risk (RR) (95% confidence interval, 95% CI), slope change: 1.00 (1.00, 1.01), step change: 0.99 (0.97, 1.01)] compared with those before the pandemic. In cause-specific analysis, there was an abrupt and sustained decrease in the mortality rate of respiratory diseases [RR (95% CI), step change: 0.81 (0.77, 0.84)]. In the analysis of deaths by location, an increase in non-accidental mortality [RR (95% CI), slope change: 1.01 (1.01, 1.02), step change: 1.16 (1.11, 1.22)] and several cause-specific mortalities was observed outside of medical facilities. Conclusions The non-accidental mortality rate in South Korea for the first year of the pandemic followed the historical trends. However, there was a decrease in mortality associated with respiratory diseases, and an increase in mortality occurring outside of medical facilities. The findings may be attributed to changes in public behaviours, and availability of medical resources during the pandemic. [ABSTRACT FROM AUTHOR]