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Background/Purpose: To develop a prediction model for emergency medical technicians (EMTs) to identify trauma patients at high risk of deterioration to emergency medical service (EMS)-witnessed traumatic cardiac arrest (TCA) on the scene or en route. Methods: We developed a prediction model using the classical cross-validation method from the Pan-Asia Trauma Outcomes Study (PATOS) database from 1 January 2015 to 31 December 2020. Eligible patients aged ≥18 years were transported to the hospital by the EMS. The primary outcome (EMS-witnessed TCA) was defined based on changes in vital signs measured on the scene or en route. We included variables that were immediately measurable as potential predictors when EMTs arrived. An integer point value system was built using multivariable logistic regression. The area under the receiver operating characteristic (AUROC) curve and Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration in the derivation and validation cohorts. Results: In total, 74,844 patients were eligible for database review. The model comprised five prehospital predictors: age 20/minute, pulse oximetry

Completing an ultramarathon leads to an immediate postrace surge of erythropoietin (EPO). Patients with chronic liver disease may have high plasma EPO concentrations. This study aims to explore whether plasma EPO concentrations vary between hepatitis B virus carrier (HBVc) and non-HBVc runners during long distance running. Blood samples were collected from 8 HBVc and 18 non-HBVc runners at 3 different time points: 1 week before, immediately following, and then 24 h after the 100-km ultramarathon race. Samples were analyzed for plasma EPO levels. EPO concentration had a statistically significant rise immediately after the race (8.7 [7.1–11.9] mU·mL−1 to 23.7 [14.8–37.2] mU·mL−1, P < 0.001) and maintained the high levels 24 h after the race finished (16.7 [11.5–21.0] mU·mL−1, P < 0.001) in all participants. The mean of EPO concentration was 8.9 (5.7–13.2) mU·mL−1 in HBVc runners and was 8.7 (7.7–11.2) mU·mL−1 in non-HBVc runners in the prerace. In HBVc runners, plasma EPO levels were no different at baseline (P = 0.657) and increased in the same fashion in response to ultramarathon compared with non-HBVc runners. Plasma EPO levels between the two groups were not statistically different at any time point. Prolonged endurance exercise led to a significant increase in EPO. A comparable increase in EPO levels was observed in HBVc and non-HBVc runners during and 24 h after 100-km ultramarathon. However, a small sample size might have affected the ability to detect a difference if it does exist.

BackgroundThe diagnosis of acute mountain sickness, which lacks a reliable and objective diagnostic tool, still depends on the clinical symptoms and signs and remains a major threat and unpredictable disease affecting millions of mountaineers.ObjectivesTo record electroencephalography signals with small, convenient, wireless equipment and to test whether electroencephalography parameters, which are more sensitive and reliable markers, could predict the symptoms of acute mountain sickness.MethodsTwenty-five participants were enrolled and separated into two groups to climb Mount Jade in Taiwan. We collected electrocardiography signals and arterial oxygen saturation data at ground, moderate (2,400 m), and high altitude (3,400 m). A spectral analysis of the electrocardiography was performed to assess the study subjects' electroencephalography activity at different frequencies (α, β, θ, δ) and the mean power frequency of electrocardiography. The clinical symptoms and Lake Louise Acute Mountain Sickness scores of the subjects were recorded for comparison.ResultsA significant change in the δ power of electroencephalography was recorded in subjects ascending from the ground to a high altitude of 3,400 m in a 4-day itinerary. In addition, between the two groups of subjects with and without acute mountain sickness (Lake Louise Acute Mountain Sickness scores < 3 and ≥ 3), the δ power of electroencephalography at the fronto-parietal 1 and parietal 3 electrodes at moderate altitude as well as the changes of δ power and mean power frequency of electrocardiography over parietal 4 at high altitude showed a significant difference. At moderate altitude, the increasing δ power of electroencephalography at the parietal 4 electrode was related to the headache symptom of acute mountain sickness before ascending to high altitude.ConclusionAt moderate altitude, the δ power increase of electroencephalography at the P4 electrode could be a predictor of acute mountain sickness symptoms before ascending to high altitude. Thus, electroencephalography had the potential to identify the risk of acute mountain sickness.

Background: Appropriate utilization of intensive care unit (ICU) beds are essential. Patients with critical illness who have do not resuscitate (DNR) have a reduced priority of intensive care. However, the possibility of recovery/survival is ambiguous and multifactorial. Objective: To deliberate the characteristics and outcomes of critical illness in patients with prior DNR who were admitted to the emergency department (ED)-ICU. Method: This was a retrospective cohort study conducted between April 2015 and November 2015 in a university-based hospital. Non-traumatic patients with DNR admitted to ED-ICU from ED were included. Results: Seventy-eight non-trauma patients with prior DNR status were included in the final analysis. 51.3% (40/78) patients were male with median age 83 (IQR: 75–89) years. The median APACHE II score was 24.5 (IQR: 20–30). 50% (39/78) of the DNR patients survived to discharge. Patients who survived to discharge had lower APACHE II score (23 (IQR: 20–28) vs. 28 (18–38), p = 0.028). There was no significant difference in age, gender, and Charlson index. ROC curves were constructed, generating a cut-off of the APACHE II score at 29.5 for determining survival to discharge (AUC = 0.644, p = 0.028). In multivariate Cox proportional model, APACHE II score above 29.5 was an independent predictor for mortality. (Hazard ratio = 2.46; 95% confidence interval: 1.04–5.83, p = 0.042). Conclusion: Our study found that 50% of patients with prior DNR on ICU admission survived to discharge, indicating that aggressive care is not definitely futile. Further prospective studies are required to evaluate the cost-effectiveness and patients' and/or families' satisfaction of the ICU admission of DNR patients. Keywords: Do not resuscitate, Futility, Intensive care units

The Modified Early Warning Score (MEWS) reflects the physiological changes of cardiac arrest and has been used in identifying patient deterioration. Physiological reserve capacity is an important outcome predictor, but is seldom reported due to recording limitations in cardiac arrest patients. The aim of the study was to evaluate whether periarrest MEWS could be a further prognostic factor in in-hospital cardiac arrest. Methods: This was a retrospective cohort study of nontrauma adult patients who had experienced in-hospital cardiac arrest during emergency department stays at an urban, 2600-bed tertiary medical center in Taiwan from February 2011 to July 2013. Data regarding patients' characteristics, Charlson Comorbidity Score, MEWS score before events, mode of arrest, and outcome details were extracted following the Utstein guidelines for uniform reporting of cardiac arrest. Results: During the 30-month period, 234 patients suffered in-hospital cardiac arrest during emergency department stays, and 99 patients with periarrest MEWS were included in the final analysis. The MEWS at triage did not differ significantly between survival-to-discharge and mortality groups (3.42 ± 2.2 vs. 4.02 ± 2.65, p = 0.811). Periarrest MEWS was lower in the survival-to-discharge group (4.41 ± 2.28 vs. 5.82 ± 2.84, p = 0.053). In multivariate logistic regression analysis, periarrest MEWS was an independent predictors for survival to discharge. A rise in periarrest MEWS reduced the chance of survival to discharge by 0.77-fold (95% confidence interval: 0.60–0.97, p = 0.028). Conclusion: The simplest MEWS system not only can be used as a prevention measure, but the periarrest MEWS could also be considered as an independent predictor of mortality after in-hospital cardiac arrest.

Atrial fibrillation (AF) is the most common arrhythmia. The most common diagnostic method, 12-lead electrocardiogram (ECG), can record episodes of arrhythmia from which the type and severity can be determined. The Heart Spectrum Blood Pressure Monitor (P2; OSTAR Meditech Corp., New Taipei City, Taiwan) is used to measure cardiovascular pressure change with fast Fourier transform (FFT) analysis to obtain heart rate frequency variability and accurate blood pressure data. We compared the diagnostic efficacy of the Heart Spectrum Blood Pressure Monitor to a 12-lead ECG (gold standard) for patients with AF. Three measurement methods were used in this study to analyze the heart index and compare the results with simultaneous 12-lead ECG: blood pressure; mean arterial pressure, which was calculated from individual blood pressure as a constant pressure; and a constant pressure of 60 mmHg. The physician used a 12-lead ECG and the Heart Spectrum Blood Pressure Monitor simultaneously. The Heart Spectrum Blood Pressure Monitor used FFT analysis to diagnose AF, and the findings were compared to the 12-lead ECG readings. This unblinded clinical trial was conducted in the emergency department of Taipei Medical University Hospital. Twenty-nine subjects with AF and 33 without AF aged 25 to 97 y (mean, 63.5 y) were included. Subjects who were exposed to high-frequency surgical equipment during testing, those with cardiac pacemakers or implantable defibrillators, and pregnant women were excluded. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 97%, 97%, 97%, and 97%, respectively, for method 1; 90%, 100%, 100%, and 91%, respectively, for method 2; and 100%, 94%, 94%, and 100%, respectively, for method 3. The sensitivity, specificity, PPV, and NPV for both methods ranged between 90% and 100%, indicating that the Heart Spectrum Blood Pressure Monitor can be effectively applied for AF detection.

[This corrects the article DOI: 10.1371/journal.pone.0133146.].

Ultramarathon is a high endurance exercise associated with a wide range of exercise-related problems, such as acute kidney injury (AKI). Early recognition of individuals at risk of AKI during ultramarathon event is critical for implementing preventative strategies.To investigate the impact of speed variability to identify the exercise-related acute kidney injury anticipatively in ultramarathon event.This is a prospective, observational study using data from a 100 km ultramarathon in Taipei, Taiwan. The distance of entire ultramarathon race was divided into 10 splits. The mean and variability of speed, which was determined by the coefficient of variation (CV) in each 10 km-split (25 laps of 400 m oval track) were calculated for enrolled runners. Baseline characteristics and biochemical data were collected completely 1 week before, immediately post-race, and one day after race. The main outcome was the development of AKI, defined as Stage II or III according to the Acute Kidney Injury Network (AKIN) criteria. Multivariate analysis was performed to determine the independent association between variables and AKI development.26 ultramarathon runners were analyzed in the study. The overall incidence of AKI (in all Stages) was 84.6% (22 in 26 runners). Among these 22 runners, 18 runners were determined as Stage I, 4 runners (15.4%) were determined as Stage II, and none was in Stage III. The covariates of BMI (25.22 ± 2.02 vs. 22.55 ± 1.96, p = 0.02), uric acid (6.88 ± 1.47 vs. 5.62 ± 0.86, p = 0.024), and CV of speed in specific 10-km splits (from secondary 10 km-split (10th - 20th km-split) to 60th - 70th km-split) were significantly different between runners with or without AKI (Stage II) in univariate analysis and showed discrimination ability in ROC curve. In the following multivariate analysis, only CV of speed in 40th - 50th km-split continued to show a significant association to the development of AKI (Stage II) (p = 0.032).The development of exercise-related AKI was not infrequent in the ultramarathon runners. Because not all runners can routinely receive laboratory studies after race, variability of running speed (CV of speed) may offer a timely and efficient tool to identify AKI early during the competition, and used as a surrogate screening tool, at-risk runners can be identified and enrolled into prevention trials, such as adequate fluid management and avoidance of further NSAID use.

Background: Iron is a vital trace element for energy production and oxygen transportation; importantly, it is essential to athletic performance. Maintaining iron balance is tightly controlled at systemic and cellular levels. This study aimed to determine serum iron tests, hepcidin levels, and cellular iron import and export activities in peripheral blood mononuclear cells (PBMCs) in ultramarathon runners to elucidate the association of systemic inflammation response and iron metabolism. Methods: Sixteen amateur runners were enrolled. Blood samples were taken 1 week before, immediately, and 24 h after the run. Plasma hepcidin levels were measured by enzyme-linked immunosorbent assay. The expression levels of divalent metal iron transporter 1 (DMT1), ZRT/IRT-like protein 14 (ZIP14), transferrin receptor 1 (TfR1), and ferroportin (FPN) in PBMCs were measured using real-time quantitative reverse transcription-polymerase chain reaction. Results: Serum iron concentrations and transferrin saturation significantly decreased immediately after the race and dramatically recovered 24 h post-race. Serum ferritin levels had a statistically significant rise immediately after the race and remained high 24 h after the completion of the race. Ultramarathons were associated with increased plasma interleukin-6 concentrations corresponding to the state of severe systemic inflammation and therefore boosted plasma hepcidin levels. The expression levels of DMT1 and FPN mRNA were markedly decreased immediately and 24 h after the race. The ZIP14 and TfR1 mRNA expression in PBMCs significantly decreased immediately after the race and returned to the baseline level at 24 h post-race. Positive significant correlations were observed between plasma hepcidin and ferritin levels. Conclusion: Iron homeostasis and systemic inflammatory response are closely interconnected. Cellular iron import and export mRNA activities in PBMCs were acutely inhibited during an ultramarathon. [ABSTRACT FROM AUTHOR]

The immediate and long-term impact of severe acute respiratory syndrome (SARS) outbreak on emergency department (ED) visits and hospital expenditures for these visits has not been thoroughly investigated. The objectives of this retrospective observational study investigated the impact of SARS outbreak on ED visits and the cost of these visits in a designated SARS medical center. Methods: Data related to the total number of ED visits and their costs were collected for the SARS epidemic period in 2003 and the same period in the preceding year in 2002. Data collected included total number of ED visits, services provided, triage categories, and total expenditures for all patients. Data for before and during the outbreak were retrieved and compared. Results: At the peak of the SARS epidemic, the reduction in daily ED visits reached 51.6% of pre-epidemic numbers (p < 0.01). In pediatric, trauma and non-trauma patients, the maximum mean decreases in number of visits were 80.0% (p < 0.01), 57.6% (p < 0.01) and 40.8% (p < 0.01), respectively. In triage 1, 2 and 3 patients, the maximum mean decreases were 18.1% (p < 0.01), 55.9% (p < 0.01) and 53.7% (p < 0.01), respectively. The maximum decrease in total costs was 37.7% (p < 0.01). The maximum mean costs per patient increased 35.9% (p < 0.01). The proportions of increases in mean costs for each patient were attributed to laboratory investigations (31.4%), radiography (21.9%) and medications (29.5%). Conclusion: The SARS outbreak resulted in a marked reduction in the number of ED visits which persisted for 3 months after the end of the epidemic. Total cost of treating individual patients showed a simultaneous marked increase, while overall operational costs in the ED showed a marked decrease. The increased total cost for each patient was attributed to the increased number of diagnostic procedures to screen for possible SARS in the ED.

The feasibility of a real-time electrocardiogram (ECG) transmission via satellite phone from Mount Everest to determine a climber's suitability for continued ascent was examined. Four Taiwanese climbers were enrolled in the 2009 Mount Everest summit program. Physiological measurements were taken at base camp (5300 m), camp 2 (6400 m), camp 3 (7100 m), and camp 4 (7950 m) 1 hour after arrival and following a 10 minute rest period. A total of 3 out of 4 climbers were able to summit Mount Everest successfully. Overall, ECG and global positioning system (GPS) coordinates of climbers were transmitted in real-time via satellite phone successfully from base camp, camp 2, camp 3, and camp 4. At each camp, Resting Heart Rate (RHR) was transmitted and recorded: base camp (54-113 bpm), camp 2 (94-130 bpm), camp 3 (98-115 bpm), and camp 4 (93-111 bpm). Real-time ECG and GPS coordinate transmission via satellite phone is feasible for climbers on Mount Everest. Real-time RHR data can be used to evaluate a climber's physiological capacity to continue an ascent and to summit.

Background: The change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels follows a paradox imposed by strenuous endurance exercise. Previous reports showed significant body weight (BW) loss was common in ultramarathon runners. This study investigated whether the BW change and renin--angiotensin--aldosterone system activation contribute to exercise-induced NT-proBNP release. Methods: A total of 26 participants who finished a 100 km ultramarathon in Taiwan were enrolled. For each participant, blood samples and spot urine samples were collected 1 week before the race, as well as immediately and 24 hours after the finish. BW change was recorded to monitor the hydration status. Results: Prolonged endurance exercise led to a substantial increase in NT-proBNP. Compared with prerace values, NT-proBNP levels significantly increased immediately after the race (24.3 ± 20.2 pg/mL to 402.9 ± 305.9 pg/mL, p < 0.05) and maintained high levels until 24 hours after the race (143.7 ± 126.1 pg/mL, p < 0.05). The fractional excretion of sodium values was below 1% in three different time points. The 100 km ultramarathon resulted in significant BW loss and elevated renin and aldosterone levels. However, only 24 hours after the race, a positive significant relationship was found between NT-proBNP and aldosterone levels (p = 0.007, r² = 0.267), but a negative significant relationship between NT-proBNP and BW increased during the recovery phase (p < 0.001, r² = 0.372). Conclusion: The mechanism of NT-proBNP release immediately following the race was multifaceted. During the recovery phase, rehydration might lead to the decrease of NT-proBNP. Our observations with regard to aldosterone and NT-proBNP might be in response to help the body maintains hydration state. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the prevalence and characteristics of acute kidney injury (AKI) in 100-km ultramarathon runners. Design: Prospective observational study. Setting: The 2011 Soochow University ultramarathon, in which each athlete ran for 100 km. Participants: All Taiwanese entrants who participated in the 100-km race and lived in the northern part of Taiwan were invited to participate in the study. Main Outcome Measures: Acute kidney injury was defined using the Acute Kidney Injury Network criteria. Blood and urine samples were collected 1 week before, immediately after, and 1 day after the race. Results: Immediately after the race, 85% (22) of the 26 subjects were diagnosed with AKI, 65% (16) with moderate dehydration, 23% (6) with muscle cramps, and 12% (3) with hematuria. Body weight was significantly decreased from prerace to all postrace measurements. Plasma levels of potassium ion, creatinine, renin, and aldosterone were significantly elevated immediately after the race and then significantly reduced 1 day after the race. Changes in plasma levels of sodium, creatine kinase, and creatine kinase–MB, as well as urine potassium and creatinine, were indicative of AKI. Conclusions: Transient AKI and muscle cramps are very common in 100-km ultramarathon runners. All transient ultra-runners who developed AKI in this study recovered their renal function 1 day later. Clinical Relevance: Ultramarathon running is associated with a wide range of significant changes in hematological parameters, several of which can be associated with potentially serious renal and physiological abnormalities. [ABSTRACT FROM AUTHOR]

The article discusses the results of a study on the correlation between serial weight changes and athletic performance in 52 race participants during 12- and 24-hour international ultramarathons held by the Soochow University in 2003. The researchers found that the majority of weight decrease and dehydration in both the 12- and 24-hour races occurred during the first eight hours, with the most rapid decreases apparent over the first four hours. They recommend the optimization of fluid intake in the first eight hours for both 12- and 24-hours runners and in 16 to 20 hours for 24-hour marathon runners.

The support systems for the Emergency Medical Services (EMS) at mass gatherings, such as the local marathon or large international baseball games, are underdeveloped. The purposes of this study were to extend well-developed, triage-based, EMS Personal Digital Assistant (PDA) support systems to cover pre-hospital emergency medical services and onsite evaluation forms for the mass gatherings, and to evaluate users' perceived ease of use and usefulness of the systems in terms of Davis' Technology Acceptance Model (TAM). The systems were developed based on an established intelligent triage PDA support system and two other forms -- the general EMS form from the Taipei EMT and the customer-made Mass Gathering Medical form used by a medical center. Twenty-three nurses and six physicians in the medical center, who had served at mass gatherings, were invited to examine the new systems and answer the TAM questionnaire. The PDA systems were composed of 450 information items within 42 screens in 6 categories. The results supported the potential for using triage-based PDA systems at mass gatherings. Overall, most of the subjects agreed that the systems were easy to use and useful for mass gatherings, and they were willing to accept the systems. [ABSTRACT FROM AUTHOR]

PURPOSE: To examine the efficacy and safety of administration of calcium and magnesium orally and intraperitoneally to treat severe sodium fluoride intoxication. MATERIALS AND METHODS: Mice were initially gavaged a lethal dose of sodium fluoride (NaF) or water. Then, mice were treated with water or varying concentrations of calcium chloride (CaCl2) or magnesium sulfate (MgSO4) via intraperitoneal (IP) route or via oral route. Mice were monitored for 24h, and the time of death was recorded. RESULTS: IP injections of large amounts of CaCl2 or MgSO4 were dangerous. All mice gavaged with water and then treated with oral CaCl2 or MgSO4 survived and displayed normal activity during the experiment. The survival rate of mice gavaged with a lethal dose of NaF and then treated with a high dose of oral CaCl2 or MgSO4 was significantly higher than those of using low dose. CONCLUSION: Oral administration of a high dose of CaCl2 or MgSO4 is a simple, safe, and effective adjunctive method for treating severe oral fluoride poisoning. [ABSTRACT FROM AUTHOR]