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Background and Objectives: We aimed to develop a cranial suture traction therapy program, a non-surgical therapeutic method for facial asymmetry correction. Materials and Methods: Six experts, including rehabilitation medicine specialists, oriental medical doctors, dentistry specialists, five experts, including Master’s or doctoral degree holders in skin care and cosmetology with more than 10 years of experience in the field, 4 experts including educators in the field of skin care, a total of 15 people participated in the validation of the development of the cranial suture traction therapy program in stages 1 to 3. Open questions were used in the primary survey. In the second survey, the results of the first survey were summarized and the degree of agreement regarding the questions in each category was presented. In the third survey, the degree of agreement for each item in the questionnaire was analyzed statistically. Results: Most of the questions attained a certain level of consensus by the experts (average of ≥ 4.0). The difference between the mean values was the highest for the third survey at 0.33 and was the lowest between the second and third surveys at 0.47. The results regarding the perceived degree of importance for each point of the evaluation in both the second and third stages of the cranial suture traction therapy program were verified using the content validity ratio. The ratio for the 13 evaluation points was within the range of 0.40−1.00; thus, the Delphi program for cranial suture traction therapy verified that the content was valid. Conclusions: As most questions attained a certain level of consensus by the experts, it can be concluded that these questions are suitable, relevant, and important. The commercialization of the cranial suture traction treatment program will contribute to the correction and prevention of facial dislocations or asymmetry, and the developed treatment will be referred to as cranial suture traction therapy (CSTT).

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.

We analyzed the prognostic performance of optic nerve sheath diameter (ONSD) on thin-slice (0.6 mm) brain computed tomography (CT) reconstruction images as compared to routine-slice (4 mm) images. We conducted a retrospective analysis of brain CT images taken within 2 h after cardiac arrest. The maximal ONSD (mONSD) and optic nerve sheath area (ONSA) were measured on thin-slice images, and the routine ONSD (rONSD) and gray-to-white matter ratio (GWR) were measured on routine-slice images. We analyzed their area under the receiver operator characteristic curve (AUC) and the cutoff values for predicting a poor 6-month neurological outcome (a cerebral performance category score of 3–5). Of the 159 patients analyzed, 113 patients had a poor outcome. There was no significant difference in rONSD between the outcome groups (p = 0.116). Compared to rONSD, mONSD (AUC 0.62, 95% CI: 0.54–0.70) and the ONSA (AUC 0.63, 95% CI: 0.55–0.70) showed better prognostic performance and had higher sensitivities to determine a poor outcome (mONSD, 20.4% [95% CI, 13.4–29.0]; ONSA, 16.8% [95% CI, 10.4–25.0]; rONSD, 7.1% [95% CI, 3.1–13.5]), with specificity of 95.7% (95% CI, 85.2–99.5). A combined cutoff value obtained by both the mONSD and GWR improved the sensitivity (31.0% [95% CI, 22.6–40.4]) of determining a poor outcome, while maintaining a high specificity. In conclusion, rONSD was clinically irrelevant, but the mONSD had an increased sensitivity in cutoff having acceptable specificity. Combination of the mONSD and GWR had an improved prognostic performance in these patients.

Objective The National Early Warning Score (NEWS), based on the patients’ vital signs, detects clinical deterioration in critically ill patients and is used to reduce the incidence of in-hospital cardiac arrest. However, although mortality prediction based on vital signs may be difficult in older patients, the effectiveness of the NEWS has not yet been evaluated in this population. This study aimed to test the hypothesis that an elevated NEWS at admission increases the mortality risk in older patients admitted to the emergency department (ED). Methods We conducted a single-center retrospective study, including patients admitted to the ED between November 2016 and February 2017. We included patients aged >65 years who were admitted to the ED for any medical problem. The NEWS was calculated at the time of ED admission. The primary outcome was in-hospital mortality. Results In total, 3,169 patients were included in this study. Median age was 75 years (interquartile range [IQR], 70 to 80 years), and 1,557 (49.1%) patients were male. The in-hospital mortality rate was 5.1% (161 patients). Median NEWS was higher in non-survivors than in survivors (5 [IQR, 3–8] vs. 1 [IQR, 0–3], P65 years.

Background: The therapeutic hypothermia protocol for out of hospital cardiac arrest is not standardized and the decision to apply therapeutic hypothermia relies on a physician’s judgment. Elderly patients who rely on this judgment are less likely to receive therapeutic hypothermia. Objectives: This study aimed to provide an analysis of the impact and utility of therapeutic hypothermia on elderly out of hospital cardiac arrest. Methods: This was a multicenter, retrospective, observational, registry-based study from 2007 to 2012. Adults who suffered out-of-hospital cardiac arrest and were treated with therapeutic hypothermia were included. We divided the patients into a group of elderly patients 65 years or older and a group of young adults under 65 years old and compared the neurologic outcomes and adverse events after one-to-one matching by propensity score. Results: In total, 930 patients were enrolled in the study. Among these patients, 343 were ⩾65 years, while 587 were Conclusion: Elderly patients exhibited a decreased survival to hospital discharge and good neurologic outcomes. The two groups showed no differences in the frequency of adverse events during therapeutic hypothermia, when comparing in a propensity score matching cohort analysis.

Background. Recent studies have presented the effects of cardiac arrest on long-term cognitive function and quality of life. However, no study has evaluated cognitive function in the early stage after regaining consciousness. Purpose. The objectives of this study were to analyse the incidence, clinical course, and associated factors of cognitive impairment of cardiac arrest survivors in intensive care unit (ICU). Patients and methods. We administered the Mini-Mental State Examination (MMSE) to cardiac arrest survivors who were treated with targeted temperature management (TTM) immediately after regaining consciousness. Patients whose MMSE scores indicated impaired cognitive function (MMSE Results. In 92 patients, the median MMSE score was 21.0 (interquartile range (IQR), 16.0–24.0), and cognitive impairment was found in 64 patients. Fifty-three patients completed follow-up MMSEs, and the median scores were 20.0 (IQR, 13.5–23.0) for the first and 25.0 (IQR, 21.5–28.0) for the last test. Of the specific domains, recall (0.0 (IQR, 0.0–1.0) to 2.0 (IQR, 1.0–3.0)) and attention/calculation (3.0 (IQR, 1.0–4.0) to 4.0 (IQR, 2.0–5.0)) were the most affected domains until ICU discharge. The factors that were correlated with cognitive impairment on the last MMSE were older age (OR, 1.07 (95% CI, 1.01–1.14), p=0.016), increased time to return of spontaneous circulation (ROSC) (OR, 1.08 (95% CI, 1.02–1.15), p=0.012), and length of hospital stay (OR, 1.07 (95% CI, 1.00–1.14), p=0.044). Conclusions. Cognitive impairments were common immediately after patients regained consciousness but recovered substantially before ICU discharge. Recall and attention/calculation still were impaired until ICU discharge, and older age, increased time to ROSC, and LOS were associated with this cognitive decline.

We evaluated the performance of cardiac arrest-specific prognostication scores developed for outcome prediction in the early hours after out-of-hospital cardiac arrest (OHCA) in predicting long-term outcomes using independent data. The following scores were calculated for 1,163 OHCA patients who were treated with targeted temperature management (TTM) at 21 hospitals in South Korea: OHCA, cardiac arrest hospital prognosis (CAHP), C-GRApH (named on the basis of its variables), TTM risk, 5-R, NULL-PLEASE (named on the basis of its variables), Serbian quality of life long-term (SR-QOLl), cardiac arrest survival, revised post-cardiac arrest syndrome for therapeutic hypothermia (rCAST), Polish hypothermia registry (PHR) risk, and PROgnostication using LOGistic regression model for Unselected adult cardiac arrest patients in the Early stages (PROLOGUE) scores and prediction score by Aschauer et al. Their accuracies in predicting poor outcome at 6 months after OHCA were determined using the area under the receiver operating characteristic curve (AUC) and calibration belt. In the complete-case analyses, the PROLOGUE score showed the highest AUC (0.923; 95% confidence interval [CI], 0.904-0.941), whereas the SR-QOLl score had the lowest AUC (0.749; 95% CI, 0.711-0.786). The discrimination performances were similar in the analyses after multiple imputation. The PROLOGUE, TTM risk, CAHP, NULL-PLEASE, 5-R, and cardiac arrest survival scores were well calibrated. The rCAST and PHR risk scores showed acceptable overall calibration, although they showed miscalibration under the 80% CI level at extreme prediction values. The OHCA score, C-GRApH score, prediction score by Aschauer et al., and SR-QOLl score showed significant miscalibration in both complete-case (P = 0.026, 0.013, 0.005, and0.001, respectively) and multiple-imputation analyses (P = 0.007, 0.018,0.001, and0.001, respectively). In conclusion, the discrimination performances of the prognostication scores were all acceptable, but some showed significant miscalibration.

Purpose To assess the performance of the post-cardiac arrest (CA) prognostication strategy algorithm recommended by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) in 2020. Methods This was a retrospective analysis of the Korean Hypothermia Network Prospective Registry 1.0. Unconscious patients without confounders at day 4 (72–96 h) after return of spontaneous circulation (ROSC) were included. The association between the prognostic factors included in the prognostication strategy algorithm, except status myoclonus and the neurological outcome, was investigated, and finally, the prognostic performance of the prognostication strategy algorithm was evaluated. Poor outcome was defined as cerebral performance categories 3–5 at 6 months after ROSC. Results A total of 660 patients were included in the final analysis. Of those, 108 (16.4%) patients had a good neurological outcome at 6 months after CA. The 2020 ERC/ESICM prognostication strategy algorithm identified patients with poor neurological outcome with 60.2% sensitivity (95% CI 55.9–64.4) and 100% specificity (95% CI 93.9–100) among patients who were unconscious or had a GCS_M score ≤ 3 and with 58.2% sensitivity (95% CI 53.9–62.3) and 100% specificity (95% CI 96.6–100) among unconscious patients. When two prognostic factors were combined, any combination of prognostic factors had a false positive rate (FPR) of 0 (95% CI 0–5.6 for combination of no PR/CR and poor CT, 0–30.8 for combination of No SSEP N20 and NSE 60). Conclusion The 2020 ERC/ESICM prognostication strategy algorithm predicted poor outcome without an FPR and with sensitivities of 58.2–60.2%. Any combinations of two predictors recommended by ERC/ESICM showed 0% of FPR.

Background The association of body mass index with outcome in patients treated with targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) is unclear. The purpose of this study was to examine the effect of body mass index (BMI) on neurological outcomes and mortality in resuscitated patients treated with TTM after OHCA. Methods This multicenter, prospective, observational study was performed with data from 22 hospitals included in the Korean Hypothermia Network KORHN-PRO registry. Comatose adult patients treated with TTM after OHCA between October 2015 and December 2018 were enrolled. The BMI of each patient was calculated and classified according to the criteria of the World Health Organization (WHO). Each group was analyzed in terms of demographic characteristics and associations with six-month neurologic outcomes and mortality after cardiac arrest (CA). Results Of 1,373 patients treated with TTM identified in the registry, 1,315 were included in this study. One hundred two patients were underweight (BMI 2), 798 were normal weight (BMI 18.5–24.9 kg/m2), 332 were overweight (BMI 25–29.9 kg/m2), and 73 were obese (BMI ≥ 30 kg/m2). The higher BMI group had younger patients and a greater incidence of diabetes and hypertension. Six-month neurologic outcomes and mortality were not different among the BMI groups (p = 0.111, p = 0.234). Univariate and multivariate analyses showed that BMI classification was not associated with six-month neurologic outcomes or mortality. In the subgroup analysis, the underweight group treated with TTM at 33°C was associated with poor neurologic outcomes six months after CA (OR 2.090, 95% CI 1.010–4.325, p = 0.047), whereas the TTM at 36°C group was not (OR 0.88, 95% CI 0.249–3.112, p = 0.843). Conclusions BMI was not associated with six-month neurologic outcomes or mortality in patients surviving OHCA. However, in the subgroup analysis, underweight patients were associated with poor neurologic outcomes when treated with TTM at 33°C.

Porcine circovirus type 3 (PCV3) in domestic pigs was first reported in South Korea in 2017. Here, we report the first complete genome sequences of two PCV3 strains isolated from Korean wild boar, which enhance our understanding about the genetic relatedness of PCV3 in domestic pigs and wild boar.

The effect of early coronary angiography (CAG) in out-of-hospital cardiac arrest (OHCA) patients without ST-elevation (STE) is still controversial. It is not known which subgroups of patients without STE are the most likely to benefit. The objective of this study was to evaluate the association between emergency CAG and neurologic outcomes and identify subgroups with improved outcomes when emergency CAG was performed. This prospective, multicenter, observational cohort study was based on data from the Korean Hypothermia Network prospective registry (KORHN-PRO) 1.0. Adult OHCA patients who were treated with targeted temperature management (TTM) without any obvious extracardiac cause were included. Patients were dichotomized into early CAG (&le, 24 h) and no early CAG (&gt, 24 h or not performed) groups. High-risk patients were defined as having the Global Registry of Acute Coronary Events (GRACE) score &gt, 140, time from collapse to return of spontaneous circulation (ROSC) &gt, 30 min, lactate level &gt, 7.0 mmol/L, arterial pH &lt, 7.2, cardiac enzyme elevation and ST deviation. The primary outcome was good neurologic outcome at 6 months after OHCA. Of the 1373 patients from the KORHN-PRO 1.0 database, 678 patients met the inclusion criteria. The early CAG group showed better neurologic outcomes at 6 months after cardiac arrest (CA) (adjusted odds ratio: 2.21 (1.27&ndash, 3.87), p = 0.005). This was maintained even after propensity score matching (adjusted odds ratio: 2.23 (1.39&ndash, 3.58), p &lt, 0.001). In the subgroup analysis, high-risk patients showed a greater benefit from early CAG. In contrast, no significant association was found in low-risk patients. Early CAG was associated with good neurologic outcome at 6 months after CA and should be considered in high-risk patients.

The gray-to-white matter ratio (GWR) has been used to identify brain damage in comatose patients after cardiac arrest. However, Hounsfield units (HUs), the measurement of brain density on computed tomography (CT) images, may vary depending on the machine type or parameter. Therefore, differences in CT scanners may affect the GWR in post-cardiac arrest patients. We performed a retrospective study on comatose post-cardiac arrest patients who visited the hospital from 2007 to 2017. Two CT, Lightspeed and SOMATOM, scanners were used. Two observers independently measured the HUs of the caudate nucleus, putamen, posterior internal capsule, and corpus callosum using regions of interest. We compared the GWR calculated from the HUs measured at different CT scanners. The analysis of different scanners showed statistically significant differences in the measured HUs and GWR. The HUs and GWR of Lightspeed were measured lower than SOMATOM. The difference between the two CT scanners was also evident in groups divided by neurological prognosis. The area under the curve of the receiver operating characteristic curve to predict poor outcomes of Lightspeed was 0.798, and the cut-off value for 100% specificity was 1.172. The SOMATOM was 0.855, and the cut-off value was 1.269. The difference in scanners affects measurements and performance characteristics of the GWR in post-cardiac arrest patients. Therefore, when applying the results of the GWR study to clinical practice, reference values for each device should be presented, and an integrated plan should be prepared.

ObjectiveThe aim of this study in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM) was to evaluate the prognostic value of OHCA, C-GRApH, and CAHP scores with initial neurologic examinations for predicting neurologic outcomes.MethodsThis retrospective study included OHCA patients treated with TTM from 2009 to 2017. We calculated three cardiac arrest (CA)-specific risk scores (OHCA, C-GRApH, and CAHP) at the time of admission. The initial neurologic examination included an evaluation of the Full Outline of UnResponsiveness brainstem reflexes (FOUR_B) and Glasgow Coma Scale motor (GCS_M) scores. The primary outcome was the neurologic outcome at hospital discharge.ResultsOf 311 subjects, 99 (31.8%) had a good neurologic outcome at hospital discharge. The OHCA score had an area under the receiver operating characteristic curve (AUROC) of 0.844 (95% confidence interval (CI): 0.798-0.884), the C-GRApH score had an AUROC of 0.779 (95% CI: 0.728-0.824), and the CAHP score had an AUROC of 0.872 (95% CI: 0.830-0.907). The addition of the FOUR_B or GCS_M score to the OHCA score improved the prediction of poor neurologic outcome (with FOUR_B: AUROC = 0.899, p = 0.001; with GCS_M: AUROC = 0.880, p = 0.004). The results were similar with the C-GRApH and CAHP scores in predicting poor neurologic outcome.ConclusionsThis study confirms the good prognostic performance of CA-specific scores to predict neurologic outcomes in OHCA patients treated with TTM. By adding new variables associated with the initial neurologic examinations, the prognoses of neurologic outcomes improved compared to the existing scoring models.

Introduction: Despite recent advances in critical care, out-of-hospital cardiac arrest (OHCA) patients still have a low probability of survival. For the purpose of an objective assessment of a patient’s risk of death or neurological deficits, several clinical tools have recently been developed. Hypothesis: The first hypothesis is that OHCA and C-GRApH score could predict neurologic outcome after OHCA patients treated with targeted temperature management (TTM). The second hypothesis is that adding neurologic examination to those scores could further improve outcome prediction after OHCA. Methods: This retrospective study included OHCA patients treated with TTM from 2009 to 2017 in a tertiary teaching hospital in Seoul, Korea. We calculated two cardiac arrest specific risk scores (OHCA and C-GRApH) at the time of admission. Initial neurologic examination (Full Outline of UnResponsiveness Brainstem reflexes (FOUR_B) score and Glasgow Coma Scale motor score (GCS_M)) was also evaluated. The primary outcome was neurological outcome at 6 months after CA. Results: Of 311 subjects, 100 (32.2%) had a good neurologic outcome at 6 months after CA. OHCA score had AUC of 0.843 (95% CI 0.797 - 0.888) and C-GRApH score had AUC of 0.774 (95% CI 0.717 - 0.830). Addition of FOUR_B or GCS_M to OHCA score improved prediction of poor neurologic outcome (AUC 0.891, p = 0.001 for FOUR_B and AUC 0.878, p=0.004 for GCS_M). Results were similar for C-GRApH score to predict poor neurologic outcome. Conclusions: This study confirms the good prognostic performance of cardiac arrest specific scores to predict neurological outcomes in OHCA patients treated with TTM. Addition of neurologic examination variables further improved prognostication for neurologic outcome.

OBJECTIVE The objective of this study was to test the hypothesis that hemoglobin concentration after return of spontaneous circulation (ROSC) is associated with neurologic outcome after cardiac arrest in patients treated with targeted temperature management. METHODS We studied consecutive adult patients with out-of-hospital cardiac arrest treated with targeted temperature management between January 2009 and December 2015. We quantified the association between post ROSC hemoglobin concentrations and good neurologic outcome (defined as Cerebral Performance Category of 1 and 2) at hospital discharge using multivariate logistic regression analysis. RESULTS A total of 246 subjects were ultimately included in this study. The mean age was 54 years (standard deviation, 17); 168 (68%) subjects were male. Eighty-seven (35%) subjects had a good neurologic outcome at hospital discharge. Hemoglobin concentrations were higher in the good outcome group than in the poor outcome group (14.4±2.0 vs. 12.8±2.5 g/dL, P

// Jung Woo Eun 1 , Hee Doo Yang 1 , Soo Hyun Kim 2 , Sungyoup Hong 3 , Kyu Nam Park 2 , Suk Woo Nam 1 and Sikyoung Jeong 3 1 Department of Pathology, Functional RNomics Research Center, Cancer Evolution Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea 2 Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea 3 Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Daejeon, Republic of Korea Correspondence to: Sikyoung Jeong, email: // Keywords : peripheral blood transcriptome, molecular signature, neurological prognosis, cardiac arrest, cerebral performance category, Pathology Section Received : October 27, 2016 Accepted : January 19, 2017 Published : January 28, 2017 Abstract Background: Early prognostication of neurological outcome in comatose patients after cardiac arrest (CA) is important for devising patient treatment strategies. However, there is still a lack of sensitive and specific biomarkers for easy identification of these patients. We evaluated whether molecular signatures from blood of CA patients might help to improve the prediction of neurological outcome. Methods: We examined 22 comatose patients resuscitated after CA and obtained peripheral blood samples 48 hours after CA. To identify novel blood biomarkers, we aimed to measure neurological outcomes according to the Cerebral Performance Category (CPC) score at 6 months after CA and to determine blood transcriptome-based molecular signature of poor neurological outcome group. Results: According to the CPC score, 10 patients exhibited a CPC score of one and 12 patients, a CPC score four to five. Blood transcriptomics revealed differently expressed profiles between the good outcome group and poor outcome group. A total of 150 genes were down-regulated and 237 genes were up-regulated in the poor neurological outcome group compared with good outcome group. From the blood transcriptome-based signatures, we identified that MAPK3, BCL2 and AKT1 were more specific and sensitive diagnostic biomarkers in poor neurological outcome with an area under the curve of 0.867 ( p

Cerebral Venous Thrombosis (CVT) is a relatively uncommon but important cause of stroke that tends to affect young adults, especially women. Head trauma with or without skull fracture was reported to be triggering factors for CVT, but the underlying pathophysiology was not well elucidated. Endothelial injury and coexistent hypercoagulability were supposed to contribute to CVT after head trauma without skull fracture. We report a 49-year-old female patient who presented with headache with vomiting after head trauma and was initially diagnosed as post-traumatic Intracerebral Hemorrhage (ICH), but subsequently, progressed to CVT that resulted in cerebral venous infarction with hemorrhagic transformation. Magnetic Resonance brain Venography (MRV) confirmed CVT in superior sagittal sinus as well as right transverse and sigmoid sinuses. She was treated with endovascular mechanical thrombectomy followed by anticoagulation. The coagulopathy panel was checked both in hospital and in outpatient clinic for evaluating the etiology underlying post-traumatic nonpyogenic CVT. Persistently elevated level of plasma Factor VIII was identified. We should consider that patients with recent head trauma history without skull fracture and coexistent hypercoagulability could develop CVT resulting in cerebral venous infarction with hemorrhagic transformation even when the patient showed no definite focal neurologic deficit or the patient’s initial CT scan revealed no intracranial hemorrhage.

Background We hypothesized that the absence of P25 and the N20–P25 amplitude in somatosensory evoked potentials (SSEPs) have higher sensitivity than the absence of N20 for poor neurological outcomes, and we evaluated the ability of SSEPs to predict long-term outcomes using pattern and amplitude analyses. Methods Using prospectively collected therapeutic hypothermia registry data, we evaluated whether cortical SSEPs contained a negative or positive short-latency wave (N20 or P25). The N20–P25 amplitude was defined as the largest difference in amplitude between the N20 and P25 peaks. A good or poor outcome was defined as a Glasgow-Pittsburgh Cerebral Performance Category (CPC) score of 1–2 or 3–5, respectively, 6 months after cardiac arrest. Results A total of 192 SSEP recordings were included. In all patients with a good outcome (n = 51), both N20 and P25 were present. Compared to the absence of N20, the absence of N20–P25 component improved the sensitivity for predicting a poor outcome from 30.5% (95% confidence interval [CI], 23.0–38.8%) to 71.6% (95% CI, 63.4–78.9%), while maintaining a specificity of 100% (93.0–100.0%). Using an amplitude

Introduction: Several studies have shown that the alpha-delta ratio (ADR) is associated with ischemic brain injury. Recently, an animal study has revealed that the ADR reaches the maximum point at 11 hours after ROSC, followed by downward curve (ADR peak) in the continuous EEG recordings of the rats with good outcome after cardiac arrest. We examined the existence of the early ADR peak after cardiac arrest in human. Methods: This is a prospective, observational study. Forty patients who survived out-of-hospital cardiac arrest underwent 33°C-targeted temperature management. We induced 33°C within 5 hours after ROSC and maintained for 24 hours, followed by 12 hours of rewarming period. All patients received sedative and paralytic agents until the restoration of normothermia. We started continuous EEG monitoring within 20 hours after ROSC until 72 hours after ROSC or mental recovery. We calculated alpha (8 - 13 Hz) and delta (0.5 - 4 Hz) frequency bands and computed ADR in the bifrontal channel (F3 - F4), bicentral channel (C3 - C4) and biparietal channel (P3 - P4). We did not remove artifact nor seizure events. Therefore, the whole continuous recordings were analyzed. Good neurologic outcome was defined as cerebral performance category 1 and 2 one month after ROSC. Results: Twenty-five patients showed poor outcome, while 15 patients showed good outcome. The figure is showing mean ADR ± SD change over time. The ADR reaches its highest amplitude 10 hours after ROSC and gradually decreases in the patients with good outcome regardless of the recording channel. However, the 10-hour ADR was not significantly different between the groups due to the large variances. Conclusions: Similar to the rats, the ADR peak appears early in the human patients with good outcome. However, due to the highly variable trend, application of ADR peak as a prognostic marker is limited. Regardless, the ADR implicates the crucial window of brain recovery time and remains an important subject requiring further study.

High quality integrated post-cardiac arrest care can significantly influence the outcome of patients with cardiac arrest, especially neurological recovery, and numerous studies have been conducted on this topic. In the 2015 Korean cardiopulmonary resuscitation (CPR) guidelines, post-cardiac arrest care was emphasized with effective advanced life support as one of the essential chains for survival. Based on an in-depth scientific evidence review using a standardized methodological approach proposed by the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) working group, the guidelines either partially updated the recommendations or added new recommendations for each specific topic.

BackgroundPrognostication after cardiac arrest (CA) needs a multimodal approach, but the optimal method is not known. We tested the hypothesis that the combination of neuron-specific enolase (NSE) and neuroimaging could improve outcome prediction after CA treated with targeted temperature management (TTM).MethodsA retrospective observational cohort study was performed on patients who underwent at least one NSE measurement between 48 and 72 hr; received both a brain computed tomography (CT) scan within 24 hr and diffusion-weighted magnetic resonance imaging (DW-MRI) within 7 days after return of spontaneous circulation (ROSC); and were treated with TTM after out-of-hospital CA between 2009 and 2017 at the Seoul St. Mary's Hospital in Korea. The primary outcome was a poor neurological outcome at 6 months after CA, defined as a cerebral performance category of 3-5.ResultsA total of 109 subjects underwent all three tests and were ultimately included in this study. Thirty-four subjects (31.2%) experienced good neurological outcomes at 6 months after CA. The gray matter to white matter attenuation ratio (GWR) was weakly correlated with the mean apparent diffusion coefficient (ADC), PV400 and NSE (Spearman's rho: 0.359, -0.362 and -0.263, respectively). NSE was strongly correlated with the mean ADC and PV400 (Spearman's rho: -0.623 and 0.666, respectively). Serum NSE had the highest predictive value among the single parameters (area under the curve (AUC) 0.912, sensitivity 70.7% for maintaining 100% specificity). The combination of a DWI parameter (mean ADC or PV400) and NSE had better prognostic performance than the combination of the CT parameter (GWR) and NSE. The addition of the GWR to a DWI parameter and NSE did not improve the prediction of neurological outcomes.ConclusionThe GWR (≤ 24 hr) is weakly correlated with the mean ADC (≤ 7 days) and NSE (highest between 48 and 72 hr). The combination of a DWI parameter and NSE has better prognostic performance than the combination of the GWR and NSE. The addition of the GWR to a DWI parameter and NSE does not improve the prediction of neurological outcomes after CA treatment with TTM.

Background— Modern treatments have improved the survival rate following cardiac arrest, but prognostication remains a challenge. We examined the prognostic value of continuous electroencephalography according to time by performing amplitude-integrated electroencephalography on patients with cardiac arrest receiving therapeutic hypothermia. Methods and Results— We prospectively studied 130 comatose patients treated with hypothermia from September 2010 to April 2013. We evaluated the time to normal trace (TTNT) as a neurological outcome predictor and determined the prognostic value of burst suppression and status epilepticus, with a particular focus on their time of occurrence. Fifty-five patients exhibited a cerebral performance category score of 1 to 2. The area under the curve for TTNT was 0.97 (95% confidence interval, 0.92–0.99), and the sensitivity and specificity of TTNT36 hours. Burst suppression and status epilepticus predicted poor neurological outcome (positive predictive value of 98.3% and 96.4%, respectively). The combination of these factors predicted a negative outcome at a median of 6.2 hours after resuscitation (sensitivity and specificity of 92.0% and 96.4%, respectively). Conclusions— A TTNT

There is little consensus regarding many post-cardiac arrest care parameters. Variability in such practices could confound the results and generalizability of post-arrest care research. We sought to characterize the variability in post-cardiac arrest care practice in Korea and the United States. A 54-question survey was sent to investigators participating in one of two research groups in South Korea (Korean Hypothermia Network [KORHN]) and the United States (National Post-Arrest Research Consortium [NPARC]). Single investigators from each site were surveyed (N = 40). Participants answered questions based on local institutional protocols and practice. We calculated descriptive statistics for all variables. Forty surveys were completed during the study period with 30 having greater than 50% of questions completed (75% response rate; 24 KORHN and 6 NPARC). Most centers target either 33°C (N = 16) or vary the target based on patient characteristics (N = 13). Both bolus and continuous infusion dosing of sedation are employed. No single indication was unanimous for cardiac catheterization. Only six investigators reported having an institutional protocol for withdrawal of life-sustaining therapy (WLST). US patients with poor neurological prognosis tended to have WLST with subsequent expiration (N = 5), whereas Korean patients are transferred to a secondary care facility (N = 19). Both electroencephalography modality and duration vary between institutions. Serum biomarkers are commonly employed by Korean, but not US centers. We found significant variability in post-cardiac arrest care practices among US and Korean medical centers. These practice variations must be taken into account in future studies of post-arrest care.

【Objectives: The aim of this study was to explore whether emergency bell could shorten door to electrocardiograms (ECG) time in chest pain patients presenting to emergency department (ED) by self-transport. Methods: This was a planned 6-month before-and-after interventional study design. We set up the emergency bell in walk-in patients' waiting room. Prior to the change, patients were triaged before an ECG was obtained. In new process, as soon as patient with chest pain push the emergency bell, emergency physicians examined patient and prioritized performing ECG. We analyzed door to electrocardiograms (DTE) times for patients with chest pain and ST segment elevation myocardial infarction (STEMI) patients between two periods. Results: During the enrollment period, a total of 63 patients called emergency bell. The median DTE time was 6 min (interquartile range: 3.0 - 9.0) and 82.5% received an ECG within 10 minutes, and only three patients were STEMI. DTE time in patient with chest pain was not different between two periods (p=0.980). Before intervention period, 15 walk-in patients admitted in ED for STEMI and 53.8% of STEMI patients received an ECG within 10 minutes. After intervention period, total 19 walk-in patients admitted in ED for STEMI. Of these, 89.5% met the time requirement. Conclusion: Because a small portion of patients with chest pain activated the emergency bell, new strategy for promotion of emergency bell must be needed.】