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

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

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

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

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

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

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

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

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

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

OBJECTIVE We investigated whether patients with out-of-hospital cardiac arrest (OHCA) due to an acute myocardial infarction without cardiogenic shock required higher doses of vasopressors with low targeted temperature management (TTM) after return of spontaneous circulation. METHODS We included consecutive comatose patients resuscitated from OHCA between January 2011 and December 2013. Patients with return of spontaneous circulation, regional wall motion abnormality on echocardiography, and coronary artery stenosis of ≥70% on percutaneous coronary artery angiography were enrolled. These patients received 36°C TTM or 33°C TTM following approval of TTM by patients' next-of-kin (36°C and 33°C TTM groups, respectively). The cumulative vasopressor index was compared between groups. RESULTS During induction phase, dose of vasopressors did not differ between groups. In the maintenance phase, the norepinephrine dose was 0.37±0.57 and 0.26±0.91 µg·kg-1·min-1 in the 33°C and 36°C TTM groups, respectively (P

The present study aimed to compare the ventricular enhancement time between humeral intraosseous access (HIO) and brachial intravenous access (BIV) during cardiopulmonary resuscitation (CPR) in adult humans. To our knowledge, this is the first such study during CPR in adult humans.This prospective single-centre observational cohort study assessed the medical records of patients who underwent CPR between January 2018 and March 2018. The primary endpoints were the left and right ventricular enhancement (LVE and RVE, respectively) times after administration of a microbubble contrast agent via HIO or BIV. Continuous variables are reported as means and standard deviations depending on normal distribution, while categorical variables are reported as frequencies and percentages. The paired t-test and analysis of variance were used to compare HIO and BIV. Differences were considered significant at a P-value0.05.The study included 10 patients. The HIO time (15.60 ± 6.45 s) was significantly lower than the BIV time (20.80 ± 7.05 s; P = 0.009). The RVE time was significantly lower with HIO (5.60 ± 1.71 s) than with BIV (15.40 ± 3.24 s; P 0.001). Additionally, the LVE time was significantly lower with HIO (120.20 ± 4.18 s) than with BIV (132.00 ± 3.09 s; P 0.001).Our results indicated that the arrival times of a drug at the right and left ventricles are significantly lower with HIO than with BIV in an adult cardiac arrest model.

Purpose Ultrasonography (US) has good accuracy for diagnosing appendicitis when it is performed by emergency physicians. This study aimed to determine the amount of experience that is required to achieve competency in this field. Methods Three novice emergency medicine residents completed a 1-day training course regarding the US diagnosis of appendicitis. Then, they performed appendix US in the emergency department on patients complaining of right lower quadrant pain. All included patients also underwent computed tomography or US performed by a board-certified radiologist, to confirm the emergency US diagnosis. The agreement between the diagnoses of novices and experts was evaluated. Results A total of 266 patients were included, and the overall Cohen's kappa coefficient was 0.77 (95% confidence interval [CI]: 0.69-0.84). The kappa value of first 20 cases was 0.49 (95% CI: 0.27-0.71). It increased rapidly during evaluation of the first 20 cases. After the first 20 cases, the kappa coefficient was 0.84 (95% CI: 0.77-0.92). The sensitivity and specificity values for the first 20 cases were 64.3% (95% CI: 77.6%-90.7%) and 84.4% (95% CI: 85.4%-95.4%), respectively. After the first 20 cases, the sensitivity and specificity values increased to 90.9% (95% CI: 83.4%-95.8%) and 93.5% (95% CI: 87.0%-97.3%), respectively. Conclusions A minimum of 20 cases are needed to achieve competency in emergency US diagnosis of acute appendicitis.

Background To perform high-quality cardiopulmonary resuscitation (CPR), high-quality chest compression and ventilation support should be performed. However, many providers still have not maintained an adequate ventilation rate but hyperventilated during CPR. Thus, this study was conducted to verify that the compression-adjusted ventilation (CAV) would be a more accurate ventilation method compared with the conventional ventilation (CV). Methods Volunteer medical students and emergency medical services personnel were recruited. They were randomly divided into either the CV group or the CAV group. In the CV group, participants performed ventilation with estimation of the rate of 8 to 10 per minute (1 ventilation/6-8 seconds). In the CAV group, the ventilation rate was adjusted in line with the compression rate (compression:ventilation, 12:1). In each group, 2-rescuer adult CPR was performed on a manikin, which was intubated with an endotracheal tube, during a period of 8 minutes. The compression rate and the ventilation rate were recorded during CPR. Results Data on 56 medical students and 41 emergency medical services personnel were analyzed. No significant difference was observed in compression rate ( P =.817); however, median (interquartile range) ventilation rate differed significantly between the CV and CAV groups (8.79 [2.19] per minute vs 9.25 [1.07] per minute, P = .016). In addition, compared with the CV group, adequacy of ventilation rate was better in the CAV group (47.9% vs 85.7%, P Conclusion In comparison with the CV, the CAV is a more accurate method for maintenance of an adequate ventilation rate.