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Antemortem specimens are sometimes the sole sources available for forensic investigation, and samples collected in nonideal ways are inevitably employed to achieve toxicological analysis. It is essential to assess the effects of blood collection tubes on the recoveries of emerging synthetic cathinones (SC) to estimate actual drug concentrations, and no such systematic investigations have been previously carried out. Seventy-one SC with various LogP values were employed to examine commonly used blood collection tubes, including plasma tubes, serum tubes and gel-containing tubes in recoveries which determined by a reliable LC-MS/MS method. Significantly poor recoveries for hydrophobic SC were obtained using serum separating tubes (SST). Notably, the suppressed recoveries in SST can be reversed by adding anticoagulants. Adding a procoagulant to a plasma separating tube (PST) considerably reduced recoveries, which indicated that clotting processes in the presence of polymeric gels contributed to poor recoveries of these hydrophobic drugs. In this study, we find that clotting formation in the presence of polymeric gels could significantly affect the determination of hydrophobic drugs. However, in real-world scenarios, nonideal collection methods are inevitably employed for antemortem specimens. Thus, it is important to rigorously interpret forensic toxicological results, especially for susceptible species.

Whether the electrocardiography (ECG) serial changes predict outcomes in cardiac arrest survivors undergoing therapeutic hypothermia remains unclear.This retrospective observational study enrolled 366 adult nontraumatic cardiac arrest survivors who underwent therapeutic hypothermia in a tertiary transfer center during 2006-2018. The ECG at return of spontaneous circulation (ROSC), during hypothermia and after rewarming were analyzed. 295 cardiac arrest survivors were included. Compared with the survivors, the non-survivors had longer QRS durations at the ROSC (118.33 ± 32.47 ms vs 106.88 ± 29.78 ms, p 0.001) and after rewarming (99.26 ± 25.07 ms vs 93.03 ± 19.09 ms, p = 0.008). The enrolled patients were classified into 4 groups based on QRS duration at the ROSC and after rewarming, namely (1) narrow-narrow (narrow QRS at ROSC and narrow QRS after rewarming, n = 156), (2) narrow-wide (n = 29), (3) wide-narrow (n = 87), and (4) wide-wide (n = 23) group. The wide-wide group had the worst survival rates [odds ratio (OR) = 0.141, p = 0.001], followed by the narrow-wide group (OR 0.223, p = 0.003) and the wide-narrow group (OR 0.389, p = 0.003).In cardiac arrest survivors given therapeutic hypothermia, QRS durations at the ROSC, after rewarming and their changes may predict survival to hospital discharge.

Objective: Heart rate variability (HRV) reflects autonomous nervous system disturbance and is used for seizure prediction. The aim of this study was to develop a real-time, continuous physiological medical signal data acquisition system in seizure detection for intensive care unit (ICU). Methods: This prospective study was conducted in National Taiwan University Hospital from August 2018 to October 2019. This study included 20 patients who (a) had a sustained return of spontaneous circulation following out-of-hospital cardiac arrest, (b) were over 18 years old, (c) and were admitted to the emergency ICU for post-cardiac-arrest care. One-lead electrocardiography and bilateral two-channel electroencephalography recorders were synchronically used to conduct measurements for a maximum of 72 hours. The recorded data were wirelessly real-time transmitted by a proxy transmitting module through an access point and a local gateway. A system with a novel algorithm processed the signals and conducted feature extraction and supervised learning for seizure detection. Results: A total of 89 nonseizure and 83 seizure events were detected by the system. Seizure occurred in two-thirds of the patients assessed by intensivists and neurologists. Four HRV parameters, namely standard deviation of normal-to-normal R-wave intervals, high frequency, low frequency-high frequency ratio, and sample entropy, were determined as potential features for identifying seizures. The sensitivity and specificity of the developed system were 0.74 and 0.81, respectively, and the positive predictive value was 0.82. Conclusion: The developed system can be used to identify seizure events through HRV features. Significance: The current study achieved real-time seizure detection and overcame previous limitations on continuity and accessibility.

Objectives To evaluate whether the recommended observation period of 7 days for cardiac arrest survivors is sufficient for conscious recovery and to identify the variables associated with eventual neurologic recovery among patients with delayed awakening. Design A retrospective cohort study. Setting A single tertiary medical center. Patients Five-hundred twenty-nine nontraumatic adult cardiac arrest survivors with prearrest favorable neurologic function (Cerebral Performance Category 1-2) who survived to hospital discharge during 2011-2019. Interventions The enrolled patients were classified into favorable (Cerebral Performance Category 1-2) and poor (Cerebral Performance Category 3-4) neurologic recovery according to their neurologic function at hospital discharge. Among patients with favorable neurologic recovery, those who recovered within 7 days were assigned to the early recovery group or after 7 days as the late recovery group. Measurements and main results There were 395 patients exhibiting favorable neurologic recovery (n = 357 in the early group, n = 38 in late group) and 134 patients exhibiting poor neurologic recovery (poor recovery group). Among patients who remained unconscious on day 7, delayed awakening was associated with male sex (odds ratio [OR], 3.905; 95% CI, 1.153-13.221), prehospital return of spontaneous circulation (OR, 7.628; 95% CI, 2.084-27.922), therapeutic hypothermia (OR, 4.320; 95% CI, 1.624-11.488), and extracorporeal cardiopulmonary resuscitation (OR, 4.508; 95% CI, 1.414-14.371). Being transferred from another hospital, however, was less likely to be associated with delayed awakening (OR, 0.061; 95% CI, 0.009-0.431). The median duration for patients to regain clear consciousness in the late recovery group was 12.12 days. No patient who recovered consciousness had an unfavorable electroencephalography pattern, however, in patients with poor recovery, the 7-day electroencephalography showed 45 patients with generalized suppression (33.6%), two with burst suppression (1.5%), 14 with seizure/epileptic discharge (10.5%), and one with status epilepticus (0.7%). Conclusions Up to 9.6% of cardiac arrest patients with favorable outcomes recover consciousness after the recommended 7 days of observation, indicating the observation time of 7 days seems justified but longer duration may be needed. The results of the culturally and clinically isolated population may limit the application to other population.

Protocolized postarrest care that includes targeted temperature management (TTM) improves survival and neurological outcomes in cardiac arrest survivors. Whether the accumulated experience regarding the use of the protocolized approach also benefits patients who did not undergo TTM has yet to be investigated. Adults (≥18 years old) with nontraumatic cardiac arrest and who survived to intensive care unit (ICU) admission were retrospectively recruited from a single tertiary medical centre from 2006 to 2009 and 2011 to 2017. Patients were excluded if they had traumatic injuries, were pregnant, did not survive to ICU admission, regained clear consciousness within 3 h after the return of spontaneous circulation, or underwent TTM. The sum of TTM cases since 2006 and before the cardiac arrest of each enrolled patient was used as a substitute index for the amount of experience accumulated from the use of protocolized TTM care. In total, 802 non-TTM patients were enrolled in the final analysis. The rate of survival to hospital discharge increased from 25.9% in 2006 to 33.3% in 2017. Regarding neurological recovery at hospital discharge, the incidence of favourable neurological function (cerebral performance category: 1 or 2) increased from 10.3% in 2006 to 23.5% in 2017. A multiple logistic regression indicated a significant association between the cumulative TTM case numbers and neurological outcomes in patients who did not receive TTM. The improvement of neurological outcomes in adult nontraumatic cardiac arrest survivors who did not receive TTM was associated with the cumulative number of cases receiving protocolized TTM care. In the era of TTM, the use of only historical control data might lead to bias, which is caused by overlooking the influence of a more refined protocolized postarrest care that includes TTM.KEY MESSAGEThe cumulative number of cases receiving protocolized TTM care, which we used as a substitute index for the amount of experience accumulated from the use of protocolized postarrest care that includes TTM, was associated with the improvement of neurological outcomes in adult nontraumatic cardiac arrest survivors who did not receive TTM. The cumulative number of cases receiving protocolized TTM care, which we used as a substitute index for the amount of experience accumulated from the use of protocolized postarrest care that includes TTM, was associated with the improvement of neurological outcomes in adult nontraumatic cardiac arrest survivors who did not receive TTM.

Background Frontline health care workers, including physicians, are at high risk of contracting coronavirus disease (COVID-19) owing to their exposure to patients suspected of having COVID-19. Objective The aim of this study was to evaluate the benefits and feasibility of a double triage and telemedicine protocol in improving infection control in the emergency department (ED). Methods In this retrospective study, we recruited patients aged ≥20 years referred to the ED of the National Taiwan University Hospital between March 1 and April 30, 2020. A double triage and telemedicine protocol was developed to triage suggested COVID-19 cases and minimize health workers’ exposure to this disease. We categorized patients attending video interviews into a telemedicine group and patients experiencing face-to-face interviews into a conventional group. A questionnaire was used to assess how patients perceived the quality of the interviews and their communication with physicians as well as perceptions of stress, discrimination, and privacy. Each question was evaluated using a 5-point Likert scale. Physicians’ total exposure time and total evaluation time were treated as primary outcomes, and the mean scores of the questions were treated as secondary outcomes. Results The final sample included 198 patients, including 93 cases (47.0%) in the telemedicine group and 105 cases (53.0%) in the conventional group. The total exposure time in the telemedicine group was significantly shorter than that in the conventional group (4.7 minutes vs 8.9 minutes, P Conclusions The implementation of the double triage and telemedicine protocol in the ED during the COVID-19 pandemic has high potential to improve infection control.

BACKGROUND Frontline health care workers, including physicians, are at high risk of contracting coronavirus disease (COVID-19) owing to their exposure to patients suspected of having COVID-19. OBJECTIVE The aim of this study was to evaluate the benefits and feasibility of a double triage and telemedicine protocol in improving infection control in the emergency department (ED). METHODS In this retrospective study, we recruited patients aged ≥20 years referred to the ED of the National Taiwan University Hospital between March 1 and April 30, 2020. A double triage and telemedicine protocol was developed to triage suggested COVID-19 cases and minimize health workers’ exposure to this disease. We categorized patients attending video interviews into a telemedicine group and patients experiencing face-to-face interviews into a conventional group. A questionnaire was used to assess how patients perceived the quality of the interviews and their communication with physicians as well as perceptions of stress, discrimination, and privacy. Each question was evaluated using a 5-point Likert scale. Physicians’ total exposure time and total evaluation time were treated as primary outcomes, and the mean scores of the questions were treated as secondary outcomes. RESULTS The final sample included 198 patients, including 93 cases (47.0%) in the telemedicine group and 105 cases (53.0%) in the conventional group. The total exposure time in the telemedicine group was significantly shorter than that in the conventional group (4.7 minutes vs 8.9 minutes, PPPP CONCLUSIONS The implementation of the double triage and telemedicine protocol in the ED during the COVID-19 pandemic has high potential to improve infection control.

Purpose Although hemodynamic instability is expected during the post-cardiac arrest period, the implications of hemodynamic parameters for outcomes remain unclear. Each phase of targeted temperature management (TTM) affects hemodynamic responses differently. This study aims to investigate the association of hemodynamic parameters with outcomes in patients receiving TTM after cardiac arrest. Methods The study prospectively enrolled patients who were treated with TTM (33 °C for 24 h) after cardiac arrest. We assessed clinical and hemodynamic variables at pre-specified time points in survivors and non-survivors as well as among those with favorable vs. poor neurologic outcomes at discharge. Results The study analyzed the records of 95 patients who completed TTM; at discharge 54 (57%) were alive and 21 (22%) had favorable neurological outcomes. Heart rate(HR) at 24 h > 93/min, cardiac index (CI) at 12 h 2 and lower average of mean arterial blood pressure(MAP) at 36 h and 48 h were independently associated with in-hospital mortality (P Conclusions Our results indicate that lower MAP and HR more than 93/min are associated with in-hospital mortality during the initial 48 h after ROSC. CI at 12 h 2 is associated with survival but not with neurological outcome. During the course of post-cardiac arrest TTM, these markers of hemodynamic status may be useful predictors of outcomes.

s / Resuscitation 96S (2015) 43–157 135 trend toward higher frequency of Gram-negative bacteria in OHCA patients compared to IHCA (22% vs 12%; p=0.08). Therewas no difference in the rate of fungal infection betweenOHCAand IHCA (15% vs 14%; p=0.8). Conclusion: Approximately one third of post-arrest patients hadpathogenic respiratorymicroorganisms in the early post-arrest period. The most common isolates were Gram-negative bacteria. Overall, there is no difference in the prevalence in culture positive results between OHCA and IHCA. http://dx.doi.org/10.1016/j.resuscitation.2015.09.320