Recovery from acute kidney injury is an independent predictor of survival at 30 days only after out-of-hospital cardiac arrest who were treated by targeted temperature management

Background: Development of acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) is associated with mortality and poor neurological outcome. However, the effect of recovery from AKI after OHCA is uncertain. This study investigates whether recovery from AKI was associated with the rate of survival and neurological outcome at 30 days after OHCA. Methods: This is a prospective multicentre observational cohort study of adult OHCA patients treated with targeted temperature management (TTM) across five hospitals in South Korea between February 2019 and July 2020. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. The primary outcome was the rate of survival at 30 days, and the secondary outcome was the rate of survival with a favourable neurological outcome at 30 days, defined by a score of 3 or less on the modified Rankin scale. Results: Among the 2,018 patients with OHCA, 79 were treated with TTM. After excluding two patients with incomplete data on outcomes, 77 were analysed. AKI developed in 43 (56%) patients. Among them, 22 (51%) recovered from AKI. Although the rate of survival at 30 days for the recovery group was superior to the non-recovery group (82% vs. 24%, P < 0.001), the rate of survival with a favourable neurological outcome at 30 days for the recovery group was not different than that for the non-recovery group (32% vs. 10%, P = 0.132). Recovery from AKI was an independent predictor of survival at 30 days after OHCA in the multivariate analysis (adjusted odds ratio, 22.737; 95% confidence interval, 3.814-135.533; P = 0.001); however, it was not associated with a favourable neurological outcome at 30 days after OHCA in the multivariate analysis. Conclusion: Recovery from AKI was an independent predictor of survival at 30 days only after OHCA who were treated by TTMope

Machine Learning Model Development and Validation for Predicting Outcome in Stage 4 Solid Cancer Patients with Septic Shock Visiting the Emergency Department: A Multi-Center, Prospective Cohort Study

A reliable prognostic score for minimizing futile treatments in advanced cancer patients with septic shock is rare. A machine learning (ML) model to classify the risk of advanced cancer patients with septic shock is proposed and compared with the existing scoring systems. A multi-center, retrospective, observational study of the septic shock registry in patients with stage 4 cancer was divided into a training set and a test set in a 7:3 ratio. The primary outcome was 28-day mortality. The best ML model was determined using a stratified 10-fold cross-validation in the training set. A total of 897 patients were included, and the 28-day mortality was 26.4%. The best ML model in the training set was balanced random forest (BRF), with an area under the curve (AUC) of 0.821 to predict 28-day mortality. The AUC of the BRF to predict the 28-day mortality in the test set was 0.859. The AUC of the BRF was significantly higher than those of the Sequential Organ Failure Assessment score and the Acute Physiology and Chronic Health Evaluation II score (both p < 0.001). The ML model outperformed the existing scores for predicting 28-day mortality in stage 4 cancer patients with septic shock. However, further studies are needed to improve the prediction algorithm and to validate it in various countries. This model might support clinicians in real-time to adopt appropriate levels of care.ope

Association between the body mass index and outcomes of patients resuscitated from out-of-hospital cardiac arrest: a prospective multicentre registry study

Background: The effects of the body mass index (BMI) on outcomes of patients resuscitated from cardiac arrest are controversial. Therefore, the current study investigated the association between the BMI and the favourable neurologic outcomes and survival to discharge of patients resuscitated from out-of-hospital cardiac arrest (OHCA). Methods: This multicentre, prospective, nationwide OHCA registry-based study was conducted using data from the Korean Cardiac Arrest Resuscitation Consortium (KoCARC). We enrolled hospitals willing to collect patient height and weight and included patients who survived to the hospital between October 2015 and June 2018. The included patients were categorised into the underweight (< 18.5 kg/m2), normal weight (≥18.5 to < 25 kg/m2), overweight (≥25 to < 30 kg/m2), and obese groups (≥30 kg/m2) according to the BMI per the World Health Organization (WHO) criteria. The primary outcome was a favourable neurologic outcome; the secondary outcome was survival to discharge. Univariate and multivariate analyses were performed to investigate the association between BMI and outcomes. Results: Nine hospitals were enrolled; finally, 605 patients were included in our analysis and categorised per the WHO BMI classification. Favourable neurologic outcomes were less frequent in the underweight BMI group than in the other groups (p = 0.002); survival to discharge was not significantly different among the BMI groups (p = 0.110). However, the BMI classification was not associated with favourable neurologic outcomes or survival to discharge after adjustment in the multivariate model. Conclusion: The BMI was not independently associated with favourable neurologic and survival outcomes of patients surviving from OHCA.ope

An observational study of surface versus endovascular cooling techniques in cardiac arrest patients: a propensity-matched analysis

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

A Simulation Analysis for the Shortening of the Patients' Stay Time in the Emergency Department

The purpose of this research is to find the reasons of overcrowding in the emergency department of an hospital, then to shorten the total stay time of patients. The fact that main causes of the overcrowding exist in the process of the emergency department was discovered by analysis of the data. In order to improve these process, simulation model was developed by ARENA 7.0. Staff's service time, staff's organization, process ratio, and patient's waiting time were estimated in the simulation model in consideration of the decision of the patient's course of action. Several scenarios such as the simplification of the process, the setup of dedicated pathology lab, and mixed method were suggested and evaluated. Total stay time of the patients would be reduced up to 28.45%.ope

Vasospasm-related Sudden Cardiac Death Has Outcomes Comparable with Coronary Stenosis in Out-of-Hospital Cardiac Arrest

Background: Characteristics of coronary vasospasm-related sudden cardiac death are not well understood. We aimed to compare the characteristics and clinical outcomes between coronary vasospasm and stenosis, in out-of-hospital cardiac arrest (OHCA) survivors, who underwent coronary angiogram (CAG). Methods: We conducted a multicenter retrospective observational registry-based study at 8 Korean tertiary care centers. Data of OHCA survivors undergoing CAG between 2010 and 2015 were extracted. Patients were divided into vasospasm and stenosis (stenosis > 50%) groups based on CAG findings. The primary and the secondary outcomes were survival and a good neurologic outcome at 30 days after OHCA. Patients in the vasospasm and stenosis groups were propensity score matched. Results: Of the 413 included patients, vasospasm and stenosis groups comprised 87 and 326 patients, respectively. There were 279 (66.7%) survivors and 206 (49.3%) patients with good neurologic outcomes. The vasospasm group had better clinical characteristics for outcome (younger age, less diabetes and hypertension, more prehospital restoration of spontaneous circulation, higher Glasgow Coma Scale, less ST segment elevation, and less requirement of circulatory support). The vasospasm group had better survival (75/87 vs. 204/326, P < 0.001) and good neurologic outcomes (62/87 vs. 144/326, P < 0.001). However, vasospasm was not independently associated with survival (odds ratio [OR], 0.980; 95% confidence interval [CI], 0.400-2.406) or neurologic outcomes (OR, 0.870; 95% CI, 0.359-2.108) after adjustment and vasospasm was not associated with survival and neurologic outcome in propensity score-matched cohorts. Conclusion: Our analysis of propensity score-matched cohorts finds that vasospasm OHCA survivors have survival and neurologic outcomes comparable with those of stenotic OHCA survivors.ope

Development and validation of the VitaL CLASS score to predict mortality in stage IV solid cancer patients with septic shock in the emergency department: a multi-center, prospective cohort study

Background: Clinical decision-making of invasive high-intensity care for critically ill stage IV cancer patients in the emergency department (ED) is challenging. A reliable and clinically available prognostic score for advanced cancer patients with septic shock presented at ED is essential to improve the quality of intensive care unit care. This study aimed to develop a new prognostic score for advanced solid cancer patients with septic shock available early in the ED and to compare the performance to the previous severity scores. Methods: This multi-center, prospective cohort study included consecutive adult septic shock patients with stage IV solid cancer. A new scoring system for 28-day mortality was developed and validated using the data of development (January 2016 to December 2017; n = 469) and validation sets (January 2018 to June 2019; n = 428). The developed score's performance was compared to that of the previous severity scores. Results: New scoring system for 28-day mortality was based on six variables (score range, 0-8): vital signs at ED presentation (respiratory rate, body temperature, and altered mentation), lung cancer type, and two laboratory values (lactate and albumin) in septic shock (VitaL CLASS). The C-statistic of the VitaL CLASS score was 0.808 in the development set and 0.736 in the validation set, that is superior to that of the Sequential Organ Failure Assessment score (0.656, p = 0.01) and similar to that of the Acute Physiology and Chronic Health Evaluation II score (0.682, p = 0.08). This score could identify 41% of patients with a low-risk group (observed 28-day mortality, 10.3%) and 7% of patients with a high-risk group (observed 28-day mortality, 73.3%). Conclusions: The VitaL CLASS score could be used for both risk stratification and as part of a shared clinical decision-making strategy for stage IV solid cancer patients with septic shock admitting at ED within several hours.ope

2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 5. Post-cardiac arrest care

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Development of an Emergency Abdominal Ultrasound Course in Korea: 1-Year Experience

Purpose: This report describes our 1-year experience with an emergency abdominal ultrasound course that we developed for emergency medicine residents and physicians. Methods: The five-hour course consisted of didactic lectures and hands-on practice. A 1-hour didactic lecture was provided. The lecture consisted of basic ultrasound physics and principles, and anatomy for abdominal ultrasound. In the hands-on session, the instructors demonstrated the abdominal ultrasound techniques and then the students practiced on standard patients. Participants evaluated the programs using a five or ten point Likert scale. After two months to one year, the participants evaluated the usefulness of the course, their knowledge, and their self confidence. Results: A total of 61 trainees participated in eight courses. The evaluation scores for overall quality of content, clinical utility, quality of educational method, quality of instructor, and time allocation were 4.4±0.7, 4.5±0.6, 4.3±0.6, 4.4 ±0.6, 4.1±0.7, respectively. Score of self-confidence of each scan before and after the course were as follows: liver scan, 3.2±2.1 to 6.9±1.2; gallbladder and bile duct scan 3.0±2.5 to 6.9±1.2; pancreas scan, 2.4±2.1 to 6.3±1.3; renal scan, 3.6±2.6 to 7.6±1.3. Evaluation scores were followed up after two months to one year to estimate self confidence of each scan. Results were as follows: liver scan, 6.1±1.5; gallbladder and bile duct scan, 6.5±1.6; pancreas scan, 5.5±1.8; renal scan, 7.2±1.5. Conclusion: The Emergency Abdominal Ultrasound Course is a fairly successful course. But continuous improvement of educational content, and development of an objective evaluation tool need to be done.ope

Current Duty Hours of Emergency Resident Physicians in Korea: Multicenter Cross-sectional Study

Purpose: This study was conducted in order to determine the current status of duty hours of emergency resident physicians in Korea. Methods: The training committee of the Korean Society of Emergency Medicine surveyed using a questionnaire on resident training status, which contained the total number of duty hours during four weeks of July (first to 28th day) according to the grades of the resident physician. The proportions of both irregular working hours and independent working hours without supervision of a board certified physician were also evaluated. Results: Responses from 80 hospitals out of 97 training hospitals were analyzed. The average number of duty hours of emergency resident physicians was 63.7±10.7 hours/week. The proportion of hospitals for which the average number of duty hours exceeded 80 hours/week was 16.1%. Irregular working hours consisted of 63.9%. Residents in 15(18.7%) hospitals worked 3.7~73.5% of their duty hours without supervision of a board certified physician. The higher grade resident had fewer working hours (p<0.001). No statistical difference was observed in the rate of both irregular work and unsupervised work according to the grade. Conclusion: Results of this study showed that nine(11.3%) hospitals had average duty hours above 80 hours/week. In Korea, training hospitals should prepare to minimize the impact of duty hour restriction in the near future, as well as to improve training quality.ope