The appropriateness of single page of activation of the cardiac catheterization laboratory by emergency physician for patients with suspected ST-segment elevation myocardial infarction: a cohort study

<p>Abstract</p> <p>Background</p> <p>The early use of reperfusion therapy has a significant effect on the prognosis of patients with ST-segment elevation myocardial infarction (STEMI), and it is recommended that emergency department (ED) physicians activate the cardiac catheterization laboratory (CCL) as soon as possible to treat these patients. The aim of this study was to examine the appropriateness of emergency physician activation of the CCL for patients with suspected STEMI. Inappropriate activations (i.e., false positive activations) were identified according to a variety of criteria.</p> <p>Methods</p> <p>All patients with emergency physician CCL activations between August 2009 and April 2011 were included in the study. False positive cases were defined according to ECG criteria and cardiologists' reviews of patients' initial clinical information.</p> <p>Results</p> <p>ED physicians used a STEMI page to activate the CCL 117 times. According to reviews by cardiologists, this activation was appropriate 89.8% of the time (in 105/117 cases). Truly unnecessary activation (i.e., cases in which STEMI was not identified by the cardiologists, no clear culprit coronary artery was present, no significant coronary artery disease and cardiac biomarkers were negative) occurred 5.1% of the time (in 6/117 cases).</p> <p>Conclusions</p> <p>CCL activation was appropriate for most patients and was unnecessary in a relatively small percentage of cases. This result supports the current recommendation for CCL activation by emergency physicians. Such early activation is a key strategy in the reduction of door-to-balloon time.</p

Assessment of serum biomarkers and coagulation/fibrinolysis markers for prediction of neurological outcomes of out of cardiac arrest patients treated with therapeutic hypothermia

Objective Despite increased survival in patients with cardiac arrest, it remains difficult to determine patient prognosis at the early stage. This study evaluated the prognosis of cardiac arrest patients using brain injury, inflammation, cardiovascular ischemic events, and coagulation/fibrinolysis markers collected 24, 48, and 72 hours after return of spontaneous circulation (ROSC). Methods From January 2011 to December 2016, we retrospectively observed patients who underwent therapeutic hypothermia. Blood samples were collected immediately and 24, 48, and 72 hours after ROSC. Neuron-specific enolase (NSE), S100-B protein, procalcitonin, troponin I, creatine kinase-MB, pro-brain natriuretic protein, D-dimer, fibrin degradation product, antithrombin-III, fibrinogen, and lactate levels were measured. Prognosis was evaluated using Glasgow-Pittsburgh cerebral performance categories and the predictive accuracy of each marker was evaluated. The secondary outcome was whether the presence of multiple markers improved prediction accuracy. Results A total of 102 patients were included in the study: 39 with good neurologic outcomes and 63 with poor neurologic outcomes. The mean NSE level of good outcomes measured 72 hours after ROSC was 18.50 ng/mL. The area under the curve calculated on receiver operating characteristic analysis was 0.92, which showed the best predictive power among all markers included in the study analysis. The relative integrated discrimination improvement and category-free net reclassification improvement models showed no improvement in prognostic value when combined with all other markers and NSE (72 hours). Conclusion Although biomarker combinations did not improve prognostic accuracy, NSE (72 hours) showed the best predictive power for neurological prognosis in patients who received therapeutic hypothermia

Differences in youngest-old, middle-old, and oldest-old patients who visit the emergency department

Objective As aging progresses, clinical characteristics of elderly patients in the emergency department (ED) vary by age. We aimed to study differences among elderly patients in the ED by age group. Methods For 2 years, patients aged 65 and older were enrolled in the study and classified into three groups: youngest-old, ages 65 to 74 years; middle-old, 75 to 84 years; and oldest-old, ≥85 years. Participants’ sex, reason for ED visit, transfer from another hospital, results of treatment, type of admission, admission department and length of stay were recorded. Results During the study period, a total 64,287 patients visited the ED; 11,236 (17.5%) were aged 65 and older, of whom 14.4% were 85 and older. With increased age, the female ratio (51.5% vs. 54.9% vs. 69.1%, P<0.001), medical causes (79.5% vs. 81.3% vs. 81.7%, P=0.045), and admission rate (35.3% vs. 42.8% vs. 48.5%, P<0.001) increased. Admissions to internal medicine (57.5% vs. 59.3% vs. 64.7%, P<0.001) and orthopedic surgery (8.5% vs. 11.6% vs. 13.8%, P< 0.001) also increased. The ratio of admission to intensive care unit showed no statistical significance (P=0.545). Patients over age 85 years had longer stays in the ED (330.9 vs. 378.9 vs. 407.2 minutes, P<0.001), were discharged home less (84.4% vs. 78.9% vs. 71.5%, P<0.001), and died more frequently (6.3% vs. 10.4% vs. 13.0%, P<0.001). Conclusion With increased age, the proportion of female patients and medical causes increased. Rates of admission and death increased with age and older patients had longer ED and hospital stays

High white blood cell count and erythrocyte sedimentation rate are associated with perforated appendicitis in children

Purpose To investigate the predictors of perforated appendicitis (PA) in pediatric patients with appendicitis seen in the emergency department. Methods We retrospectively reviewed 564 pediatric patients ( 13.5 × 109/L (odds ratio [OR], 3.27; confidence interval [CI], 1.49-7.18; P = 0.003) and ESR > 15 mm/h (OR, 3.18; 95% CI, 2.13-4.74; P < 0.001) are independent predictors of PA. Conclusion WBC count and ESR might be better predictors of PA in pediatric patients with appendicitis in the emergency department than the Alvarado score and CRP concentration

Factors associated with administration of analgesics for children with forearm fracture

Purpose Analgesia is essential for the treatment of children’s fracture. We aimed to investigate the factors associated with administration of analgesics in children with forearm fracture. Methods We retrospectively reviewed medical records of children (< 20 years) with forearm fracture who visited 2 tertiary hospital emergency departments from 2014 to 2015. We analyzed factors, such as gender, age, whether the mother accompanied the visit, visiting time and route, mechanism of injury, duration of symptoms, complicated fracture, manual reduction, surgery, and type and route of analgesics. We also performed logistic regression analysis to identify the factors associated with administration of analgesics. Results Of 179 children with forearm fracture, 48 (26.8%) were administered analgesics. These children showed older age, shorter duration of symptoms, and more frequent visit with their mothers, visit during the day, use of emergency medical services, and surgery. After logistic regression analysis, we found use of emergency medical service (adjusted odds ratio [OR], 8.73; 95% confidence interval [CI], 3.16-24.08; P < 0.001), visit with the mother (OR, 6.23; 95% CI, 1.68-23.09; P = 0.006), age (OR, 1.18; 95% CI, 1.05-1.32; P = 0.004), and duration of symptoms (OR, 0.99; 95% CI, 0.986-0.999; P = 0.035) as the factors associated with administration of analgesics. Conclusion The factors associated with administration of analgesics might be communicating skill-related factors, such as older age and shorter duration of symptoms. Children with poor communicating skill may need more aggressive analgesia in the emergency department

Variability of extracorporeal cardiopulmonary resuscitation utilization for refractory adult out-of-hospital cardiac arrest: an international survey study.

Objective: A growing interest in extracorporeal cardiopulmonary resuscitation (ECPR) as a rescue strategy for refractory adult out-of-hospital cardiac arrest (OHCA) currently exists. This study aims to determine current standards of care and practice variation for ECPR patients in the USA and Korea. Methods: In December 2015, we surveyed centers from the Korean Hypothermia Network (KORHN) Investigators and the US National Post-Arrest Research Consortium (NPARC) on current targeted temperature management and ECPR practices. This project analyzes the subsection of questions addressing ECPR practices. We summarized survey. Results: Overall, 9 KORHN and 4 NPARC centers reported having ECPR programs and had complete survey data available. Two KORHN centers utilized extracorporeal membrane oxygenation only for postarrest circulatory support in patients with refractory shock and were excluded from further analysis. Centers with available ECPR generally saw a high volume of OHCA patients (10/11 centers care for \u3e75 OHCA a year). Location of, and providers trained for cannulation varied across centers. All centers in both countries (KORHN 7/7, NPARC 4/4) treated comatose ECPR patients with targeted temperature management. All NPARC centers and four of seven KORHN centers reported having a standardized hospital protocol for ECPR. Upper age cutoff for eligibility ranged from 60 to 75 years. No absolute contraindications were unanimous among centers. Conclusion: A wide variability in practice patterns exist between centers performing ECPR for refractory OHCA in the US and Korea. Standardized protocols and shared research databases might inform best practices, improve outcomes, and provide a foundation for prospective studies

Rapamycin Rescues the Poor Developmental Capacity of Aged Porcine Oocytes

Unfertilized oocytes age inevitably after ovulation, which limits their fertilizable life span and embryonic development. Rapamycin affects mammalian target of rapamycin (mTOR) expression and cytoskeleton reorganization during oocyte meiotic maturation. The goal of this study was to examine the effects of rapamycin treatment on aged porcine oocytes and their in vitro development. Rapamycin treatment of aged oocytes for 24 h (68 h in vitro maturation [IVM]; 44 h+10 μM rapamycin/24 h, 47.52±5.68) or control oocytes (44 h IVM; 42.14±4.40) significantly increased the development rate and total cell number compared with untreated aged oocytes (68 h IVM, 22.04±5.68) (p<0.05). Rapamycin treatment of aged IVM oocytes for 24 h also rescued aberrant spindle organization and chromosomal misalignment, blocked the decrease in the level of phosphorylated-p44/42 mitogen-activated protein kinase (MAPK), and increased the mRNA expression of cytoplasmic maturation factor genes (MOS, BMP15, GDF9, and CCNB1) compared with untreated, 24 h-aged IVM oocytes (p<0.05). Furthermore, rapamycin treatment of aged oocytes decreased reactive oxygen species (ROS) activity and DNA fragmentation (p<0.05), and downregulated the mRNA expression of mTOR compared with control or untreated aged oocytes. By contrast, rapamycin treatment of aged oocytes increased mitochondrial localization (p<0.05) and upregulated the mRNA expression of autophagy (BECN1, ATG7, MAP1LC3B, ATG12, GABARAP, and GABARAPL1), anti-apoptosis (BCL2L1 and BIRC5; p<0.05), and development (NANOG and SOX2; p<0.05) genes, but it did not affect the mRNA expression of pro-apoptosis genes (FAS and CASP3) compared with the control. This study demonstrates that rapamycin treatment can rescue the poor developmental capacity of aged porcine oocytes

Variability of extracorporeal cardiopulmonary resuscitation utilization for refractory adult out-of-hospital cardiac arrest: an international survey study

Objective A growing interest in extracorporeal cardiopulmonary resuscitation (ECPR) as a rescue strategy for refractory adult out-of-hospital cardiac arrest (OHCA) currently exists. This study aims to determine current standards of care and practice variation for ECPR patients in the USA and Korea. Methods In December 2015, we surveyed centers from the Korean Hypothermia Network (KORHN) Investigators and the US National Post-Arrest Research Consortium (NPARC) on current targeted temperature management and ECPR practices. This project analyzes the subsection of questions addressing ECPR practices. We summarized survey results using descriptive statistics. Results Overall, 9 KORHN and 4 NPARC centers reported having ECPR programs and had complete survey data available. Two KORHN centers utilized extracorporeal membrane oxygenation only for postarrest circulatory support in patients with refractory shock and were excluded from further analysis. Centers with available ECPR generally saw a high volume of OHCA patients (10/11 centers care for >75 OHCA a year). Location of, and providers trained for cannulation varied across centers. All centers in both countries (KORHN 7/7, NPARC 4/4) treated comatose ECPR patients with targeted temperature management. All NPARC centers and four of seven KORHN centers reported having a standardized hospital protocol for ECPR. Upper age cutoff for eligibility ranged from 60 to 75 years. No absolute contraindications were unanimous among centers. Conclusion A wide variability in practice patterns exist between centers performing ECPR for refractory OHCA in the US and Korea. Standardized protocols and shared research databases might inform best practices, improve outcomes, and provide a foundation for prospective studies