Impact of Difficult Airway Training on Performance of Korean Paramedic Students in Simulated Normal and Difficult Airway Scenarios: A Randomized Educational Intervention Study

Aim: Evaluate the impact of difficult airway traning on Korean paramedic students' performance during manikin-based airway management simulations. Methods: 40 Korean paramedic students with previous training in airway management and endotracheal intubation were randomly assigned to an intervention or control group. Students in the intervention group completed 16 additional hours of training using curriculum from the Difficult Airway Course<sup>™</sup>. Both groups were then tested on a series of airway management scenarios using a Laerdal SimMan<sup>®</sup> manikin. Results: All participants were able to secure the airway in a normal intubaion scenario, though the intervention group did so fasster on average (121.9 seconds vs. 161.2 seconds in the control group, p=.04). None of the students in the control group were able to secure the airway of a manikin manifesting tongue edema, shile 18 of 20 students in the intervention group sere successful. Students in both groups were equally likily to secure the airway of a manikin fitted with a cervical spine immobilization collar. Students in the intervention group were more likely to employ video laryngoscopy or use a gum elastic bougie to assist during intubaion. On average, students in the intervention group scored significantly higher on a checklist of airway management maneuvers for all three scenarios (p<.001) and reported higher confidence in their ability to manage both a normal and difficult airway (p=0.011 and p=0.003, respectively). Conclusion: Difficult airway training improves Korean paramedic students' performance on simulated airway managenent scenarios

Translation, Cultural Adaptation, and Validation of a Korean Version of the Information Needs in Cardiac Rehabilitation Scale

Objective To translate and culturally adapt the Information Needs in Cardiac Rehabilitation (INCR) questionnaire into Korean and perform psychometric validation. Methods The original English version of the INCR, in which patients are asked to rate the importance of 55 topics, was translated into Korean (INCR-K) and culturally adapted. The INCR-K was tested on 101 cardiac rehabilitation (CR) participants at Kangwon National University Hospital and Seoul National University Bundang Hospital in Korea. Structural validity was assessed using principal component analysis, and Cronbach’s alpha of the areas was computed. Criterion validity was assessed by comparing information needs according to CR duration and knowledge sufficiency according to receipt of education. Half of the participants were randomly selected for 1 month of re-testing to assess their responsiveness. Results Following cognitive debriefing, the number of items was reduced to 41 and ratings were added to assess participants’ sufficient knowledge of each item. The INCR-K structure comprised eight areas, each with sufficient internal consistency (Cronbach’s alpha>0.7). Criterion validity was supported by significant differences in mean INCR-K scores based on CR duration and knowledge sufficiency ratings according to receipt of education (p<0.05). Information needs and knowledge sufficiency ratings increased after 1 month of CR, thus supporting responsiveness (p<0.05). Conclusion The INCR-K demonstrated adequate face, content, cross-cultural, structural, and criterion validities, internal consistency, and responsiveness. Information needs changed with CR, such that multiple assessments of information needs may be warranted as rehabilitation progresses to facilitate patient-centered education

Validation of the Korean criteria for trauma team activation

Objective We conducted a study to validate the effectiveness of the Korean criteria for trauma team activation (TTA) and compared its results with a two-tiered system. Methods This observational study was based on data from the Korean Trauma Data Bank. Within the study period, 1,628 trauma patients visited our emergency department, and 739 satisfied the criteria for TTA. The rates of overtriage and undertriage in the Korean one-tiered system were compared with the two-tiered system recommended by the American College of Surgery-Committee on Trauma. Results Most of the patient’s physiologic factors reflected trauma severity levels, but anatomical factors and mechanism of injury did not show consistent results. In addition, while the rate of overtriage (64.4%) was above the recommended range according to the Korean criteria, the rate of undertriage (4.0%) was within the recommended range. In the simulated two-tiered system, the rate of overtriage was reduced by 5.5%, while undertriage was increased by 1.8% compared to the Korean activation system. Conclusion The Korean criteria for TTA showed higher rates of overtriage and similar undertriage rates compared to the simulated two-tier system. Modification of the current criteria to a two-tier system with special considerations would be more effective for providing optimum patient care and medical resource utilization

Sensitivity, specificity, and predictive value of cardiac symptoms assessed by emergency medical services providers in the diagnosis of acute myocardial infarction: a multi-center observational study

Objective For patients with acute myocardial infarction (AMI), symptoms assessed by emergency medical services (EMS) providers have a critical role in prehospital treatment decisions. The purpose of this study was to evaluate the diagnostic accuracy of EMS provider-assessed cardiac symptoms of AMI. Methods Patients transported by EMS to 4 study hospitals from 2008 to 2012 were included. Using EMS and administrative emergency department databases, patients were stratified according to the presence of EMS-assessed cardiac symptoms and emergency department diagnosis of AMI. Cardiac symptoms were defined as chest pain, dyspnea, palpitations, and syncope. Disproportionate stratified sampling was used, and medical records of sampled patients were reviewed to identify an actual diagnosis of AMI. Using inverse probability weighting, verification bias-corrected diagnostic performance was estimated. Results Overall, 92,353 patients were enrolled in the study. Of these, 13,971 (15.1%) complained of cardiac symptoms to EMS providers. A total of 775 patients were sampled for hospital record review. The sensitivity, specificity, positive predictive value, and negative predictive value of EMS provider-assessed cardiac symptoms for the final diagnosis of AMI was 73.3% (95% confidence interval [CI], 70.8 to 75.7), 85.3% (95% CI, 85.3 to 85.4), 3.9% (95% CI, 3.6 to 4.2), and 99.7% (95% CI, 99.7 to 99.8), respectively. Conclusion We found that EMS provider-assessed cardiac symptoms had moderate sensitivity and high specificity for diagnosis of AMI. EMS policymakers can use these data to evaluate the pertinence of specific prehospital treatment of AMI

Ketamine use for endotracheal intubation in severe sepsis and septic shock

Objective. We conducted this study to evaluate the clinical outcomes of patients with severe sepsis and septic shock who were treated with ketamine for endotracheal intubation. Methods. A single-center, retrospective study was carried out to compare the outcomes of patients with severe sepsis and septic shock who received a ketamine or non-ketamine agent for rapid sequence intubation (RSI). We analyzed the sepsis registry for adult patients who presented to the emergency department (ED), met the criteria for severe sepsis or septic shock, and underwent endotracheal intubation between August 2008 and March 2014. Te primary outcome was 28-day mortality. We performed a multivariable logistic regression analysis to assess the association between ketamine use for intubation and 28-day mortality. Results. In all, 170 patients were intubated during the study period. Of the eligible patients, 95 received ketamine and 75 received a non-ketamine agent. Te 28-day mortality of the ketamine group was not signifcantly diferent from that of the nonketamine group (38% vs. 40%, respectively,P=0.78). Te unadjusted odds ratio (OR) of ketamine use for 28-day mortality was 0.92 (95% CI: 0.49–1.70, P=0.78). Te association remained insignifcant afer adjusting for age, gender, malignancy, initial lactate level on ED admission, time to frst antibiotic administration, Acute Physiology and Chronic Health Evaluation II score on admission day, and propensity score regarding ketamine use (adjusted OR: 1.09; 95% confdence interval [CI]: 0.49–2.40;P=0.84). Initial serum lactate on ED admission was the only signifcant predictive factor of 28-day mortality (adjusted OR: 1.23; 95% CI: 1.10–1.38; P<0.01). Conclusions. For patients with severe sepsis and septic shock who were intubated using RSI, we found no signifcant diference in 28-day mortality between those who received ketamine as a sedative agent and those who received alternative sedatives

Effect of typhoons on the Korean national emergency medical service system

Objective While the effect of typhoons on emergency medicine has been evaluated, data are scarce on their effects on the emergency medical service (EMS). This study evaluated the effect of typhoons on EMS patients and performance. Methods The study period was January 2010 to December 2012. Meteorological data regarding typhoons were provided by the Korean Meteorological Administration. EMS data were retrieved from the EMS database of the national emergency management agency. The database includes ambulance run sheets, which contain clinical and operational data. In this case-crossover study, the cases and controls were EMS calls on the day of typhoon warnings and calls one week prior to the typhoon warnings, respectively. Results During the study period, 11 typhoons affected Korea. A total of 14,521 cases were selected for analysis. Overall, there were no obvious differences between the case and control groups. However, there were statistically significant differences in age, place, and time requests. There were fewer patients between 0 and 15 years of age (P=0.01) and more unconscious patients (P=0.01) in the case group. The EMS operational performance, as measured by the times elapsed between call to start, call to field, and call to hospital did not differ significantly. There was also no significant difference in the time from hospital arrival between the cases (28.67, standard deviation 16.37) and controls (28.97, standard deviation 28.91) (P=0.39). Conclusion Typhoons did not significantly affect the EMS system in this study. Further study is necessary to understand the reasons for this finding

Anti-Diarrheal Effects of a Combination of Korean Traditional Herbal Extracts and Dioctahedral Smectite on Piglet Diarrhea Caused by Escherichia coli and Salmonella typhimurium

The present study evaluated anti-diarrheal effects of a mixture of Coptidis rhizoma, Lonicerae flos, and Paeonia japonica (1:1:1, v/v/v) methanol extracts and dioctahedral smectite (CLPD) on piglet diarrhea caused by Escherichia coli (E. coli) and Salmonella typhimurium (S. typhimurium). Diarrhea index of group 1 administered by 0.5% CLPD mixed with feed, decreased with the passage of time and was insignificantly differed compared to that of control. In group 2 administered by 1.0% CLPD mixed with feed, diarrhea index was significantly decreased compared to that of control and group I during overall experimental periods (P<0.05). After administration of CLPD mixed with feed, the number of E. coli and S. typhimurium in piglet feces of group 1 except for the 1st day was significantly decreased compared to that of the control group (P<0.05), and the number of E. coli and S. typhimurium in piglet feces of group 2 except for the 1st day was significantly decreased compared to that of the control group and group I (P<0.05). This study showed that CLPD had anti-diarrheal effect on E. coli and S. typhimurium causing diarrhea in piglets. CLPD could be an effective candidate for the treatment of enteric bacterial infections in piglets

Cutaneous Polyarteritis Nodosa Presented with Digital Gangrene: A Case Report

Cutaneous polyarteritis nodosa (CPAN) is an uncommon form of vasculitis involving small and medium sized arteries of unknown etiology. The disease can be differentiated from polyarteritis nodosa by its limitation to the skin and lack of progression to visceral involvement. The characteristic manifestations are subcutaneous nodule, livedo reticularis, and ulceration, mostly localized on the lower extremity. Arthralgia, myalgia, peripheral neuropathy, and constitutional symptoms such as fever and malaise may also be present. We describe a 34-yr-old woman presented with severe ischemic change of the fingertip and subcutaneous nodules without systemic manifestations as an unusual initial manifestation of CPAN. Therapy with corticosteroid and alprostadil induce a moderate improvement of skin lesions. However, necrosis of the finger got worse and the finger was amputated

A multi-institutional study of the prevalence of BRCA1 and BRCA2 large genomic rearrangements in familial breast cancer patients

Background: Large genomic rearrangements (LGRs) in the BRCA1/2 genes are frequently observed in breast cancer patients who are negative for BRCA1/2 small mutations. Here, we examined 221 familial breast cancer patients from 37 hospitals to estimate the contribution of LGRs, in a nationwide context, to the development of breast cancer. Methods: Direct sequencing or mutation scanning followed by direct sequencing was performed to screen small mutations. BRCA1/2 small mutation-negative patients were screened for the presence of LGRs using a multiple ligation-dependent probe amplification (MLPA) assay. Results: Using a combined strategy to detect the presence of small mutations and LGRs, we identified BRCA1/2 small mutations in 78 (35.3%) out of 221 familial breast cancer patients and BRCA1 LGRs in 3 (2.1%) out of 143 BRCA1/2 small mutation-negative patients: the deletion of exons 11–13, the deletion of exons 13–15, and whole gene deletion of exons 1-24. The novel deletion of exons 11–13 is thought to result from a non-homologous recombination event mediated by a microhomology sequence comprised of 3 or 4 base pairs: c.3416_4357 + 1863delins187 (NG_005905.2: g.33369_44944delins187). Conclusions: In this study, we showed that LGRs were found in 3.7% (3/81) of the patients who had mutations in BRCA1 or BRCA2, and 7.5% (3/40) of patients with mutations in BRCA1. This suggests that the contribution of LGRs to familial breast cancer in this population might be comparable to that in other ethnic populations. Given these findings, an MLPA to screen for mutations in the BRCA1 gene is recommended as an initial screening test in highly selective settings.Peer Reviewe