A combination of the Modified Early Warning Score and the Korean Triage and Acuity Scale as a triage tool in patients with infection.

OBJECTIVE: We evaluated the utility of the Korean Modified Early Warning Score (KMEWS), which combines the Modified Early Warning Score (MEWS) and the Korean Triage and Acuity Scale (KTAS), as a triage tool to screen for infection in patients who visit the emergency department. METHODS: We retrospectively reviewed data extracted from electronic medical records. Patients aged ≥18 years with an infection who were admitted to the hospital via the emergency department between January 2018 and December 2019 were eligible for inclusion. The KMEWS score was calculated as the sum of the KTAS level and the MEWS score. We generated receiver operating characteristic curves and determined the area under the receiver operating characteristic curve (AUC) for the KMEWS, KTAS, MEWS, and Mortality in Emergency Department Sepsis (MEDS) scales. The primary outcome was septic shock, and secondary outcomes were intensive care unit admission and in-hospital mortality. RESULTS: The AUC values (95% confidence interval) for predicting septic shock were as follows: KMEWS, 0.910 (0.902-0.918); MEWS, 0.896 (0.887-0.904); KTAS score, 0.809 (0.798-0.819); and MEDS, 0.927 (0.919-0.934). The AUC values (95% confidence interval) for predicting in-hospital mortality were as follows: KMEWS, 0.752 (0.740-0.764); MEWS, 0.717 (0.704-0.729); KTAS score, 0.764 (0.752-0.776); and MEDS, 0.844 (0.834-0.854). The AUC values (95% confidence interval) for predicting intensive care unit admission were as follows: KMEWS, 0.826 (0.816-0.837); MEWS, 0.782 (0.770-0.793); KTAS score, 0.821 (0.810-0.831); and MEDS, 0.839 (0.829-0.849). CONCLUSION: The KMEWS, which is a combination of the MEWS and the KTAS scores, might be a useful triage tool in emergency department patients who present with infection, particularly for predicting septic shock.

Early identified risk factors and their predictive performance of brain death in out-of-hospital cardiac arrest survivors.

BACKGROUND: Early prediction of brain death (BD) after the return of spontaneous circulation (ROSC) in patients with cardiac arrest would be useful for the proper distribution of good quality transplantable organs and medical resources. We aimed to early identify independent risk factors of BD and their predictive performance in out-of-hospital cardiac arrest (OHCA) survivors. METHODS: This retrospective observational study included adult OHCA survivors from May 2018 to February 2021. Independent risk factors for progression to BD were identified by performing multivariate logistic regression analysis, including clinical, laboratory, biological parameters and prognostic factors, obtained within 6 h after ROSC. Neuron-specific enolase (NSE) level were categorized into quartile. The primary outcome was BD occurrence. RESULTS: Overall, 108 patients were included in this analysis, 31 (29%) of whom had BD. In multivariate logistic regression analysis, initial serum NSE levels in the fourth quartile compared to the first quartile (odds ratio [OR], 88.5; 95% confidence interval [CI]: 7.0-1113.6) and absence of pupil light reflex (PLR) (OR, 40.3; 95% CI: 3.8-430.3) were independently associated with BD. According to the receiver operating characteristic curve analysis, initial serum NSE levels and PLR showed good-to-excellent and fair-to-good prognostic performance, respectively (area under the curve [AUC], 0.90; 95% CI: 0.83-0.95 vs. 0.81; 95% CI: 0.72-0.88). Additionally, the combination of both the risk factors (AUC, 0.96; 95% CI: 0.90-0.99) showed significantly higher predictive performance for BD than when using them individually (P = 0.04 and P < 0.01, respectively). CONCLUSION: High levels of initial serum NSE and PLR obtained within 6 h after ROSC may help early predict progression to BD in OHCA survivors. A large prospective multicenter study should be conducted to confirm these results.

Lactate dehydrogenase to albumin ratio as a prognostic factor in lower respiratory tract infection patients.

PURPOSE: 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). METHODS: 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. RESULTS: 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. CONCLUSION: The LDH/ALB ratio may serve as an independent prognostic factor for in-hospital mortality in patients with LRTI.

[Cholangiocarcinoma with distant cutaneous metastases].

Cutaneous metastases rarely develop in patients with internal malignancy. Cholangiocarcinoma, a malignant cancer of the bile duct, is a relatively rare adenocarcinoma and has a poor prognosis. Few reports have mentioned cutaneous metastases of cholangiocarcinoma, and the most of them were due to direct tumor seeding by percutaneous procedures. Herein, we report a case of cholangiocarcinoma with distant cutaneous metastases in a 60-year-old man.