The association between the neutrophil lymphocyte ratio and local edema after viper snake envenomation in South Korea.

The role of the inflammatory process in the pathogenesis of local edema-related envenomation has not been explored with endemic venomous snakebites in Korea. Gloydius species are responsible for most snakebites in South Korea. In this study we aimed to investigate whether the neutrophil-lymphocyte ratio is relevant to snake envenomation-induced local edema in South Korea. This retrospective study divided 126 patients into two groups according to local edema severity at presentation. Logistic regression models were used to investigate the association between the neutrophil-lymphocyte ratio and local edema. Sixty-one (48.4%) patients had grade 2 or higher local edema at presentation despite 21 of them being given antivenom before presentation. During hospitalization, local edema progressed in 61 patients 48 (11.5-48) hours after presentation, and 54 patients demonstrated grade 3 or higher local edema. A higher neutrophil-lymphocyte ratio at presentation after adjustment for factors related to envenomation and antivenom administration and factors influencing the neutrophil-lymphocyte ratio were associated with both a higher grade of local edema at presentation and a higher peak local edema grade during hospitalization. The delta neutrophil-lymphocyte ratio during the first 24 h after presentation was related to the local edema progression after presentation. The neutrophil-lymphocyte ratio at presentation is associated with the severity of local edema-related envenomation. Furthermore, the change in the neutrophil-lymphocyte ratio during the first 24 h is related to the risk of local edema progression. Further clinical and experimental research aimed at investigating the role of inflammation on the pathogenesis of local edema should be conducted. This study may suggest the introduction of short-term anti-inflammatory agents considering the failure of antivenom to curb local edema.

High incidence of acute kidney injury in extracorporeal resuscitation, Leading to poor prognosis.

Background: Extracorporeal membrane oxygenation (ECMO) patients have a high incidence of acute kidney injury (AKI). Extracorporeal cardiopulmonary resuscitation (ECPR) patients are more likely to develop AKI than ECMO patients because of serious injury during cardiac arrest (CA). Objectives: This study aims to assess the occurrence and outcomes of AKI in ECPR and ECMO, and to identify specific risk factors and clinical implications of AKI in ECPR. Methods: This is a retrospective observational study from a single tertiary care hospital in Gwangju, Korea. Adults (≥18 years) who received ECMO with cardiac etiology in the emergency and inpatient departments from January 2015 to December 2021 were included. The patients (n = 169) were divided into two groups, ECPR and ECMO without CA, and the occurrence of AKI was investigated. The primary outcome of the study was in-hospital mortality, and the secondary outcomes were six-month cerebral performance category (CPC) and AKI during hospitalization. Results: The incidence of AKI was significantly higher with ECPR (67.5 %) than with ECMO without CA (38.4 %). ECPR was statistically significant for Expire (adjusted OR (aOR) 2.45, 95 % CI 1.28-4.66) and Poor CPC (2.59, 1.32-5.09). AKI was also statistically significant for Expire (6.69, 3.37-13.29) and Poor CPC (5.45, 2.73-10.88). AKI was the determining factor for the outcomes of ECPR (p = 0.01). Conclusions: ECPR patients are more likely to develop AKI than ECMO without CA patients. In ECPR patients, AKI leads to poor outcomes. Therefore, clinicians should be careful not to develop AKI in ECPR patients.

Clinical features of snake envenomation in South Korea.

INTRODUCTION: Three venomous snakes of the Gloydius genus belonging to the Viperidae family cause most snake envenomations in South Korea. Envenomation signs often include local swelling, coagulopathy, and rhabdomyolysis. The benefit of additional antivenom after the initial does is unclear. METHODS: This retrospective study divided patients into four groups according to the presence of rhabdomyolysis (creatine kinase ≥1000 IU/L) and coagulopathy, which were defined using the Korean Society on Thrombosis and Hemostasis disseminated intravascular coagulation score (rhabdomyolysis, coagulopathy, combination, and local effects groups). We describe the clinical features of envenomation and the antivenom response. RESULTS: Greater local swelling predicted more severe snakebite pain. Ninety of the 231 enrolled patients (38.9%) developed rhabdomyolysis. The patients with severe rhabdomyolysis in the combination group displayed higher peak creatine kinase activity than the rhabdomyolysis group. Seven patients with rhabdomyolysis, including two patients requiring kidney replacement therapy, developed acute kidney injury, but the incidence of acute kidney injury did not differ between the combination group and rhabdomyolysis group. Bleeding developed in 3.5% of the patients, but its incidence did not differ between the combination and coagulopathy groups. Approximately half of all patients needed repeated antivenom administration, mainly due to the local envenomation effect. Earlier administration of additional antivenom for progressive local swelling did not reduce the hospitalization duration. CONCLUSION: Rhabdomyolysis is one of the major effects of Gloydius snake envenomation in South Korea, although it is not associated with the same risk of clinical deterioration as coagulopathy. Additionally, the ability of antivenom to ameliorate local swelling should be investigated to prevent unnecessary antivenom administration in South Korea.

The trend of ammonia levels in patients with glufosinate ammonium poisoning with respect to neurotoxicity.

Since glufosinate irreversibly inhibits glutamine synthetase, leading to intracellular accumulation of ammonia, hyperammonemia is considered one of the main mechanisms of glufosinate ammonium toxicity in humans. However, whether hyperammonemia causes neurotoxicity has not yet been studied. Therefore, the purpose of this study was to determine whether the serum ammonia level is elevated before the development of neurotoxicity. In this retrospective observational study, we analyzed data from consecutive patients diagnosed with acute glufosinate ammonium poisoning. The primary outcome was the development of neurotoxicity following the poisoning. Patients who developed neurotoxicity were characterized by higher initial ammonia levels compared to patients without neurotoxicity (121.0 µg/dL [87.0; 141.0] vs 83.0 µg/dL [65.0; 119.0], p < 0.01). However, there was no increase in ammonia levels over time in both the asymptomatic and neurotoxicity groups when serial serum ammonia levels were examined from emergency department admission to hospital discharge. In addition, there was no statistically significant difference between the peak ammonia levels in the asymptomatic group and the peak ammonia levels before symptom onset in the neurotoxicity group (135.0 µg/dL [109.0; 158.0] vs 144.0 µg/dL [120.0; 189.0], p = 0.15). Following the onset of neurotoxicity, the serum ammonia level increased significantly (125.0 [111.0; 151.0] µg/dL to 148.0 [118.0; 183.0] µg/dL, p < 0.01). In conclusion, hyperammonemia cannot be assumed as the cause of neurotoxicity in glufosinate ammonium poisoning and further research is needed to examine the exact mechanism of GA poisoning.

The novel human HtrA2 ortholog in zebrafish: New molecular insight and challenges into the imbalance of homeostasis.

High temperature requirement A2 (HtrA2) contributes to regulating mitochondrial quality control and maintaining the balance between the death and survival of cells and living organisms. However, the molecular mechanism of HtrA2 in physiological and pathophysiological processes remains unclear. HtrA2 exhibits multifaceted characteristics according to the expression levels and acts opposite functions depending on its subcellular localization. Thus, innovative technologies and systems that can be freely manipulated at the quantitative, biochemical, molecular and cellular levels are needed to address not only the challenges faced by HtrA2 research but also the general obstacles to protein research. Here, we are the first to identify zebrafish HtrA2 (zHtrA2) as the true ortholog of human HtrA2 (hHtrA2), by in silico sequence analysis of genomic DNA and molecular biological techniques, which is highly conserved structurally and functionally as a serine protease and cell death regulator. The zHtrA2 protein is primarily localized in the mitochondria, where alanine-exposed mature zHtrA2 ((A)-zHtrA2) is generated by removing 111 residues at the N-terminus of pro-zHtrA2. The (A)-zHtrA2 released from the mitochondria into the cytosol induces the caspase cascade by binding to and inhibiting hXIAP, a cognate partner of hHtrA2. Notably, zHtrA2 has well conserved properties of serine protease that specifically cleaves hParkin, a cognate substrate of hHtrA2. Interestingly, cytosolic (M)-zHtrA2, which does not bind hXIAP, induces atypical cell death in a serine protease-dependent manner, as occurs in hHtrA2. Thus, the zebrafish-zHtrA2 system can be used to clarify the crucial role of HtrA2 in maintaining the survival of living organisms and provide an opportunity to develop novel therapeutics for HtrA2-associated diseases, such as neurodegenerative diseases and cancer, which are caused by dysregulation of HtrA2.

Prognostic value of neutrophil to lymphocyte ratio in the diagnosis of neurotoxicity after glufosinate ammonium poisoning.

Neurotoxicity related to glufosinate ammonium is known to occur after a latent period of 4-60 hr following ingestion of this herbicide. However, neurotoxicity is difficult to predict in the emergency department (ED) and only a few parameters are known to be useful to indicate development of neurotoxicity. Determination of a systemic inflammation parameter such as the neutrophil to lymphocyte ratio (NLR), is a rapid and simple method which was found to be a prognostic marker in various clinical conditions such as sepsis, cardiac disorders, stroke, and cancer. Therefore, the aim of this study was to determine whether the NLR might predict neurotoxicity and be used at ED to detect neurotoxicity induced following glufosinate ammonium poisoning in admitted patients. This retrospective observational study collected data from consecutive patients diagnosed with acute glufosinate ammonium poisoning between January 2005 and December 2020. The primary outcome was development of neurotoxicity following acute glufosinate ammonium poisoning. Out of the 72 patients selected 44 patients (61.1%) exhibited neurotoxic symptoms. Neurotoxicity appeared with an approximate latent period of 12 hr. The NLR was significantly higher in the group displaying neurotoxicity. Multivariable analysis showed that the NLR was significant in predicting neurotoxicity. The NLR was independently associated with neurotoxicity initiated by glufosinate ammonium. Therefore, the use of the NLR might help clinically to readily and rapidly predict development of neurotoxicity associated with glufosinate ammonium at the ED.

Diagnostic value of transthoracic echocardiography compared to electrocardiogram in predicting coronary artery stenosis among patients after cardiac arrest.

BACKGROUND: In the absence of ST-segment elevation (STE) in post-return of spontaneous circulation (ROSC) electrocardiogram (ECG), coronary angiography (CAG) is required in patients with suspected coronary artery disease (CAD). However, it is a challenge to identify patients with CAD after cardiac arrest (CA). Recent European Society of Cardiology guidelines recommends transthoracic echocardiography in patients presenting with cardiac arrest. We aimed to assess the diagnostic value of regional wall motion abnormalities (RWMAs) on transthoracic echocardiography (TTE) compared to ECG in diagnosing significant coronary artery stenosis in CA patients. METHODS: This is a retrospective, observational study of adult CA patients with presumed cardiac etiology who underwent CAG from a single tertiary care hospital. We compared the predictive value of RWMA on TTE and STE on ECG in significant stenosis of ≥70% of the coronary artery diameter. The primary outcome was significant stenosis on CAG. RESULTS: There were 145 patients included in this study and CAG revealed significant stenosis in 76 (52.4%) patients. Among the 76 patients with significant stenosis, 68 (89.5%) had RWMA on TTE and 41 (54.0%) had STE. RWMA on TTE (OR 3.67; 95% CI 1.52-8.85) was independently associated with significant stenosis. Combining both RWMA on TTE and STE on ECG improved performance in the receiver operating characteristic curve analysis (area under the curve 0.722) for predicting significant stenosis compared to using only ECG alone (p = 0.001). CONCLUSIONS: RWMAs on TTE was independently associated with significant stenosis. The RWMA and STE combination had better predictive performance than using only STE on ECG to predict significant stenosis.

Is two-dimensional echocardiography better than electrocardiography for predicting patient outcomes after cardiac arrest?

BACKGROUND: Coronary artery stenosis increases hospital mortality and leads to poor neurological recovery in cardiac arrest (CA) patients. However, electrocardiography (ECG) cannot fully predict the presence of coronary artery stenosis in CA patients. Hence, we aimed to determine whether regional wall motion abnormality (RWMA), as observed by two-dimensional echocardiography (2DE), predicted patient survival outcomes with greater accuracy than did ST segment elevation (STE) on ECG in CA patients who underwent coronary angiography (CAG) after return of spontaneous circulation. METHODS: This was a retrospective observational study of adult patients with CA of presumed cardiac etiology who underwent CAG at a single tertiary care hospital. We investigated whether RWMA observed on 2DE predicted patient outcomes more accurately than did STE observed on ECG. The primary outcome was incidence of hospital mortality. The secondary outcomes were Glasgow-Pittsburgh Cerebral Performance Category scores measured 6 months after discharge and significant coronary artery stenosis on CAG. RESULTS: Among the 145 patients, 36 (24.8%) experienced in-hospital death. In multivariable analysis of survival outcomes, only total arrest time (P=0.011) and STE (P=0.035) were significant. The odds ratio (OR) and 95% confidence interval (CI), which were obtained by adjusting the total arrest time for survival outcomes, were significant only for STE (OR, 0.40; 95% CI, 0.17-0.94). The presence of RWMA was not a significant factor. CONCLUSIONS: While STE predicted survival outcomes in adult CA patients, RWMA did not. The decision to perform CAG after CA should include ECG under existing guidelines. The use of RWMA has limited benefits in treatment of this population.

The clinical role of serum albumin in Organophospate poisoning.

This retrospective study investigated whether the serum albumin (SA) concentration at presentation is associated with mortality and the mechanism underlying the association. This study enrolled 217 patients poisoned with organophosphate (OP). Hypoalbuminemia (albumin <3.5 g/dL) at presentation was identified in 18.4% of the patients poisoned with OP. The hypoalbuminemia group experienced a more complicated clinical course and had a higher mortality rate than the normoalbuminemia and hyperalbuminemia groups. The SA concentration correlated with the CRP level at presentation but not with the body mass index in patients with OP poisoning. Furthermore, the change in the SA concentration during the first 24 hours also correlated with the change in BuChE activity in patients with fenitrothion poisoning. The SA concentration at presentation was independently associated with mortality after adjusting for inflammation and nutritional status. This study showed that the SA concentration at presentation is associated with the mortality risk of patients poisoned with OP. This association is independent of inflammation and nutritional status in OP poisoning, and in particular, the protective effect of SA might contribute to this association in fenitrothion poisoning. These results should be validated.

Does alcohol play the role of confounder or neuroprotective agent in acute carbon monoxide poisoning?

Objectives: This study investigated whether alcohol influences the predictive value of initial blood lactate concentration and Glasgow Coma Scale (GCS) score at presentation for the severity of acute carbon monoxide (CO) poisoning and neurologic outcome in patients with acute CO poisoning. Additionally, whether alcohol has a neuroprotective effect after acute CO poisoning was evaluated.Methods: This retrospective study included 158 patients who presented with acute CO poisoning between January 2017 and July 2018 and had an available blood alcohol content (BAC) at presentation. The baseline characteristics, clinical course during hospitalization and neurologic status at 30 days after acute CO poisoning were collected and compared according to BAC. To account for possible confounding or neuroprotective effects of alcohol, BAC was introduced as a continuous variable and a stratified categorical variable in the analysis.Results: The mean and maximum BAC at presentation were 56.8 mg/dl and 408 mg/dl, respectively, in 158 patients presented at a mean of 1.0 hour after acute CO poisoning. Lactate, adjusted for previously suggested predictors, was not associated with acute CO poisoning severity; however, after additional adjustment with BAC variables, lactate was associated with CO poisoning severity. Initial GCS score was associated with CO poisoning severity during hospitalization and neurologic outcome at 30 days after acute CO poisoning, regardless of BAC adjustment. BAC variables were negatively associated with CO poisoning severity but not neurologic outcome at 30 days.Discussion and conclusion: The severity of CO poisoning should never be predicted based on serum lactate alone without adjusting for BAC. However, the initial GCS score can be used as a predictor of CO poisoning severity and the neurologic outcome at 30 days after acute CO poisoning, regardless of alcohol consumption history. Alcohol does not have a neuroprotective effect on acute CO poisoning. Further study is needed to validate these results.

Quantitative analysis of aconitine in body fluids in a case of aconitine poisoning.

Aconitine belongs to the Aconitum alkaloids and is a natural toxic substance. Aconitine has been used as a traditional medicine in East Asian culture. Today, aconitine is still in use with or without a prescription, in the Republic of Korea. Here we present a case report of accidental death due to acute aconitine poisoning. An 81-year-old woman ingested liquid that had been heat extracted from the root of the Aconitum plant; she presented to the emergency room 1 h after ingestion. Her electrocardiogram showed irregular ventricular arrhythmias including ventricular tachycardia; she progressed to cardiac arrest. Cardiopulmonary resuscitation and anti-arrhythmic drugs were administered, but the patient did not survive. An autopsy was performed 2 days postmortem. Toxicological analysis was performed, and aconitine was detected by liquid chromatography tandem mass spectrometry. The antemortem blood concentration of aconitine was 39.1 ng/ml and the concentrations of aconitine in the postmortem cardiac blood, peripheral blood, cerebrospinal fluid (CSF), pericardial fluid, and urine were 21.1 ng/ml, 28.6 ng/ml, 6.8 ng/ml, 24.1 ng/ml, and 67.4 ng/ml, respectively. This is the first forensic case report of an aconitine poisoning death in the Republic of Korea with quantitative measurement of aconitine in the antemortem blood and various postmortem body fluids. To the best of our knowledge, this is the first report of the detection of aconitine in the CSF. These data about the distribution of aconitine in the antemortem blood and various postmortem body fluids is helpful for future aconitine poisoning death cases.

Is an increased PaO2 in a normobaric state safe in acute CO poisoning?

Our objective was to determine how much PaO2 levels increase after normobaric oxygen (NBO) therapy and whether NBO therapy exerts therapeutic effects regardless of the PaO2 level. We suggest the optimal PaO2 level to use during NBO therapy for the acute treatment of carbon monoxide (CO) poisoning. This retrospective study included 311 patients who received oxygen administration after CO poisoning and had a measurable PaO2 level upon arrival. Baseline characteristics, clinical courses and long-term neurological outcome were collected and compared. The PaO2 level upon arrival was 192 (161-225) mm Hg, and 272 (87.5%) of the patients presented with hyperoxia. The incidence of poor long-term neurological outcome was 11.3% at a median follow-up period of 35 months. PaO2 levels upon arrival were higher in patients with good long-term neurological outcome than in those with poor outcome. The incidence of poor long-term neurological outcome was significantly dependent on the PaO2 level when patients were stratified at 100-mm Hg increments. A multivariate regression analysis showed that PaO2 levels, when considered a continuous, interval or ordinal variable, were associated with long-term neurological outcome in separate models. According to the three models, a PaO2 level of 200-300 mm Hg has the lowest risk of poor long-term neurological outcome. The results of the analysis of the predicted probability of poor long-term outcome according to the PaO2 level exhibited a U-shaped curve. Further large-scale studies are needed to confirm the association between 200-300 mm Hg of PaO2 and long-term neurological outcome and evaluate the impact of PaO2 levels above 300 mm Hg on acute CO poisoning outcome.

Use of qSOFA Score in Predicting the Outcomes of Patients With Glyphosate Surfactant Herbicide Poisoning Immediately Upon Arrival at the Emergency Department.

AIM: This study aimed to identify whether quick sequential organ failure assessment (qSOFA) performed immediately upon arrival can predict the outcome of patients with glyphosate surfactant herbicide (GlySH) poisoning. METHODS: Adult patients with GlySH poisoning between January 2006 and April 2017 were included in this retrospective observational study. The qSOFA score (respiratory rate ≥22 breaths per minute, systolic blood pressure <100 mm Hg, and altered mental status) was assessed immediately upon arrival at the emergency department. The primary outcome was in-hospital mortality, and the secondary outcomes were life-threatening complications and organ injury. RESULTS: Of the 150 patients who ingested GlySH, 14 (9.3%) died. The qSOFA score was significantly higher in the non-survival group (P < 0.001). qSOFA (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.41-5.76) was independently associated with in-hospital mortality. The area under curve value of qSOFA was 0.841 (95% CI, 0.772-0.895). As qSOFA score increased from 0 to 3, the in-hospital mortality significantly increased (P < 0.001). The frequency of life-threatening complications, including organ injury, increased as the qSOFA score increased from 0 to 3 (P < 0.001). CONCLUSIONS: The qSOFA score measured upon arrival shows good prognostic performance in patients with GlySH poisoning. Moreover, the qSOFA may predict the development of life-threatening complications including organ injury. Thus, more attention should be paid to patients with GlySH poisoning with higher qSOFA scores.

The predictive value of scores based on peripheral complete blood cell count for long-term neurological outcome in acute carbon monoxide intoxication.

Growing evidence indicates that inflammation is associated with neurological sequelae after CO poisoning. Several scores incorporating the peripheral complete blood cell (CBC) count have been introduced as indicators of systemic inflammation. This study investigated whether these scores can improve the predictive accuracy for long-term neurological outcome of acute carbon monoxide (CO) poisoning. Two hundred seventy-nine patients who suffered from acute CO poisoning were included. Data on the demographic details, serial peripheral CBC counts and scores based on peripheral CBC counts (neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), systemic immune inflammation index [SII]) over the first 12 hours after presentation together with the clinical course during hospitalization and long-term neurological outcome were collected. Both a multivariate logistic regression model with only significant univariate predictors and a model with univariate predictors plus each score for long-term neurological outcome were constructed. Patients with a poor long-term neurological outcome had higher neutrophil and monocyte counts and lower lymphocyte counts over the first 12 hours after admission than patients with a good outcome. The diagnostic performance of the NLR, MLR and SII over the first 12 hours for predicting long-term neurological outcome was acceptable. These scores at presentation were independently associated with the long-term neurological outcome. Among these scores, only the SII at presentation significantly improved the predictive accuracy of the model when combined with clinical parameters (AUC 0.949, 95% CI 0.916-0.972 vs AUC 0.923, 95% CI 0.884-0.952 for the model with clinical parameters only, P = 0.0476). The optimal cut-off value for SII at presentation was 1012.2, resulting in a sensitivity of 97% (84.2%-99.9%) and specificity of 64.6% (58.2%-70.6%). The SII at presentation could significantly improve the prognostic accuracy for predicting the long-term neurological outcome in patients with acute CO poisoning. Because the SII is an inexpensive and easily measurable parameter, it might be used as a prognostic tool in clinical fields.

The qSOFA Score: A Simple and Accurate Predictor of Outcome in Patients with Glyphosate Herbicide Poisoning.

This study aimed to investigate whether the quick Sequential Organ Failure Assessment (qSOFA) score at emergency department (ED) presentation can help improve the risk assessment of glyphosate-surfactant herbicide (GlySH) poisoning complications. A total of 150 patients presenting with acute glyphosate herbicide ingestion were enrolled in this retrospective observational study. The qSOFA scores at presentation, ΔqSOFA (calculated by subtracting the worst qSOFA score from 1 hr after admission from the qSOFA score at presentation), baseline characteristics, clinical courses and outcome were collected and analysed. A total of 41 patients had life-threatening complications (27.3%), and 14 patients died (9.3%). Patients with a qSOFA score of 0 at presentation had a 1.5% incidence rate of complications. As the qSOFA score at presentation increased from 1 to 3, the rate of life-threatening complications significantly increased from 29.6% to 100%. Patients with a ΔqSOFA of 1 had a higher frequency of complications than did patients with a ΔqSOFA of 0. The qSOFA score (OR: 8.39, 95% CI: 3.51-26.67) and ΔqSOFA (OR: 27.60, 95% CI: 3.87-575.67) were associated with the development of life-threatening complications in the multivariate analysis. The qSOFA score showed high sensitivity (97.56%), and the ΔqSOFA score showed high specificity (99.08%). The values of area under the curve were significantly higher in the models using the qSOFA and ΔqSOFA than they were in the models using previously known prognostic factors (p < 0.01). The clinician should pay more attention to patients with high qSOFA scores at presentation or an increase in the qSOFA score 1 hr after admission.

Serum N-terminal proBNP, not troponin I, at presentation predicts long-term neurologic outcome in acute charcoal-burning carbon monoxide intoxication.

OBJECTIVE: This study aimed to investigate whether the serum N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin I levels at emergency department (ED) presentation predict long-term neurologic outcomes after acute charcoal-burning carbon monoxide (CO) poisoning. METHODS: This retrospective study included 220 patients suffering from charcoal-burning CO poisoning. The demographics, serum NT-proBNP and troponin I levels at ED presentation, treatment, clinical course during hospitalization, and long-term neurologic outcomes were collected. RESULTS: The median serum NT-proBNP level at presentation was 48.8 (16.5-259) pg/mL, and 78 patients (35.5%) had elevated troponin I (>0.04 ng/mL) after acute charcoal-burning CO poisoning. The upper NT-proBNP and elevated troponin I groups had higher prevalences of respiratory failure, hypotension, and myocardial injury during hospitalization and altered mentality (GCS ≤14) at discharge than the lower NT-proBNP and normal troponin I groups. The incidence of persistent severe neurologic sequelae at 25 months after acute CO poisoning was 10.9%. The upper NT-proBNP and elevated troponin I groups had a higher incidence of poor long-term neurologic outcome than the counterpart groups. Log-transformed NT-proBNP and elevated troponin I were associated with poor long-term neurologic outcome in the univariate analysis, but only the adjusted log-transformed NT-proBNP remained an independent factor in the multivariate analysis. Compared with a predictive model including previously proposed predictors, the addition of log NT-proBNP improved the diagnostic accuracy for predicting poor long-term neurologic outcome. The serum NT-proBNP values for predicting poor long-term neurologic outcome were 74.6 and 32.7 pg/mL at fixed sensitivities of 95 and 99%, respectively. CONCLUSIONS: Elevated serum NT-proBNP at ED presentation is correlated with a risk of poor long-term neurologic outcome after discharge in cases of acute charcoal-burning CO poisoning. NT-proBNP could significantly improve the risk stratification of patients who will experience poor long-term neurologic outcome after CO poisoning. This potentially valuable marker should be further validated.

Cardiovascular Effects and Fatality May Differ According to the Formulation of Glyphosate Salt Herbicide.

This study aimed to compare adverse cardiovascular events and fatalities and to identify the risk factors for fatalities associated with the glyphosate salt herbicide formulation. Additionally, we examined whether glyphosate ammonium salt herbicides increased serum ammonia levels. One hundred forty-seven patients were divided into an ammonium group (glyphosate ammonium salt herbicide) and an isopropylamine (IPA) group (glyphosate IPA salt herbicide) according to the type of glyphosate salt formulation ingested. Although no differences in the variables were observed between the groups, the IPA group had more fatalities, a higher incidence of QTc prolongation and a higher tendency for PR prolongation than the ammonium group. Additionally, the IPA group required a longer duration of vasopressor administration. PR prolongation and age were independently associated with fatalities in glyphosate IPA salt poisoning cases in the multivariate regression. Serum ammonia levels were higher at presentation and decreased continuously during the first 48 h after presentation in the ammonium group. This study is the first to suggest potentially different toxicities, especially cardiovascular effects, of glyphosate herbicide poisoning in humans based on the glyphosate salt herbicide formulation and to determine the association between PR prolongation and fatality in glyphosate IPA salt herbicide poisoning cases.

Successful extracorporeal life support in respiratory failure after copper sulphate ingestion.

A 44-year-old woman intentionally ingested a solution of copper sulphate. She had minimal intravascular haemolysis and methemoglobinaemia but developed acute respiratory distress syndrome (ARDS) 4 hours after acute copper sulphate poisoning. This required extracorporeal membrane oxygenation (ECMO) management in the intensive care unit. Subsequently, she improved clinically and was successfully weaned from ECMO. Acute copper sulphate poisoning can cause severe pulmonary toxicity even in the absence of other serious symptoms. Therefore, a physician treating acute copper sulphate poisoning should look out for respiratory symptoms even in the absence of other common symptoms. We suggest early initiation of venovenous ECMO in those with ARDS following copper sulphate poisoning.

Malignant Syndrome in Parkinson Disease Similar to Severe Infection.

A 70-year-old woman with Parkinson disease was admitted to the emergency department with altered consciousness, fever and convulsive movements without experiencing withdrawal from antiparkinsonian medication. Six hours after the emergency department visit, the patient had a hyperpyrexia (> 40°C) and a systolic blood pressure of 40 mmHg. There was no evidence of bacterial infection based on extensive workups. The patient was discharged without aggravation of Parkinson disease symptoms after treatment that included administration of dantrolene sodium, enforcement of continuous renal replacement therapy and cooling blankets. Malignant syndrome should be suspected if high fever occurs in Parkinson disease patients without evidence of a definitive infection.

Hydrogel Functionalized Janus Membrane for Skin Regeneration.

In this study, a hydrogel functionalized Janus membrane is developed and its capacity is examined as a wound dressing biomaterial. A hydrophobic fluoropolymer, poly(3,3,4,4,5,5,6,6,7,7,8,8,9,9,10,10,10-heptadecafluorodecyl methacrylate) (PHFDMA), is uniformly coated onto macroporous polyester membrane through initiated chemical vapor deposition process on both sides. PHFDMA-coated macroporous membrane exhibits antibacterial property, allows air permeation, and inhibits water penetration. Janus membrane property is obtained by exposing one side of PHFDMA coated membrane with 1 m KOH solution, which allows PHFDMA cleavage resulting in carboxylic acid residue. This carboxylic acid residue is then further functionalized with gelatin methacrylate-based photocrosslinkable hydrogel for moisture retention and growth factor release. When applied to full thickness dorsal skin defect model, functionalized hydrogel allows moisture retention and hydrophobic surface prevents exudate leaks via water repellence. Furthermore, hydrogel functionalized Janus membrane enhances the wound healing rate and induces thick epidermal layer formation. In conclusion, the multifunctional Janus membrane with hydrophobic outer surface and immobilized hydrogel on the other surface is fabricated for an innovative strategy for wound healing.