Proximal hyper-intense vessel sign on initial FLAIR MRI in hyper-acute middle cerebral artery ischemic stroke: a retrospective observational study.

BACKGROUND: A hyper-intense vessel sign on fluid attenuated inversion recovery magnetic resonance imaging (FHV) represents slow blood flow in the cerebral arteries. PURPOSE: To investigate the relationship between the proximal FHV (pFHV) on initial magnetic resonance imaging (MRI) and the status of the culprit vessel (stenosis, obstruction) in hyper-acute strokes affecting the territory of the middle cerebral artery (MCA). MATERIAL AND METHODS: The study participants consisted of 105 patients presenting to the emergency department (ED) with acute MCA infarction within 4.5 h of onset of symptoms. Patients underwent brain MRI within 45 min of arrival at the ED and angiography within 2 h of arrival. Culprit vessel status and presence of a pFHV on initial MRI were investigated retrospectively. RESULTS: The pFHV was observed in 71/105 (67.6%) patients who presented with a hyper-acute MCA infarction. All patients with hyper-acute MCA infarction caused by internal carotid artery (90.6% caused by M1 occlusion, 92.9% caused by M2 occlusion) showed a pFHV on initial MRI. After logistic regression analysis, the presence of a pFHV showed significant positive correlation with large vessel occlusion (adjusted odds ratio [OR] 34.533, 95% confidence interval [CI] 9.781-121.926; P < 0.001). A pFHV was not associated with severe large vessel stenosis. CONCLUSION: A pFHV is independently representative of the acute occlusion of intervention-eligible proximal arteries within the territory of the MCA. If a patient with a hyper-acute MCA infarction shows a pFHV, aggressive flow augmentation strategies and early activation of intervention team should be warranted for best patient outcome.

Manikin study showed that counting inflation breaths out loud improved the speed of resuming chest compressions during two-person paediatric cardiopulmonary resuscitation.

AIM: We investigated whether counting inflation breaths out loud during cardiopulmonary resuscitation (CPR) led to an earlier resumption of chest compressions. METHODS: In this randomised controlled manikin simulation study, conducted from February 2015 to April 2015, 32 fourth-year Korean medical students, equally divided into study and control groups, performed 10 cycles of 15:2 CPR while administering inflation breaths using a bag mask. The first study participant counted the number of inflation breaths out loud, and the second study participant was told to perform chest compressions as soon as they heard their colleague say two. The control group did not count out loud. The groups were blinded to the study outcomes and put in separate rooms. RESULTS: The median chest compression interruption time was shorter in the study group than the control group (40 vs 46 seconds, p < 0.01, r = 0.70), and the median chest compression fraction (CCF) was higher (68 vs 62%, p < 0.01, r = 0.71). Other quality outcomes related chest compressions and ventilation did not differ between the groups. CONCLUSION: Counting the number of inflation breaths out loud was a simple method that improved the speed of resuming chest compressions and increased CCFs in 15:2 CPR.

Serum Procalcitonin: An Independent Predictor of Clinical Outcome in Health Care-Associated Pneumonia.

BACKGROUND: Early prediction of the clinical outcomes for health care-associated pneumonia (HCAP) patients is challenging. OBJECTIVES: This is the first study to evaluate procalcitonin (PCT) as a predictor of outcomes in HCAP patients. METHODS: We conducted an observational study based on data for HCAP patients prospectively collected between 2011 and 2014. Outcome variables were intensive care unit (ICU) admission and 30-day mortality. PCT was categorized into three groups: <0.5, 0.5-2.0, and >2.0 ng/ml. We analysed multiple variables including age, sex, comorbidities, clinical findings, and PCT group to assess their association with outcomes. RESULTS: Of 245 HCAP patients, 99 (40.4%) were admitted to an ICU and 44 (18.0%) died within 30 days. The median PCT level was significantly higher in the ICU admission (1.19 vs. 0.4 ng/ml; p < 0.001) and 30-day mortality (3.3 vs. 0.4 ng/ml; p < 0.001) groups. In multivariate analysis, high PCT (>2.0 ng/ml) was strongly associated with ICU admission [odds ratio 3.734, 95% confidence interval (CI) 1.753-7.951; p = 0.001] and 30-day mortality (hazard ratio 2.254, 95% CI 1.250-5.340; p = 0.035). In receiver operating characteristic analysis, PCT had a poor discrimination power regarding ICU admission [0.695 of the area under the curve (AUC)] and a fair discrimination power regarding 30-day mortality in HCAP patients (0.768 of the AUC). CONCLUSIONS: High PCT on admission was strongly associated with ICU admission and 30-day mortality in HCAP patients. However, application of PCT alone seems to be limited to predicting outcomes.

A vertical two-thumb technique is superior to the two-thumb encircling technique for infant cardiopulmonary resuscitation.

AIM: The two-thumb encircling (TTE) technique often results in suboptimal cardiac compression and does not meet the requirements of current resuscitation guidelines. We compared this technique with the vertical two-thumb (VTT) technique, our novel modification of the TTE technique. METHODS: This was a prospective randomised crossover simulation study of out-of-hospital infant cardiopulmonary resuscitation (CPR). Participants who had completed a basic life support course performed 10 cycles of cardiac compressions on a manikin for each technique. RESULTS: We enrolled 36 medical doctors who had applied for a hospital internship in this study. The VTT generated significantly higher pressure than the TTE and the pressure difference ranged from 26.8 to 62.9 mmHg for each cycle, with a mean difference of 43.5 mmHg (95% CI, 37.8-49.2). The difference in pressure showed a tendency to increase with increasing cycles of cardiac compressions. The participants' heart and respiratory rate was higher with the VTT, but they said that it was easier to perform cardiac compressions with this technique. CONCLUSION: The VTT technique generated more pressure than the TTE technique in a simulated model of infant out-of-hospital CPR. It can provide an alternative compression technique for effective infant CPR, especially for the rescuers with small hands or a weak grip.

Utility of the Pentax-AWS in performing tracheal intubation while wearing chemical, biological, radiation and nuclear personal protective equipment: a randomised crossover trial using a manikin.

INTRODUCTION: Following a chemical, biological, radiation and nuclear (CBRN) incident, prompt establishment of an advanced airway is required for patients with respiratory failure within the warm zone, while wearing personal protective equipment (PPE). Previous studies reported that intubation attempts were prolonged, and incidence of esophageal intubation was increased with conventional Macintosh laryngoscope (McL), while wearing CBRN-PPE. Pentax-AWS (AWS), a recently introduced portable video laryngoscope, was compared with the McL to test its utility for tracheal intubation while wearing CBRN-PPE. METHODS: 31 participants performed unsuited and suited intubations on an advanced life support simulator. The sequence of intubating devices and PPE wearing were randomised. Time to complete tracheal intubation (primary end point), time to see the vocal cords, overall success rate, percentage of glottic opening, dental compression and ease of intubation were measured. RESULTS: Suited intubations required significantly longer time to complete intubation than unsuited intubations, in both McL and AWS (22.2 vs 26.4 s, 14.2 vs 18.2 s, respectively). However, suited AWS intubations required shorter time to complete tracheal intubation than unsuited McL intubations (18.2 vs 22.2 s). In secondary outcomes, moreover, suited intubations using the AWS compared favourably with unsuited intubations using the McL. CONCLUSIONS: Although the CBRN-PPE adversely affected time required to complete tracheal intubation with the AWS, suited intubations using the AWS were even superior to unsuited intubations using the McL. The AWS should be a promising device to perform tracheal intubation while wearing the CBRN-PPE.

Conventional blood tests in predicting influenza A (H1N1) rapidly.

PURPOSE: Although real-time reverse transcriptase-polymerase chain reactions (rRT-PCR) are gold standard for the diagnosis of influenza A (H1N1), the results can be delayed up to several days, which is problematic during a pandemic. Because of this limitation of rRT-PCR, clinicians have often had to set a treatment plan that was solely based on clinical suspicion. We investigated the hematological and biochemical factors that are associated with rRT-PCR results, in order to help clinicians deal with acute febrile patients during influenza pandemics. METHODS: We conducted a retrospective, cross-sectional study of 465 emergency department patients who underwent both rRT-PCR and blood tests at the same time. Hematological and biochemical findings were compared between the rRT-PCR-positive group and rRT-PCR-negative group. RESULTS: Levels of leukocytes, hemoglobin, platelets, blood urea nitrogen (BUN), total bilirubin, lactate dehydrogenase, serum glucose, C-reactive protein (CRP), and procalcitonin were significantly different between the two groups in the univariate analyses. In the multivariate analyses, leukocyte counts ≤ 10.8 (× 10(9))/L [odd ratio (OR) = 8.2, sensitivity = 93.7%, NPV = 85.3%], BUN levels ≤ 7.1 µmol/L (OR = 3.0, sensitivity = 93.7%, NPV = 85.3%), and CRP levels ≤ 60 mg/L (OR = 2.4, sensitivity = 93.7%, NPV = 85.3%) were independently associated with positive rRT-PCR results. CONCLUSIONS: Leukocyte counts, BUN levels and CRP levels were important predictors of rRT-PCR-positive results for 2009 influenza A (H1N1) in adults.

Clinical investigation on acute pyelonephritis without pyuria: a retrospective observational study.

BACKGRUOUND: The current guidelines for the diagnosis of acute pyelonephritis (APN) recommend that APN be diagnosed based on the clinical features and the presence of pyuria. However, we observed that some of the patients who are diagnosed with APN do not have characteristic clinical features or pyuria at the initial examination. We performed this study to investigate the characteristics of APN without pyuria. METHODS: A retrospective, cross-sectional study was conducted on 391 patients diagnosed with APN based on clinical and radiologic findings, between 2015 and 2019. The clinical features, laboratory results, and computed tomography (CT) findings were compared between patients with normal white blood cell (WBC) counts and those with abnormal WBC counts (WBC of 0-5/high power field [HPF] vs. >5/HPF) in urine. RESULTS: More than 50% of patients with APN had no typical urinary tract symptoms and one-third of them had no costovertebral angle (CVA) tenderness. Eighty-eight patients (22.5%) had normal WBC counts (0-5/HPF) on urine microscopy. There was a negative correlation between pyuria (WBC of >5/HPF) and previous antibiotic use (odds ratio, 0.249; 95% confidence interval, 0.140-0.441; p<0.001), and the probability of pyuria was reduced by 75.1% in patients who took antibiotics before visiting the emergency room. CONCLUSION: The diagnosis of APN should not be overlooked even if there are no typical clinical features, or urine microscopic examination is normal. If a patient has already taken antibiotics at the time of diagnosis, imaging studies such as CT should be performed more actively, regardless of the urinalysis results.

Clinical study on ureteritis observed in contrast-enhanced computed tomography in the emergency department.

OBJECTIVE: We aimed to investigate the causes and clinical and laboratory features of patients with ureteritis observed on intravenous contrast-enhanced abdominopelvic computed tomography (APCT) conducted in the emergency department (ED). METHODS: All APCTs conducted in the ED from November 2017 to November 2020 were investigated for the presence of ureteritis. The incidence of ureteritis, presumed cause of ureteritis, and clinical as well as laboratory features of patients with ureteritis were retrospectively analyzed. RESULTS: Ureteritis was observed in 422 out of 7,386 patients (5.7%) who underwent APCTs. The two main reasons for undergoing APCT in the ED were abdominal pain (49%) and infection focus workup (33%). The first major cause of ureteritis was urinary tract infection (UTI) (351 of 422, 83%). Most patients (85%) were febrile, but 208 (59%) exhibited no urinary symptoms such as dysuria, increased frequency, or residual urine sense. The second major cause of ureteritis was ureteral stones (42 of 422, 10%). Thirty-two of 42 patients (76%) had simple obstructive uropathy, while 24% of patients had a combined infection along with an obstruction. Other rare causes were malignancy and the spread of adjacent inflammation. CONCLUSION: Ureteritis was a common finding observed in 5.7% of patients who underwent APCTs at the ED, and most of them were secondary to UTIs and ureteral stones. UTIs can cause ureteritis even without typical symptoms or signs suggestive of UTI, and diagnosis without an APCT can be difficult. More liberal use of APCTs should be considered when the cause of fever is difficult to diagnose.

Tracheal intubation during chest compressions using Pentax-AWS(®), GlideScope (®), and Macintosh laryngoscope: a randomized crossover trial using a mannequin.

BACKGROUND: A randomized crossover trial was conducted to compare the performance of two videolaryngoscopes (Pentax-AWS(®), GlideScope(®)) with the Macintosh laryngoscope for tracheal intubation during continuous chest compressions on a mannequin. METHODS: Thirty-two inexperienced junior interns performed tracheal intubations on an advanced life support simulator with either a normal or difficult airway scenario. The sequence of intubating devices and airway difficulty were randomized. The following data were measured and recorded: time to complete tracheal intubation (primary end point), overall success rate, time to visualize the vocal cords, percentage of glottic opening, dental compression, and ease of intubation. RESULTS: With a normal airway, the times (median [interquartile range]) to complete tracheal intubation were shorter with the Pentax-AWS (12.1 [10.1-14.4] sec) and the GlideScope (14.3 [12.4-17.6] sec) than with the Macintosh laryngoscope (16.5 [13.1-22.1] sec) (P < 0.03 for both). The time difference between the two videolaryngoscopes was not statistically significant. With a difficult airway scenario, the times to complete tracheal intubation were 13.9 [10.9-20.4] sec, 19.2 [16.4-32.3] sec, and 30.1 [21.0-56.5] sec, respectively (P < 0.05 for all differences). The videolaryngoscopes were also more effective than the Macintosh laryngoscope with respect to secondary outcomes. CONCLUSIONS: The two videolaryngoscopes were superior to the Macintosh laryngoscope in terms of performing tracheal intubation during continuous chest compressions on a mannequin. In a difficult airway scenario simulating cardiac arrest, the Pentax-AWS performed better than the GlideScope.

Molecular and functional characterization of detrusor PDGFRα positive cells in spinal cord injury-induced detrusor overactivity.

Volume accommodation occurs via a novel mechanism involving interstitial cells in detrusor muscles. The interstitial cells in the bladder are PDGFRα+, and they restrain the excitability of smooth muscle at low levels and prevents the development of transient contractions (TCs). A common clinical manifestation of spinal cord injury (SCI)-induced bladder dysfunction is detrusor overactivity (DO). Although a myogenic origin of DO after SCI has been suggested, a mechanism for development of SCI-induced DO has not been determined. In this study we hypothesized that SCI-induced DO is related to loss of function in the regulatory mechanism provided by PDGFRα+ cells. Our results showed that transcriptional expression of Pdgfra and Kcnn3 was decreased after SCI. Proteins encoded by these genes also decreased after SCI, and a reduction in PDGFRα+ cell density was also documented. Loss of PDGFRα+ cells was due to apoptosis. TCs in ex vivo bladders during filling increased dramatically after SCI, and this was related to the loss of regulation provided by SK channels, as we observed decreased sensitivity to apamin. These findings show that damage to the mechanism restraining muscle contraction during bladder filling that is provided by PDGFRα+ cells is causative in the development of DO after SCI.

Immediate laparoscopic nontransvesical repair without omental interposition for vesicovaginal fistula developing after total abdominal hysterectomy.

BACKGROUND AND OBJECTIVE: We conducted this study to evaluate the feasibility and efficacy of immediate laparoscopic nontransvesical repair without omental interposition for vesicovaginal fistula (VVF) developing after total abdominal hysterectomy (TAH), which causes not only social and economic misery for the patient but also considerable stress to the physicians who perform the surgery. METHODS: We performed a retrospective review of 5 women who underwent immediate laparoscopic nontransvesical repair without omental interposition for VVFs, developing after TAH from October 2007 to March 2009. In terms of laparoscopic procedure, cystoscopy was performed to confirm the location of fistula and ureteral openings, initially. Without opening the bladder, the fistula tract was identified, and the bladder was dissected from the vagina. The bladder defect was closed by using intracorporeal, continuous, and double-layer suturing, laparoscopically. The vaginal defect was closed using interrupted and single-layer suturing, vaginally. A Foley catheter was inserted for 2 weeks and removed after bladder integrity was confirmed with a retrograde cystogram. RESULTS: The median age and body mass index of the patients were 47 years and 22.3 kg/m², respectively. Operating time, hemoglobin change, and hospital stay were 95 minutes, 1.1 g/dL, and 5 days, respectively. There were no complications or laparoconversions. During follow-up (median 56.1 weeks; range 26.6 to 74.0), there was no evidence of recurrence. CONCLUSIONS: Immediate laparoscopic nontransvesical repair without omental interposition might be an effective, feasible alternative to the traditional methods in select patients with small sized (<1 cm) VVF developing after TAH.

Utility of a Modified Oropharyngeal Airway for Performing Tracheal Intubation Using a Fiberoptic Bronchoscope and Video Stylet: A Randomized Crossover Trial Using a Manikin.

PURPOSE: The purpose of this study was to assess if a modified airway (MA), developed by the authors, would act as a guide and improve the performance of intubation when used with a video stylet (VS) or fiberoptic bronchoscope (FOB) for endotracheal intubation. METHODS: This randomized crossover simulation study using manikins was conducted with 36 novice operators. Time to complete intubation, time to see the glottis, and success rate of intubation of each device were measured and compared with or without use of MA. RESULTS: For intubation using FOB with MA, the median time to complete intubation significantly reduced from 46 to 31 seconds with a medium effect size (p=0.004, r = 0.483), and the median time to see the glottis significantly reduced from 7 to 5 seconds with a medium effect size (p=0.032, r = 0.357). The overall success rate was not statistically different between FOB with MA (33/36, 91.7%) and FOB alone (31/36, 86.1%); however, the cumulative success rate over time for FOB with MA was higher than that for FOB alone (p=0.333). For intubation using VS, there were no differences in the time to see the glottis and time to complete intubation between VS with MA and VS alone (p=0.065 and p=0.926, respectively), and the cumulative success rate was not statistically significant (p=0.594). CONCLUSION: Adjunct use of MA helped reduce time to complete intubation in FOB, but not in VS. If an inexperienced operator uses FOB, it would be helpful to use MA as an adjunct device.

Chronic Gastritis Is Associated with a Decreased High-Density Lipid Level: Histological Features of Gastritis Based on the Updated Sydney System.

Chronic gastritis could activate a systemic inflammatory response that could result in adverse lipid profiles. To determine the severity of chronic gastritis, Helicobacter pylori (HP), mononuclear cell (lymphocytes and plasma cells), and neutrophil scores were assessed on the basis of the updated Sydney system (USS), which is widely used for histological grading. The aim of this study was to assess the relationships between gastric histological features and lipid profile levels. This study included 15,322 males and 5929 females who underwent a health checkup and gastric biopsy at the Kangbuk Samsung Medical Center (KBSMC). We analyzed whether the HP, mononuclear cell, and neutrophil grades according to the USS were related to serum leukocyte count, unhealthy behaviors, and lipid profile levels. Gastritis with HP, neutrophils, or moderate to severe mononuclear cells was associated with an elevated serum leukocyte count. A high leukocyte count was related to increased low-density lipoproteins (LDL) and triglycerides/very-low-density lipoprotein (VLDL) and decreased high-density lipoproteins (HDL). In multivariate analyses, chronic gastritis with HP or moderate to severe mononuclear cells was significantly associated with decreased HDL in males, while mononuclear cells were significantly related to decreased HDL in females. Chronic gastritis was associated with an increased systemic inflammatory response, which was associated with unfavorable lipid profiles, especially low HDL levels.

Model for end-stage liver disease, model for end-stage liver disease-sodium and Child-Turcotte-Pugh scores over time for the prediction of complications of liver cirrhosis.

BACKGROUND/AIMS: There has been no report concerning the predictive capability of each scoring system in determining the development of complications of liver cirrhosis such as variceal bleeding and/or hepatic encephalopathy. METHODS: We retrospectively studied 128 patients with liver cirrhosis [92 males; mean (standard deviation) 54.2 (11.2) years] admitted to our institution from March 2004 to April 2006. Seventy-three patients (57.0%, group 1) were admitted because of complications of cirrhosis and 55 patients (43.0%, group 2) were admitted for causes unrelated to complications of cirrhosis. We calculated values for model for end-stage liver disease (MELD), MELD-sodium (MELD-Na) and Child-Turcotte-Pugh (CTP) scores on admission and at 3 and 6 months before admission. Each delta score was defined as the difference in the scores of 3 and 6 months before admission. RESULTS: The relative risk for complications in the patients with DeltaMELD/3 months >/=1.35, DeltaMELD-Na/3 months >/=1.35 and DeltaCTP/3 months >/=1 was 2.05 [95% confidence intervals (CI) 1.47-2.85, P<0.01], 2.04 (95% CI 1.45-2.88, P<0.01) and 1.98 (95% CI 1.39-2.81, P<0.01) respectively. The area under the receiver-operating characteristic curves of DeltaMELD/3 months, DeltaMELD-Na/3 months and DeltaCTP/3 months for the occurrence of cirrhotic complications were 0.691, 0.694 and 0.722 respectively. A higher DeltaMELD/3 months (>/=1.35), DeltaMELD-Na/3 months (>/=1.35) and DeltaCTP/3 months (>/=1) was associated with decreased survival. CONCLUSIONS: Delta model for end-stage liver disease/3 months, DeltaMELD-Na/3 months and DeltaCTP/3 months were clinically useful parameters for predicting the occurrence of cirrhotic complications.

Characteristics of blood tests in patients with acute cerebral infarction who developed symptomatic intracranial hemorrhage after intravenous administration of recombinant tissue plasminogen activator.

OBJECTIVE: Patients suspected as having acute ischemic stroke usually undergo blood tests, including coagulation-related indexes, because thrombocytopenia and coagulopathy are contraindications for recombinant tissue plasminogen activator (rtPA) administration. We aimed to identify blood test indexes associated with symptomatic intracranial hemorrhage (sICH) in patients with acute ischemic stroke who received intravenous rtPA. METHODS: This retrospective observational study included patients diagnosed with acute ischemic stroke who were treated with intravenous rtPA at the emergency department of a tertiary hospital in Seoul between February 2008 and January 2018. Blood test indexes were compared between the sICH and non-sICH groups. Logistic regression and receiver-operating characteristic curve analyses were performed. RESULTS: In this study, 375 patients were finally included. Of 375 patients, 42 (11.2%) showed new intracranial hemorrhage on follow-up brain computed tomography, of whom 14 (3.73%) had sICH. Platelet count, aspartate aminotransferase and lactate dehydrogenase levels were significantly different between the sICH and non-sICH groups, and platelet count showed statistical significance in the regression analysis. Significantly lower platelet counts were observed in the sICH group than in the non-sICH group (174,500 vs. 228,000/mm3, P=0.020). The best cutoff platelet count was 195,000/mm3, and patients with platelet counts of <195,000/mm3 had a 5.4- times higher risk of developing sICH than those with platelet counts of ≥195,000/mm3. CONCLUSION: Platelet count was the only independent parameter associated with sICH among the blood test indexes. Mild thrombocytopenia may increase the risk of sICH after intravenous administration of rtPA.

Differential diagnoses of magnetic resonance imaging for suspected acute appendicitis in pregnant patients.

BACKGROUND: Accurate and timely diagnosis of acute surgical disease in pregnant patient is challenging. Although magnetic resonance imaging (MRI) is the most accurate modality to diagnose acute appendicitis in pregnant patients, it is often used as a last resort because of high cost and long scan time. We performed this study to analyze differential diagnoses of appendix MRI and to investigate if there are any blood tests that can predict surgical condition in pregnant patients. METHODS: A retrospective, cross-sectional study was conducted on 46 pregnant patients who underwent non-enhanced appendix MRI in suspicion of acute appendicitis from 2010 to 2016. Differential diagnoses of appendix MRI were analyzed and blood tests were compared between those who had surgical and non-surgical disease. RESULTS: Appendix MRI differentiated two surgical disease; acute appendicitis and ovarian torsion; and various non-surgical conditions such as uterine myoma, hydronephrosis, ureterolithiasis and diverticulitis among clinically suspected acute appendicitis in pregnancy. The diagnostic accuracy of MRI for acute appendicitis in this study was 93.5%. Patients who had surgical disease showed significantly higher WBC count (≥11,000/mm3), proportion of neutrophils in the WBC (≥79.9%), neutrophil-to-lymphocyte ratio (NLR≥6.4), levels of C-reactive protein (CRP≥1.82 mg/dL) and bilirubin (≥0.66 mg/dL) than those who had non-surgical disease. CONCLUSION: MRI can reliably differentiate surgical conditions and several blood tests (WBC, proportion of neutrophils in the WBC, NLR, CRP, bilirubin) can help anticipate acute surgical condition among pregnant patients suspected to have acute appendicitis.

Effect of metronome rates on the quality of bag-mask ventilation during metronome-guided 30:2 cardiopulmonary resuscitation: A randomized simulation study.

BACKGROUND: Metronome guidance is a feasible and effective feedback technique to improve the quality of cardiopulmonary resuscitation (CPR). The rate of the metronome should be set between 100 to 120 ticks/minute and the speed of ventilation may have crucial effect on the quality of ventilation. We compared three different metronome rates (100, 110, 120 ticks/minute) to investigate its effect on the quality of ventilation during metronome-guided 30:2 CPR. METHODS: This is a prospective, randomized, crossover observational study using a RespiTrainer○r. To simulate 30 chest compressions, one investigator counted from 1 to 30 in cadence with the metronome rate (1 count for every 1 tick), and the participant performed 2 consecutive ventilations immediately following the counting of 30. Thirty physicians performed 5 sets of 2 consecutive (total 10) bag-mask ventilations for each metronome rate. Participants were instructed to squeeze the bag over 2 ticks (1.0 to 1.2 seconds depending on the rate of metronome) and deflate the bag over 2 ticks. The sequence of three different metronome rates was randomized. RESULTS: Mean tidal volume significantly decreased as the metronome rate was increased from 110 ticks/minute to 120 ticks/minute (343±84 mL vs. 294±90 mL, P=0.004). Peak airway pressure significantly increased as metronome rate increased from 100 ticks/minute to 110 ticks/minute (18.7 vs. 21.6 mmHg, P=0.006). CONCLUSION: In metronome-guided 30:2 CPR, a higher metronome rate may adversely affect the quality of bag-mask ventilations. In cases of cardiac arrest where adequate ventilation support is necessary, 100 ticks/minute may be better than 110 or 120 ticks/minute to deliver adequate tidal volume during audio tone guided 30:2 CPR.

Hematologic parameters to predict negative cerebrospinal fluid examination results among neurologically intact patients who underwent lumbar puncture on suspicion of central nervous system infection.

OBJECTIVE: Cerebrospinal fluid (CSF) examination is mandatory whenever central nervous system (CNS) infection is suspected. However, pleocytosis is not detected in a substantial number of suspected patients who undergo CSF examination. This study aimed to identify parameters that can aid in predicting negative CSF examination results (defined as a white blood cell count of <5 cells/high-power field). METHODS: The study included 101 neurologically intact patients who underwent lumbar puncture because of suspicion of CNS infection. Patients were divided into negative and positive CSF examination groups, and their initial blood tests were comparatively analyzed. RESULTS: The negative group had a significantly higher proportion of neutrophils in white blood cells (81.5% vs. 75.8%, P=0.012), lower proportion of lymphocytes in white blood cells (9.3% vs. 16.7%, P=0.001), a higher neutrophil-to-lymphocyte ratio (9.1 vs. 4.4, P=0.001), a lower lymphocyte-to-monocyte ratio (1.6 vs. 2.4, P=0.008), and a higher C-reactive protein level (21.0 vs. 5.0 mg/L, P<0.001) than the positive group. In the receiver-operating characteristic analysis, neutrophil-to-lymphocyte ratio and C-reactive protein had an area under the curve of >0.7, and the best cutoff values were 6.0 (accuracy 70.3%) and 12.7 mg/L (accuracy 76.2%), respectively. CONCLUSION: The neutrophil-to-lymphocyte ratio ≥6 and C-reactive protein level ≥12.7 mg/L was significantly associated with negative CSF examination result.

Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators.

AIM: This study compared endotracheal intubation (ETI) performance during cardiopulmonary resuscitation (CPR) between direct laryngoscopy (DL) and video laryngoscopy (VL) (GlideScope(®)) by experienced intubators (>50 successful ETIs). METHODS: This was a prospective randomized controlled study conducted in an emergency department between 2011 and 2013. Intubators who used DL or VL were randomly allocated to ETI during CPR. Data were collected from recorded video clips and rhythm sheets. The success, speed, complications, and chest compressions interruption were compared between the two devices. RESULTS: Total 140 ETIs by experienced intubators using DL (n=69) and VL (n=71) were analysed. There were no significant differences between DL and VL in the ETI success rate (92.8% vs. 95.8%; p=0.490), first-attempt success rate (87.0% vs. 94.4%; p=0.204), and median time to complete ETI (51 [36-67] vs. 42 [34-62]s; p=0.143). In both groups, oesophageal intubation and dental injuries seldom occurred. However, longer chest compressions interruption occurred using DL (4.0 [1.0-11.0]s) compared with VL (0.0 [0.0-1.0]s) and frequent serious no-flow (interruption>10s) occurred with DL (18/69 [26.1%]) compared with VL (0/71) (p<0.001). For highly experienced intubators (>80 successful ETIs), frequent serious no-flow occurred in DL (14/55 [25.5%] vs. 0/57 in VL). CONCLUSIONS: The ETI success, speed and complications during CPR did not differ significantly between the two devices for experienced intubators. However, the VL was superior in terms of completion of ETI without chest compression interruptions. TRIAL REGISTRATION: Clinical Research Information Service (CRIS) in South Korea KCT0000849.

Comparison of the GlideRite to the conventional malleable stylet for endotracheal intubation by the Macintosh laryngoscope: a simulation study using manikins.

OBJECTIVE: To compare the effectiveness of the GlideRite stylet with the conventional malleable stylet (CMS) in endotracheal intubation (ETI) by the Macintosh laryngoscope. METHODS: This study is a randomized, crossover, simulation study. Participants performed ETI using both the GlideRite stylet and the CMS in a normal airway model and a tongue edema model (simulated difficult airway resulting in lower percentage of glottic opening [POGO]). RESULTS: In both the normal and tongue edema models, all 36 participants successfully performed ETI with the two stylets on the first attempt. In the normal airway model, there was no difference in time required for ETI (TETI) or in ease of handling between the two stylets. In the tongue edema model, the TETI using the CMS increased as the POGO score decreased (POGO score was negatively correlated with TETI for the CMS, Spearman's rho=-0.518, P=0.001); this difference was not seen with the GlideRite (rho=-0.208, P=0.224). The TETI was shorter with the GlideRite than with the CMS, however, this difference was not statistically significant (15.1 vs. 18.8 seconds, P=0.385). Ease of handling was superior with the GlideRite compared with the CMS (P=0.006). CONCLUSION: Performance of the GlideRite and the CMS were not different in the normal airway model. However, in the simulated difficult airway model with a low POGO score, the GlideRite performed better than the CMS for direct laryngoscopic intubation.