The collateral map: prediction of lesion growth and penumbra after acute anterior circulation ischemic stroke.

OBJECTIVES: This study evaluated the collateral map's ability to predict lesion growth and penumbra after acute anterior circulation ischemic strokes. METHODS: This was a retrospective analysis of selected data from a prospectively collected database. The lesion growth ratio was the ratio of the follow-up lesion volume to the baseline lesion volume on diffusion-weighted imaging (DWI). The time-to-maximum (Tmax)/DWI ratio was the ratio of the baseline Tmax > 6 s volume to the baseline lesion volume. The collateral ratio was the ratio of the hypoperfused lesion volume of the phase_FU (phase with the hypoperfused lesions most approximate to the follow-up DWI lesion) to the hypoperfused lesion volume of the phase_baseline of the collateral map. Multiple logistic regression analyses were conducted to identify independent predictors of lesion growth. The concordance correlation coefficients of Tmax/DWI ratio and collateral ratio for lesion growth ratio were analyzed. RESULTS: Fifty-two patients, including twenty-six males (mean age, 74 years), were included. Intermediate (OR, 1234.5; p < 0.001) and poor collateral perfusion grades (OR, 664.7; p = 0.006) were independently associated with lesion growth. Phase_FUs were immediately preceded phases of the phase_baselines in intermediate or poor collateral perfusion grades. The concordance correlation coefficients of the Tmax/DWI ratio and collateral ratio for the lesion growth ratio were 0.28 (95% CI, 0.17-0.38) and 0.88 (95% CI, 0.82-0.92), respectively. CONCLUSION: Precise prediction of lesion growth and penumbra can be possible using collateral maps, allowing for personalized application of recanalization treatments. Further studies are needed to generalize the findings of this study. CLINICAL RELEVANCE STATEMENT: Precise prediction of lesion growth and penumbra can be possible using collateral maps, allowing for personalized application of recanalization treatments. KEY POINTS: • Cell viability in cerebral ischemia due to proximal arterial steno-occlusion mainly depends on the collateral circulation. • The collateral map shows salvageable brain extent, which can survive by recanalization treatments after acute anterior circulation ischemic stroke. • Precise estimation of salvageable brain makes it possible to make patient-specific treatment decision.

Survey on caregiver competency and retraining needs.

OBJECTIVES: This study investigated caregivers' job image, abilities, and educational needs, which are rapidly increasing owing to an aging society. DESIGN: A self-administered written survey was conducted at 12 general hospitals in Korea from February 1, 2022 to March 15, 2023. SAMPLE: A total of 451 caregivers participated in the survey as subjects of analysis, and 560 nurses participated as external observers. MEASUREMENTS: The caregivers' self-assessment results regarding job performance, educational needs, and retraining needs were compared with those of external observers. RESULTS: Caregivers evaluated themselves significantly higher in all areas of job performance compared to the evaluations of external observers. In particular, the caregivers' self-evaluation of their abilities in "Recording and Reporting," "Basic Resuscitation," "Safety and Infection Control," and "Understanding Major Illnesses" was different from the evaluation of nurses. Both the caregivers and external observers agreed on the need for caregiver retraining, with 1-2 hours of supplementary training every 12 months being the most preferred amount of retraining. CONCLUSIONS: There was a significant difference between caregivers' self-evaluations of their capabilities and the external observers' evaluations. Therefore, systematic professional caregiver retraining is necessary.

Prognostic value of collateral perfusion estimation by arterial spin labeling for acute anterior circulation ischemic stroke.

PURPOSE: This study aimed to verify the value of arterial spin labeling (ASL) collateral perfusion estimation for predicting functional outcomes in acute anterior circulation ischemic stroke. METHODS: This secondary analysis of an ongoing prospective observational study included data from participants with acute ischemic stroke due to steno-occlusion of the internal carotid artery and/or the middle cerebral artery within 8 h of symptom onset. We compared the collateral map, which is a 5-phase collateral imaging derived from dynamic contrast-enhanced magnetic resonance angiography, and ASL to validate the ASL collateral perfusion estimation. Multiple logistic regression analyses were conducted to identify independent predictors of favorable functional outcomes. RESULTS: One hundred forty-eight participants (68 ± 13 years, 96 men) were evaluated. The ASL collateral perfusion grade was positively correlated with the collateral perfusion grade of the collateral map (P < .001). Younger age (OR = 0.53, 95% CI = 0.36-0.78, P = .002), lower baseline NIHSS score (OR = 0.85, 95% CI = 0.78-0.92, P < .001), intermediate ASL collateral perfusion grade (OR = 4.02, 95% CI = 1.43-11.26, P = .008), good ASL collateral perfusion grade (OR = 26.37, 95% CI = 1.06-655.01, P = .046), and successful reperfusion (OR = 5.84, 95% CI = 2.08-16.42, P < .001) were independently associated with favorable functional outcomes. CONCLUSION: ASL collateral perfusion estimation provides prognostic information, which can be helpful in guiding management decisions.

Reducing amount of contrast agent after compression of right brachial artery using a blood pressure cuff in computed tomography cerebrovascular angiography.

OBJECTIVE: To invastgate feasibility of low-dose contrast agent in cerebral computed tomography angiography (CTA) to alleviate side effects. METHOD: Siemens' Somatom Definition AS+CT scanner, Heine's blood pressure monitor G7-M237 (BP cuff) and Ultravist contrast agent (370 mg Iodine/ml) are used. CTA is acquired using following scan parameters including slice thickness of 1mm, image acquisition parameters of 128×0.6 mm, pitch size of 0.8 mm, 175 effective mAs, 120 kVp tube voltage, scan delay time of 3 seconds, and the scan time of 4 seconds. This study is conducted by securing the IV route in the left antecubital vein before injection of contrast agent, wrapping BP cuff around the branchial artery of the opposite right arm after setting the pressure to 200 mmHg. Then, the injection rate of the contrast agent is fixed at 4.5 cc/sec and contrast agent was injected in three different amounts (70, 80, and 100 cc). Bp cuff is released from this moment when HU value reachs 100. RESULT: In this study, the mean HU values measured from common carotid artery are 412.45±5.89 when injecting 80cc contrast agent and using BP cuff and 399.64±5.51 when injecting 100 cc contrast agenet and not using BP cuff, respectively. In middle cerebral artery M1, the mean HU values are 325.23±38.29 when injecting 80cc contrast agent and using BP cuff and 325.00±30.63 when injecting 100cc contrast agent blood and not using pressure cuff, respectively. Difference of mean HU values is not statistically significant (p > 0.05) with and without using BP cuff. CONCLUSION: This study demonstrates that reducing amount of contrast agent is possible when the right brachial artery is compressed using BP cuff. Study results indicate that reducing 20% injection of contrast agent in CT cerebrovascular angiography can still yield comparable imaging results with conventional contrast angent usage, which implies that less side effects are expected with a contrast agent injection. Thus, this study can serve as a reference for potential reducing side effect during CT cerebrovascular angiography.

Collateral and permeability imaging derived from dynamic contrast material-enhanced MR angiography in prediction of PH 2 hemorrhagic transformation after acute ischemic stroke: a pilot study.

PURPOSE: To evaluate the role of collateral and permeability imaging derived from dynamic contrast material-enhanced magnetic resonance angiography to predict PH 2 hemorrhagic transformation in acute ischemic stroke. METHODS: The secondary analysis of a published data from participants with acute ischemic stroke. The multiphase collateral map and permeability imaging were generated by using dynamic signals from dynamic contrast material-enhanced magnetic resonance angiography obtained at admission. To identify independent predictors of PH 2 hemorrhagic transformation, age, sex, risk factors, baseline National Institutes of Health Stoke Scale (NIHSS) score, baseline DWI lesion volume, collateral-perfusion status, mode of treatment, and successful early reperfusion were evaluated with multiple logistic regression analyses and the significance of permeability imaging in prediction of PH 2 hemorrhagic transformation was evaluated by subgroup analysis. RESULTS: In 115 participants, including 70 males (mean (SD) age, 69 (12) years), PH 2 hemorrhagic transformation occurred in 6 participants with very poor collateral-perfusion status (MAC 0). MAC 0 (OR, 0.06; 95% CI, 0.01, 0.74; P = .03) was independently associated with PH 2 hemorrhagic transformation. In 22 participants with MAC 0, the permeable signal on Kep permeability imaging was the only significant characteristic associated with PH 2 hemorrhagic transformation (P = .009). The specificity of Kep permeability imaging was 93.8% (95% confidence interval: 69.8, 99.8) in predicting PH 2 hemorrhagic transformation. CONCLUSION: Individual-based prediction of PH 2 hemorrhagic transformation in patients with acute ischemic stroke may be possible with multiphase collateral map and permeability imaging derived from dynamic contrast material-enhanced magnetic resonance angiography.

The effect of high-dose intramuscular epinephrine on the recovery of spontaneous circulation in an asphyxia-induced cardiac arrest rat model.

BACKGROUND: Obtaining vascular access can be challenging during resuscitation following cardiac arrest, and it is particularly difficult and time-consuming in paediatric patients. We aimed to compare the efficacy of high-dose intramuscular (IM) versus intravascular (IV) epinephrine administration with regard to the return of spontaneous circulation (ROSC) in an asphyxia-induced cardiac arrest rat model. METHODS: Forty-five male Sprague-Dawley rats were used for these experiments. Cardiac arrest was induced by asphyxia, and defined as a decline in mean arterial pressure (MAP) to 20 mmHg. After asphyxia-induced cardiac arrest, the rats were randomly allocated into one of 3 groups (control saline group, IV epinephrine group, and IM epinephrine group). After 540 s of cardiac arrest, cardiopulmonary resuscitation was performed, and IV saline (0.01 cc/kg), IV (0.01 mg/kg, 1:100,000) epinephrine or IM (0.05 mg/kg, 1:100,000) epinephrine was administered. ROSC was defined as the achievement of an MAP above 40 mmHg for more than 1 minute. Rates of ROSC, haemodynamics, and arterial blood gas analysis were serially observed. RESULTS: The ROSC rate (61.5%) of the IM epinephrine group was less than that in the IV epinephrine group (100%) but was higher than that of the control saline group (15.4%) (log-rank test). There were no differences in MAP between the two groups, but HR in the IM epinephrine group (beta coefficient = 1.02) decreased to a lesser extent than that in the IV epinephrine group with time. CONCLUSIONS: IM epinephrine induced better ROSC rates compared to the control saline group in asphyxia-induced cardiac arrest, but not compared to IV epinephrine. The IM route of epinephrine administration may be a promising option in an asphyxia-induced cardiac arrest.

Tunicamycin as a Novel Redifferentiation Agent in Radioiodine Therapy for Anaplastic Thyroid Cancer.

The silencing of thyroid-related genes presents difficulties in radioiodine therapy for anaplastic thyroid cancers (ATCs). Tunicamycin (TM), an N-linked glycosylation inhibitor, is an anticancer drug. Herein, we investigated TM-induced restoration of responsiveness to radioiodine therapy in radioiodine refractory ATCs. 125I uptake increased in TM-treated ATC cell lines, including BHT101 and CAL62, which was inhibited by KClO4, a sodium-iodide symporter (NIS) inhibitor. TM upregulated the mRNA expression of iodide-handling genes and the protein expression of NIS. TM blocked pERK1/2 phosphorylation in both cell lines, but AKT (protein kinase B) phosphorylation was only observed in CAL62 cells. The downregulation of glucose transporter 1 protein was confirmed in TM-treated cells, with a significant reduction in 18F-fluorodeoxyglucose (FDG) uptake. A significant reduction in colony-forming ability and marked tumor growth inhibition were observed in the combination group. TM was revealed to possess a novel function as a redifferentiation inducer in ATC as it induces the restoration of iodide-handling gene expression and radioiodine avidity, thereby facilitating effective radioiodine therapy.

Multiphase MR Angiography Collateral Map: Functional Outcome after Acute Anterior Circulation Ischemic Stroke.

Background Collateral circulation determines tissue fate and affects treatment result in acute ischemic stroke. A precise method for collateral estimation in an optimal imaging protocol is necessary to make an appropriate treatment decision for acute ischemic stroke. Purpose To verify the value of multiphase collateral imaging data sets (MR angiography collateral map) derived from dynamic contrast material-enhanced MR angiography for predicting functional outcomes after acute ischemic stroke. Materials and Methods This secondary analysis of an ongoing prospective observational study included data from participants with acute ischemic stroke due to occlusion or stenosis of the unilateral internal carotid artery and/or M1 segment of the middle cerebral artery who were evaluated within 8 hours of symptom onset. Data were obtained from March 2016 through August 2018. The collateral grading based on the MR angiography collateral map was estimated by using six-scale MR acute ischemic stroke collateral (MAC) scores. To identify independent predictors of favorable functional outcomes, age, sex, risk factors, baseline National Institutes of Health Stroke Scale (NIHSS) score, baseline diffusion-weighted imaging (DWI) lesion volume, site of steno-occlusion, collateral grade, mode of treatment, and early reperfusion were evaluated with multiple logistic regression analyses. Results One hundred fifty-four participants (mean age ± standard deviation, 69 years ± 13; 99 men) were evaluated. Younger age (odds ratio [OR], 0.45; 95% confidence interval [CI]: 0.29, 0.70; P < .001), lower baseline NIHSS score (OR, 0.85; 95% CI: 0.78, 0.94; P < .001), MAC score of 3 (OR, 27; 95% CI: 4.0, 179; P < .001), MAC score of 4 (OR, 17; 95% CI: 2.1, 134; P = .007), MAC score of 5 (OR, 27; 95% CI: 2.5, 306; P = .007), and successful early reperfusion (OR, 7.5; 95% CI: 2.6, 22; P < .001) were independently associated with favorable functional outcomes in multivariable analysis. There was a linear negative association between collateral perfusion grades and functional outcomes (P < .001). Conclusion An MR angiography collateral map was clinically reliable for collateral estimation in patients with acute ischemic stroke. This map provided patient-specific pacing information for ischemic progression. © RSNA, 2020.

Effects of emergency department boarding on mortality in patients with ST-segment elevation myocardial infarction.

OBJECTIVE: Patients with ST-segment elevation myocardial infarction (STEMI) are sometimes boarded in the emergency department (ED) after percutaneous coronary intervention (PCI). We evaluated the effects of direct and indirect admission to the CCU on mortality and the effect on length of stay (LOS) in patients with STEMI. METHOD: This was a retrospective observational study of patients with STEMI between Jan 2014 and Nov 2017. The patients were divided into the direct admission (DA) group, who were admitted into the CCU immediately after PCI, and the indirect admission (IA) group, who were admitted after boarding in the ED. The primary endpoint was in-hospital mortality. Secondary endpoints were 3-month mortality, LOS in CCU and hospital, and LOS under intensive care. RESULTS: During the study period, 780 patients were enrolled and analyzed. The in-hospital mortality rate and 3-month mortality rate were 5.9% (46 patients) and 8.5% (66 patients). The DA group and IA group had similar in-hospital and 3-month mortality rates (P = .50, P = .28). The median CCU LOS and hospital LOS was similar for both groups (P = .28, P = .46). However, LOS under in intensive care for the IA group was significantly longer than that of the DA group (DA, 31.9 h; IA, 38.7 h; P < .001). CONCLUSION: This study suggests that direct admission after PCI and indirect admission was not associated with mortality in patients with STEMI. In addition, the stay in ED also appears to be associated with the duration of stay under critical care.

Emergency Department Triage Early Warning Score (TREWS) predicts in-hospital mortality in the emergency department.

AIM: The purpose is to assess the adequacy of the National Early Warning Score (NEWS) in the emergency department (ED) and the usefulness of the Triage in Emergency Department Early Warning Score (TREWS) that has been developed using the NEWS in the ED. METHODS: In this retrospective observational cohort study, we performed univariable and multivariable regression analyses with 81,520 consecutive ED patients to develop a new scoring system, the TREWS. The primary outcome was in-hospital mortality within 24 h, and secondary outcomes were in-hospital mortality within 48 h, 7 days, and 30 days. The prognostic properties of the TREWS were compared with those of the NEWS, Modified Early Warning Score (MEWS), and Rapid Emergency Medicine Score (REMS) using the area under the receiver operating characteristic curve (AUC) technique. RESULTS: The AUC of the TREWS for in-hospital mortality within 24 h was 0.906 (95% CI, 0.903-0.908), those of the NEWS, MEWS, and REMS were 0.878 (95% CI, 0.875-0.881), 0.857 (95% CI, 0.854-0.860), and 0.834 (95% CI, 0.831-0.837), respectively. Differences in the AUC between the TREWS and NEWS, the TREWS and MEWS, and the TREWS and REMS were 0.028 (95% CI, 0.022-0.033; p < .001), 0.049 (95% CI, 0.041-0.057; p < .001), and 0.072 (95% CI, 0.063-0.080; p < .001), respectively. The TREWS showed significantly superior performance in predicting secondary outcomes. CONCLUSION: The TREWS predicts in-hospital mortality within 24 h, 48 h, 7 days, and 30 days better than the NEWS, MEWS, and REMS for patients arriving at the ED.

In Vivo Optical Reporter-Gene-Based Imaging of Macrophage Infiltration of DNCB-Induced Atopic Dermatitis.

This study was conducted to monitor the macrophage infiltration of atopic dermatitis (AD)-like skin lesions and to evaluate the effects of anti-AD therapeutic agents in immunocompetent mice via optical reporter-gene-based molecular imaging. The enhanced firefly luciferase (effluc)-expressing macrophage cell line (Raw264.7/effluc) was intravenously introduced into mice with 2,4-dinitrochlorobenzene (DNCB)-induced AD, followed by bioluminescent imaging (BLI). After in vivo imaging, AD-like skin lesions were excised, and ex vivo imaging and Western blotting were conducted to determine the presence of infused macrophages. Finally, the therapeutic effect of dexamethasone (DEX), an AD-modulating agent, was evaluated via macrophage tracking. In vivo imaging with BLI revealed the migration of the reporter macrophages to DNCB-induced AD-like skin lesions on day 1 post-transfer. The greatest recruitment was observed on day 3, and a decline in BLI signal was observed on day 14. Notably, in vivo BLI clearly showed the inhibition of the reporter macrophage infiltration of DNCB-induced AD-like skin lesions by DEX, which was consistent with the reduced AD symptoms observed in DEX-treated mice. We successfully visualized the macrophage migration to DNCB-induced AD-like skin lesions, proving the feasibility of macrophage imaging for evaluating AD-regulating drugs in living organisms.

Isolation of Unstable Isomers of Lucilactaene and Evaluation of Anti-Inflammatory Activity of Secondary Metabolites Produced by the Endophytic Fungus Fusarium sp. QF001 from the Roots of Scutellaria baicalensis.

The filamentous fungal pathogen Fusarium sp. causes several crop diseases. Some Fusarium sp. are endophytes that produce diverse valuable bioactive secondary metabolites. Here, extensive chemical investigation of the endophytic fungus, Fusarium sp. QF001, isolated from the inner rotten part of old roots of Scutellariae baicalensis resulted in the isolation of two new photosensitive geometrical isomers of lucilactaene (compounds 2 and 3) along with lucilactaene (6) and six other known compounds (fusarubin (1), (+)-solaniol (4), javanicin (5), 9-desmethylherbarine (7), NG391 (8) and NG393 (9)). Newly isolated isomers and lucilactaene were unstable under light at room temperature and tended to be a mixture in equilibrium state when exposed to a polar protic solvent during reversed phase chromatography. Normal phase chromatography under dim light conditions with an aprotic mobile phase led to the successful isolation of the relatively unstable isomers 2 and 3. Their structures were elucidated as 8(Z)-lucilactaene (2) and 4(Z)-lucilactaene (3) based on spectroscopic data. The absolute configuration of 4 was speculated to be R by computer-assisted specific rotation analysis. The isolated compounds could inhibit NO production and suppress pro-inflammatory cytokines expression in LPS-stimulated macrophage cells. These properties of the isolated compounds indicate their potential use as anti-inflammatory drugs.

New Fused Pyrrolopyridine-Based Copolymers for Organic Solar Cell.

A fused pyrrolopyridine core having substituents on the nitrogen atom instead of the carbon atom of the indoloindole unit is developed as a new donor unit for organic electronics. The new donor-acceptor copolymers, PDHPHBT, PDHPFBT, and PDHP2FBT, are synthesized using the new donor unit, well-known benzothiadiazole derivatives containing fluorine atoms as the acceptor. The thermal, optical, and electrochemical properties of these novel copolymers are reported. A solar cell using PDHPFBT with diphenyl ether has an open-circuit voltage, short-circuit current, fill factor, and power conversion efficiency of 0.86 V, 11.32 mA cm-2 , 0.59%, and 5.68%, respectively, under AM 1.5G illumination (100 mW cm-2 ) in the absence of annealing.

The ratio of N-terminal pro-B-type natriuretic peptide to troponin I for differentiating acute coronary syndrome.

INTRODUCTION: It is difficult to differentiate whether coronary or non-coronary causes in patients with elevated troponin I (TnI) in emergency department (ED). The aim of this study was to develop a clinical decision tool for differentiating a coronary cause in the patients with elevated TnI. METHODS: This was a retrospective observational study that enrolled consecutive ED patients. Patients were included in the study if they were ≥16 years of age, had admitted through ED with a medical illness, and TnI levels at initial evaluation in the ED were ≥0.2 ng/mL. Patients diagnosed with ST elevation myocardial infarction or congestive heart failure were excluded. Coronary angiography, electrocardiogram, laboratory results, echocardiography, and clinical characteristics were analyzed. RESULTS: Among the included 1441 patients, 603 and 838 patients were categorized into an acute coronary syndrome (ACS) group and non-acute coronary syndrome (non-ACS) group, respectively. The ratio of N-terminal pro-Btype natriuretic peptide (NT-proBNP) to TnI was significantly higher in the non-ACS group compared to the ACS group. The AUC of NT-proBNP/TnI (0.805, 95% CI, 0.784-0.826) was significantly superior to that of NT-proBNP/creatinine kinase-MB, TnI, and NT-proBNP. The patients of the non-ACS group with high levels of TnI and BNP showed more critically ill manifestation at the time of presentation and higher mortality. CONCLUSION: NT-proBNP/TnI may help to distinguish medical patients with elevated TnI whether the elevated TnIs were caused from ACSs or from conditions other than ACS.

PEGylated crushed gold shell-radiolabeled core nanoballs for in vivo tumor imaging with dual positron emission tomography and Cerenkov luminescent imaging.

BACKGROUND: Radioactive isotope-labeled gold nanomaterials have potential biomedical applications. Here, we report the synthesis and characterization of PEGylated crushed gold shell-radioactive iodide-124-labeled gold core nanoballs (PEG-124I-Au@AuCBs) for in vivo tumor imaging applications through combined positron emission tomography and Cerenkov luminescent imaging (PET/CLI). RESULTS: PEG-124I-Au@AuCBs showed high stability and sensitivity in various pH solutions, serum, and in vivo conditions and were not toxic to tested cells. Combined PET/CLI clearly revealed tumor lesions at 1 h after injection of particles, and both signals remained visible in tumor lesions at 24 h, consistent with the biodistribution results. CONCLUSION: Taken together, the data provided strong evidence for the application of PEG-124I-Au@AuCBs as promising imaging agents in nuclear medicine imaging of various biological systems, particularly in cancer diagnosis.

The impact of the improvement in internal medicine consultation process on ED length of stay.

INTRODUCTION: Although consultations are essential for delivering safe, high-quality care to patients in emergency departments, they contribute to emergency department patient flow problems and overcrowding which is associated with several adverse outcomes, such as increases in patient mortality and poor quality care. This study aimed to investigate how time flow metrics including emergency department length of stay is influenced by changes to the internal medicine consultation policy. METHOD: This study is a pre- and post-controlled interventional study. We attempted to improve the internal medicine consultation process to be more concise. After the intervention, only attending emergency physicians consult internal medicine chief residents, clinical fellows, or junior staff of each internal medicine subspecialty who were on duty when patients required special care or an admission to internal medicine. RESULTS: Emergency department length of stay of patients admitted to the department of internal medicine prior to and after the intervention decreased from 996.94min to 706.62min. The times from consultation order to admission order and admission order to emergency department departure prior to and after the intervention were decreased from 359.59min to 180.38min and from 481.89min to 362.37min, respectively. The inpatient mortality rates and Inpatient bed occupancy rates prior to and after the intervention were similar. CONCLUSION: The improvements in the internal medicine consultation process affected the flow time metrics. Therefore, more comprehensive and cooperative strategies need to be developed to reduce the time cycle metrics and overcrowding of all patients in the emergency department.

Predictor of Isolated Trauma in Head: A New Simple Predictor for Survival of Isolated Traumatic Brain Injury.

BACKGROUND: Mortality prediction in patients with brain trauma during initial management in the emergency department (ED) is essential for creating the foundation for a better prognosis. OBJECTIVE: This study aimed to create a simple and useful survival predictive model for patients with isolated blunt traumatic brain injury that is easily available in the ED. METHODS: This is a retrospective study based on the trauma registry data of an academic teaching hospital. The inclusion criteria were age ≥ 15 years, blunt and not penetrating mechanism of injury, and Abbreviated Injury Scale (AIS) scores between 1 and 6 for head and 0 for all other body parts. The primary outcome was 30-day survival probability. Internal and external validation was performed. RESULTS: After univariate logistic regression analysis based on the derivation cohort, the final Predictor of Isolated Trauma in Head (PITH) model for survival prediction of isolated traumatic brain injury included Glasgow Coma Scale (GCS), age, and coded AIS of the head. In the validation cohort, the area under the curve of the PITH score was 0.970 (p < 0.0001; 95% confidence interval 0.960-0.978). Sensitivity and specificity were 95% and 81.7% at the cutoff value of 0.9 (probability of survival 90%), respectively. CONCLUSIONS: The PITH model performed better than the GCS; Revised Trauma Score; and mechanism of injury, GCS, age, and arterial pressure. It will be a useful triage method for isolated traumatic brain injury in the early phase of management.

The Revised Trauma Score plus serum albumin level improves the prediction of mortality in trauma patients.

INTRODUCTION: The Revised Trauma Score (RTS) is used worldwide in prehospital practice and in the emergency department (ED) settings to triage trauma patients. The main purpose of this study was to evaluate the value of the RTS plus serum albumin (RTS-A) and to compare it with other existing trauma scores as well as to compare the predictive performance of the Trauma and Injury Severity Score with the RTS-A (TRISS-A) with the original TRISS. METHODS: This was a single center, trauma registry based observational cohort study. Data were collected from consecutive patients with blunt or penetrating injuries who presented to the emergency department of a tertiary referral hospital, between January 2012 and June 2016. 3145 and 2447 patients were assigned to the derivation group and validation group, respectively. Main outcome was in-hospital mortality. RESULTS: Among patients in the derivation group, the median [interquartile range] age was 59 [43-73] years, and 66.7% were male. The area under the receiver operating characteristic curves (AUC) of the RTS-A (0.948; 95% CI: 0.939-0.955) was higher than that of the RTS (0.919; 95% CI: 0.909-0.929). In patients with blunt trauma, the AUC of the TRISS-A (0.960; 95% CI: 0.952-0.967) was significantly higher than that of the original TRISS (0.949; 95% CI: 0.941-0.957). CONCLUSION: The value of the RTS-A predicts the in-hospital mortality of trauma patients better than the RTS, and the TRISS-A is a better mortality predictor compared to the original TRISS in patients with blunt trauma.

The new trauma score (NTS): a modification of the revised trauma score for better trauma mortality prediction.

BACKGROUND: Since its introduction, the Revised Trauma Score (RTS) has been widely used to determine the prognosis of trauma patients. Recent studies have revealed a need to change the parameters of the RTS. We have designed a new trauma score (NTS) based on revised parameters, including the adoption of the actual Glasgow Coma Scale (GCS) score instead of a GCS code, the revision of the systolic blood pressure interval used for the code value and the incorporation of peripheral oxygen saturation (SpO2) instead of respiratory rate. The purpose of this study was to evaluate the predictive performance of the NTS for in-hospital mortality compared with the RTS and other trauma scores. METHODS: This was a prospective observational study using data from the trauma registry of a tertiary hospital. The subjects were selected from patients who arrived at the ED between July 1, 2014, and June 30, 2016, and, for external validation purposes, those who arrived at the ED between July 1, 2011, and June 30, 2013. Demographic data and physiological data were analyzed. NTS models were calculated using logistic regression for GCS score, SBP code values, and SpO2. The mortality predictive performance of NTS was compared with that of other trauma scores. RESULTS: A total of 3263 patients for derivation and 3106 patients for validation were included in the analysis. The NTS showed better discrimination than the RTS (AUC = 0.935 vs. 0.917, respectively, AUC difference = 0.018, p = 0.001; 95% CI, 0.0071-0.0293) and similar discrimination to that of mechanism, Glasgow Coma scale, age, and arterial pressure (MGAP) and the Glasgow Coma Scale, age, and systolic arterial pressure (GAP). In the validation cohort, the global properties of the NTS for mortality prediction were significantly better than those of the RTS (AUC = 0.919 vs. 0.906, respectively; AUC difference = 0.013, p = 0.013; 95% CI, 0.0009-0.0249) and similar to those of the MGAP and GAP. CONCLUSIONS: The NTS predicts in-hospital mortality substantially better than the RTS.

Pneumoperitoneum by Inguinal Laceration after Traffic Accident.

BACKGROUND: The leading cause of surgical pneumoperitoneum is hollow viscus perforation, which accounts for approximately 90% of cases. A nonsurgical etiology may account for up to about 10% of the causes of pneumoperitoneum. However, a pneumoperitoneum often poses significant management dilemmas for surgeons, especially when signs of peritonitis are absent or when the cause is unknown prior to laparotomy. We present the first case of pneumoperitoneum due to inguinal laceration without viscus perforation after a traffic accident. CASE REPORT: A 17-year-old male patient was admitted to the emergency department with a deep laceration of 7∼8 cm with bleeding in the right inguinal region after a collision with a passenger car while riding a bicycle. The abdominal examination revealed diffuse abdominal tenderness on deep palpation without peritoneal signs. A chest radiograph showed no free gas below the diaphragm. On computed tomography angiography of the aorta, subcutaneous emphysema in the right inguinal and femoral areas and free air in the peritoneal cavity were observed. There was no bowel perforation in an exploratory laparotomy, but the right femoral sheath ruptured, and exposure of the femoral vessels into the peritoneal cavity was observed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A pneumoperitoneum can be caused by femoral sheath rupture without hollow viscus perforation in patients with a penetrating groin injury. Therefore, emergency physicians should not pursue solely abdominal/pelvic sources of a pneumoperitoneum in patients with a penetrating groin injury.