The usefulness of lactate/albumin ratio, C-reactive protein/albumin ratio, procalcitonin/albumin ratio, SOFA, and qSOFA in predicting the prognosis of patients with sepsis who presented to EDs.

PURPOSE: Early identification of sepsis with a poor prognosis in the emergency department (ED) is crucial for prompt management and improved outcomes. This study aimed to examine the predictive value of sequential organ failure assessment (SOFA), quick SOFA (qSOFA), lactate to albumin ratio (LAR), C-reactive protein to albumin ratio (CAR), and procalcitonin to albumin ratio (PAR), obtained in the ED, as predictors for 28-day mortality in patients with sepsis and septic shock. MATERIALS AND METHODS: We included 3499 patients (aged ≥19 years) from multicenter registry of the Korean Shock Society between October 2015 and December 2019. The SOFA score, qSOFA score, and lactate level at the time of registry enrollment were used. Albumin, C-reactive protein, and procalcitonin levels were obtained from the initial laboratory results measured upon ED arrival. We evaluated the predictive accuracy for 28-day mortality using the area under the receiver operating characteristic (AUROC) curve. A multivariable logistic regression analysis of the independent predictors of 28-day mortality was performed. The SOFA score, LAR, CAR, and PAR were converted to categorical variables using Youden's index and analyzed. Adjusting for confounding factors such as age, sex, comorbidities, and infection focus, adjusted odds ratios (aOR) were calculated. RESULTS: Of the 3499 patients, 2707 (77.4%) were survivors, whereas 792 (22.6%) were non-survivors. The median age of the patients was 70 (25th-75th percentiles, 61-78), and 2042 (58.4%) were male. LAR for predicting 28-day mortality had the highest AUROC, followed by the SOFA score (0.715; 95% confidence interval (CI): 0.69-0.74 and 0.669; 95% CI: 0.65-0.69, respectively). The multivariable logistic regression analysis revealed that the aOR of LAR >1.52 was 3.75 (95% CI: 3.16-4.45), and the aOR, of SOFA score at enrollment >7.5 was 2.67 (95% CI: 2.25-3.17). CONCLUSION: The results of this study showed that LAR is a relatively strong predictor of sepsis prognosis in the ED setting, indicating its potential as a straightforward and practical prognostic factor. This finding may assist healthcare providers in the ED by providing them with tools to risk-stratify patients and predict their mortality.

The prognostic value of the phosphate-to-albumin ratio in patients with OHCA: A multicenter observational study.

PURPOSE: In patients with out-of-hospital cardiac arrest (OHCA), early and accurate outcome prediction is crucial for making treatment decisions and informing their relatives. A previous study reported an association between high phosphate levels and unfavorable neurological outcomes after return of spontaneous circulation (ROSC); however, its prognostic value was insufficient when used independently. Therefore, this study aimed to validate the usefulness of the phosphate-to-albumin ratio (PAR) in predicting neurological outcomes and in-hospital mortality by incorporating albumin, another known prognostic indicator. MATERIALS AND METHODS: This multicenter observational study included adult OHCA survivors from October 2015 to June 2021. The primary endpoint was an unfavorable neurological outcome at hospital discharge, defined as a cerebral performance category score of 3-5. The in-hospital mortality rates were also evaluated. RESULTS: Of the 2397 adult OHCA survivors, PAR differed significantly between the unfavorable and favorable neurological outcome groups, as well as between the non-survival and survival to hospital discharge groups (2.4 vs 1.4, 2.5 vs 1.6, respectively). The area under the receiver operating characteristic curve (AUROC) value of the PAR for predicting unfavorable neurological outcome was 0.81 (95% confidence interval [CI], 0.79-0.83), and the AUROC value for predicting in-hospital mortality was 0.76 (95% CI, 0.74-0.78). In multivariable analysis, the PAR was independently associated with unfavorable neurological outcome (odds ratio [OR] 1.30, 95% CI 1.15-1.37; p < 0.001) and in-hospital mortality (OR 1.24, 95% CI 1.12-1.38; p < 0.001). CONCLUSION: The PAR is a readily obtainable and independent prognostic indicator for patients with ROSC after OHCA, helping healthcare providers in predicting outcomes.

Predicting acute brain lesions on magnetic resonance imaging in acute carbon monoxide poisoning: a multicenter prospective observational study.

An acute brain lesion (ABL) identified by brain magnetic resonance imaging (MRI) after acute carbon monoxide (CO) poisoning is a strong prognostic factor for the development of delayed neuropsychiatric syndrome (DNS). This study aimed to identify predictors of ABLs on MRI in patients with acute CO poisoning. This was a multicenter prospective registry-based observational study conducted at two tertiary hospitals. A total of 1,034 patients were included. Multivariable logistic regression analysis showed that loss of consciousness (LOC) (adjusted odds ratio [aOR] 2.68, 95% Confidence Interval [CI]: 1.49-5.06), Glasgow Coma Scale (GCS) score < 9 (aOR 2.41, 95% CI: 1.49-3.91), troponin-I (TnI) (aOR 1.22, 95% CI: 1.08-1.41), CO exposure duration (aOR 1.09, 95% CI: 1.05-1.13), and white blood cell (WBC) (aOR 1.05, 95% CI: 1.01-1.09) were independent predictors of ABLs on MRI. LOC, GCS score, TnI, CO exposure duration, and WBC count can be useful predictors of ABLs on MRI in patients with acute CO poisoning, helping clinicians decide the need for an MRI scan or transfer the patient to an appropriate institution for MRI or hyperbaric oxygen therapy.

Diagnostic performance of rapid antigen tests for SARS-CoV-2 transmission risk based on cycle threshold values in the emergency department.

BACKGROUND: This study aimed to investigate the diagnostic performance of the rapid antigen test (RAT) for screening patients with cycle threshold (Ct) values of SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) in the emergency department. Previous studies have shown that Ct values could be used as indicators of infectiousness. Therefore, we considered the Ct value an indicator of potential infectiousness. METHODS: This single-center retrospective observational study was conducted between January 1, 2020, and March 31, 2022. Patients who underwent both RT-PCR and RAT for the diagnosis of COVID-19 were included. Patients with negative RT-PCR results were excluded. Patients with Ct values lower than 26 and 30 were considered potentially infectious for COVID-19. RESULT: A total of 386 patients were analyzed. At Ct value cutoffs of 26 and 30, the result of the RAT showed a sensitivity of 82% and 74%, specificity of 84% and 89%, and area under the curve (AUC) of 0.829 and 0.813, respectively, in the receiver operating characteristic curve. However, the NPV was relatively low at 55% and 25%. CONCLUSION: The RAT might be a rapid screening tool for detecting patients with the infectiousness of SARS-CoV-2. However, considering the low NPV, it is challenging to depend only on a negative test result from an antigen test to terminate quarantine. Clinicians should consider additional factors, such as the duration of symptoms and the immunocompromised state, for SARS-CoV-2 transmission.

Association of Socioeconomic Status With Long-Term Outcome in Survivors After Out-of-Hospital Cardiac Arrest: Nationwide Population-Based Longitudinal Study.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a major public health problem and a leading cause of death worldwide. Previous studies have focused on improving the survival of people who have had OHCA by analyzing short-term survival outcomes, such as the return of spontaneous circulation, 30-day survival, and survival to discharge. Research has been conducted on prehospital prognostic factors to improve the survival of patients with OHCA, among which the association between socioeconomic status (SES) and survival has been reported. SES could affect bystander cardiopulmonary resuscitation rates and whether OHCA is witnessed, and low cardiopulmonary resuscitation education rates are associated with low SES. It has been reported that areas with high SES have shorter hospital transfer times and more public defibrillators per person. Previous studies have shown the impact of SES disparities on the short-term survival of patients with OHCA. However, understanding the impact of SES on the long-term prognosis of OHCA survivors remains limited. As long-term outcomes are more indicative of a patient's ongoing health care needs and the burden on public health than short-term outcomes, understanding the long-term prognosis of OHCA survivors is important. OBJECTIVE: This study aimed to identify whether SES influenced the long-term outcomes of OHCA. METHODS: Using health claims data obtained from the National Health Insurance (NHI) service in Korea, we included OHCA survivors who were hospitalized between January 2005 and December 2015. The patients were divided into 2 groups: NHI and Medical Aid (MA) groups, with the MA group defined as having a low SES. Cumulative mortality was estimated using the Kaplan-Meier method, and a Cox proportional hazards model was used to evaluate the impact of SES on long-term mortality. A subgroup analysis was performed based on whether cardiac procedures were performed. RESULTS: We followed 4873 OHCA survivors for up to 14 years (median of 3.3 years). The Kaplan-Meier survival curve showed that the MA group had a significantly decreased long-term survival rate compared to the NHI group. With an adjusted hazard ratio (aHR) of 1.52 (95% CI 1.35-1.72), low SES was associated with increased long-term mortality. The overall mortality rate of the patients who underwent cardiac procedures in the MA group was significantly higher than that of the NHI group (aHR 1.72, 95% CI 1.05-2.82). The overall mortality rate of patients without cardiac procedures was also increased in the MA group compared to the NHI group (aHR 1.39, 95% CI 1.23-1.58). CONCLUSIONS: OHCA survivors with low SES had an increased risk of poor long-term outcomes compared with those with higher SES. OHCA survivors with low SES who have undergone cardiac procedures need considerable care for long-term survival.

Effectiveness of Initial Troponin I and Brain Natriuretic Peptide Levels as Biomarkers for Predicting Delayed Neuropsychiatric Sequelae in Patients with CO Poisoning: A Retrospective Multicenter Observational Study.

BACKGROUND: Delayed neuropsychiatric sequelae (DNS) are a severe complication of carbon monoxide (CO) poisoning, and predicting DNS is difficult. This study aimed to investigate whether cardiac markers can be used as biomarkers to predict DNS occurrence following acute CO poisoning. METHODS: This was a retrospective observational study that included patients with acute CO poisoning who visited two emergency medical centers in Korea from January 2008 to December 2020. The primary outcome was whether the occurrence of DNS was associated with laboratory results. RESULTS: Of the 1327 patients with CO poisoning, 967 patients were included. Troponin I and BNP were significantly higher in the DNS group. As a result of multivariate logistic regression analysis, it was found that troponin I, mentality, creatine kinase, brain natriuretic peptide, and lactate levels independently influenced DNS occurrence in CO poisoning patients. The adjusted odds ratios for DNS occurrence were 2.12 (95% CI 1.31-3.47, p = 0.002) for troponin I and 2.80 (95% CI 1.81-3.47, p < 0.001) for BNP. CONCLUSION: Troponin I and BNP might be useful biomarkers for predicting the occurrence of DNS in patients with acute CO poisoning. This finding can help to identify high-risk patients who require close monitoring and early intervention to prevent DNS.

Analysis of Anxiety or Depression and Long-term Mortality Among Survivors of Out-of-Hospital Cardiac Arrest.

Importance: The recent American Heart Association guidelines added a sixth link in the chain of survival highlighting recovery and emphasized the importance of psychiatric outcome and recovery for survivors of out-of-hospital cardiac arrest (OHCA). The prevalence of psychiatric disorders among this population was higher than that in the general population. Objective: To examine the prevalence of depression or anxiety and the association of these conditions with long-term mortality among individuals who survive OHCA. Design, Setting, and Participants: A longitudinal population-based cohort study was conducted to analyze long-term prognosis in patients hospitalized for OHCA between January 1, 2005, and December 31, 2015, who survived for 1 year or longer. Patients with cardiac arrest due to traumatic or nonmedical causes, such as injuries, poisoning, asphyxiation, burns, or anaphylaxis, were excluded. Data were extracted on depression or anxiety diagnoses in this population within 1 year from the database of the Korean National Health Insurance Service and analyzed April 7, 2022, and reanalyzed January 19 to 20, 2023. Main Outcomes and Measures: Follow-up data were obtained for up to 14 years, and the primary outcome was long-term cumulative mortality. Long-term mortality among patients with and without a diagnosis of depression or anxiety were evaluated. Results: The analysis included 2373 patients; 1860 (78.4%) were male, and the median age was 53.0 (IQR, 44.0-62.0) years . A total of 397 (16.7%) patients were diagnosed with depression or anxiety, 251 (10.6%) were diagnosed with depression, and 227 (9.6%) were diagnosed with anxiety. The incidence of long-term mortality was significantly higher in the group diagnosed with depression or anxiety than in the group without depression or anxiety (141 of 397 [35.5%] vs 534 of 1976 [27.0%]; P = .001). With multivariate Cox proportional hazards regression analysis, the adjusted hazard ratio of long-term mortality for total patients with depression or anxiety was 1.41 (95% CI, 1.17-1.70); depression, 1.44 (95% CI, 1.16-1.79); and anxiety, 1.20 (95% CI, 0.94-1.53). Conclusions and Relevance: In this study, among the patients who experienced OHCA, those diagnosed with depression or anxiety had higher long-term mortality rates than those without depression or anxiety. These findings suggest that psychological and neurologic rehabilitation intervention for survivors of OHCA may be needed to improve long-term survival.

Genetic markers for depressive disorders with earlier age at onset.

Age at onset has been considered a potential indicator of underlying genetic risk in depression research. However, the variants associated with earlier age at onset of depressive disorder have not been elucidated. To evaluate the genetic architecture of depression onset, whole-exome sequencing of samples from 1000 patients with depressive disorder was performed. Cox proportional hazard models with false discovery rate-adjusted P-values were used to estimate the hazard ratios; carriers and non-carriers of individual coding variants were compared in terms of age at onset of depression with adjustment for sociodemographic and clinical characteristics. The clinical relevance of the candidate variants was also examined. Whole-exome sequencing revealed four variants in the CCL14, FYB, GPRASP1, and CTNND2 genes associated with an increased risk of depressive disorder with earlier age at onset. Although no individual variant was associated with any clinical characteristic except AAO, together they were associated with younger AAO, younger age at visit for treatment, and recurrent and atypical depression. Our data suggest novel candidate genes for depressive disorder with earlier age at onset. These genes could serve as markers allowing early identification of patients at risk of depression, and thus earlier intervention.

Genetic Markers for Later Remission in Response to Early Improvement of Antidepressants.

Planning subsequent treatment strategies based on early responses rather than waiting for delayed antidepressant action can be helpful. We identified genetic markers for later non-remission in patients exhibiting poor early improvement using whole-exome sequencing data of depressive patients treated in a naturalistic manner. Among 1000 patients, early improvement at 2 weeks (reduction in Hamilton Depression Rating Scale [HAM-D] score ≥ 20%) and remission at 12 weeks (HAM-D score ≤ 7) were evaluated. Gene- and variant-level analyses were conducted to compare patients who did not exhibit early improvement and did not eventually achieve remission (n = 126) with those who exhibited early improvement and achieved remission (n = 385). Genes predicting final non-remission in patients who exhibited poor early improvement (COMT, PRNP, BRPF3, SLC25A40, and CGREF1 in males; PPFIBPI, LZTS3, MEPCE, MAP1A, and PFAS in females; ST3GAL5 in the total population) were determined. Among the significant genes, variants in the PRNP (rs1800014), COMT (rs6267), BRPF3 (rs200565609), and SLC25A40 genes (rs3213633) were identified. However, interpretations should be made cautiously, as complex pharmacotherapy involves various genes and pathways. Early detection of poor early improvement and final non-remission based on genetic risk would be helpful for decision-making in a clinical setting.

Sex differences in the genetic architecture of depression.

The prevalence and clinical characteristics of depressive disorders differ between women and men; however, the genetic contribution to sex differences in depressive disorders has not been elucidated. To evaluate sex-specific differences in the genetic architecture of depression, whole exome sequencing of samples from 1000 patients (70.7% female) with depressive disorder was conducted. Control data from healthy individuals with no psychiatric disorder (n = 72, 26.4% female) and East-Asian subpopulation 1000 Genome Project data (n = 207, 50.7% female) were included. The genetic variation between men and women was directly compared using both qualitative and quantitative research designs. Qualitative analysis identified five genetic markers potentially associated with increased risk of depressive disorder in females, including three variants (rs201432982 within PDE4A, and rs62640397 and rs79442975 within FDX1L) mapping to chromosome 19p13.2 and two novel variants (rs820182 and rs820148) within MYO15B at the chromosome 17p25.1 locus. Depressed patients homozygous for these variants showed more severe depressive symptoms and higher suicidality than those who were not homozygotes (i.e., heterozygotes and homozygotes for the non-associated allele). Quantitative analysis demonstrated that the genetic burden of protein-truncating and deleterious variants was higher in males than females, even after permutation testing. Our study provides novel genetic evidence that the higher prevalence of depressive disorders in women may be attributable to inherited variants.

Comparison of two-thumb encircling and two-finger technique during infant cardiopulmonary resuscitation with single rescuer in simulation studies: A systematic review and meta-analysis.

BACKGROUND: The recommended chest compression technique for a single rescuer performing infant cardiopulmonary resuscitation is the two-finger technique. For 2 rescuers, a two-thumb-encircling hands technique is recommended. Several recent studies have reported that the two-thumb-encircling hands technique is more effective for high-quality chest compression than the two-finger technique for a single rescuer performing infant cardiopulmonary resuscitation. We undertook a systematic review and meta-analysis of infant manikin studies to compare two-thumb-encircling hands technique with two-finger technique for a single rescuer. METHODS: We searched MEDLINE, EMBASE, and the Cochrane Library for eligible randomized controlled trials published prior to December 2017, including cross-over design studies. The primary outcome was the mean difference in chest compression depth (mm). The secondary outcome was the mean difference in chest compression rate (counts/min). A meta-analysis was performed using Review Manager (version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). RESULTS: Six studies that had reported data concerning both chest compression depth and chest compression rate were included. The two-thumb-encircling hands technique was associated with deeper chest compressions compared with two-finger technique for mean chest compression depth (mean difference, 5.50 mm; 95% confidence interval, 0.32-10.69 mm; P = .04), but no significant difference in the mean chest compression rate (mean difference, 7.89 counts/min; 95% confidence interval, to 0.99, 16.77 counts/min; P = .08) was noted. CONCLUSION: This study indicates that the two-thumb-encircling hands technique is a more appropriate technique for a single rescuer to perform high-quality chest compression in consideration of chest compression depth than the two-finger technique in infant manikin studies.

Comparison of Heart Proportions Compressed by Chest Compressions Between Geriatric and Nongeriatric Patients Using Mathematical Methods and Chest Computed Tomography: A Retrospective Study.

BACKGROUND: Current guidelines recommended that chest compression depths during car-diopulmonary resuscitation (CPR) should be at least one-fifth of the external chest ante-riorposterior (AP) diameter. The chest AP diameter increases because of dorsal kyphosis, senile emphysema, and poor lung compliance associated with aging. This study aimed to compare the proportion of the heart compressed by chest compression (based on the ejection fraction [EF]) in geriatric and nongeriatric patients. METHODS: We performed a retrospective analysis of the chest computed tomography findings obtained between January 2010 and August 2016 and measured the chest anatomical parameters such as the perpendicular external and internal chest AP diameters with the heart AP diameter. Based on values of these parameters, EFs with 50- and 60-mm depths were obtained. In addition, we investigated and compared the proportion of 50- and 60-mm depths and heart AP to external chest AP diameter between the 2 groups. RESULTS: We randomly selected and analyzed 100 of 1,921 geriatric and 100 of 22,090 nongeriatric populations from a database. The means±standard deviations of EFs with 50- and 60-mm depths for geriatric and nongeriatric people were 37.1%±12.1% vs. 43.2%±13.8% and 47.5%±12.8% vs. 54.6%±14.8%, respectively (all p<0.001). The proportion of 50- and 60-mm depths and heart AP to external chest AP diameter were significantly different between the 2 groups (all p<0.05). CONCLUSION: Chest compression depths based on current guidelines are not sufficient for geriatric patients during CPR; hence, deeper chest compressions would be considered.