Analysis of older adults visiting the emergency department with fever as a suspected Covid-19 vaccine-related adverse reaction: A retrospective multicenter study.

INTRODUCTION: After COVID-19 vaccination was initiated, the number of patients visiting the emergency department (ED) with vaccine-related adverse reactions increased. We investigated the clinical features of older adults (aged 65 years and older) visiting the ED with self-reported COVID-19 postvaccination fever. METHODS: We conducted a retrospective observational study at three EDs between March 2021 and September 2021. Patients who reported adverse reactions, fever (≥37.5 °C) and/or febrile sensation or rigors following COVID-19 vaccination were included. The demographic and clinical data of these patients were collected by reviewing their medical records. RESULTS: A total of 562 patients were selected, and 396 (70.5%) were female. The older adult group included 155 (27.6%) patients, and the median age was 75 (69-79 years). The older adults less frequently had a fever (≥37.5 °C) upon ED presentation (75.5% vs. 85.7%, respectively), used more emergency medical services (43.9% vs. 18.7%, respectively), and visited an ED more frequently during early hours (00:00-06:00) (31% vs. 20.1%, respectively) compared to the younger adults (p = 0.004, p < 0.001 and p = 0.036). Fewer older adults visited an ED within 2 days of fever onset (73.5% vs. 84%) (p = 0.012), and more older adults were admitted for medical conditions other than vaccine-related adverse reactions (32.9% vs. 4.2%) (p < 0.001). Older adults received more thorough testing (laboratory and imaging tests). Among the older adults, the admission rate was associated with age (p = 0.003). CONCLUSION: Older adults presenting with fever as an adverse reaction following COVID-19 vaccination less frequently had a fever upon visiting the ED, required more ED testing, and had higher admission rates for non-vaccination-related medical conditions.

Factors related to the serious adverse events in patients visiting the emergency department after ChAdOx1 and mRNA COVID-19 vaccination.

INTRODUCTION: We investigated the clinical characteristics, outcomes and factors related to the serious adverse events (AEs) of patients visiting the emergency department (ED) with various AEs after ChAdOx1 and mRNA COVID-19 vaccination. METHODS: Patients with AEs who visited the ED between March 2021 and September 2021 were selected from three EDs. The clinical data of these patients were collected by retrospectively reviewing medical records. Serious adverse events (AEs) were defined as any adverse medical events that led to hospital admission. RESULTS: A total of 3572 patients visited the ED with AEs; 69.6% were administered mRNA vaccines, and the median (IQR) age was 48 (31-63) years. Regarding chief complaints, chest pain/discomfort (43.7%) was most common in the mRNA vaccines group, while fever (15.8%) was more commonly presented in the ChAdOx1 group. Most patients (93.9%) were discharged from the ED. In multivariate analysis, age ≥70 years, days from vaccination to ED visit ≥8 days, fever and dyspnea as chief complaints were higher independent risk factors for serious AEs (OR 27.94, OR 2.55, OR 1.95 and OR 2.18: p < 0.001, p < 0.001, p = 0.003 and p = 0.003, respectively). CONCLUSION: Most patients who visited the ED with AEs after vaccination were discharged from the ED regardless of the type of vaccine. Emergency physicians need to differentiate serious AEs and consider factors that may require admission to the ED.

Pre-Hospital Delay in Patients With Acute Stroke During the Initial Phase of the Coronavirus Disease 2019 Outbreak.

BACKGROUND: When a sudden outbreak of an infectious disease occurs, emergency medical services (EMS) response could be negatively affected. The poor prognosis of acute stroke may be largely attributed to delays in treatment. This study aimed to identify the impact of the sudden outbreak of coronavirus disease 2019 (COVID-19) on EMS response for patients with acute stroke. METHODS: This comparative cross-sectional study was conducted in 25 safety centers in Seoul, Korea. We enrolled patients with acute stroke who were transferred to the emergency department by EMS. The study period was from February-April 2020 and the same period in 2019. Patients were divided into two groups, pre-COVID-19 period and early-COVID-19 period, and previously collected patient data were analyzed. We performed comparative analyses of EMS response and clinical outcomes between the groups. RESULTS: Of 465 patients, 231 (49.7%) had an acute stroke during the study period. There was no significant difference between clinical characteristics of patients with acute stroke before and after the COVID-19 outbreak. EMS response times increased significantly during the early COVID-19 outbreak. The intensive care unit admission rate and mortality rate increased during the early COVID-19 outbreak. CONCLUSION: In the initial phase after the sudden COVID-19 outbreak, EMS response times for acute stroke were delayed and the clinical outcomes of patients with acute stroke deteriorated.

Clinical Features of Patients Presenting to the Emergency Department With Cardiovascular Adverse Reactions After COVID-19 mRNA Vaccination.

BACKGROUND: Since the implementation of the nationwide coronavirus disease 2019 (COVID-19) vaccination campaign, emergency departments (EDs) have had an increasing number of patients reporting postvaccination cardiovascular adverse effects. We investigated the clinical features of patients who visited the ED for cardiovascular adverse reactions after COVID-19 mRNA vaccination. METHODS: We conducted a retrospective observational study in two EDs. Patients with cardiovascular adverse reactions after COVID-19 mRNA vaccination who visited EDs between June 1, 2021, and October 15, 2021, were selected. The clinical data of these patients were collected by reviewing medical records. RESULTS: Among 683 patients, 426 (62.4%) were female. The number of patients in their 20s was the highest (38.9% of males, 28.2% of females) (P < 0.001). More patients visited the ED for adverse reactions following the first vaccine dose than following the second dose (67.6% vs. 32.2%). Chief complaints were chest pain/discomfort (74.4%), dyspnea (14.3%) and palpitation (11.3%). The final diagnosis was a nonspecific cause (63.1%), and 663 (97.1%) patients were discharged from the ED. The admission rate was higher in males than in females (3.9% vs. 1.9%). Myocarditis was diagnosed in four males, who showed mild clinical progression and were discharged within 5 hospital days. CONCLUSION: Most patients who visited the ED with cardiovascular adverse reactions were discharged from the ED, but some were admitted for other medical diseases as well as adverse vaccine reactions. Therefore, further surveillance and a differential diagnosis of cardiovascular adverse events after COVID-19 mRNA vaccination should be considered by emergency physicians.

Efficacy of blood urea nitrogen and the neutrophil-to-lymphocyte ratio as predictors of mortality among elderly patients with genitourinary tract infections: A retrospective multicentre study.

OBJECTIVES: To investigate whether initial blood urea nitrogen (BUN) and the neutrophil-to-lymphocyte ratio (NLR) in the emergency department (ED) are associated with mortality in elderly patients with genitourinary tract infections. METHODS: A total of 541 patients with genitourinary tract infections in 5 EDs between November 2016 and February 2017 were included and retrospectively reviewed. We assessed age, sex, comorbidities, vital signs, and initial laboratory results, including BUN, NLR and the SOFA criteria. The primary outcome was all-cause in-hospital mortality. RESULTS: The nonsurvivor group included 32 (5.9%) elderly patients, and the mean arterial pressure (MAP), NLR and BUN were significantly higher in this group than in the survivor group (p < 0.001, p = 0.003, p < 0.001). In multivariate analysis, MAP <70 mmHg, NLR ≥23.8 and BUN >28 mg/dl were shown to be independent risk factors for in-hospital mortality (OR 3.62, OR 2.51, OR 2.76: p = 0.002, p = 0.033, p = 0.038, respectively). Additionally, NLR ≥23.8 and BUN >28 were shown to be independent risk factors for mortality in admitted elderly with complicated UTI (p = 0.030, p = 0.035). When BUN and NLR were combined with MAP, the area under the ROC curve (AUROC) value was 0.807 (0.771-0.839) for the prediction of mortality, the sensitivity was 87.5% (95% CI 71.0-96.5), and the specificity was 61.3% (95% CI 56.9-65.5%). CONCLUSION: The initial BUN and NLR values with the MAP were good predictors associated with all-cause in-hospital mortality among elderly genitourinary tract infections visiting the ED.

The qSOFA score combined with the initial red cell distribution width as a useful predictor of 30 day mortality among older adults with infection in an emergency department.

PURPOSE: This study aimed to investigate whether the qSOFA and initial red cell distribution width (RDW) in the emergency department (ED) are associated with mortality in older adults with infections who visited the ED. METHODS: This was a retrospective study conducted in 5 EDs between November 2016 and February 2017. We recorded age, sex, comorbidities, body temperature, clinical findings, and initial laboratory results, including the RDW. The initial RDW values and the qSOFA criteria were obtained at the time of the ED visit. The primary outcome was 30 day mortality. RESULTS: A total of 1,446 patients were finally included in this study, of which 134 (9.3%) died within 30 days and the median (IQR) age was 77 (72, 82) years. In the multivariable analysis, the RDW (14.0-15.4%) and highest RDW (> 15.4%) quartile were shown to be independent risk factors for 30 day mortality (OR 2.12; 95% CI 1.12-4.02; p = 0.021) (OR 3.35; 95% CI 1.83-6.13; p < 0.001). The patients with qSOFA 2 and 3 were shown to have the high odds ratios of 30-day mortality (OR 3.50; 95% CI 2.09-5.84; p < 0.001) (OR 11.30; 95% CI 5.06-25.23; p < 0.001). The qSOFA combined with the RDW quartile for the prediction of 30 day mortality showed an AUROC value of 0.710 (0.686-0.734). CONCLUSION: The qSOFA combined with the initial RDW value was associated with 30-day mortality among older adults with infections in the ED. The initial RDW may help emergency physicians predict mortality in older adults with infections visiting the ED.

Association of the COVID-19 Pandemic and Low-rescue Suicide Attempts in Patients Visiting the Emergency Department after Attempting Suicide.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic may increase the total number of suicide attempts and the proportion of low-rescue attempts. We investigated the factors affecting low-rescue suicide attempts using the risk-rescue rating scale (RRRS) among patients who visited the emergency department (ED) after attempting suicide before or during the COVID-19 pandemic. METHODS: We retrospectively investigated suicide attempts made by patients who visited our ED from March 2019 to September 2020. Patients were classified into two groups based on whether they attempted suicide before or during the COVID-19 pandemic. Data on demographic variables, psychiatric factors, suicide risk factors and rescue factors were collected and compared. RESULTS: A total of 518 patients were included in the study, 275 (53.1%) of whom attempted suicide during the COVID-19 pandemic. The proportion of patients who made low-rescue suicide attempts differed before and during the COVID-19 pandemic (37.1% vs. 28.8%) (P = 0.046). However, the proportions of patients who made high-risk suicide attempts and high-lethality suicide attempts did not significantly differ between the two periods. The independent risk factors for low-rescue suicide attempts were age and the COVID-19 pandemic (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.03; P = 0.006) (OR, 1.52; 95% CI, 1.03-2.25; P = 0.034). CONCLUSION: The COVID-19 pandemic was associated with low-rescue suicide attempts in patients visiting the ED after attempting suicide. Thus, we need to consider the implementation of measures to prevent low-rescue suicide attempts during similar infectious disease crises.

Factors Associated with Delay of Emergency Medical Services Activation in Patients with Acute Stroke.

BACKGROUND: The poor prognosis of acute stroke may be largely attributed to delays in treatment. Emergency medical services (EMS) usage is associated with a significant reduction in the delay in stroke treatment. The aims of this study were to identify factors associated with the delay in EMS activation for patients with acute stroke. METHODS: This study was conducted at 26 Fire Safety Centers in five districts of Seoul, Korea. Patients with acute stroke transferred by EMS and admitted to a tertiary referral hospital from January 2014 to December 2018 were enrolled. In this cross-sectional study, the dependent variable was the time from stroke onset to EMS activation time. Patients were divided into two groups, onset-to-alarm time ≤ 30 min and onset-to-alarm time > 30 min, and previously collected patient data were analyzed. We performed logistical regression analyses of characteristics differing significantly between groups. RESULTS: Out of 480 patients, 197 (41%) had onset-to-alarm times > 30 min. Significant variables in the logistical analysis were alert mental state (adjusted odds ratio [aOR]: 2.77; 95% confidence interval [CI]: 1.31-6.13), pre-stroke mRS ≥ 2 (aOR: 2.46; 95% CI: 1.26-4.95), onset occurrence at private space (aOR: 2.31; 95% CI: 1.23-4.41), recognizing symptoms between 0 and 8 am (aOR: 2.30; 95% CI: 1.25-4.31), ischemic stroke (aOR: 1.88; 95% CI: 1.04-3.43), and witnessed by others (aOR: 0.32; 95% CI: 0.18-0.55). CONCLUSIONS: Delay in EMS activation for acute stroke cases is possibly related to difficult situations to recognize stroke symptoms, such as alert mental state, pre-stroke mRS ≥ 2, onset occurrence at private space, recognizing symptoms between 0 and 8 am, and unwitnessed by others.

The neutrophil-to-lymphocyte ratio is associated with bacteremia in older adults visiting the emergency department with urinary tract infections.

PURPOSE: We evaluated the clinical features of older adults visiting the emergency department (ED) with urinary tract infections (UTIs), and the diagnostic utility of the neutrophil-to-lymphocyte ratio (NLR) in terms of identifying bacteremia. METHODS: In total, 479 older adults admitted with UTIs via the ED between January 2010 and December 2015 were retrospectively reviewed. We recorded age, sex, comorbidities, body temperature, clinical findings, and initial laboratory results, including the NLR. RESULTS: A UTI with bacteremia was identified in 186 (38.8%) older adults. Bacteremia was associated with a longer hospital stay (median 10 vs. 8 days, p < 0.001). NLRs and C-reactive protein, blood urea nitrogen and creatinine levels were significantly higher in the bacteremia group than in the non-bacteremia group (p < 0.001, p = 0.016, p = 0.008, and p = 0.011, respectively). The area under the curve for the NLR was 0.624 (95% CI = 0.579-0.668, p < 0.001), and the cutoff was 9.0 (sensitivity 74.2, specificity 49.2%). Independent risk factors for bacteremia were an NLR ≥ 9 and fever ≥ 39 °C (OR 2.43, OR 2.75: p < 0.001, p < 0.001, respectively). CONCLUSION: Bacteremia was associated with a longer hospital stay in older adults with UTIs, in whom the initial NLR and high fever reliably predicted bacteremia. The NLR may help emergency physicians to predict bacteremia in older adults with UTIs visiting the ED.

Factors Affecting Collaborations between a Tertiary-level Emergency Department and Community-based Mental Healthcare Centers for Managing Suicide Attempts.

BACKGROUND: Community-based active contact and follow-up are known to be effective in reducing the risk of repeat suicide attempts among patients admitted to emergency departments after attempting suicide. However, the characteristics that define successful collaborations between emergency departments and community-based mental healthcare centers in this context are not well known. METHODS: This study investigated patients visiting the emergency department after suicide attempts from May 2017 to April 2019. Patients were classified in either the successful collaboration group or the failed collaboration group depending on whether or not they were linked to a community-based follow-up intervention. Clinical features and socioeconomic status were considered as independent variables. Logistic regression analysis was performed to identify factors influencing the collaboration. RESULTS: Of 674 patients, 153 (22.7%) were managed successfully via the targeted collaboration. Completion of hospital-based psychological counseling (adjusted odds ratio [aOR], 233.55; 95% confidence interval [CI], 14.99-3,637.67), supported out-of-pocket expenses (aOR, 11.17; 95% CI, 3.03-41.03), Korean Triage and Acuity Scale 1-3 (aOR, 4.31; 95% CI, 1.18-15.73), suicide attempt associated with mental disorder (aOR, 0.15; 95% CI, 0.04-0.52), and self-discharge against medical advice (aOR, 0.12; 95% CI, 0.02-0.70) were independent factors influencing the collaboration. CONCLUSION: Completion of hospital-based psychological counseling was the most highly influential factor determining the outcome of the collaboration between the emergency department and community-based mental healthcare center in the management of individuals who had attempted suicide. Completion of hospital-based psychological counseling is expected to help reduce the risk of repeat suicide attempts.

Procalcitonin as a prognostic marker for sepsis based on SEPSIS-3.

BACKGROUND: The revised definition of sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection (SEPSIS-3). The objective of this study was to evaluate procalcitonin (PCT) for the diagnosis and prognosis of sepsis using SEPSIS-3. METHODS: We enrolled 248 patients, who were admitted to the emergency department with suspected bacterial infection from June 2016 to February 2017. Definite bacterial infection was defined by proven culture results, and probable bacterial infection was based on diagnostic modalities other than culture. The sequential organ failure assessment (SOFA) score of 2 points or more from the baseline was diagnosed as sepsis. PCT was measured by the AFIAS-6 immunoassay system (Boditech Med Inc.) using whole blood. White blood cell (WBC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ERS) were evaluated. RESULTS: The final diagnosis was sepsis in 185 patients with infection of respiratory and genitourinary tract constituted 84.6%. The area under the receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) was as follows: PCT, 0.682 (0.589-0.765); CRP, 0.583 (0.487-0.673); ESR, 0.540 (0.515-0.699); and WBC, 0.611 (0.455-0.633), respectively. In multivariate analysis, age, SOFA, and PCT (log scale) predicted non-survivors with an odds ratio with 95% confidence interval of 1.055 (1.008-1.105), 1.303 (1.142-1.486), and 2.004 (1.240-3.238), respectively. Among sepsis group, initial PCT was increased in non-survivor (23.2 ng/dL) compared to survivor group (8.1 ng/dL) with statistical significance (P = .005). CONCLUSIONS: PCT could support and predict the unfavorable prognosis of sepsis based on SEPSIS-3, whereas diagnostic potential of PCT requires further evaluations.

Elderly patients visiting the emergency department for deliberate self-poisoning: do they present a more severe poisoning severity score than the nonelderly patients in the initial 24 h?

PURPOSE: Many elderly patients arrive at the emergency department (ED) complaining of deliberate self-poisoning (DSP). This study determined the poisoning severity of elderly patients who committed DSP. METHODS: A study was performed with 1329 patients (> 15 years of age) who were treated for DSP at two EDs between January 2010 and December 2016. We classified these patients into two groups based on age (an elderly group ≥ 65 years of age and a nonelderly group). Information was collected on age, sex, cause, ingestion time, drug type, suicide attempt history, initial poisoning severity score (PSS), final PSS, outcome, etc. RESULTS: In total, 242 (18.2%) patients were included in the elderly group, of whom 211 (86.9%) were treated for a first suicide attempt. Admission to the intensive-care unit (ICU) (43.8% vs. 25.5%) and endotracheal intubation (16.1% vs. 4.9%) occurred more frequently in the elderly group than in the nonelderly group (p < 0.001). The frequencies of initial severe PSSs (3 and 4) in the elderly group were 9.1% (N = 22) and 1.2% (N = 3), respectively. Multivariate logistic regression analysis showed that the ICU admission of DSP patients was significantly associated with being elderly (OR of 1.47, 95% CI 1.04-2.09, p = 0.029) and with having a GCS of < 13 (OR of 2.67, 95% CI 1.99-3.57, p < 0.001) and an initial PSS of (3,4) (OR of 3.66, 95% CI 2.14-6.26, p < 0.001). In addition, the presence of underlying diseases (coronary heart disease and cerebrovascular disease) yielded high ORs [(OR of 13.13, 95% CI 2.80-61.57, p = 0.001), (OR of 7.34, 95% CI 1.38-39.09, p = 0.020)]. CONCLUSION: Elderly patients who visited the ED for DSP exhibited overall more severe PSSs and poorer in-hospital prognosis than did nonelderly DSP patients.

Factors Associated with Vancomycin-Resistant Enterococcus Colonization in Patients Transferred to Emergency Departments in Korea.

BACKGROUND: Vancomycin-resistant enterococci (VRE) infections have become a major healthcare-associated pathogen problem worldwide. Nosocomial VRE infections could be effectively controlled by screening patients at high risk of harboring VRE and thereby lowering the influx of VRE into healthcare centers. In this study, we evaluated factors associated with VRE colonization in patients transferred to emergency departments, to detect patients at risk for VRE carriage. METHODS: This study was conducted in the emergency department of a medical college-affiliated hospital in Korea. Every patient transferred to the emergency department and admitted to the hospital from January to December 2016 was screened for VRE using rectal cultures. In this cross-sectional study, the dependent variable was VRE colonization and the independent variables were demographic and clinical factors of the patients and factors related to the transferring hospital. Patients were divided into two groups, VRE and non-VRE, and previously collected patient data were analyzed. Then we performed logistic regression analyses of characteristics that differed significantly between groups. RESULTS: Out of 650 patients, 106 (16.3%) had positive VRE culture results. Significant variables in the logistic analysis were transfer from geriatric long-term care hospital (adjusted odds ration [aOR]: 8.017; 95% confidence interval [CI]: 1.378-46.651), hospital days (4-7 days; aOR: 7.246; 95% CI: 3.229-16.261), duration of antimicrobial exposure (1-3 days; aOR: 1.976; 95% CI: 1.137-3.436), and age (aOR: 1.025; 95% CI: 1.007-1.043). CONCLUSION: VRE colonization in patients transferred to the emergency department is associated primarily with factors related to the transferred hospitals rather than demographic and clinical characteristics.

Targeted temperature management after cardiac arrest with anaphylaxis.

Fatal anaphylaxis is uncommon but not rare. Extrapolated mortality rates are 0.52% of total anaphylaxis patients Bock et al. (Jan. 2001) [1]. Nevertheless, compared with the incidence of the other cardiac arrest events, the incidence of cardiac arrest due to anaphylaxis is relatively small. As a result, the effect using targeted temperature management after anaphylaxis is not clearly understood. We report the case of a 63-year-old man who developed cardiac arrest after ingestion of two pieces of peach. He was resuscitated and his circulation returned spontaneously after approximately 11min of cardiopulmonary resuscitation, but he was unresponsive and had fixed dilated pupils. We initiated therapeutic hypothermia on the basis of protocol for 24h. The patient was gradually and successfully cooled and rewarmed. The patient opened his eyes spontaneously on day 5, obeyed commands on day 6, and was discharged on day 18. At the time of discharge, he had no neurologic deficiencies or other complications.

Neutrophil-to-lymphocyte count ratio is associated with perforated appendicitis in elderly patients of emergency department.

PURPOSE: The diagnostic value of the neutrophil-to-lymphocyte count ratio (NLR) and the Appendicitis Inflammatory Response (AIR) score for identifying acute appendicitis (AA) perforation in elderly patients in the emergency department (ED) were evaluated. METHODS: A total of 103 patients who were admitted for appendectomy for AA via the ED between January 2012 and December 2014 were reviewed retrospectively. Patients aged 65 and over were included. Patient age, sex, comorbidities, body temperature, clinical findings and initial laboratory results including white blood cell (WBC) count, NLR, serum levels of CRP and total bilirubin (TB) in the ED were assessed, and the AIR score was calculated. RESULTS: Perforation due to AA was identified in 58 (56.3 %) elderly patients. Median WBC count, neutrophil count, CRP and TB were significantly higher in the perforated group compared to the non-perforated group (p = 0.005, p = 0.001, p = 0.004 and p = 0.012) in the ED. The NLR was significantly different in the two groups (perforated vs non-perforated group, 9.5 vs 5.1, p < 0.001). The area under the curve value of NLR was 0.755 (95 % CI 0.660-0.834), and the cutoff value was 5.6 (sensitivity 78.0 % and specificity 65.9 %). In multivariate logistic analysis, NLR > 5.6 [odds ratio (OR) 6.794, p = 0.001] was significant independent factor for AA perforation in elderly patients. The AIR score risk probability did not differ between the two groups of elderly patients (p = 0.094). Twenty-five (42.4 %) patients in the perforated group and five (11.4 %) patients in the non-perforated group were classified as high probability by the modified AIR score including the NLR value (p = 0.001). CONCLUSION: We suggest that the initial NLR in the elderly patient is the most powerful predictive factor for the diagnosis of AA perforation in the ED.

Are prognostic scores and biomarkers such as procalcitonin the appropriate prognostic precursors for elderly patients with sepsis in the emergency department?

BACKGROUND: The mortality of patients with severe sepsis and septic shock is still high, and the prognosis of elderly patients tends to be particularly poor. Therefore, this study sought to conduct a comparative analysis of the abbreviated mortality in emergency department sepsis (abbMEDS) score, sequential organ failure assessment (SOFA) score, infection probability score (IPS), initial procalcitonin (PCT), and cytokine levels to investigate the effectiveness of each index in predicting the prognosis of elderly patients with sepsis in the emergency department (ED). METHODS: This was a single-center prospective study, and classified 55 patients (≥65 years of age) with systemic inflammatory response syndrome (SIRS) from January 2013 to December 2013 in the ED. A total of 36 elderly patients were diagnosed with sepsis. The prediction of prognosis using the prognostic scores (abbMEDS, SOFA, IPS) was analyzed. An early blood examination (WBC count, C-reactive protein, PCT, and cytokines) was conducted within the first 2 h of the patient's arrival at the ED. RESULTS: The median (IQR) age of subjects was 76.5 (70.5-81.5). After 28 days, 27 subjects (75 %) had survived, and 9 (25 %) had died. Fifteen (41.7 %) were sent to intensive care units (ICUs). The SOFA score and abbMEDS showed higher median (IQR) values of 9.5 (7.0-11.0) and 13.5 (12.0-15.0), respectively, in the ICU group than in the general ward group (p < 0.001). Analysis of the levels of PCT, IL-10, IL-6, and IL-5 had a significantly better ability to predict ICU admission (p = 0.001, p = 0.023, p = 0.030, p = 0.001). The prediction of mortality in the first 28 days via SOFA and the abbMEDS resulted in scores of 11.0 (8.0-11.0) and 14.0 (12.5-15.5) (p = 0.004, p = 0.003), respectively. However, levels of IPS, PCT, and cytokines did not show significant differences. CONCLUSIONS: In predicting ICU admission and the death of elderly sepsis patients in ED, SOFA and abbMEDS scores were effective. Of the various biomarkers, PCT, IL-10, IL-6, and IL-5 were effective in predicting ICU admission, but were not effective in predicting the death of elderly sepsis patients.

Diagnosis and evaluation of severity of sepsis via the use of biomarkers and profiles of 13 cytokines: a multiplex analysis.

BACKGROUND: The object of this study was to evaluate biomarkers for diagnosis of sepsis, hematologic parameters, and cytokine profiles for use in the diagnosis and evaluation of severity of sepsis. METHODS: We enrolled 127 consecutive patients with systemic inflammatory response syndrome (SIRS), 97 of whom were diagnosed with sepsis. The following biomarkers were evaluated: procalcitonin (PCT); C-reactive protein (CRP); erythrocyte sedimentation rate (ESR); white blood cell count, immature granulocyte (IG) count; and multiplex cytokines, including interleukin (IL)1-ß (IL1ß), IL2, IL4, IL5, IL6, IL9, IL10, IL12p70, IL13, IL17, IL22, tumor necrosis factor-α (TNFα), and interferon-γ (IFNγ). A cytokine bead immunoassay was used to perform simultaneous measurements. RESULTS: The disease involving urinary and respiratory tract constituted 57.5% of all patients. The severity of infection was classified as follows: SIRS patients, n=30; sepsis patients, n=81; and septic shock/severe sepsis patients, n=16. PCT, IL6, and CRP had high area under receiver operation characteristic curve (AUCs) and accuracy, which is as follows: PCT: 0.841, 80.5%; IL6: 0.811, 77.1%; CRP: 0.784, 73.8%, respectively. Severity of sepsis could be discriminated by PCT, IL6, and IL5. Unlike other cytokines, IFNγ had an inverse relation with severity of sepsis. The relationship between cytokine profiles and clinical diagnosis of sepsis was unclear. CONCLUSIONS: PCT, IL6, and CRP values could assist diagnosis, and PCT, IL6, and IL5 had discriminative properties for determination of severity of sepsis. IFNγ revealed a distinct inverse relationship with severity of sepsis. As there was no relationship between cytokine profiles and sepsis, further studies are required to develop clinical applications.

Application of 18F-FDG brain PET for survival prediction in a rat model of hanging-induced hypoxic brain injury.

BACKGROUND: Accurate prediction of survival outcomes after hanging is a crucial and challenging issue in comatose survivors. In this preclinical study, we evaluated the potential utility of using brain glucose metabolism as measured by fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) for survival prediction in a rat model of hanging-induced hypoxic brain injury (HBI). METHODS: HBI was induced by mechanical hanging using Sprague Dawley rats. 18F-FDG brain PET images were acquired in 26 HBI rats three hours post-injury (3 h post-injury) and 4 controls. During the 1 month follow-up period, HBI rats were further classified as survivors (n = 15) and nonsurvivors (n = 11). Between-group regional (standardized uptake values normalized to the reference whole brain = SUVRWB, cerebellum = SUVRCB, and pons = SUVRpons) and voxel-based analyses were performed. The prognostic value of the SUVR was tested for overall survival (OS). In addition, diffusion-weighted imaging (DWI) was performed in 2 controls and 5 HBI rats (3 survivors, 2 nonsurvivors, 3 h post), and an apparent diffusion coefficient (ADC) map was generated. RESULTS: The nonsurvivor group showed a significantly lower SUVRWB, SUVRCB, and SUVRpons of the cerebral cortices than the survivor group (all p < 0.001). Voxel-based comparison also demonstrated significant reduction in the nonsurvivor group compared with the survivor group (family-wise error-corrected p < 0.05). However, there was no significant difference between controls and survivors. Of 3 reference regions, the SUVRpons demonstrated the largest difference between the survivor and nonsurvivor groups. With an optimal cutoff value of 1.12 (AUC 0.952, p < 0.001), the SUVRpons predicted survival outcomes with a sensitivity of 81.8% and specificity of 100%. The OS of the low SUVRpons group was significantly shorter than that the high SUVRpons group (p < 0.001). The mean ADC values of each brain region showed no significant difference according to survival outcomes. CONCLUSIONS: These results suggest the potential utility of 18F-FDG brain PET for predicting survival in hanging-induced HBI.

Prolonged Length of Stay in the Emergency Department and Mortality in Critically Ill Elderly Patients with Infections: A Retrospective Multicenter Study.

BACKGROUND: This study aimed at investigating whether the length of stay (LOS) in the emergency department (ED) is associated with mortality in elderly patients with infections admitted to the intensive care unit (ICU). Delayed admission to the ICU may be associated with adverse clinical outcomes in elderly patients with infections. METHODS: This was a retrospective study conducted with subjects over 65 years of age admitted to the ICU from 5 EDs. We recorded demographic data, clinical findings, initial laboratory results, and ED LOS. Outcomes were all-cause in-hospital mortality and hospital LOS. A multivariable regression model was applied to identify factors predictive of mortality. RESULTS: A total of 439 patients admitted to the ICU via the ED were included in this study, 132 (30.1%) of whom died in the hospital. The median (IQR) age was 78 (73, 83) years. In multivariable analysis, a history of malignancy (OR: 3.76; 95% CI: 1.88-7.52; p < 0.001), high lactate level (OR: 1.13; 95% CI: 1.01-1.27; p=0.039), and ED LOS (OR: 1.01; 95% CI: 1.00-1.02; p=0.039) were independent risk factors for all-cause in-hospital admission. Elderly patients with an ED LOS >12 hours had a longer hospital LOS (p=0.018), and those with an ED LOS > 24 hours had a longer hospital LOS and higher mortality rate (p=0.044, p=0.008). CONCLUSIONS: This study shows that prolonged ED LOS is independently associated with all-cause in-hospital mortality in elderly patients with infections requiring ICU admission. ED LOS should be considered in strategies to prevent adverse outcomes in elderly patients with infections who visit the ED.

Initial red cell distribution width as a predictor of poor neurological outcomes in out-of-hospital cardiac arrest survivors in a prospective, multicenter observational study (the KoCARC study).

This study aimed to investigate whether the initial red cell distribution width (RDW) at the emergency department (ED) is associated with poor neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors. We performed a prospective observational analysis of patients admitted to the ED between October 2015 and June 2018 from the Korean Cardiac Arrest Research Consortium registry. We included OHCA patients who visited the ED and achieved return of spontaneous circulation. Initial RDW values were measured at the time of the ED visit. The primary outcome was a poor neurological (Cerebral Performance Category, or CPC) score of 3-5. A total of 1008 patients were ultimately included in this study, of whom 712 (70.6%) had poor CPC scores with unfavorable outcomes. Higher RDW quartiles (RDW 13.6-14.9%, RDW ≥ 15.0%), older age, female sex, nonshockable initial rhythm at the scene, unwitnessed cardiac arrest, bystander cardiopulmonary resuscitation (CPR), medical history, low white blood cell counts and high glucose levels were associated with poor neurological outcomes in univariate analysis. In multivariate analysis, the highest RDW quartile was independently associated with poor neurological outcomes (odds ratio 2.04; 95% confidence interval 1.12-3.69; p = 0.019) at hospital discharge after adjusting for other confounding factors. Other independent factors including age, initial rhythm, bystander CPR and high glucose were also associated with poor neurological outcomes. These results show that an initial RDW in the highest quartile as of the ED visit is associated with poor neurological outcomes at hospital discharge among OHCA survivors.