Repetitive hyperbaric oxygen therapy for paroxysmal sympathetic hyperactivity after acute carbon monoxide poisoning.

Delayed neuropsychological sequelae (DNS) are relatively common complications of acute carbon monoxide (CO) poisoning, and usually develop within several days to weeks after the initial clinical recovery from acute CO poisoning. DNS can consist of various symptoms such as memory loss, confusion, ataxia, seizures, urinary incontinence, fecal incontinence, emotional lability, disorientation, hallucinations, mutism, cortical blindness, psychosis, parkinsonism, gait disturbances, rigidity, bradykinesia, and other motor disturbances. Paroxysmal sympathetic hyperactivity (PSH) is a potentially life-threatening disease secondary to acute acquired brain injury. It is characterized by episodic and simultaneous paroxysmal increases in sympathetic and motor activities, not rare in patients with a severe traumatic brain injury. The term PSH is clinically more accurate than the previously used ones describing such conditions as non-stimulated tachycardia, hypertension, tachypnea, hyperthermia, external posturing, diaphoresis, and paroxysmal autonomic instability with dystonia. Development of PSH typically prolongs the length of hospital stay and potentially leads to a secondary brain injury or even death. To date, the occurrence of PSH in the DNS after acute CO poisoning has not been reported in the literature. Potential mechanisms underlying the development of DNS in the deep white matter of the brain are immune-related inflammation and vasodilatation. Repetitive hyperbaric oxygen therapy, combined with methylprednisolone administration, may inhibit DNS progression by inducing cerebral oxygenation, inhibiting inflammation, and reducing cerebral edema. Herein, we report three cases in which the patients recovered from the PSH as DNS after CO poisoning after receiving repetitive hyperbaric oxygen therapy.

Incidence patterns of nervous system diseases after carbon monoxide poisoning: a retrospective longitudinal study in South Korea from 2012 to 2018.

OBJECTIVE: To analyze the incidence patterns of nervous system diseases in survivors of carbon monoxide (CO) poisoning using nationwide claims data from South Korea. METHODS: A national cohort was abstracted from a database that includes patients diagnosed with CO poisoning between January 2012 and December 2018. For all nervous system diseases, we investigated the frequency, pattern of incidence, effect of intensive care unit admission, and the standardized incidence ratios (SIRs) to estimate the risk of nervous system disease after CO poisoning. RESULTS: Of 26,778 patients, 18,720 (69.9%) were diagnosed with nervous system diseases after CO poisoning. The most common disease was disorders of sleep initiation and maintenance (n=701, 3.74%), followed by tension-type headache (n=477, 2.55%) and anoxic brain injury (n=406, 2.17%). Over half of the nervous system diseases occurred within the first year after CO poisoning. The cumulative hazard ratio for nervous system diseases in patients admitted to the intensive care unit was 2.25 (95% confidence interval [CI], 2.07-2.44). Among the frequent nervous system diseases after CO poisoning, patients had a higher risk of disorders of initiating and maintaining sleep (SIR, 1.61; 95% CI, 1.52-1.71), tension-type headache (SIR, 2.41; 95% CI, 2.23-2.61), anoxic brain injury (SIR, 58.76; 95% CI, 53.95-63.88), and post-zoster neuralgia (SIR, 1.94; 95% CI, 1.70-2.20). CONCLUSION: Patients who experience CO poisoning are at higher risk for several nervous system diseases. Therefore, monitoring for specific nervous system diseases is important after CO poisoning within the first year.

Predictive Value of Estimated Lean Body Mass for Neurological Outcomes after Out-of-Hospital Cardiac Arrest.

BACKGROUND: Postcardiac arrest patients with a return of spontaneous circulation (ROSC) are critically ill, and high body mass index (BMI) is ascertained to be associated with good prognosis in patients with a critically ill condition. However, the exact mechanism has been unknown. To assess the effectiveness of skeletal muscles in reducing neuronal injury after the initial damage owing to cardiac arrest, we investigated the relationship between estimated lean body mass (LBM) and the prognosis of postcardiac arrest patients. METHODS: This retrospective cohort study included adult patients with ROSC after out-of-hospital cardiac arrest from January 2015 to March 2020. The enrolled patients were allocated into good- and poor-outcome groups (cerebral performance category (CPC) scores 1-2 and 3-5, respectively). Estimated LBM was categorized into quartiles. Multivariate regression models were used to evaluate the association between LBM and a good CPC score. The area under the receiver operating characteristic curve (AUROC) was assessed. RESULTS: In total, 155 patients were analyzed (CPC score 1-2 vs. 3-5, n = 70 vs. n = 85). Patients' age, first monitored rhythm, no-flow time, presumed cause of arrest, BMI, and LBM were different (p < 0.05). Fourth-quartile LBM (≥48.98 kg) was associated with good neurological outcome of postcardiac arrest patients (odds ratio = 4.81, 95% confidence interval (CI), 1.10-25.55, p = 0.04). Initial high LBM was also a predictor of good neurological outcomes (AUROC of multivariate regression model including LBM: 0.918). CONCLUSIONS: Initial LBM above 48.98kg is a feasible prognostic factor for good neurological outcomes in postcardiac arrest patients.

Targeted temperature management in patients with severe heatstroke: Three case reports and treatment recommendations.

RATIONALE: Unprecedented heatwaves over the past several years are getting worse with longer duration in the course of global warming. Heatstroke is a medical emergency with multiple organ involvement and life-threatening illness with a high mortality rate of up to 71%. Uncontrolled damage to the central nervous system can result in severe cerebral edema, permanent neurological sequelae, and death. However, regarding the therapeutic aspects of heat stroke, there was no therapeutic strategy after the rapid cooling of the core body temperature to <39°C to prevent further injury. PATIENT CONCERNS: Each of 3 patients developed a change of mental statuses after the exposure to summer heatwaves or relatively high environmental temperatures with high humidity in the sauna. DIAGNOSES: The patients were diagnosed with severe heatstroke since they showed cerebral edema and multiple organ dysfunction based on the results from laboratory tests and the findings in brain computed tomography scan. INTERVENTIONS: The patients underwent induced therapeutic hypothermia (<36°C) between 24 and 36 hours in the management of severe heatstroke. OUTCOMES: The patients survived from cerebral edema and multiple organ dysfunction. LESSONS: We believe that targeted temperature management (<36°C) will help treat severe heatstroke. Thus it should be considered for reducing the chance of development of complications in multiple organs, especially in the central nervous system, when managing patients with severe heatstroke.

Stroke Incidence in Survivors of Carbon Monoxide Poisoning in South Korea: A Population-Based Longitudinal Study.

BACKGROUND Carbon monoxide (CO) poisoning is a suspected risk factor for stroke. However, the association between stroke occurrence and carbon monoxide poisoning remains unclear. This nationwide study in Korea analyzed the incidence of stroke in survivors of CO poisoning. MATERIAL AND METHODS In this nationwide, population-based longitudinal study, the database of the Health Insurance Review and Assessment Service was searched to identify patients diagnosed with CO poisoning from 2012 to 2018. Their incidence of ischemic and hemorrhagic strokes, the patterns of stroke incidences, the annual incidence rates in sequential time, the standardized incidence ratio (SIR), and the effects of hyperbaric oxygen therapy (HBOT) were analyzed. RESULTS Of the 29 301 patients diagnosed with CO poisoning during the study period, 984 (3.36%) were diagnosed with stroke after CO poisoning, with approximately 50% occurring within 1 year after CO poisoning. The overall SIR for stroke was 19.49 (95% confidence interval [CI], 17.92-21.12) during the first year, decreasing to 5.64 (95% CI, 4.75-6.66) during the second year. Overall stroke hazard ratio (HR) in the patients admitted to the ICU for CO poisoning was 2.28 (95% CI, 1.19-2.27), compared with 2.35 (95% CI, 1.94-2.84) for ischemic stroke and 1.76 (95% CI, 1.11-2.78) for hemorrhagic stroke. Cumulative HRs did not differ between patients who were and were not treated with HBOT for stroke. CONCLUSIONS CO poisoning is a high-risk factor for the development of stroke, evidenced by high incidences of stroke after CO poisoning. Practical strategies for preventing stroke after CO poisoning are needed, because stroke after CO poisoning affects adults of almost all ages, significantly increasing their socioeconomic burden.

Novel Treatment Strategy for Patients with Venom-Induced Consumptive Coagulopathy from a Pit Viper Bite.

Pit viper venom commonly causes venom-induced consumptive coagulopathy (VICC), which can be complicated by life-threatening hemorrhage. VICC has a complex pathophysiology affecting multiple steps of the coagulation pathway. Early detection of VICC is challenging because conventional blood tests such as prothrombin time (PT) and activated partial thromboplastin time (aPTT) are unreliable for early-stage monitoring of VICC progress. As the effects on the coagulation cascade may differ, even in the same species, the traditional coagulation pathways cannot fully explain the mechanisms involved in VICC or may be too slow to have any clinical utility. Antivenom should be promptly administered to neutralize the lethal toxins, although its efficacy remains controversial. Transfusion, including fresh frozen plasma, cryoprecipitate, and specific clotting factors, has also been performed in patients with bleeding. The effectiveness of viscoelastic monitoring in the treatment of VICC remains poorly understood. The development of VICC can be clarified using thromboelastography (TEG), which shows the procoagulant and anticoagulant effects of snake venom. Therefore, we believe that TEG may be able to be used to guide hemostatic resuscitation in victims of VICC. Here, we aim to discuss the advantages of TEG by comparing it with traditional coagulation tests and propose potential treatment options for VICC.

Epidemiology and regional differences of acute poisonings of eight cities in Gyeonggi-do province in Korea using data from the National Emergency Department Information System of Korea.

OBJECTIVE: We aimed to analyze the differences in epidemiological aspects and clinical courses of acute poisonings in each region of the Gyeonggi-do province in Korea. METHODS: This retrospective study analyzed data from the National Emergency Department Information System of Korea. We retrospectively reviewed cases of acute poisonings between April 2006 and March 2015 recorded at 13 emergency departments in eight different cities of Gyeonggi-do province in Korea. The differences in the incidence, age distribution, causative agent, and clinical course of poisonings among regions were the main outcomes measured. RESULTS: The proportion of poisonings in the ≤9 age group was high in Yongin (17.44%) and that in ≥65 age group was high in Gwangmyeong (21.76%). The proportion of cases involving carbon monoxide was high in Ansan (8.82%) in patients hospitalized and the proportion of cases involving pesticides was high in Pyeongtaek (52.78%) in patients admitted to the intensive care unit. The admission rate of poisoned patients was high in Osan (36.02%). CONCLUSION: In this study, differences in the characteristics of poisoned patients between 8 cities were noted. Therefore, hospitals need to arrange treatment resources for poisoned patients according to the characteristics of the specific region. The. RESULTS: of this study may serve as evidence for new strategies to prepare for the acute poisonings in hospitals.

Does Exposure to Computed Tomography Contrast Media Increase Risk of End-Stage Renal Disease?

BACKGROUND There are many studies on acute kidney injury (AKI) after exposure to contrast media in patients with chronic kidney disease (CKD). However, whether the risk of end-stage renal disease (ESRD) increases after exposure to contrast media in the long term, regardless of development of AKI after such exposure, has not been studied. MATERIAL AND METHODS The electronic health records of patients diagnosed with CKD and followed up from 2014 to 2018 at a tertiary university hospital were retrospectively collected. Patients were divided into patients who progressed to ESRD (ESRD group) and those who did not (non-ESRD group). Patients in the non-ESRD group were matched 1: 1 to those in the ESRD group by using disease risk score generation and matching. Multivariate logistic regression analysis was performed to assess the effect of contrast media exposure on progression to ESRD. RESULTS In total, 179 patients were enrolled per group; 178 (99.4%) were in CKD stage 3 or above in both groups. Average serum creatinine was 4.31±3.02 mg/dl and 3.64±2.55 mg/dl in the ESRD and non-ESRD groups, respectively (p=0.242). Other baseline characteristics were not statistically significant, except for the number of times contrast-enhanced computed tomography (CECT) was performed (0.00 [Interquartile range (IQR) 0.00-2.00] in the ESRD group and 0.00 [IQR 0.00-1.00] in the non-ESRD group [p=0.006]); in multivariate logistic regression, this number (OR=1.24, 95% CI=1.08-1.47, p=0.006) was significantly related to progression to ESRD. CONCLUSIONS The use of CECT increased the risk of ESRD 1.2-fold in advanced and stable CKD outpatients after 5-year follow-up.

Risk Stratification of Intermediate-Risk Children With Minor Head Injury.

The Pediatric Emergency Care Applied Research Network rule helps emergency physicians identify very low-risk children with minor head injury who can forgo head computed tomography. This rule contributes to reduction in lifetime risk of radiation-induced cancers while minimizing missing clinically important traumatic brain injury. However, in intermediate-risk children, decisions on whether to perform computed tomography remain at the emergency physicians' discretion. To reduce this gray zone, this review summarizes evidence for risk stratification of intermediate-risk children with minor head injury.

Diastolic dysfunction is associated with an increased risk of postcontrast acute kidney injury.

STUDY OBJECTIVE: Computed tomography (CT) is an important imaging modality in diagnosing a variety of disorders. Although systolic heart failure is a well-known risk factor for postcontrast acute kidney injury (PC-AKI), few studies have evaluated the association between diastolic dysfunction and PC-AKI. Therefore, the aim of our study was to investigate whether PC-AKI occurs more likely in patients with diastolic dysfuction. METHODS: This retrospective study was conducted by collecting the data of patients who visited an emergency medical center between January 2008 and December 2014. Patients who underwent contrast-enhanced CT (CECT) in the emergency department and had undergone echocardiography within 1 month of CECT were included. We defined PC-AKI as an elevation in the serum creatinine level of ≥0.5 mg/dL or ≥25% within 72 hours after CECT. RESULTS: We included 327 patients, aged 18 years and older, who had a CECT scan and underwent an echocardiography within 1 month of the CECT scan at our institute over 20 years. The mean value of estimated glomerular filtration rate and E/E (early left ventricular filling velocity to early diastolic mitral annular velocity ratio) was 51.55 ±â€Š7.66 mL·min·1.73 m and 11.56 ±â€Š5.33, respectively. A total of 32 patients (9.79%) developed PC-AKI. The prevalence of diabetes mellitus and chronic kidney disease was significantly higher in the PC-AKI group than in the non-PC-AKI group. Echocardiographic findings revealed that E/E was significantly increased in patients with PC-AKI. The logistic regression analysis showed that a higher E/E value (odds ratio [OR] 5.39, 95% confidence interval [CI] 1.51-25.23, P = .015) was a significant risk factor for PC-AKI. CONCLUSION: This study demonstrated that, among the echocardiographic variables, E/E was an independent predictor of PC- AKI. This, in turn, suggests that diastolic dysfunction may be a useful parameter in PC-AKI risk stratification.

Pilot study on a rewarming rate of 0.15°C/hr versus 0.25°C/hr and outcomes in post cardiac arrest patients.

OBJECTIVE: Cerebral hemodynamic and metabolic changes may occur during the rewarming phase of targeted temperature management in post cardiac arrest patients. Yet, studies on different rewarming rates and patient outcomes are limited. This study aimed to investigate post cardiac arrest patients who were rewarmed with different rewarming rates after 24 hours of hypothermia and the association of these rates to the neurologic outcomes. METHODS: This study retrospectively investigated post cardiac arrest patients treated with targeted temperature management and rewarmed with rewarming rates of 0.15°C/hr and 0.25°C/hr. The association of the rewarming rate with poor neurologic outcomes (cerebral performance category score, 3 to 5) was investigated. RESULTS: A total of 71 patients were analyzed (0.15°C/hr, n=36; 0.25°C/hr, n=35). In the comparison between 0.15°C/hr and 0.25°C/hr, the poor neurologic outcome did not significantly differ (24 [66.7%] vs. 25 [71.4%], respectively; P=0.66). In the multivariate analysis, the rewarming rate of 0.15°C/hr was not associated with the 1-month neurologic outcome improvement (odds ratio, 0.54; 95% confidence interval, 0.16 to 1.69; P=0.28). CONCLUSION: The rewarming rates of 0.15°C/hr and 0.25°C/hr were not associated with the neurologic outcome difference in post cardiac arrest patients.

Predictors of poor prognosis in patients with heat stroke.

OBJECTIVE: The predictors of poor prognosis in heat stroke (HS) remain unknown. This study investigated the predictive factors of poor prognosis in patients with HS. METHODS: Data were obtained and analyzed from the health records of patients diagnosed with heat illness at Ajou university hospital between January 2008 and December 2017. Univariate and multivariate analyses were performed to identify the independent predictors of poor prognosis. RESULTS: Thirty-six patients (median age, 54.5 years; 33 men) were included in the study. Poor prognosis was identified in 27.8% of the study population (10 patients). The levels of S100B protein, troponin I, creatinine, alanine aminotransferase, and serum lactate were statistically significant in the univariate analysis. Multiple regression analysis revealed that poor prognosis was significantly associated with an increased S100B protein level (odds ratio, 177.37; 95% confidence interval, 2.59 to 12,143.80; P=0.016). The S100B protein cut-off level for predicting poor prognosis was 0.610 µg/L (area under the curve, 0.906; 95% confidence interval, 0.00 to 1.00), with 86% sensitivity and 86% specificity. CONCLUSION: An increased S100B protein level on emergency department admission is an independent prognostic factor of poor prognosis in patients with HS. Elevation of the S100B protein level represents a potential target for specific and prompt therapies in these patients.

Analysis of trends in usage of analgesics and sedatives in intensive care units of South Korea: A retrospective nationwide population-based study.

The use of analgesics and sedatives plays an important role in improving patient outcomes in the intensive care unit (ICU). Various drugs exist, each with associated differences in patient outcomes; therefore, critical and intensive care medicine societies have developed guidelines for usage of analgesics and sedatives for improved patient outcomes. However, studies investigating drug use in the ICU have been based on surveys administered to medical staff, without accurate insight into the drug use based on prescriptions and behaviors of ICU medical staff, thus failing to demonstrate the actual status of the implementation of these guidelines into clinical practice. Using data from the Health Insurance Review and Assessment Service in South Korea, we analyzed the current use of analgesics and sedatives in ICUs nationally. In addition, we compared the use of analgesics and sedatives in the ICU based on the latest guidelines.We performed a nationwide retrospective study using data available in the Health Insurance Review and Assessment Service database. We included 779,985 patients who had been admitted to the ICU from January 1, 2010, to December 31, 2014. Descriptive statistics were calculated to analyze the type and frequency of analgesic and sedative use in the ICU, using drug codes for analgesics and sedatives commonly prescribed in the ICU.The most commonly used analgesics and sedatives for all patients admitted to the ICU were pethidine (26.14%) and midazolam (32.18%), respectively. Sedatives and analgesics were more commonly used in mechanically ventilated patients. Among analgesics, the usage rate of pethidine and morphine decreased, whereas the usage rate of fentanyl and remifentanil increased. Among sedatives, the usage rate of benzodiazepine decreased, whereas the usage rate of propofol increased.There was discordance between current usage of analgesics and sedatives and the recommended usage stipulated by ICU guidelines. However, the trend of drug usage is changing to match the guidelines, which recommend maintenance of light sedation using an analgesia-based regimen and usage of short-acting drugs for routine monitoring of pain, agitation, and delirium in ICU care.

Therapeutic Aspects of Carbon Monoxide in Cardiovascular Disease.

Carbon monoxide (CO) is being increasingly recognized as a potential therapeutic with important signaling functions in various diseases. Carbon monoxide-releasing molecules (CORMs) show anti-apoptotic, anti-inflammatory, and anti-oxidant effects on the tissues of organisms, thus contributing to tissue homeostasis. An increase in reactive oxygen species production from the mitochondria after exposure to CO is also considered one of the underlying mechanisms of cardioprotection, although mitochondrial inhibition is the main toxic mechanism of CO poisoning. This review highlights the mechanism of the biological effects of CO and its potential application as a therapeutic in clinical settings, including in cardiovascular diseases. This review also discusses the obstacles and limitations of using exogenous CO or CORMs as a therapeutic option, with respect to acute CO poisoning.

Recapitulation of pharmacogenomic data reveals that invalidation of SULF2 enhance sorafenib susceptibility in liver cancer.

Gene mutations play critical roles during cancer development and progression, and therefore represent targets for precision medicine. Here we recapitulated the pharmacogenomic data to delineate novel candidates for actionable mutations and therapeutic target drugs. As a proof-of-concept, we demonstrated that the loss-of-function of SULF2 by mutation (N491K) or inhibition enhanced sorafenib sensitivity in liver cancer cells and in vivo mouse models. This effect was mediated by deregulation of EGFR signaling and downstream expression of LCN2. We also report that the liver cancer patients non-responding to sorafenib treatment exhibit higher expression of SULF2 and LCN2. In conclusion, we suggest that SULF2 plays a key role in sorafenib susceptibility and resistance in liver cancer via deregulation of LCN2. Diagnostic or therapeutic targeting of SULF2 (e.g., OKN-007) and/or LCN2 can be a novel precision strategy for sorafenib treatment in cancer patients.

Neuroprotective effect of ethanol in acute carbon monoxide intoxication: A retrospective study.

In acute carbon monoxide (CO) intoxication, treatment of neurologic injury and prevention of neurological sequelae are primary concerns. Ethanol is the one of the frequent substances which is co-ingested in intentional CO poisoning. Neuroprotective effect of ethanol was highlighted and demonstrated in isolated brain injury recently. We assessed the neuroprotective effect of ethanol in acute CO intoxication using magnetic resonance imaging (MRI).We retrospectively reviewed medical records for patients who visited an emergency medical center of a university-affiliated hospital during a period of 73 months, from March 2009 to April 2015. Enrolled patients were divided into 2 groups, patients with or without abnormal brain lesion in brain MRI. Multivariate logistic regression analysis was performed to assess the factors associated with brain injury in MRI.A total of 109 patients with acute CO intoxication were evaluated of which 66 (60.55%) tested positive in brain MRI. MRI lesion-positive patients were more likely to have electrocardiogram change, elevation of serum troponin I and s100 protein level and lower serum ethanol level. Serum ethanol positivity was an independent factor for prevalence of brain injury in MRI in acute CO poisoning.This study revealed that ethanol which is co-ingested in acute CO intoxication may work the neuroprotective effect and could consequence more favorable neurological outcome in acute CO intoxication.

Anterograde Amnesia after Acute Glufosinate Ammonium Intoxication.

Glufosinate ammonium (GA) intoxication causes several neurologic complications. We report a rare but typical case of GA intoxication associated with anterograde amnesia and bilateral hippocampal involvement. A 53-year-old woman with GA intoxication presented to the emergency department. Initial general and neurologic examinations were unremarkable but, from the day after admission, she exhibited anterograde amnesia. On brain magnetic resonance imaging, the signal intensity in the hippocampus was symmetrically and bilaterally increased. She was discharged with no medical problems, but the anterograde amnesia remained. Eleven days after the onset of amnesia, she returned to the neurology outpatient department with persisting anterograde amnesia but improving symptoms.

Patients who leave the emergency department against medical advice.

OBJECTIVE: Discharge against medical advice (DAMA) from the emergency department (ED) accounts for 0.1% to 2.7% of all ED discharges. DAMA carries a risk of increased mortality and readmissions. Our aim was to investigate the general characteristics of DAMA patients and the differences between them and non-DAMA patients. METHODS: We reviewed data collected by the National Emergency Medical Center between 2010 and 2011. Subjects were categorized into 2 groups, namely, the DAMA group and the non-DAMA group. We compared these groups with respect to age, gender, trauma or non-trauma status, type of hospital, health insurance, level of consciousness on admission, and diagnosis. RESULTS: Of 8,000,529 patients, 222,389 (2.78%) left against medical advice. The risk factors for DAMA across all age groups were as follows: no medical insurance (odds ratio [OR], 1.993), initial response to voice (OR, 2.753) or pain (OR, 2.101), trauma admission (OR, 1.126), admission to a local emergency medical center (OR, 1.215), and increased age. A high risk of DAMA was observed among patients with immune, endocrine, psychiatric, neurological, circulatory diseases, and external causes of morbidity and mortality. CONCLUSION: Although DAMA cases account for only a small percentage of hospital discharges, they are important because DAMA patients have high readmission and mortality rates. It is therefore important to understand the general characteristics and predictors of DAMA in order to improve patient outcome and minimize the economic burden on the healthcare system.