Modified Cardiovascular Sequential Organ Failure Assessment Score in Sepsis: External Validation in Intensive Care Unit Patients.

BACKGROUND: There is a need to update the cardiovascular (CV) Sequential Organ Failure Assessment (SOFA) score to reflect the current practice in sepsis. We previously proposed the modified CV SOFA score from data on blood pressure, norepinephrine equivalent dose, and lactate as gathered from emergency departments. In this study, we externally validated the modified CV SOFA score in multicenter intensive care unit (ICU) patients. METHODS: A multicenter retrospective observational study was conducted on ICU patients at six hospitals in Korea. We included adult patients with sepsis who were admitted to ICUs. We compared the prognostic performance of the modified CV/total SOFA score and the original CV/total SOFA score in predicting 28-day mortality. Discrimination and calibration were evaluated using the area under the receiver operating characteristic curve (AUROC) and the calibration curve, respectively. RESULTS: We analyzed 1,015 ICU patients with sepsis. In overall patients, the 28-day mortality rate was 31.2%. The predictive validity of the modified CV SOFA (AUROC, 0.712; 95% confidence interval [CI], 0.677-0.746; P < 0.001) was significantly higher than that of the original CV SOFA (AUROC, 0.644; 95% CI, 0.611-0.677). The predictive validity of modified total SOFA score for 28-day mortality was significantly higher than that of the original total SOFA (AUROC, 0.747 vs. 0.730; 95% CI, 0.715-0.779; P = 0.002). The calibration curve of the original CV SOFA for 28-day mortality showed poor calibration. In contrast, the calibration curve of the modified CV SOFA for 28-day mortality showed good calibration. CONCLUSION: In patients with sepsis in the ICU, the modified SOFA score performed better than the original SOFA score in predicting 28-day mortality.

Prevalence of Carbon Monoxide Poisoning and Hyperbaric Oxygen Therapy in Korea: Analysis of National Claims Data in 2010-2019.

This study aimed to investigate the prevalence of carbon monoxide (CO) poisoning and the provision of hyperbaric oxygen therapy (HBOT) in South Korea. We used data from the Korea Health Insurance Review and Assessment service. In total, 44,361 patients with CO poisoning were identified across 10 years (2010-2019). The prevalence of CO poisoning was found to be 8.64/10,000 people, with a gradual annual increment. The highest prevalence was 11.01/10,000 individuals, among those aged 30-39 years. In 2010, HBOT was claimed from 15 hospitals, and increased to 30 hospitals in 2019. A total of 4,473 patients received HBOT in 10 years and 2,684 (60%) were treated for more than 2 hours. This study suggested that the prevalence of both CO poisoning and HBOT in Korea gradually increased over the past 10 years, and disparities in prevalence were observed by region.

Quantification of biological nitrogen fixation by Mo-independent complementary nitrogenases in environmental samples with low nitrogen fixation activity.

Biological nitrogen fixation (BNF) by canonical molybdenum and complementary vanadium and iron-only nitrogenase isoforms is the primary natural source of newly fixed nitrogen. Understanding controls on global nitrogen cycling requires knowledge of the isoform responsible for environmental BNF. The isotopic acetylene reduction assay (ISARA), which measures carbon stable isotope (13C/12C) fractionation between ethylene and acetylene in acetylene reduction assays, is one of the few methods that can quantify isoform-specific BNF fluxes. Application of classical ISARA has been challenging because environmental BNF activity is often too low to generate sufficient ethylene for isotopic analyses. Here we describe a high sensitivity method to measure ethylene δ13C by in-line coupling of ethylene preconcentration to gas chromatography-combustion-isotope ratio mass spectrometry (EPCon-GC-C-IRMS). Ethylene requirements in samples with 10% v/v acetylene are reduced from > 500 to ~ 20 ppmv (~ 2 ppmv with prior offline acetylene removal). To increase robustness by reducing calibration error, single nitrogenase-isoform Azotobacter vinelandii mutants and environmental sample assays rely on a common acetylene source for ethylene production. Application of the Low BNF activity ISARA (LISARA) method to low nitrogen-fixing activity soils, leaf litter, decayed wood, cryptogams, and termites indicates complementary BNF in most sample types, calling for additional studies of isoform-specific BNF.

Modified cardiovascular SOFA score in sepsis: development and internal and external validation.

BACKGROUND: The Sepsis-3 criteria introduced the system that uses the Sequential Organ-Failure Assessment (SOFA) score to define sepsis. The cardiovascular SOFA (CV SOFA) scoring system needs modification due to the change in guideline-recommended vasopressors. In this study, we aimed to develop and to validate the modified CV SOFA score. METHODS: We developed, internally validated, and externally validated the modified CV SOFA score using the suspected infection cohort, sepsis cohort, and septic shock cohort. The primary outcome was 28-day mortality. The modified CV SOFA score system was constructed with consideration of the recently recommended use of the vasopressor norepinephrine with or without lactate level. The predictive validity of the modified SOFA score was evaluated by the discrimination for the primary outcome. Discrimination was assessed using the area under the receiver operating characteristics curve (AUC). Calibration was assessed using the calibration curve. We compared the prognostic performance of the original CV/total SOFA score and the modified CV/total SOFA score to detect mortality in patients with suspected infection, sepsis, or septic shock. RESULTS: We identified 7,393 patients in the suspected cohort, 4038 patients in the sepsis cohort, and 3,107 patients in the septic shock cohort in seven Korean emergency departments (EDs). The 28-day mortality rates were 7.9%, 21.4%, and 20.5%, respectively, in the suspected infection, sepsis, and septic shock cohorts. The model performance is higher when vasopressor and lactate were used in combination than the vasopressor only used model. The modified CV/total SOFA score was well-developed and internally and externally validated in terms of discrimination and calibration. Predictive validity of the modified CV SOFA was significantly higher than that of the original CV SOFA in the development set (0.682 vs 0.624, p < 0.001), test set (0.716 vs 0.638), and all other cohorts (0.648 vs 0.557, 0.674 vs 0.589). Calibration was modest. In the suspected infection cohort, the modified model classified more patients to sepsis (66.0 vs 62.5%) and identified more patients at risk of septic mortality than the SOFA score (92.6 vs 89.5%). CONCLUSIONS: Among ED patients with suspected infection, sepsis, and septic shock, the newly-developed modified CV/total SOFA score had higher predictive validity and identified more patients at risk of septic mortality.

Effect of Prehospital Epinephrine on Out-of-Hospital Cardiac Arrest Outcomes: A Propensity Score-Matched Analysis.

PURPOSE: A pilot project using epinephrine at the scene under medical control is currently underway in Korea. This study aimed to determine whether prehospital epinephrine administration is associated with improved survival and neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients who received epinephrine during cardiopulmonary resuscitation (CPR) in the emergency department. MATERIALS AND METHODS: This retrospective observational study used a nationwide multicenter OHCA registry. Patients were classified into two groups according to whether they received epinephrine at the scene or not. The associations between prehospital epinephrine use and outcomes were assessed using propensity score (PS)-matched analysis. Multivariable logistic regression analysis was performed using PS matching. The same analysis was repeated for the subgroup of patients with non-shockable rhythm. RESULTS: PS matching was performed for 1084 patients in each group. Survival to discharge was significantly decreased in the patients who received prehospital epinephrine [odds ratio (OR) 0.415, 95% confidence interval (CI) 0.250-0.670, p<0.001]. However, no statistical significance was observed for good neurological outcome (OR 0.548, 95% CI 0.258-1.123, p=0.105). For the patient subgroup with non-shockable rhythm, prehospital epinephrine was also associated with lower survival to discharge (OR 0.514, 95% CI 0.306-0.844, p=0.010), but not with neurological outcome (OR 0.709, 95% CI 0.323-1.529, p=0.382). CONCLUSION: Prehospital epinephrine administration was associated with decreased survival rates in OHCA patients but not statistically associated with neurological outcome in this PS-matched analysis. Further research is required to investigate the reason for the detrimental effect of epinephrine administered at the scene.

Predictive model for diagnosing central lesions in emergency department patients with isolated dizziness who undergo diffusion-weighted magnetic resonance imaging.

OBJECTIVES: Only 5% to 10% of patients who visit the emergency department (ED) with isolated dizziness without neurologic abnormalities may have central lesions; however, it is important to distinguish central lesions through brain imaging. This study was conducted to create a nomogram to provide an objective medical basis for selectively performing magnetic resonance imaging (MRI) among patients with isolated dizziness. METHODS: This retrospective observational study enrolled patients who visited the ED of a tertiary hospital with isolated dizziness and underwent diffusion-weighted MRI and subsequently consulted with the departments of neurology, neurosurgery, or otorhinolaryngology. Multivariable logistic regression analysis was performed to identify risk factors in patients diagnosed with central lesions to create a nomogram with the significant variables. RESULTS: Of the 1,078 patients who were screened, 119 were diagnosed with central lesions. Significant variables in the multivariable logistic regression analysis were albumin levels (odds ratio [OR] = 0.339, 95% confidence interval [CI] = 0.188 to 0.610, p = 0.0003), inorganic phosphate levels (OR = 0.891, 95% CI = 0.832 to 0.954, p = 0.0010), history of ischemic stroke (OR = 3.170, 95% CI = 1.807 to 5.560, p < 0.0001), presyncope (OR = 3.152, 95% CI = 1.184 to 8.389, p = 0.0216), and nystagmus (OR = 0.365, 95% CI = 0.237 to 0.561, p < 0.0001). The area under the receiver operating characteristic curve of the nomogram created with these variables was 0.7315 (95% CI = 0.6842 to 0.7788, p < 0.0001). CONCLUSIONS: Albumin, inorganic phosphate, previous stroke, presyncope, and nystagmus were associated with the predictive diagnosis of central lesions among patients admitted to the ED with isolated dizziness. The novel nomogram created using these variables can help in objectively determining the need for MRI in patients presenting with isolated dizziness to the ED.

Physiological processes and gross energy budget of the submerged longline-cultured Pacific oyster Crassostrea gigas in a temperate bay of Korea.

Physiological processes and gross energy budget of the longline-cultured Pacific oyster Crassostrea gigas were investigated in Geoje-Hansan Bay, Korea during two entire culturing periods. Based on physiological measurements of food consumption, feces production, ammonium excretion, and respiration from July 2008 to February 2009 and from July 2013 to February 2014, scope for growth appeared to be positive during most of the culturing period, except for one period with extremely high temperatures (up to 25°C). Estimates of physiological energy production matched well with tissue energy increment measured by gross biochemical composition during the culturing period, suggesting that the oysters might adjust their physiological performance to relatively low concentrations of suspended particulate matter in the bay to optimize energy acquisition. Such an adaptive adjustment includes an increased absorption of energy and a reduced loss of metabolic and excretory energy, resulting in positive production under high culturing density. Using physiological measurements, we further assessed the feedback effects of the longline aquaculture of oysters on the bay system. Ecological efficiency, estimated by a series of energetic efficiencies at the whole bay level, was low compared with Lindeman's law of trophic efficiency. Biodeposition and ammonia excretion rates in this study were relatively low compared with other intertidal plastic bag cultures. These results indicate that the cultured oysters might have only minor effects on benthic and pelagic environments of the bay. Overall, our results suggest that the adaptive physiological performance of oysters and consequently weak feedback effects on ambient habitats should facilitate sustainable longline aquaculture in the bay for a prolonged period without severe habitat deterioration.

Trophic linkage of a temperate intertidal macrobenthic food web under opportunistic macroalgal blooms: A stable isotope approach.

The effects of blooms of opportunistic green macroalgae, Ulva prolifera, on the trophic structure of the macrobenthic food web in a temperate intertidal zone on the western coast of Korea were evaluated using carbon and nitrogen stable isotopes. Biomasses of Ulva and microphytobenthos (MPB) increased significantly at the macroalgae-bloom and the non-bloom sites, respectively, from March to September 2011. The δ(13)C values of most the consumers were arrayed between those of MPB and Ulva at both sites, and differed according to feeding strategies at the macroalgae-bloom site. Seasonally increasing magnitudes in δ(13)C and δ(15)N values of consumers were much steeper at the macroalgae-bloom site than at the non-bloom site. Our findings provide evidence that blooming green macroalgae play a significant role as a basal resource supporting the intertidal macrobenthic food web and their significance varies with feeding strategies of consumers as well as the resource availability.

Trophic structure in a pilot system for the integrated multi-trophic aquaculture off the east coast of Korean peninsula as determined by stable isotopes.

To assess the potential for nutritional exploitation of caged-fish-derived waste through the use of extractive co-cultured species in a pilot system for an integrated multi-trophic aquaculture (IMTA), we compared their C and N stable isotope ratios with those of uncultured macroinvertebrates in and around the system. Black rockfish were co-cultured with sea cucumber, oyster, and two macroalgae as extractive species. Isotope signatures of the co-cultured sea cucumber at the IMTA site differed from those at the control site, indicating their assimilation of aquaculture wastes. In contrast, δ(13)C and δ(15)N of individual taxa of the cultured oyster and uncultured invertebrates were consistent between sites, suggesting a minor contribution of the aquaculture waste to benthic and pelagic food chains in and around the IMTA system. These results provide evidence of the suitability of using sea cucumber as an extractive species to reduce the impact of a monoculture system on the ambient environment.

Stable isotope analysis of a newly established macrofaunal food web 1.5 years after the Hebei Spirit oil spill.

We examined trophic relationships in a newly established community 1.5 years after the Hebei Spirit oil spill on the west coast of Korea. Carbon and nitrogen stable isotope ratios in consumers and their potential food sources were compared between the oil-spill site and reference site, located 13.5 km from the oil-spill spot. The isotopic mixing model and a novel circular statistics rejected the influx of petrogenic carbon into the community and identified spatial consistencies such as the high contributions of microphytobenthos, food-chain length, and the isotopic niche of each feeding guild between sites. We suggested that high level of trophic plasticity and the prevalence of omnivory of consumers may promote the robustness of food web against the oil contamination. Furthermore, we highlighted the need of holistic approaches including different functional groups to quantify changes in the food web structure and assess the influence of different perturbations including oil spill.