Clinical Utility of the Tokyo Guidelines 2018 for Acute Cholangitis in the Emergency Department and Comparison with Novel Markers (Neutrophil-to-Lymphocyte and Blood Nitrogen Urea-to-Albumin Ratios).

Introduction: The Tokyo Guidelines 2018 (TG2018) is a scoring system used to recommend the clinical management of AC. However, such a scoring system must incorporate a variety of clinical outcomes of acute cholangitis (AC). In an emergency department (ED)-based setting, where efficiency and practicality are highly desired, clinicians may find the application of various parameters challenging. The neutrophil-to-lymphocyte ratio (NLR) and blood urea nitrogen-to-albumin ratio (BAR) are relatively common biomarkers used to assess disease severity. This study evaluated the potential value of TG2018 scores measured in an ED to predict a variety of clinical outcomes. Furthermore, the study also compared TG2018 scores with NLR and BAR scores to demonstrate their usefulness. Methods: This retrospective observational study was performed in an ED. In total, 502 patients with AC visited the ED between January 2016 and December 2021. The primary endpoint was to evaluate whether the TG2018 scoring system measured in the ED was a predictor of intensive care, long-term hospital stays (≥14 days), percutaneous transhepatic biliary drainage (PTBD) during admission care, and endotracheal intubation (ETI). Results: The analysis included 81 patients requiring intensive care, 111 requiring long-term hospital stays (≥14 days), 49 requiring PTBD during hospitalization, and 14 requiring ETI during hospitalization. For the TG2018 score, the adjusted OR (aOR) using (1) as a reference was 23.169 (95% CI: 9.788-54.844) for (3) compared to (1). The AUC of the TG2018 for the need for intensive care was 0.850 (95% CI: 0.815-0.881) with a cutoff of >2. The AUC for long-term hospital stays did not exceed 0.7 for any of the markers. the AUC for PTBD also did not exceed 0.7 for any of the markers. The AUC for ETI was the highest for BAR at 0.870 (95% CI: 0.837-0.899) with a cutoff value of >5.2. Conclusions: The TG2018 score measured in the ED helps predict various clinical outcomes of AC. Other novel markers such as BAR and NLR are also associated, but their explanatory power is weak.

Association of B-Type Natriuretic Peptide Level with Clinical Outcome in Out-of-Hospital Cardiac Arrest in Emergency Department Patients.

OBJECTIVES: B-type natriuretic peptide (BNP) is used for outcome assessment of various diseases. We designed this study to investigate whether BNP, which has been proven useful in the risk stratification of sudden cardiac arrest (SCA) of cardiac etiology, can also prove to be a valuable prognostic tool for SCA also included with non-cardiac etiology. In this study, we aim to investigate the relationship between measured BNP levels and clinical outcomes in SCA, regardless of the cause of SCA. METHODS: This retrospective multicenter observational study was performed in two tertiary university hospitals and one general hospital between January 2015 and December 2020. The total number of SCA patients was 1625. The patients with out-of-hospital cardiac arrest over 19 years old and acquired laboratory data, including BNP at emergency department (ED) arrival, were included. BNP was measured during advanced Cardiovascular Life Support (ACLS). The exclusion criteria were age under 18 years, traumatic arrest, and without BNP. RESULTS: The median BNP was 171.8 (range; 5-5000) pg/mL in the return of Spontaneous Circulation (ROSC), higher than No-ROSC (p = 0.007). The median BNP concentration was 99.7 (range; 5-3040.68) pg/mL in the survival to discharge, which was significantly lower than the death group (p = 0.012). The odds ratio of survival to discharge decreased proportionally to the BNP level. The odds ratio of neurologic outcome was not correlated with the BNP level. CONCLUSION: In patients with SCA of all origins, low BNP concentration measured during ACLS correlated with an increased ratio of survival to discharge. However, BNP measured during ACLS was not found to be an independent factor.

Case report: Early carotid stent shortening in patient with radiation-induced carotid stenosis.

Carotid artery stenting (CAS) for carotid stenosis has been widely used as an alternative treatment in patients not eligible for surgery. The shortening of a carotid stent rarely occurs. We report a case of early shortening of CAS in a patient with radiation-induced carotid stenosis and discuss the potential pathophysiology and strategies for prevention. This case presents a 67-year-old man who underwent radiotherapy for oral cavity squamous cell carcinoma 7 years ago and subsequently developed severe stenosis in the left proximal internal carotid artery. The patient underwent CAS for symptomatic severe carotid stenosis. Follow-up CT angiography revealed shortening of the carotid stent, and additional carotid stenting was performed. We speculate that the possible mechanism of early complication of CAS could be slippage and shortening of the stent due to weak anchoring between the stent strut and the fibrotic arterial wall in radiation-induced carotid stenosis.

The D-Dimer to Troponin Ratio Is a Novel Marker for the Differential Diagnosis of Thoracic Acute Aortic Syndrome from Non-ST Elevation Myocardial Infarction.

BACKGROUND: Thoracic acute aortic syndrome (AAS) and non-ST elevation myocardial infarction (NSTEMI) have similar clinical presentations, making them difficult to differentiate. This study aimed to identify useful biomarkers for the differential diagnosis of thoracic AAS and NSTEMI. METHODS: This was a retrospective observational study. PARTICIPANTS: consecutive adult patients who visited the emergency department for acute chest pain between January 2015 and December 2021 diagnosed with thoracic AAS or NSTEMI. Clinical variables, including D-dimer (µg/mL) and high-sensitivity troponin T (ng/mL, hs-TnT) levels, were compared between the groups. RESULTS: A total of 52 (30.1%) and 121 (69.9%) patients were enrolled in the thoracic AAS and NSTEMI groups, respectively. Logistic regression analysis revealed that the D-dimer to hs-TnT (D/T) ratio (odds ratio (OR), 1.038; 95% confidence interval (CI), 1.020-1.056; p < 0.001) and the thrombolysis in myocardial infarction (TIMI) score (OR, 0.184; 95% CI, 0.054-0.621; p = 0.006) were associated with thoracic AAS. The D/T ratio had an area under the receiver operating characteristic curve (AUC) of 0.973 (95% CI, 0.930-0.998), and the optimal cutoff value was 81.3 with 91.4% sensitivity and 96.2% specificity. The TIMI score had an AUC of 0.769 (95% CI, 0.644-0.812), and the optimal cutoff value was 1.5 with 96.7% sensitivity and 38.5% specificity. CONCLUSION: the D/T ratio may be a simple and useful parameter for differentiating thoracic AAS from NSTEMI.

Diagnostic Value of Serum Lactate Dehydrogenase Level Measured in the Emergency Department in Predicting Clinical Outcome in Out-of-Hospital Cardiac Arrest: A Multicenter, Observational Study.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is complex, and risk stratification tools have the potential to include components other than clinical risk indicators, thus requiring extensive studies. Simple and accurate biomarkers for OHCA patients with poor prognoses are still needed. Serum lactate dehydrogenase (LDH) has been identified as a risk factor in patients with various diseases, such as cancer, liver disease, severe infections, and sepsis. The primary aim of this study was to assess the accuracy of LDH values at initial presentation in the emergency department (ED) in predicting the clinical outcome in OHCA. METHODS: This retrospective multicenter observational study was performed in the ED of two tertiary university hospitals and one general hospital between January 2015 and December 2021. All patients with OHCA who visited the ED were included. The primary outcome was the sustained return of spontaneous circulation (ROSC; >20 min) after advanced cardiac life support (ACLS). The secondary outcome was survival to discharge (including home care and nursing care discharge) among patients with ROSC. The neurological prognosis was considered a tertiary outcome in patients who survived to discharge. RESULTS: In total, 759 patients were enrolled in the final analysis. The median LDH level in the ROSC group was 448 U/L (range: 112-4500), which was significantly lower than that in the no-ROSC group (p < 0.001). The median LDH level in the survival-to-discharge group was 376 U/L (range: 171-1620), which was significantly lower than that in the death group (p < 0.001). Using the adjusted model, the odds ratio of the LDH value (≤634 U/L) for primary outcomes was 2.418 (1.665-3.513) and the odds ratio of LDH value (≤553 U/L) for secondary outcomes was 4.961 (2.184-11.269). CONCLUSIONS: In conclusion, the serum LDH levels of patients with OHCA measured in the ED can potentially serve as a predictive marker for clinical outcomes such as ROSC and survival to discharge, although it may be difficult to predict neurological outcomes.

Effect of Sulfide and Chloride Ions on Pitting Corrosion of Type 316 Austenitic Stainless Steel in Groundwater Conditions Using Response Surface Methodology.

This study investigates the corrosion resistance of Type 316 stainless steel as a candidate material for radioactive waste disposal canisters. The viability of stainless steel is examined under groundwater conditions with variations in pH, bisulfide ions (HS-), and chloride ions (Cl-) concentrations. Utilizing response surface methodology, correlations between corrosion factors and two crucial response variables, passive film breakdown potential and protection potential, are established. Cyclic potentiodynamic polarization tests and advanced analytical techniques provide detailed insights into the material's behavior. This research goes beyond, deriving an equation through response surface methodology that elucidates the relationship between the factors and breakdown potential. HS- weakens the passive film and reduces the pitting corrosion resistance of the stainless steel. However, this study highlights the inhibitory effect of HS- on pitting corrosion when Cl- concentrations are below 0.001 M and at equivalent concentrations of HS-. Under these conditions, immediate re-passivation occurs from the destroyed passive film to metal sulfides such as FeS2, MoS2, and MoS3. As a result, no hysteresis loop occurs in the cyclic polarization curve in these conditions. This research contributes to the understanding of Type 316 stainless-steel corrosion behavior, offering implications for the disposal of radioactive waste in geological repositories.

Role of point-of-care ultrasound in critical care and emergency medicine: update and future perspective.

Point-of-care ultrasound (POCUS) is a rapidly developing technology that has the potential to revolutionize emergency and critical care medicine. The use of POCUS can improve patient care by providing real-time clinical information. However, appropriate usage and proper training are crucial to ensure patient safety and reliability. This article discusses the various applications of POCUS in emergency and critical care medicine, the importance of training and education, and the future of POCUS in medicine.

International Normalized Ratio-to-Albumin Ratio as a Novel Marker of Upper Gastrointestinal Bleeding Severity.

Introduction: Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening gastrointestinal emergency, and effective management depends on early risk stratification. The Glasgow-Blatchford and Rockall scores are commonly used prognostic measures for UGIB, although these scoring systems are relatively difficult to apply in early emergency settings. AIMS65 with five items, albumin, international normalized ratio, mental status, systolic blood pressure, and age (>65 years), showed efficacy in predicting long-term hospitalization and mortality. This study aimed to investigate the usefulness of the prothrombin time-international normalized ratio-to-albumin ratio (PTAR) in the emergency room for early UGIB risk stratification. Methods: We retrospectively examined patients who visited a tertiary academic hospital's emergency department (ED) with UGIB as the chief presentation between January 2019 and December 2020. The cutoff values and diagnostic accuracies of the PTAR, Glasgow-Blatchford score, AIMS65 score, pre-endoscopy, and complete Rockall score were analyzed, and the performance of the PTAR was compared with that of other risk stratification methods. In total, 519 patients were enrolled: 163 patients were admitted in the intensive care unit (ICU) and 35 died during admission. Multiple logistic regression analyses confirmed the association of the PTAR with ICU admission and mortality. The adjusted odd ratio (aOR) of the PTAR for ICU admission care was 8.376 (2.722-25.774), and the aOR of the PTAR for mortality was 27.846 (8.701-89.116). Conclusions: The PTAR measured in the ED is an independent factor related to ICU admission and mortality in patients with UGIB. Using ED blood laboratory results, which are reported relatively quickly and are easy to acquire and calculate, the PTAR can be used as a risk stratification marker in the early emergency setting.

Long-Term Outcomes of Local Tirofiban Infusion for Intracranial Atherosclerosis-Related Occlusion.

Local tirofiban infusion has been reported as a rescue strategy for intracranial atherosclerotic stenosis (ICAS)-related stroke. However, the long-term outcomes of local tirofiban infusion during endovascular reperfusion therapy (ERT) for ICAS-related stroke are still uncertain. This study aimed to investigate the long-term outcomes of local tirofiban infusion during ERT. We retrospectively analyzed acute patients with ICAS-related stroke who were treated with local tirofiban as a rescue strategy during ERT. The primary outcomes were ischemic stroke, transient ischemic stroke (TIA), and stroke-related death within 30 days. Secondary outcomes included ischemic stroke and TIA beyond 30 days and up to 2 years after ERT in the corresponding treated vessel, symptomatic brain hemorrhage, any stroke, and non-stroke-related death. During a median follow-up of 24.0 months, 12 patients developed an ischemic stroke and TIA (4 within 30 days and 8 afterward). The 1-year risk of stroke and TIA was 9.2% (95% confidence interval, 8.0-18.6%). This study demonstrates that 1-year outcomes of local tirofiban infusion were comparable to the results of intracranial stenting in patients with symptomatic ICAS. Local tirofiban infusion for ICAS-related stroke may be a feasible rescue strategy that can have a bridging role until the maximum effect of antiplatelet agents is achieved.

Predictors and Outcomes of Salvaging the Corticospinal Tract After Thrombectomy in Basilar Artery Occlusion Stroke.

Background: Regional eloquence of brainstem structures may contribute to neurological status in basilar artery occlusion (BAO) stroke. The corticospinal tract (CST) which is vulnerable to BAO is important for motor activity. This study investigated the impact of CST salvage on outcomes and its associated factors in patients with BAO treated with thrombectomy. Methods: We retrospectively investigated 88 patients with BAO admitted ≤24 h after onset and presented with motor deficits and who underwent thrombectomy. Patients with a pre-stroke modified Rankin Scale (mRS) score of 4-5 who did not undergo baseline brain computed tomography angiography were excluded. CST salvage was evaluated using follow-up imaging (magnetic resonance imaging [MRI] or computed tomography when MRI was not available) after thrombectomy. A good outcome was defined as a 3-month mRS score of ≤2 or 3 if a patient's pre-stroke mRS score was 3. The associations between CST salvage and outcomes and clinical parameters were analyzed using logistic regression analyses. Results: Thirty-nine (44.3%) patients had CST salvage and the same number of patients had good outcomes. CST salvage was independently associated with a good outcome [adjusted odds ratio (aOR): 18.52, 95% confidence interval (CI): 4.31-79.67, p < 0.001]. After adjusting for confounders, atrial fibrillation (aOR: 3.92, 95% CI: 1.18-13.00, p = 0.026), location of occlusion (mid-BAO; aOR: 0.21, 95% CI: 0.06-0.72, p = 0.013), length of occlusion (involved segment of BAO <2; aOR: 4.77, 95% CI: 1.30-17.59, p = 0.019), and onset-to-puncture-time ≤180 min (aOR: 4.84, 95% CI: 1.13-20.75, p = 0.034) were significantly associated with CST salvage. Conclusion: CST salvage was associated with good functional outcomes in patients with BAO treated with thrombectomy. The presence of atrial fibrillation, location and length of BAO may predict CST salvage after thrombectomy, and rapid treatment with thrombectomy may protect this eloquent tract in these patients.

Influence of cerebral microbleeds on mechanical thrombectomy outcomes.

In ischemic stroke patients undergoing endovascular treatment (EVT), we aimed to test the hypothesis that cerebral microbleeds (CMBs) are associated with clinical outcomes, while estimating the mediating effects of hemorrhagic transformation (HT), small-vessel disease burden (white matter hyperintensities, WMH), and procedural success. From a multicenter EVT registry, patients who underwent pretreatment MR imaging were analyzed. They were trichotomized according to presence of CMBs (none vs. 1-4 vs. ≥ 5). The association between CMB burden and 3-month mRS was evaluated using multivariable ordinal logistic regression, and mediation analyses were conducted to estimate percent mediation. Of 577 patients, CMBs were present in 91 (15.8%); 67 (11.6%) had 1-4 CMBs, and 24 (4.2%) had ≥ 5. Increases in CMBs were associated with hemorrhagic complications (ß = 0.27 [0.06-0.047], p = 0.010) in multivariable analysis. The CMB effect on outcome was partially mediated by post-procedural HT degree (percent mediation, 14% [0-42]), WMH (23% [7-57]) and lower rates of successful reperfusion (6% [0-25]). In conclusion, the influence of CMBs on clinical outcomes is mediated by small-vessel disease burden, post-procedural HT, and lower reperfusion rates, listed in order of percent mediation size.

Development and Validation of Simple Age-Adjusted Objectified Korean Triage and Acuity Scale for Adult Patients Visiting the Emergency Department.

PURPOSE: The study aimed to develop an objectified Korean Triage and Acuity Scale (OTAS) that can objectively and quickly classify severity, as well as a simple age-adjusted OTAS (S-OTAS) that reflects age and evaluate its usefulness. MATERIALS AND METHODS: A retrospective analysis was performed of all adult patients who had visited the emergency department at three teaching hospitals. Sex, systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, body temperature, O2 saturation, and consciousness level were collected from medical records. The OTAS was developed with objective criterion and minimal OTAS level, and S-OTAS was developed by adding the age variable. For usefulness evaluation, the 30-day mortality, the rates of computed tomography scan and emergency procedures were compared between Korean Triage and Acuity Scale (KTAS) and OTAS. RESULTS: A total of 44402 patients were analyzed. For 30-day mortality, S-OTAS showed a higher area under the curve (AUC) compared to KTAS (0.751 vs. 0.812 for KTAS and S-OTAS, respectively, p<0.001). Regarding the rates of emergency procedures, AUC was significantly higher in S-OTAS, compared to KTAS (0.807 vs. 0.830, for KTAS and S-OTAS, respectively, p=0.013). CONCLUSION: S-OTAS showed comparative usefulness for adult patients visiting the emergency department as a triage tool compared to KTAS.

Age-Adjusted D-Dimer in Ruling Out Acute Aortic Syndrome.

BACKGROUND: Recently, D-dimer has been suggested as a biomarker to rule out acute aortic syndrome (AAS). Since it increases with age, this study was conducted to reveal whether an age-adjusted D-dimer can increase diagnostic accuracy in ruling out AAS. METHOD: A retrospective observational study design was used. Consecutive adult patients who visited an emergency room between January 2015 and September 2020 and who underwent a D-dimer test and computed tomography angiography for suspected AAS were enrolled. We calculated the diagnostic accuracy of both the conventional (0.5 µg/ml) and age-adjusted (age × 0.01 in patients >50 years) D-dimer cut-offs. RESULT: D-dimer was higher in the AAS group (n = 82) than in the non-AAS group (n = 122) (10.85 (3.61-33.12) vs. 0.40 (0.23-1.07), OR: 1.139 (CI: 1.085 - 1.195), p < 0.001). The D-dimer plasma level had an area under the ROC curve of 0.915 (CI: 0.873-0.956) with AAS. At the age-adjusted cutoff point compared to a 0.5 µg/ml cutoff, the sensitivity of 97.6% and the NLR of 0.04 did not change, but the specificity increased by 5.7% to 65.6%, the PPV increased by 3.6% to 65.6%, and the NPV slightly increased by 0.2% to 97.6%. CONCLUSION: Compared with a conventional method, the age-adjusted D-dimer cutoff may have higher specificity and PPV while maintaining high sensitivity for ruling out AAS.

Role of Apparent Diffusion Coefficient Gradient Within Diffusion Lesions in Outcomes of Large Stroke After Thrombectomy.

BACKGROUND AND PURPOSE: The outcome of endovascular treatment in stroke patients with a large ischemic core is not always satisfactory. We evaluated whether the severity of baseline diffusion-weighted imaging abnormalities, as assessed by different apparent diffusion coefficient (ADC) thresholds, correlates with the clinical outcome in these patients after successful endovascular treatment. METHODS: In 82 consecutive patients with a large vessel occlusion in the anterior circulation admitted ≤24 hours after onset, a baseline diffusion lesion volume (ADC ≤620×10-6 mm2/s [ADC620]) ≥50 mL and successful recanalization by endovascular treatment were retrospectively investigated. Lesion volumes of 3 ADC thresholds (ADC620, ADC ≤520×10-6 mm2/s [ADC520], and ADC ≤540×10-6 mm2/s [ADC540]) were measured using an automated Olea software program. The performance of the ADC520/ADC620 and ADC540/ADC620 ratios in predicting the functional outcome was assessed by receiver operating characteristic curve analysis. The ADC ratio with optimal threshold showing better receiver operating characteristic performance was dichotomized at its median value into low versus high subgroup and its association with the outcome subsequently evaluated in a multivariable logistic regression model. RESULTS: The median baseline diffusion lesion volume was 80.8 mL (interquartile range, 64.4-105.4). A good functional outcome (modified Rankin Scale score, ≤2) was achieved in 35 patients (42.7%). The optimal threshold for predicting the functional outcome was identified as ADC540/ADC620 (area under the curve, 0.833) and dichotomized at 0.674. After adjusting for age, baseline National Institutes of Health Stroke Scale score, intravenous tissue-type plasminogen activator, baseline diffusion lesion volume, and onset-to-recanalization time, a low ADC540/ADC620 was independently associated with a good functional outcome (adjusted odds ratio, 10.72 [95% CI, 3.06-37.50]; P<0.001). CONCLUSIONS: A low ADC540/ADC620, which may reflect less severe ischemic stress inside a diffusion lesion, may help to identify patients who would benefit from endovascular treatment despite having a large ischemic core.

Perfusion profile evaluated by severity-weighted multiple Tmax strata predicts early neurological deterioration in minor stroke with large vessel occlusion.

Minor stroke due to large vessel occlusion (LVO) is associated with poor outcomes. Hypoperfused tissue fate may be more accurately predicted by severity-weighted multiple perfusion strata than by a single perfusion threshold. We investigated whether poor perfusion profile evaluated by multiple Tmax strata is associated with early neurological deterioration (END) in patients with minor stroke with LVO. Ninety-four patients with a baseline National Institute of Health Stroke Scale score ≤5 and anterior circulation LVO admitted within 24 hours of onset were included. Tmax strata proportions (Tmax 2-4 s, 4-6 s, 6-8 s, 8-10 s, and >10 s) against the entire hypoperfusion volume (Tmax >2 s) were measured. The perfusion profile was defined as the shift of the distribution of the Tmax strata proportions towards worse hypoperfusion severity compared with that of the entire cohort using the Wilcoxon-Mann-Whitney generalised odds ratio (OR); its performance to predict END was tested. The area under the curve of perfusion profile was 0.785 (95% confidence interval [CI]: 0.691-0.878, p < 0.001). Poor perfusion profile (generalised OR >1.052) was independently associated with END (adjusted OR 13.42 [95% CI: 4.38-41.15], p < 0.001). Thus, perfusion profile with severity-weighted multiple Tmax strata may predict END in minor stroke and LVO.

Intracranial non-occlusive intraluminal thrombus may indicate underlying etiology of large vessel occlusion in patients undergoing endovascular therapy.

BACKGROUND: The underlying etiology of intracranial non-occlusive intraluminal thrombus (iNOT) remains unknown. This study aimed to investigate whether the presence of iNOT can indicate the underlying etiology of large vessel occlusion (LVO) in patients undergoing endovascular therapy (EVT). METHODS: Among patients who underwent EVT at three comprehensive stroke centers, we included those with intracranial LVO in the anterior circulation. The presence of iNOT was determined by pretreatment DSA. We investigated the association between iNOT and intracranial atherosclerotic stenosis (ICAS) related LVO. RESULTS: Of 546 patients, 44 (8.1%) had iNOT. Patients with iNOT were younger, had less hypertension, atrial fibrillation, and a history of antiplatelet use. In addition, the involvement of the M1 segment of the middle cerebral artery (MCA) was more frequent. However, they had a lower National Institutes of Health Stroke Scale (NIHSS) score on admission and longer onset to recanalization time compared with patients with no iNOT. In a logistic regression model adjusting for age, sex, atrial fibrillation, smoking, prior antiplatelet and anticoagulant use, intravenous tissue plasminogen activator, NIHSS on admission, number of technical trials, intraprocedural re-occlusion, and the location of LVO (p<0.10 in the univariate analysis), the presence of iNOT was significantly associated with ICAS related LVO (adjusted OR 3.04; 95% CI 1.33 to 6.90; p=0.007). CONCLUSIONS: The presence of iNOT may reflect an underlying ICAS related LVO in patients undergoing EVT.

Prehospital Factors Associated with Refractory Traumatic Arrest.

OBJECTIVE: Identification of the prehospital factors associated with a poor prognosis of immediate traumatic arrest should help reduce unwarranted treatment. We aim to reveal the clinical factors related to death after traumatic arrest on the scene. METHODS: We performed a multicenter (4 tertiary hospitals in urban areas of South Korea) retrospective study on consecutive adult patients with trauma arrest on scene who were transferred by fire ambulance from January 2016 to December 2018. Patients with death on arrival in the emergency room (ER) were excluded. Prehospital data were collected from first aid records, and information on each patient's survival outcome in the ER was collected from an electronic database. Patients were divided into ER death and ER survival groups, and variables associated with prehospital trauma were compared. RESULTS: A total of 145 (84.3%) and 27 (15.7%) patients were enrolled in the ER death and survival groups, respectively. Logistic regression analysis revealed that asystole (OR 4.033, 95% CI 1.342-12.115, p = 0.013) was related to ER death and that ROSC in the prehospital phase (OR 0.100, 95% CI 0.012-0.839, p = 0.034) was inversely related to ER death. In subgroup analysis of those who suffered fall injuries, greater height of fall was associated with ER death (15.0 (5.5-25.0) vs. 4.0 (2.0-7.5) meters, p = 0.001); the optimal height cutoff for prediction of ER death was 10 meters, with 66.1% sensitivity and 100% specificity. CONCLUSIONS: In cases of traumatic arrest, asystole, no prehospital ROSC, and falls from a greater height were associated with trauma death in the ER. Termination of resuscitation in traumatic arrest cases should be done on the basis of comprehensive clinical factors.

End-Tidal Carbon Dioxide Monitoring for Spontaneous Pneumothorax.

BACKGROUND: Spontaneous pneumothorax should be classified as primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP) because treatment strategies may differ depending on underlying lung conditions and clinical course. The pulmonary dysfunction can lead to changes in end-tidal carbon dioxide (ETCO2). The aim of this study was to investigate the difference in ETCO2 between PSP and SSP. METHODS: This retrospective observational study included adult patients diagnosed with spontaneous pneumothorax in the emergency room from April 2019 to September 2020. We divided patients into PSP and SSP groups and compared ETCO2 variables between the two groups. RESULTS: There were 33 (66%) patients in the PSP group and 17 (34%) patients in the SSP group. Initial ETCO2 was lower in the SSP group than in the PSP group (30 (23-33) vs. 35 (33-38) mmHg, p=0.002). Multivariate analysis revealed that respiratory gas associated with SSP was initial ETCO2 (OR: 0.824; 95% CI: 0.697-0.974, p=0.023). The optimal cutoff for initial ETCO2 to detection of SSP was 32 mmHg (area under curve, 0.754), with 76.5% sensitivity and 72.7% specificity. CONCLUSION: ETCO2 monitoring is a reliable noninvasive indicator of differentiating between PSP and SSP. Initial ETCO2 lower than 32 mmHg is a predictor of SSP.

Impact of Left Atrial Appendage Morphology on Recurrence in Embolic Stroke of Undetermined Source and Atrial Cardiopathy.

Background: The left atrial appendage (LAA) is a major source of thrombus and non-chicken wing (CW). LAA morphology is a risk factor for embolic events in atrial fibrillation. However, the association of non-CW morphology with embolic stroke recurrence is unknown in patients with embolic stroke of undetermined source (ESUS) and atrial cardiopathy. Methods: We conducted retrospective analyses using a prospective institutional stroke registry (2013-2017). Patients with ESUS and atrial cardiopathy were enrolled. Atrial cardiopathy was diagnosed if an increased left atrial diameter (>40 mm, men; >38 mm, women), supraventricular tachycardia, or LAA filling defect on computed tomography (CT) were present. Patients admitted >24 h after onset were excluded. LAA morphology was evaluated using CT and categorized into CW vs. non-CW types. The primary outcome was embolic stroke recurrence. Multivariable Cox proportional hazards models were used to examine the independent association between LAA morphology and outcome. Results: Of 157 patients, 81 (51.6%) had CW LAA morphology. The median follow-up was 41.5 (interquartile range 12.3-58.5) months corresponding to 509.8 patient years. In total, 18 participants experienced embolic stroke recurrences (3.80 per 100 patient-years). Non-CW morphology was more associated with embolic stroke recurrence than CW morphology (hazard ratio (HR), 3.17; 95% confidence interval (CI), 1.13-8.91; p = 0.029). After adjusting for CHA2DS2-VASc score and number of potential embolic sources, non-CW morphology showed an independent association with outcome (adjusted HR, 2.90; 95% CI, 1.02-8.23; p = 0.045). Conclusions: The LAA morphology types may help identify high risk of embolic stroke recurrence in ESUS with atrial cardiopathy. LAA morphology in atrial cardiopathy may provide clues for developing therapies tailored to specific mechanisms.

Usefulness of combination usage of balloon guide catheter with contact aspiration thrombectomy.

BACKGROUND: Angiographic outcomes of contact aspiration thrombectomy (CAT), a frontline thrombectomy strategy, can vary depending on balloon guide catheter (BGC) usage, stroke etiology, and occlusion location. The purpose of this study was to analyze conditional outcomes of CAT to determine which result in maximum angiographic benefits. METHODS: Patients who received CAT for anterior circulation occlusive stroke between January 2017 and December 2018 were included. Angiographic and clinical outcomes were compared relative to BGC use, stroke etiology, and occlusion location. Multivariable analyses for first-pass reperfusion (FPR) and favorable clinical outcome were performed. RESULTS: Of 160 included patients, the rates of FPR, successful reperfusion after CAT, final successful reperfusion, and favorable clinical outcome were 43.1%, 58.1%, 81.9%, and 60.6%, respectively. BGC use was associated with a higher rate of FPR, successful reperfusion after CAT, a lower rate of distal embolization, and faster reperfusion. Based on subgroup analysis, BGC usage in ICA, MCA M1 occlusion, and cardioembolism were associated with higher FPR, successful reperfusion after CAT, and lower distal embolization. Faster reperfusion was achieved in ICA occlusions and cardioembolisms. BGC usage was an independent predictor of FPR. Favorable clinical outcome was associated with male gender, low initial NIHSS score, fast onset to reperfusion, and FPR. CONCLUSIONS: In CAT, BGC usage was associated with better angiographic outcomes, including higher FPR, successful reperfusion after CAT, prevention of distal embolization, and faster reperfusion, especially in proximal occlusions and cardioembolisms. These conditions may play a role in maximizing the benefits of CAT.