Development of occupation-based exposure matrix of lead for Korean workers: challenges and opportunities.

OBJECTIVES: Industry- and occupation-based carcinogen exposure matrices play a pivotal role in preventing occupational cancer. While the Korean CARcinogen EXposure (K-CAREX) has been developed in recent years to assess exposure prevalence and intensity by industry, the feasibility of constructing an occupation-based exposure matrix remains unexplored. Hence, the objective of this study is to explore the potential of combining the nationwide work environment measurement database (WEMD) and the special health examination database (SHED) to develop a comprehensive occupation-based exposure matrix. METHODS: The WEMD provides information on airborne lead measurements, including industry codes, but it does not include data related to occupations. In contrast, the SHED contains information on both occupation and blood lead levels. By integrating these 2 databases, we attempted to assess airborne lead exposure levels by occupation. Additionally, we performed a rank correlation analysis to compare the airborne exposure levels with corresponding blood lead levels according to occupation. RESULTS: A total of 35 425 workers who both wore air samplers for lead and underwent special health examinations for lead were extracted between 2019 and 2021. An occupation-based exposure matrix was developed to evaluate the intensity of lead exposure across a range of occupations, encompassing 51 minor occupations and 70-unit occupations. Rank correlation analyses showed strong positive correlations between airborne lead and blood lead measurements according to occupation. CONCLUSIONS: Our study findings suggest that combining 2 nationwide surveillance databases can be an effective approach for creating an occupation-based exposure matrix. However, our results also highlight several limitations that need to be addressed in future studies to improve the accuracy and reliability of such matrices.

Modification of termination of resuscitation rule with compression time interval in South Korea.

This study aimed to validate the predictive performance of the termination of resuscitation (TOR) rule and examine the compression time interval (CTI) as a criterion for modifying the rule. This retrospective observational study analyzed adult out-of-hospital cardiac arrest (OHCA) patients attended by emergency medical service (EMS) providers in mixed urban-rural areas in Korea in 2020 and 2021. We evaluated the predictive performance of basic life support (BLS) and the Korean Cardiac Arrest Research Consortium (KoCARC) TOR rule using the false-positive rate (FPR) and positive predictive value (PPV). We modified the age cutoff criterion and examined the CTI as a new criterion. According to the TOR rule, 1827 OHCA patients were classified into two groups. The predictive performance of the BLS TOR rule had an FPR of 11.7% (95% confidence interval (CI): 5.9-17.5) and PPV of 98.4% (97.6-99.2) for mortality, and an FPR of 3.6% (0.0-7.8) and PPV of 78.6% (75.9-81.3) for poor neurological outcomes at hospital discharge. The predictive performance of the KoCARC TOR rule had an FPR of 5.0% (1.1-8.9) and PPV of 98.9% (98.0-99.8) for mortality, and an FPR of 3.7% (0.0-7.8) and PPV of 50.0% (45.7-54.3) for poor neurological outcomes at hospital discharge. The modified cutoff value for age was 68 years, with an area under the receiver operating characteristic curve over 0.7. In the group that met the BLS TOR rule, the cutoff of the CTI for death was not determined and was 21 min for poor neurological outcomes. In the group that met the KoCARC TOR rule, the cutoff of the CTI for death and poor neurological outcomes at the time of hospital discharge was 25 min and 21 min, respectively. The BLS TOR and KoCARC TOR rules showed inappropriate predictive performance for mortality and poor neurological outcomes. However, the predictive performance of the TOR rule could be supplemented by modifying the age criterion and adding the CTI criterion of the KoCARC.

Benzene exposure assessment of printing workers treating petroleum-based cleaner in South Korea.

This study was conducted to check whether benzene is contained inside the petroleum-based cleaning agent used in the printing industry and measure whether it is actually exposed to the air. Benzene was analyzed inside the cleaning agent and air exposure evaluation was done by area sampling. Risk assessment was performed using the Chemical Hazard Risk Management (CHARM) technique. Most products contained benzene based on the results obtained from this study. As a result of collecting air samples and checking whether the workers were exposed to benzene actually, benzene was detected in three samples. As a result of the risk assessment, most of printing businesses scored more than four points. Benzene was detected in all petroleum-based cleaning products. In addition, benzene was detected in some of air samples. Considering the fact that even small exposure level of benzene is dangerous to worker health and most of the printing businesses in South Korea operate on a small scale with fewer than five employees so the health management system is poor, it is necessary to prepare appropriate measures to prevent work diseases provoked by benzene exposure.

Patient and hospital characteristics predict prolonged emergency department length of stay and in-hospital mortality: a nationwide analysis in Korea.

BACKGROUND: Prolonged emergency department length of stay (EDLOS) in critically ill patients leads to increased mortality. This nationwide study investigated patient and hospital characteristics associated with prolonged EDLOS and in-hospital mortality in adult patients admitted from the emergency department (ED) to the intensive care unit (ICU). METHODS: We conducted a retrospective cohort study using data from the National Emergency Department Information System. Prolonged EDLOS was defined as an EDLOS of ≥ 6 h. We constructed multivariate logistic regression models of patient and hospital variables as predictors of prolonged EDLOS and in-hospital mortality. RESULTS: Between 2016 and 2019, 657,622 adult patients were admitted to the ICU from the ED, representing 2.4% of all ED presentations. The median EDLOS of the overall study population was 3.3 h (interquartile range, 1.9-6.1 h) and 25.3% of patients had a prolonged EDLOS. Patient characteristics associated with prolonged EDLOS included night-time ED presentation and Charlson comorbidity index (CCI) score of 1 or higher. Hospital characteristics associated with prolonged EDLOS included a greater number of staffed beds and a higher ED level. Prolonged EDLOS was associated with in-hospital mortality after adjustment for selected confounders (adjusted odds ratio: 1.18, 95% confidence interval: 1.16-1.20). Patient characteristics associated with in-hospital mortality included age ≥ 65 years, transferred-in, artificially ventilated in the ED, assignment of initial triage to more urgency, and CCI score of 1 or higher. Hospital characteristics associated with in-hospital mortality included a lesser number of staffed beds and a lower ED level. CONCLUSIONS: In this nationwide study, 25.3% of adult patients admitted to the ICU from the ED had a prolonged EDLOS, which in turn was significantly associated with an increased in-hospital mortality risk. Hospital characteristics, including the number of staffed beds and the ED level, were associated with prolonged EDLOS and in-hospital mortality.

Disparities in Survival Outcomes of Out-of-Hospital Cardiac Arrest Patients between Urban and Rural Areas and the Identification of Modifiable Factors in an Area of South Korea.

This retrospective study aimed to compare the survival outcomes of adult out-of-hospital cardiac arrest (OHCA) patients between urban (Busan, Ulsan, Changwon) and rural (Gyeongnam) areas in South Korea and identify modifiable factors in the chain of survival. The primary and secondary outcomes were survival to discharge and modifiable factors in the chain of survival were identified using logistic regression analysis. In total, 1954 patients were analyzed. The survival to discharge rates in the whole region and in urban and rural areas were 6.9%, 8.7% (Busan 8.7%, Ulsan 10.3%, Changwon 7.2%), and 3.4%, respectively. In the urban group, modifiable factors associated with survival to discharge were no advanced airway management (adjusted odds ratio (aOR) 2.065, 95% confidence interval (CI): 1.138-3.747), no mechanical chest compression (aOR 3.932, 95% CI: 2.015-7.674), and an emergency medical service (EMS) transport time of more than 8 min (aOR 3.521, 95% CI: 2.075-5.975). In the rural group, modifiable factors included an EMS scene time of more than 15 min (aOR 0.076, 95% CI: 0.006-0.883) and an EMS transport time of more than 8 min (aOR 4.741, 95% CI: 1.035-21.706). To improve survival outcomes, dedicated resources and attention to EMS practices and transport time in urban areas and EMS scene and transport times in rural areas are needed.

Suicide attempt-related emergency department visits among adolescents: a nationwide population-based study in Korea, 2016-2019.

BACKGROUND: The incidence of adolescent suicide in Korea is increasing; however, nationwide data regarding short-term prediction of suicide attempts (SAs) is still limited. Therefore, this study aimed to investigate the incidence of SA-related annual emergency department (ED) visits among adolescents in Korea from 2016 to 2019 and to summarize the corresponding demographic and clinical characteristics based on the dispositions of SA-related ED visits. METHODS: Most referral hospitals provide relevant essential ED information to the National Emergency Medical Center through the National Emergency Department Information System (NEDIS). We analyzed NEDIS data on adolescent visits (aged < 20 years) for a 4-year period from 2016 to 2019. Patients were classified into the discharge and hospitalization groups for comparison, and jointpoint regression analysis was used to identify the years in which there was a change in annual percentage change (APC) in age- and sex-standardized incidence rates of SA-related ED visits. The characteristics of patients in the discharge group and hospitalization group subgroups were also compared. RESULTS: The APC in the incidence rate of SA-related ED visits in the 4-year study period revealed a 35.61% increase. The incidence rate increase was higher among females (APC: 46.26%) than among males (APC: 17.95%). Moreover, the incidence rate increased faster in mid-adolescence patients (APC: 51.12%) than in late-adolescence patients (APC: 26.98%). The proportion of poisoning as the SA method was 69.7% in the hospitalization group and 34.5% in the discharge group (p < 0.001). DISCUSSION: Our findings suggest that an increase in the number of SA-related ED visits among female and mid-adolescent patients represented the largest increase in SA-related ED visits from 2016 to 2019. Accordingly, evidence-based suicide prevention programs need to be customized based on sex and age, and further diversification of health care systems is needed through analysis of the characteristics of the dispositions of SA-related ED visits.

The Comparison of Emergency Medical Service Responses to and Outcomes of Out-of-hospital Cardiac Arrest before and during the COVID-19 Pandemic in an Area of Korea.

BACKGROUND: Since the declaration of the coronavirus disease 2019 (COVID-19) pandemic, COVID-19 has affected the responses of emergency medical service (EMS) systems to cases of out-of-hospital cardiac arrest (OHCA). The purpose of this study was to identify the impact of the COVID-19 pandemic on EMS responses to and outcomes of adult OHCA in an area of South Korea. METHODS: This was a retrospective observational study of adult OHCA patients attended by EMS providers comparing the EMS responses to and outcomes of adult OHCA during the COVID-19 pandemic to those during the pre-COVID-19 period. Propensity score matching was used to compare the survival rates, and logistic regression analysis was used to assess the impact of the COVID-19 pandemic on the survival of OHCA patients. RESULTS: A total of 891 patients in the pre-COVID-19 group and 1,063 patients in the COVID-19 group were included in the final analysis. During the COVID-19 period, the EMS call time was shifted to a later time period (16:00-24:00, P < 0.001), and the presence of an initial shockable rhythm was increased (pre-COVID-19 vs. COVID-19, 7.97% vs. 11.95%, P = 0.004). The number of tracheal intubations decreased (5.27% vs. 1.22%, P < 0.001), and the use of mechanical chest compression devices (30.53% vs. 44.59%, P < 0.001) and EMS response time (median [quartile 1-quartile 3], 7 [5-10] vs. 8 [6-11], P < 0.001) increased. After propensity score matching, the survival at admission rate (22.52% vs. 18.24%, P = 0.025), survival to discharge rate (7.77% vs. 5.52%, P = 0.056), and favorable neurological outcome (5.97% vs. 3.49%, P < 0.001) decreased. In the propensity score matching analysis of the impact of COVID-19, odds ratios of 0.768 (95% confidence interval [CI], 0.592-0.995) for survival at admission and 0.693 (95% CI, 0.446-1.077) for survival to discharge were found. CONCLUSION: During the COVID-19 period, there were significant changes in the EMS responses to OHCA. These changes are considered to be partly due to social distancing measures. As a result, the proportion of patients with an initial shockable rhythm in the COVID-19 period was greater than that in the pre-COVID-19 period, but the final survival rate and favorable neurological outcome were lower.

The effect of high-dose intramuscular epinephrine on the recovery of spontaneous circulation in an asphyxia-induced cardiac arrest rat model.

BACKGROUND: Obtaining vascular access can be challenging during resuscitation following cardiac arrest, and it is particularly difficult and time-consuming in paediatric patients. We aimed to compare the efficacy of high-dose intramuscular (IM) versus intravascular (IV) epinephrine administration with regard to the return of spontaneous circulation (ROSC) in an asphyxia-induced cardiac arrest rat model. METHODS: Forty-five male Sprague-Dawley rats were used for these experiments. Cardiac arrest was induced by asphyxia, and defined as a decline in mean arterial pressure (MAP) to 20 mmHg. After asphyxia-induced cardiac arrest, the rats were randomly allocated into one of 3 groups (control saline group, IV epinephrine group, and IM epinephrine group). After 540 s of cardiac arrest, cardiopulmonary resuscitation was performed, and IV saline (0.01 cc/kg), IV (0.01 mg/kg, 1:100,000) epinephrine or IM (0.05 mg/kg, 1:100,000) epinephrine was administered. ROSC was defined as the achievement of an MAP above 40 mmHg for more than 1 minute. Rates of ROSC, haemodynamics, and arterial blood gas analysis were serially observed. RESULTS: The ROSC rate (61.5%) of the IM epinephrine group was less than that in the IV epinephrine group (100%) but was higher than that of the control saline group (15.4%) (log-rank test). There were no differences in MAP between the two groups, but HR in the IM epinephrine group (beta coefficient = 1.02) decreased to a lesser extent than that in the IV epinephrine group with time. CONCLUSIONS: IM epinephrine induced better ROSC rates compared to the control saline group in asphyxia-induced cardiac arrest, but not compared to IV epinephrine. The IM route of epinephrine administration may be a promising option in an asphyxia-induced cardiac arrest.

Effect of Prehospital Epinephrine Use on Survival from Out-of-Hospital Cardiac Arrest and on Emergency Medical Services.

This study was to identify the effect of epinephrine on the survival of out-of-hospital cardiac arrest (OHCA) patients and changes in prehospital emergency medical services (EMSs) after the introduction of prehospital epinephrine use by EMS providers. This was a retrospective observational study comparing two groups (epinephrine group and norepinephrine group). We used propensity score matching of the two groups and identified the association between outcome variables regarding survival and epinephrine use, controlling for confounding factors. The epinephrine group was 339 patients of a total 1943 study population. The survival-to-discharge rate and OR (95% CI) of the epinephrine group were 5.0% (p = 0.215) and 0.72 (0.43-1.21) in the total patient population and 4.7% (p = 0.699) and 1.15 (0.55-2.43) in the 1:1 propensity-matched population. The epinephrine group received more mechanical chest compression and had longer EMS response times and scene times than the norepinephrine group. Mechanical chest compression was a negative prognostic factor for survival to discharge and favorable neurological outcomes in the epinephrine group. The introduction of prehospital epinephrine use in OHCA patients yielded no evidence of improvement in survival to discharge and favorable neurological outcomes and adversely affected the practice of EMS providers, exacerbating the factors negatively associated with survival from OHCA.

Effect of a multidisciplinary program to improve organ donation in the emergency department.

BACKGROUND AND IMPORTANCE: As the emergency department (ED) is an important source of potential organ donors, it may play an important role in the organ donation process. OBJECTIVE: To assess the effectiveness of the multidisciplinary organ donation improvement program (ODIP) on identifying potential donors and improving organ donation in South Korean EDs. DESIGN, SETTINGS, AND PARTICIPANTS: This study was a retrospective, observational study of the ED-inclusive ODIP implemented in 55 tertiary teaching hospitals contracted with the Korea Organ Donation Agency (KODA) since 2014. The inclusion criteria were: patients in the ED with a serious brain injury and futile prognosis or expected death of the patient within a few days, no contraindications for organ donation, and no objections registered in the donor registry. INTERVENTION: The ED-inclusive multidisciplinary approach was implemented to improve organ donation. It included regular meetings of the ODIP committee, hospital visits and staff education, improvement of notifications, and support of a coordination team. OUTCOMES MEASURE AND ANALYSIS: We assessed the changes in the number of deceased organ donors per year and notifications of potential brain-dead donors by medical staff after the implementation of the new ED-inclusive ODIP. The entire organ donation process was monitored and measured. RESULTS: There was a significant increase in deceased organ donors per million population after the implementation of the ED-inclusive multidisciplinary ODIP of KODA compared to the pre-intervention period: 5.21 vs. 9.72, difference 4.51 (95% confidence interval 2.11-6.91). During the study period, the proportion of deceased organ donors occurred from KODA-contracted hospitals increased from 25.3 to 50.3% in South Korea's total deceased organ donors. Emergency physicians of KODA-contracted hospitals notified increasingly more potential brain-dead donors each year throughout the study period (36 in 2014 vs. 135 in 2018). The longer the period contracted with KODA, the higher the potential brain-death identification rates (P < 0.001). CONCLUSION: In this retrospective study, the implementation of multidisciplinary ODIP in the ED led to significantly higher deceased organ donors per million population and awareness of potential brain-dead donors in South Korea.

Emergency Department Triage Early Warning Score (TREWS) predicts in-hospital mortality in the emergency department.

AIM: The purpose is to assess the adequacy of the National Early Warning Score (NEWS) in the emergency department (ED) and the usefulness of the Triage in Emergency Department Early Warning Score (TREWS) that has been developed using the NEWS in the ED. METHODS: In this retrospective observational cohort study, we performed univariable and multivariable regression analyses with 81,520 consecutive ED patients to develop a new scoring system, the TREWS. The primary outcome was in-hospital mortality within 24 h, and secondary outcomes were in-hospital mortality within 48 h, 7 days, and 30 days. The prognostic properties of the TREWS were compared with those of the NEWS, Modified Early Warning Score (MEWS), and Rapid Emergency Medicine Score (REMS) using the area under the receiver operating characteristic curve (AUC) technique. RESULTS: The AUC of the TREWS for in-hospital mortality within 24 h was 0.906 (95% CI, 0.903-0.908), those of the NEWS, MEWS, and REMS were 0.878 (95% CI, 0.875-0.881), 0.857 (95% CI, 0.854-0.860), and 0.834 (95% CI, 0.831-0.837), respectively. Differences in the AUC between the TREWS and NEWS, the TREWS and MEWS, and the TREWS and REMS were 0.028 (95% CI, 0.022-0.033; p < .001), 0.049 (95% CI, 0.041-0.057; p < .001), and 0.072 (95% CI, 0.063-0.080; p < .001), respectively. The TREWS showed significantly superior performance in predicting secondary outcomes. CONCLUSION: The TREWS predicts in-hospital mortality within 24 h, 48 h, 7 days, and 30 days better than the NEWS, MEWS, and REMS for patients arriving at the ED.

Effects of emergency department boarding on mortality in patients with ST-segment elevation myocardial infarction.

OBJECTIVE: Patients with ST-segment elevation myocardial infarction (STEMI) are sometimes boarded in the emergency department (ED) after percutaneous coronary intervention (PCI). We evaluated the effects of direct and indirect admission to the CCU on mortality and the effect on length of stay (LOS) in patients with STEMI. METHOD: This was a retrospective observational study of patients with STEMI between Jan 2014 and Nov 2017. The patients were divided into the direct admission (DA) group, who were admitted into the CCU immediately after PCI, and the indirect admission (IA) group, who were admitted after boarding in the ED. The primary endpoint was in-hospital mortality. Secondary endpoints were 3-month mortality, LOS in CCU and hospital, and LOS under intensive care. RESULTS: During the study period, 780 patients were enrolled and analyzed. The in-hospital mortality rate and 3-month mortality rate were 5.9% (46 patients) and 8.5% (66 patients). The DA group and IA group had similar in-hospital and 3-month mortality rates (P = .50, P = .28). The median CCU LOS and hospital LOS was similar for both groups (P = .28, P = .46). However, LOS under in intensive care for the IA group was significantly longer than that of the DA group (DA, 31.9 h; IA, 38.7 h; P < .001). CONCLUSION: This study suggests that direct admission after PCI and indirect admission was not associated with mortality in patients with STEMI. In addition, the stay in ED also appears to be associated with the duration of stay under critical care.

The ratio of N-terminal pro-B-type natriuretic peptide to troponin I for differentiating acute coronary syndrome.

INTRODUCTION: It is difficult to differentiate whether coronary or non-coronary causes in patients with elevated troponin I (TnI) in emergency department (ED). The aim of this study was to develop a clinical decision tool for differentiating a coronary cause in the patients with elevated TnI. METHODS: This was a retrospective observational study that enrolled consecutive ED patients. Patients were included in the study if they were ≥16 years of age, had admitted through ED with a medical illness, and TnI levels at initial evaluation in the ED were ≥0.2 ng/mL. Patients diagnosed with ST elevation myocardial infarction or congestive heart failure were excluded. Coronary angiography, electrocardiogram, laboratory results, echocardiography, and clinical characteristics were analyzed. RESULTS: Among the included 1441 patients, 603 and 838 patients were categorized into an acute coronary syndrome (ACS) group and non-acute coronary syndrome (non-ACS) group, respectively. The ratio of N-terminal pro-Btype natriuretic peptide (NT-proBNP) to TnI was significantly higher in the non-ACS group compared to the ACS group. The AUC of NT-proBNP/TnI (0.805, 95% CI, 0.784-0.826) was significantly superior to that of NT-proBNP/creatinine kinase-MB, TnI, and NT-proBNP. The patients of the non-ACS group with high levels of TnI and BNP showed more critically ill manifestation at the time of presentation and higher mortality. CONCLUSION: NT-proBNP/TnI may help to distinguish medical patients with elevated TnI whether the elevated TnIs were caused from ACSs or from conditions other than ACS.

Synthesis and anti-neuroinflammatory activity of N-heterocyclic analogs based on natural biphenyl-neolignan honokiol.

Novel isoxazole and pyrazole analogs based on natural biphenyl-neolignan honokiol were synthesized and evaluated for their inhibitory activities against nitric oxide production in lipopolysaccharide-activated BV-2 microglial cells. The isoxazole skeleton was constructed via nitrile oxide cycloaddition from oxime 3 and pyrazole was generated by condensation of 4-chromone and alkylhydrazine. Among the analogs, 13b and 14a showed stronger inhibitory activities with IC50 values of 8.9 and 1.2 µM, respectively, than honokiol.

Factors predicting the early mortality of trauma patients.

BACKGROUND: The aim of this study was to identify factors predicting early mortality in trauma patients. METHODS: This was a study of 6288 trauma patients admitted to the hospital between July 2011 and June 2016. Among the variables recorded for a prospective trauma registry, the following were selected for analysis: sex; age; a combination of the Glasgow Coma Scale score, age, and systolic blood pressure (SBP) (GAP); a combination of the mechanism of injury, the Glasgow Coma Scale score, age, and SBP (MGAP); SBP; respiratory rate; peripheral oxygen saturation (SpO2 value); the Glasgow Coma Scale score; laboratory variables; and presentation time. Logistic regression analysis was used to explore associations between these variables and early mortality. RESULTS: In total, 296 (4.6%) patients died within 24 hours. Univariate regression analysis indicated that age, the GAP, the MGAP, SBP, SpO2, the Glasgow Coma Scale score, base excess, hemoglobin level, platelet count, INR, and presentation time predicted early mortality. Multivariate regression showed that the GAP, the MGAP, SpO2, base excess, platelet count, and INR were independently predictive. The areas under the receiver operator curve comparisons for the GAP and MGAP models revealed the superiority of the GAP-based model. CONCLUSION: The GAP model, SpO2, base excess, platelet count, and INR predicted the early mortality of trauma patients.

Impact of early hyperoxia on 28-day in-hospital mortality in patients with myocardial injury.

INTRODUCTION: Despite relevant evidence that supplemental oxygen therapy can be harmful to patients with myocardial injury, the association between hyperoxia and the clinical outcome of such patients has not been evaluated. We assessed whether early hyperoxia negatively affects outcomes in hospitalized patients with myocardial injury. METHODS: This was a retrospective study conducted at a tertiary referral teaching hospital. Between January 2010 and December 2016, 2,376 consecutive emergency department patients with myocardial injury, defined as a peak troponin-I level ≥ 0.2 ng/mL, within the first 24 hours of presentation were included. The metrics used to define hyperoxia were the maximum average partial pressure of oxygen (PaO2MAX), average partial pressure of oxygen (PaO2AVG), and area under the curve during the first 24 hours (AUC24). The association between early hyperoxia within 24 hours after presentation and clinical outcomes was evaluated using multiple imputation and logistic regression analysis. The primary outcome was 28-day in-hospital mortality. The secondary outcomes were new-onset cardiovascular, coagulation, hepatic, renal, and respiratory dysfunctions (sequential organ failure sub-score ≥ 2). RESULTS: Compared with normoxic patients, the adjusted odds ratios (ORs) for PaO2MAX, PaO2AVG, and AUC24 were 1.55 (95% confidence interval (CI) 1.05-2.27; p = 0.026), 2.13 (95% CI 1.45-3.12; p = 0.001), and 1.73 (95% CI 1.15-2.61; p = 0.008), respectively, in patients with mild hyperoxia and 6.01 (95% CI 3.98-9.07; p < 0.001), 8.92 (95% CI 3.33-23.88; p < 0.001), and 7.32 (95% CI 2.72-19.70; p = 0.001), respectively, in patients with severe hyperoxia. The incidence of coagulation and hepatic dysfunction (sequential organ failure sub-score ≥ 2) was significantly higher in the mild and severe hyperoxia group. CONCLUSIONS: Hyperoxia during the first 24 hours of presentation is associated with an increased 28-day in-hospital mortality rate and risks of coagulation and hepatic dysfunction in patients with myocardial injury.

Predictor of Isolated Trauma in Head: A New Simple Predictor for Survival of Isolated Traumatic Brain Injury.

BACKGROUND: Mortality prediction in patients with brain trauma during initial management in the emergency department (ED) is essential for creating the foundation for a better prognosis. OBJECTIVE: This study aimed to create a simple and useful survival predictive model for patients with isolated blunt traumatic brain injury that is easily available in the ED. METHODS: This is a retrospective study based on the trauma registry data of an academic teaching hospital. The inclusion criteria were age ≥ 15 years, blunt and not penetrating mechanism of injury, and Abbreviated Injury Scale (AIS) scores between 1 and 6 for head and 0 for all other body parts. The primary outcome was 30-day survival probability. Internal and external validation was performed. RESULTS: After univariate logistic regression analysis based on the derivation cohort, the final Predictor of Isolated Trauma in Head (PITH) model for survival prediction of isolated traumatic brain injury included Glasgow Coma Scale (GCS), age, and coded AIS of the head. In the validation cohort, the area under the curve of the PITH score was 0.970 (p < 0.0001; 95% confidence interval 0.960-0.978). Sensitivity and specificity were 95% and 81.7% at the cutoff value of 0.9 (probability of survival 90%), respectively. CONCLUSIONS: The PITH model performed better than the GCS; Revised Trauma Score; and mechanism of injury, GCS, age, and arterial pressure. It will be a useful triage method for isolated traumatic brain injury in the early phase of management.

Serum lactate upon emergency department arrival as a predictor of 30-day in-hospital mortality in an unselected population.

BACKGROUND: Despite of numerous evidences that elevated serum lactate levels were associated with unfavorable outcomes, there have been no study demonstrated an optimal cutoff of serum lactate in unselected patients. This study was aimed to evaluate the prognostic property of lactate, and to identify a cutoff of serum lactate level for predicting 30-day in-hospital mortality among unselected patients presenting to the emergency department (ED). METHODS: We performed a retrospective observational study from January 2010 to December 2016. 61,151 patients were used for propensity score analysis after exclusion. 14,015 patients who underwent lactate test at ED arrival were enrolled for final analysis. RESULTS: The average treatment effect (ATE) of carrying out a lactate test on 30-day in-hospital mortality was 0.53% (adjusted odds ratio (OR) = 1.013, p = 0.19; 95% confidence interval (CI), 0.997-1.013). Adjusted OR of serum lactate calculated from multivariable analysis was 1.09 (p < 0.001; 95% CI, 1.07-1.10). The area under a ROC curve (AUC) of serum lactate was 0.711 (p < 0.001; 95% CI, 0.703-0.718). The sensitivity, specificity, and positive and negative predictive values for the cutoff > 2.6 mmol/L were 56.7%, 74.3%, 20.8%, and 93.5%, respectively. Mortality of the high-lactate group (> 2.6 mmol/L) was significantly higher than that of the low lactate group (≤ 2.6 mmol/L) (20.8% vs. 6.5%, difference = 14.3%, p < 0.01; 95% CI, 13.0% - 15.7%). CONCLUSIONS: A serum lactate level > 2.6 mmol/L predicted 30-day in-hospital mortality in unselected patients who arrived to the ED and were admitted to the hospital. Additionally, serum lactate test in the ED could be an effective screening method for identifying low risk patients.

The impact of the improvement in internal medicine consultation process on ED length of stay.

INTRODUCTION: Although consultations are essential for delivering safe, high-quality care to patients in emergency departments, they contribute to emergency department patient flow problems and overcrowding which is associated with several adverse outcomes, such as increases in patient mortality and poor quality care. This study aimed to investigate how time flow metrics including emergency department length of stay is influenced by changes to the internal medicine consultation policy. METHOD: This study is a pre- and post-controlled interventional study. We attempted to improve the internal medicine consultation process to be more concise. After the intervention, only attending emergency physicians consult internal medicine chief residents, clinical fellows, or junior staff of each internal medicine subspecialty who were on duty when patients required special care or an admission to internal medicine. RESULTS: Emergency department length of stay of patients admitted to the department of internal medicine prior to and after the intervention decreased from 996.94min to 706.62min. The times from consultation order to admission order and admission order to emergency department departure prior to and after the intervention were decreased from 359.59min to 180.38min and from 481.89min to 362.37min, respectively. The inpatient mortality rates and Inpatient bed occupancy rates prior to and after the intervention were similar. CONCLUSION: The improvements in the internal medicine consultation process affected the flow time metrics. Therefore, more comprehensive and cooperative strategies need to be developed to reduce the time cycle metrics and overcrowding of all patients in the emergency department.

Pneumoperitoneum by Inguinal Laceration after Traffic Accident.

BACKGROUND: The leading cause of surgical pneumoperitoneum is hollow viscus perforation, which accounts for approximately 90% of cases. A nonsurgical etiology may account for up to about 10% of the causes of pneumoperitoneum. However, a pneumoperitoneum often poses significant management dilemmas for surgeons, especially when signs of peritonitis are absent or when the cause is unknown prior to laparotomy. We present the first case of pneumoperitoneum due to inguinal laceration without viscus perforation after a traffic accident. CASE REPORT: A 17-year-old male patient was admitted to the emergency department with a deep laceration of 7∼8 cm with bleeding in the right inguinal region after a collision with a passenger car while riding a bicycle. The abdominal examination revealed diffuse abdominal tenderness on deep palpation without peritoneal signs. A chest radiograph showed no free gas below the diaphragm. On computed tomography angiography of the aorta, subcutaneous emphysema in the right inguinal and femoral areas and free air in the peritoneal cavity were observed. There was no bowel perforation in an exploratory laparotomy, but the right femoral sheath ruptured, and exposure of the femoral vessels into the peritoneal cavity was observed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A pneumoperitoneum can be caused by femoral sheath rupture without hollow viscus perforation in patients with a penetrating groin injury. Therefore, emergency physicians should not pursue solely abdominal/pelvic sources of a pneumoperitoneum in patients with a penetrating groin injury.