The Impact of the COVID-19 Outbreak on Emergency Medical Service:An Analysis of Patient Transportations and Time Intervals

Background@#This study aimed to investigate the impact of the coronavirus disease 2019 (COVID-19) outbreak on the Emergency Medical Service (EMS) system in South Korea. The study focused on the differences in EMS time intervals following the COVID-19 outbreak, particularly for patients with fever. @*Methods@#A retrospective analysis of EMS patient transportation data from 2017 to 2022 was conducted using the national EMS database. @*Results@#Starting from the year 2020, coinciding with the COVID-19 outbreak, all EMS time intervals experienced an increase. For the years 2017 to 2022, the mean response time interval values were 8.6, 8.6, 8.6, 10.2, 12.8, and 11.4 minutes, and the mean scene time interval values were 7.1, 7.2, 7.4, 9.0, 9.8, and 10.9 minutes. The mean transport time interval (TTI) values were 12.1, 12.3, 12.4, 14.2, 16.9, and 16.2 minutes, and the mean turnaround time interval values were 27.6, 27.9, 28.7, 35.2, 42.0, and 43.1 minutes. Fever (≥ 37.5°C) patients experienced more pronounced prolongations in EMS time intervals compared to non-fever patients and had a higher probability of being non-transported. The mean differences in TTI between fever and non-fever patients were 0.8, 0.8, 0.8, 4.3, 4.8, and 3.2 minutes, respectively, from 2017 to 2022. Furthermore, the odds ratios for fever patients being transported to the emergency department were 2.7, 2.9, 2.8, 1.1, 0.8, and 0.7, respectively, from 2017 to 2022. @*Conclusion@#The study findings highlight the significant impact of the COVID-19 outbreak on the EMS system and emphasize the importance of ongoing monitoring to evaluate the burden on the EMS system.

Worsened survival in the head-up tilt position cardiopulmonary resuscitation in a porcine cardiac arrest model

OBJECTIVE: Head elevation at an angle of 30° during cardiopulmonary resuscitation (CPR) was hemodynamically beneficial compared to supine position in a previous porcine cardiac arrest experimental study. However, survival benefit of head-up elevation during CPR has not been clarified. This study aimed to assess the effect of head-up tilt position during CPR on 24-hour survival in a porcine cardiac arrest experimental model.METHODS: This was a randomized experimental trial using female farm pigs (n=18, 42±3 kg) sedated, intubated, and paralyzed on a tilting surgical table. After surgical preparation, 15 minutes of untreated ventricular fibrillation was induced. Then, 6 minutes of basic life support was performed in a position randomly assigned to either head-up tilt at 30° or supine with a mechanical CPR device, LUCAS-2, and an impedance threshold device, followed by 20 minutes of advanced cardiac life support in the same position. Primary outcome was 24-hour survival, analyzed by Fisher exact test.RESULTS: In the 8 pigs from the head-up tilt position group, one showed return of spontaneous circulation (ROSC); all eight pigs expired within 24 hours. In the eight pigs from the supine position group, six had the ROSC; six pigs survived for 24 hours and two expired. The head-up position group showed lower 24-hour survival rate and lower ROSC rate than supine position group (P<0.01).CONCLUSION: The use of head-up tilt position with 30 degrees during CPR showed lower 24-hour survival than the supine position.

Comparison of radiation exposure by area before and after emergency center remodeling

OBJECTIVE: Radiation is used extensively in emergency centers. Computed tomography and X-ray imaging are used frequently. Portable X-rays, in particular, cause a significant amount of indirect radiation exposure to medical personnel. The authors' emergency center was remodeled, and a comparative study of radiation exposure was carried out in certain places that had experienced radiation for a long time. METHODS: The cumulative radiation dose was measured 20 times in the 24 hours prior to remodeling, and the cumulative radiation dose was measured again 20 times across the 24-hour period. The measurement points were fixed at the emergency doctor's seat (Zone A), charge nurse's seat (Zone B), and section nurse's seat (Zone C). During the 24-hour cumulative radiation measurement period, the number of portable X-ray shots was recorded in the emergency center. RESULTS: The mean of the 24-hour cumulative radiation measurements in zone A was 3.36±0.07 µSV and 4.54±0.07 µSV before and after remodeling, respectively (P<0.001). Regarding the number of portable X-rays performed during the measurement, a higher number of trials in the Pearson correction correlated with a higher radiation measurement. CONCLUSION: In an emergency medical center, there is a higher level of low-dose radiation exposure compared to that experienced from natural radioactivity. Regarding the number of portable X-rays, the cumulative radiation dose measured 24 hours after remodeling increased and can be assumed to be related to the environment.

Effect of Critical Care Transport on Patients' Survival after Inter-Hospital Transport of Critically Ill Patients

PURPOSE: Critical care transport (CCT) has been known to be beneficial for inter-hospital transport of critically ill patients. Seoul Mobile Intensive Care Unit (SMICU) has been established and provided CCT in Seoul Metropolitan City since 2015. We tested the association between SMICU transport and hospital outcome for critically ill patients. METHODS: This is a before and after intervention study. SMICU group with cardiac arrest, acute myocardial infarction, acute stroke, major trauma, respiratory failure, and shock who were transported by SMICU from January to July 2016 were collected as an intervention group. Non-SMICU group with the same above diagnosis criteria who were transported by private ambulance services during same period in 2015. By National Emergency Department Information System (NEDIS), demographics were compared for original data and sampling data. Multivariable logistic regression analysis was done to calculate the adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs) adjusting for potential confounders. RESULTS: Total 1,837 patients (128 SMICU and 1,709 non-SMICU group) for original dataset and 180 patients (60 SMICU and 120 non-SMICU group) for sampling dataset were finally analyzed. Hospital mortality rates are 22.7% in SMICU and 11.8% in non-SMICU in original dataset (p<0.001), 26.7% in SMICU and 31.7% in non-SMICU in sampling dataset (p=0.490), respectively. AOR (95% CIs) for hospital mortality by SMICU in original and sampling dataset were 0.80 (0.48-1.35) and 0.71 (0.33-1.51), respectively. CONCLUSION: The CCT for critically ill patients did not show significantly better hospital mortality in the pilot study.

Are the Cardiac Biomarkers in the Emergency Room Sufficient to Predict Adverse Events in Acute Pulmonary Embolism?

PURPOSE: The aim of this study is to determine whether cardiac biomarkers, such as N-terminal-proB-type natriuretic peptide (NT-proBNP), are good predictors of adverse events in acute pulmonary embolism (APE). METHODS: We conducted a retrospective analysis of patients with APE, which was confirmed by a computed tomography in the emergency room. Patients were divided into 2 groups: the major adverse event (MAE) group and the no-MAE group. MAE was defined as one of the following occurrences: in-hospital-death, cardiopulmonary resuscitation, mechanical ventilation, vasopressors, thrombolysis, or surgical embolectomy. Blood samples were obtained during the first hour of presentation to the emergency room. RESULTS: A total of 90 patients were included in this study. Twenty-seven patients had MAE. According to the univariate analysis, NT-proBNP, troponin I, and D-dimer plasma levels were significantly higher in the MAE group than in the noMAE group (919.8 vs. 2,131.0 ng/mL, p=0.032; 0.091 vs. 0.172 ng/mL, p=0.037; 2.43 vs. 3.74 ng/mL, p=0.049, respectively). However, according to the multivariate logistic regression, NT-proBNP was not independently associated with MAE in APE (odds ratio, 1.01; 95% confidence interval, 1.00-1.01). Conversely, troponin I was independently associated with MAE (odds ratio, 1.09; 95% confidence interval, 0.99-1.18). The NT-proBNP plasma level was not significantly different between the right ventricular dysfunction (RVD) group and the no-RVD group (p=0.178). CONCLUSION: The NT-proBNP level, unlike the troponin I level, in the emergency room was not identified as an independent predictor of MAE in acute pulmonary embolism. Further studies of large-scale with controlled timing of blood sampling and echocardiography are required.

Search for Structural Cardiac Abnormalities Following Sudden Cardiac Arrest Using Post-mortem Echocardiography in the Emergency Department: A Preliminary Study

PURPOSE: Sudden cardiac arrest (SCA) accounts for approximately 15% of all-cause mortality in the US and 50% of all cardiovascular mortalities in developed countries; 10% of cases have an underlying structural cardiac abnormality. An echocardiography has widely been used to evaluate cardiac abnormality, but it needs to be performed by emergency physicians available in the emergency department immediately after death, rather than by cardiologists. We aimed to determine whether post-mortem echocardiography (PME) performed in the emergency department may reveal such abnormalities. METHODS: We evaluated the reliability and validity of PME performed by emergency physicians in the emergency department. Measurement by a cardiologist was used as reference. RESULTS: Two emergency physicians performed PME on 3 out of the 4 included patients who died after unsuccessful cardiopulmonary resuscitation. PME was started within 10 minutes of death, and it took 10 minutes to complete. Parasternal views in either supine or left decubitus position were most helpful. The adequacy of the image was rated good to fair, and that of measurements was acceptable to borderline. Regarding the chamber size and left ventricular wall thickness, intraclass correlation coefficients for reliability and validity were 0.97 (n=15) and 0.95 (n=35), respectively (p<0.001). Evaluation of presence/absence of left ventricular wall thinning, valve calcification, and pericardial effusion was incomplete (3/7-5/7), precluding further analysis. CONCLUSION: Emergency physicians could perform reliable and valid PME to assess the chamber size and left ventricular wall thickness. A large prospective study with collaboration between emergency physicians and cardiologists would reveal the feasibility and usefulness of PME in diagnosing structural causes of sudden cardiac arrest.

The effects of the standardized extracts of Ginkgo biloba on steroidogenesis pathways and aromatase activity in H295R human adrenocortical carcinoma cells

OBJECTIVES: Aromatase inhibitors that block estrogen synthesis are a proven first-line hormonal therapy for postmenopausal breast cancer. Although it is known that standardized extract of Ginkgo biloba (EGb761) induces anti-carcinogenic effects like the aromatase inhibitors, the effects of EGb761 on steroidogenesis have not been studied yet. Therefore, the effects of EGb761 on steroidogenesis and aromatase activity was studied using a H295R cell model, which was a good in vitro model to predict effects on human adrenal steroidogenesis. METHODS: Cortisol, aldosterone, testosterone, and 17β-estradiol were evaluated in the H295R cells by competitive enzyme-linked immunospecific assay after exposure to EGb761. Real-time polymerase chain reaction were performed to evaluate effects on critical genes in steroid hormone production, specifically cytochrome P450 (CYP11/17/19/21) and the hydroxysteroid dehydrogenases (3β-HSD2 and 17β-HSD1/4). Finally, aromatase activities were measured with a tritiated water-release assay and by western blotting analysis. RESULTS: H295R cells exposed to EGb761 (10 and 100 μg/mL) showed a significant decrease in 17β-estradiol and testosterone, but no change in aldosterone or cortisol. Genes (CYP19 and 17β-HSD1) related to the estrogen steroidogenesis were significantly decreased by EGb761. EGb761 treatment of H295R cells resulted in a significant decrease of aromatase activity as measured by the direct and indirect assays. The coding sequence/ Exon PII of CYP19 gene transcript and protein level of CYP19 were significantly decreased by EGb761. CONCLUSIONS: These results suggest that EGb761 could regulate steroidogenesis-related genes such as CYP19 and 17β-HSD1, and lead to a decrease in 17β-estradiol and testosterone. The present study provides good information on potential therapeutic effects of EGb761 on estrogen dependent breast cancer.

Ethanolic extract of dandelion (Taraxacum mongolicum) induces estrogenic activity in MCF-7 cells and immature rats / 中国天然药物

Plants of the genus Taraxacum, commonly known as dandelions, are used to treat breast cancer in traditional folk medicine. However, their use has mainly been based on empirical findings without sufficient scientific evidence. Therefore, we hypothesized that dandelions would behave as a Selective estrogen receptor modulator (SERM) and be effective as hormone replacement therapy (HRT) in the postmenopausal women. In the present study, in vitro assay systems, including cell proliferation assay, reporter gene assay, and RT-PCR to evaluate the mRNA expression of estrogen-related genes (pS2 and progesterone receptor, PR), were performed in human breast cancer cells. Dandelion ethanol extract (DEE) significantly increased cell proliferation and estrogen response element (ERE)-driven luciferase activity. DEE significantly induced the expression of estrogen related genes such as pS2 and PR, which was inhibited by tamoxifen at 1 μmol·L(-1). These results indicated that DEE could induce estrogenic activities mediated by a classical estrogen receptor pathway. In addition, immature rat uterotrophic assay was carried out to identify estrogenic activity of DEE in vivo. The lowest concentration of DEE slightly increased the uterine wet weight, but there was no significant effect with the highest concentration of DEE. The results demonstrate the potential estrogenic activities of DEE, providing scientific evidence supporting their use in traditional medicine.

Appropriate In Vitro Methods for Genotoxicity Testing of Silver Nanoparticles

OBJECTIVES: We investigated the genotoxic effects of 40-59 nm silver nanoparticles (Ag-NPs) by bacterial reverse mutation assay (Ames test), in vitro comet assay and micronucleus (MN) assay. In particular, we directly compared the effect of cytochalasin B (cytoB) and rat liver homogenate (S9 mix) in the formation of MN by Ag-NPs. METHODS: Before testing, we confirmed that Ag-NPs were completely dispersed in the experimental medium by sonication (three times in 1 minute) and filtration (0.2 microm pore size filter), and then we measured their size in a zeta potential analyzer. After that the genotoxicity were measured and especially, S9 mix and with and without cytoB were compared one another in MN assay. RESULTS: Ames test using Salmonella typhimurium TA98, TA100, TA1535 and TA1537 strains revealed that Ag-NPs with or without S9 mix did not display a mutagenic effect. The genotoxicity of Ag-NPs was also evaluated in a mammalian cell system using Chinese hamster ovary cells. The results revealed that Ag-NPs stimulated DNA breakage and MN formation with or without S9 mix in a dose-dependent manner (from 0.01 microg/mL to 10 microg/mL). In particular, MN induction was affected by cytoB. CONCLUSIONS: All of our findings, with the exception of the Ames test results, indicate that Ag-NPs show genotoxic effects in mammalian cell system. In addition, present study suggests the potential error due to use of cytoB in genotoxic test of nanoparticles.

Molecular Cloning and Characterization of the Estrogen Receptor from the Slender Bitterling (Acheilognathus yamatsutae)

OBJECTIVES: In order to identify the possibility of slender bitterling (SB) (Acheilognathus yamatsutae) being used as a test species for estrogenic endocrine disrupting chemicals (EEDCs), we carried out the cloning and sequence characterization of the estrogen receptor (ER). METHODS: The ER from a slender bitterling was obtained by reverse transcriptase-polymerase chain reaction (RT-PCR), 5'- and 3'-rapid amplification of cDNA ends (5'-RACE and 3'-RACE) and T-vector cloning. The expression of ER mRNA was also analyzed in six tissues (brain, liver, kidney, gill, gonad, and intestines) by real-time PCR. RESULTS: We obtained an ER from the slender bitterling. The SB ER cDNA was 2189 base pairs (bp) in length and contained a 1707 bp open reading frame that encoded 568 amino acid residues. The SB ER amino acid sequence clustered in a monophyletic group with the ERalpha of other fish, and was more closely related to zebrafish ERalpha (88% identity) than to the ERalpha of other fish. The SB ER cDNA was divided into A/B, C, D, E and F domains. The SB ER has conserved important sequences for ER functions, such as the DNA binding domain (D domain), which are consistent with those of other teleosts. CONCLUSIONS: The ER of the slender bitterling could provide basic information in toxicological studies of EEDCs in the slender bitterling.

Na+-Ca2+ exchanger modulates Ca2+ content in intracellular Ca2+ stores in rat osteoblasts

Na+ -Ca2+ exchanger (NCX) transports Ca2+ coupled with Na+ across the plasma membrane in a bi-directional mode. Ca2+ flux via NCX mediates osteogenic processes, such as formation of extracellular matrix proteins and bone nodules. However, it is not clearly understood how the NCX regulates cellular Ca2+ movements in osteogenic processes. In this study, the role of NCX in modulating Ca2+ content of intracellular stores ([Ca2+](ER)) was investigated by measuring intracellular Ca2+ activity in isolated rat osteoblasts. Removal of extracellular Na+ elicited a transient increase of intracellular Ca2+ concentration ([Ca2+](i)). Pretreatment of antisense oligodeoxynucleotide (AS) against NCX depressed this transient Ca2+ rise and raised the basal level of [Ca2+](i). In AS-pretreated cells, the expression and activity of alkaline phosphatase (ALP), an osteogenic marker, were decreased. However, the cell viability was not affected by AS-pretreatment. Suppression of NCX activity by the AS-pretreatment decreased ATP-activated Ca2+ release from intracellular stores and significantly enhanced Ca2+ influx via store operated calcium influx (SOCI), compared to those of S-pretreated or control cells. These results strongly suggest that NCX has a regulatory role in cellular Ca2+ pathways in osteoblasts by modulating intracellular Ca2+ content.

Second-line Chemotherapy with Paclitaxel and Carboplatin for Patients with Recurrent Ovarian Carcinoma / 대한산부인과학회잡지

OBJECTIVE: This study is to investigate the efficacy and toxicity of paclitaxel plus carboplatin used as a salvage therapy. METHODS: Between June 2000 and November 2003, 10 patients aged 43-74 (median 55.0) with recurrent ovarian carcinoma were given combination chemotherapy including paclitaxel and carboplatin. The subjects received initial chemotherapy with paclitaxel plus cisplatin/carboplatin. On recurrence, paclitaxel was administered intravenously at a dose of 175 mg/m2 with carboplatin by AUC 5 every 3 weeks. The median treatment cycle was 10 cycles (range, 1 to 15 cycles). Recurrence of ovarian carcinoma was determined by elevation of serum CA-125, or radiologic imaging. Responses and toxicities were evaluated according to Gynecologic Oncology Group criteria and Common Terminology Criteria for Adverse Events from NCI (National Cancer Institute). RESULTS: The overall clinical response rate was 60.0% (6/10). Better response was observed in patients who were sensitive with initial chemotherapy. Anemia was the most frequent complication. CONCLUSION: Paclitaxel and carboplatin has been shown to be a feasible agent in patients with recurrent ovarian cancer.

Gemcitabine as second-line chemotherapy in patients with recurrent epithelial ovarian cancer: Review of four cases / 대한산부인과학회잡지

Adjuvant multiagent chemotherapy with platinum and paclitaxel after optimal cytoreductive surgery decisively improved survival rates of patients with epithelial ovarian carcinoma. However, more than two- thirds of patients with advanced disease will encounter tumor progression, underlining the need for effective second-line strategies. Continued efforts to discover new active agents for the treatment of patients with ovarian carcinoma had identified gemcitabine. Four patients with epithelial ovarian carcinoma, who were treated in Inje University Sanggye Paik Hospital and recurred thereafter received gemcitabine 1,000 mg/m2 as a 30 min intravenous infusion on days 1, 8, and 15, which was repeated every 28 days. The disease progressed in two patients, while one showed stable disease and another reached complete response. One patient expired of disease two months after the completion of therapy. Grade 3 leukopenia was successfully managed using G-CSF. Regrowth of hair lost during previous chemotherapy occurred in all subjects. We report four cases of advanced recurrent ovarian carcinoma which were treated with gemcitabine.

A Case of Tsutsugamushi Disease Presented with Granulomatous Pleural Effusion / 감염

Tsutsugamushi disease is one of the acute febrile diseases caused by Orientia tsutsugamushi that is transmitted to human by the bite of larval-stage trombiculid mite (chigger). The clinical illness is characterized by abrupt onset of fever, headache, rashes, myalgia and eschar. Chest radiologic findings show reticulonodular infiltration, cardiomegaly, lymphadenopathy and in a minority, pleural effusion. About pleural effusion, it is supposed to be caused by tsutsugamushi disease itself in most cases and no case has been reported that the pleural effusion confirmed by pleural biopsy and revealed granulomatous lesions. We experienced a case of tsutsugamushi disease with pleural effusion which was also confirmed to granulomatous lesion by pleural biopsy. So we report this case with a brief review of literatures.