Age, sex, and pre-arrest comorbidities shape the risk trajectory of sudden cardiac death- Patterns highlighted by population data in Taiwan.

OBJECTIVES: Few reports have indicated the secular trend in the sudden cardiac death (SCD) incidence and pre-arrest comorbidities. This study aimed to comprehensively analyze the trend of SCD incidence and its association with pre-arrest comorbidities. METHODS: This population-based cohort study analyzed Taiwan's National Health Insurance (NHI) research database and identified SCD incidents by inspecting data from all emergency department visits from 2011 to 2018. The inclusion criteria were ICD-9:427.5 or 427.41, or ICD-10:I46.9, I46.8, or I46.2. Pre-existing comorbidities were confirmed based on medication use. Multivariable logistic regression was adopted with covariates age, sex, and pre-existing comorbidities. RESULTS: This study reviewed a total of 184,164,969 person-year records, and identified 92,138 SCD incidents. From 2011 to 2018, the SCD incidence rate increased from 36.3 to 55.4 per 100,000 enrollees in Taiwan. The top five pre-arrest comorbidities were stable, while the prevalence of chronic kidney disease rose significantly. Compared to those aged 20-29, enrollees aged >65 years had significantly higher odds of SCD (aOR:27.30, 95% CI:26.05-28.61). Higher odds of SCD were noted in the enrollees who had a seizure (aOR:2.24, 95% CI:2.12-2.38), parkinsonism (aOR:1.81, 95% CI:1.73-1.89), psychological disorders (aOR:1.59, 95% CI:1.56-1.62), diabetes mellitus (aOR:1.44, 95% CI:1.41-1.46), heart diseases (aOR:1.41, 95% CI:1.38-1.44). CONCLUSIONS: The incidence of SCD steadily increased in Taiwan from 2011 to 2018. Hypertension, diabetes mellitus, heart disease, psychological disorders, and arthritis were major pre-arrest comorbidities. Age is the most important risk factor for SCD. Further large-scaled population-based study that investigated in diverse ethnicities from countries in addition to Asians would be warranted.

The association of time to key prehospital interventions recorded by EMT-worn video devices and sustained return of spontaneous circulation in out-of-hospital cardiac arrests.

OBJECTIVES: The quality of prehospital resuscitation provided by emergency medical technicians (EMTs) is essential to ensure better outcomes following out-of-hospital cardiac arrests (OHCA). We assessed the quality of prehospital resuscitation by recording time to key prehospital interventions using EMT-worn video devices and investigated its association with outcomes of patients with OHCA. METHODS: This retrospective, cross-sectional study included cases of non-traumatic OHCA in adults treated by EMS in Hsinchu City, Taiwan, during 2022 and 2023. We used data from high-resolution, chest-mounted wearable cameras to define and measure six Quality Indices (QIs) for prehospital resuscitation interventions (i.e., time spent recognizing OHCA). To evaluate the association between QI performance and sustained return of spontaneous circulation (ROSC), we used multivariable logistic regression. RESULTS: Of 745 patients eligible for this study, 187 (25.1%) achieved sustained ROSC. Six core QIs were analyzed: recognition of OHCA (median time: 9.0 seconds), time from recognizing OHCA to initiating cardiopulmonary resuscitation (CPR; 9.0 seconds), automated external defibrillator setup (34.0 seconds), time from recognizing OHCA to beginning ventilation (160.0 seconds), advanced airway management (300 seconds), and deploying a mechanical CPR device (50 seconds). The performance of the six QIs were not associated with sustained ROSC (Adjusted odds ratio [95% confidence interval]: 1.00 [0.99-1.00], 0.99 [0.98-1.00], 1.00 [1.00-1.01], 1.00 [1.00-1.00], 1.00 [1.00-1.00] and 0.99 [0.99-1.00], respectively). CONCLUSIONS: This study describes the rate of sustained ROSC and time to key interventions captured by EMT-worn video devices in non-traumatic OHCA patients. Although we found no direct link between QI performance and improved OHCA outcomes, this study highlights the potential of video-assisted QIs to enhance the documentation and understanding of prehospital resuscitation processes. These findings suggest that further refinement and application of these QIs could support more effective resuscitation strategies and training programs.

Loss of resilience in Taiwan's pediatric care system after the COVID-19 pandemic.

During the COVID-19 pandemic, Taiwan's pediatric healthcare system faced its most severe shortage of pediatric residents in history. This review investigates the causes, consequences, and potential solutions to this shortage. Between 2020 and 2023, the recruitment rate of pediatric residents dropped by 27.3%, increasing workloads for attending pediatricians and may worsening health outcomes for pediatric patients. Compared to South Korea and Japan, Taiwan has the highest neonatal mortality rates and lowest life expectancy at birth. Additionally, Taiwan's National Health Insurance (NHI) pays pediatricians in hospitals half of what it pays those in local clinics, hindering the attraction of pediatric hospitalists. To sustain the pediatric healthcare system, the government could consider directly compensating pediatricians at clinic rates and transitioning to a capitation payment system. Systemic recommendations include increasing health expenditure as a percentage of gross domestic production (GDP) and amending the NHI Act to eliminate the global budget payment system. Managing the resulting increase in financial responsibility could involve raising tax revenue as a percentage of GDP. Implementing these measures could strengthen the pediatric healthcare system and prevent a collapse of pediatric inpatient care.

Chief complaints and computed tomography results in the emergency department: a three-year retrospective cohort study.

BACKGROUND: Computed tomography (CT) is frequently performed in the patients who admitted to the emergency department (ED), discharged but returned to ED within 72 h. It is unknown whether the main complaints of patients assist physicians to use CT effectively. This study aimed to find the association between chief complaints and the CT results. METHODS: This three-year retrospective cohort study was conducted in the ED of a tertiary medical center. Adult patients who returned to the ED after the index visit were included from 2019 to 2021. Demographics, pre-existing diseases, chief complaints, and CT region were recorded by independent ED physicians. A logistic regression model with an odds ratio (OR) and 95% confidence interval (CI) was used to determine the relationship between chief complaints and positive CT results. RESULTS: In total, 7,699 patients revisited ED after the index visit; 1,202 (15.6%) received CT. The top chief complaints in patients who received CT were abdominal pain, dizziness, and muscle weakness. Patients with abdominal pain or gastrointestinal symptoms had a significantly higher rate of positive abdominopelvic CT than those without it (OR 2.83, 95% CI 1.98-4.05, p < 0.001), while the central nervous system and cardiopulmonary chief complaints were not associated (or negatively associated) with new positive CT findings. CONCLUSION: Chief complaints of patients on revisit to the ED are associated with different yields of new findings when CT scans of the chest, abdomen and head are performed. Physicians should consider these differential likelihoods of new positive findings based on these data.

Differences in the characteristics and patterns of adult emergency department return visits before and after the coronavirus disease 2019 outbreak.

BACKGROUND: Data about changes in the characteristics of ED return visits before and after the COVID-19 outbreak are limited. This study aimed to report the differences on utility in ED return visits after the COVID-19 outbreak. METHODS: This retrospective cohort study was conducted from 2019 to 2020. Adult patients with ED return visits were included in the analysis. Variables including demographic characteristics, pre-comorbidities, triage levels, vital signs, chief complaints, management, and diagnosis were recorded and confirmed via a manual assessment. RESULTS: The proportion of patients with ED visits decreased by 23%. Hence, that of patients with ED return visits also reduced from 2580 to 2020 patients (22%) after the COVID-19 outbreak. The average age (60-57.8 years) of patients with return visits was significantly younger, and the proportion of female patients decreased remarkably. Further, the proportion of patients with chronic pre-existing diseases at the return visit significantly differed after the COVID-19 outbreak. The proportion of patients with chief complaints including dizziness, dyspnea, cough, vomiting, diarrhea, and chills during the return visits significantly differed before and after the COVID-19 pandemic. In the multivariable logistic regression model, age, high triage level were significantly associated with unfavorable outcome return visit. CONCLUSION: The use of services in the ED has changed since the COVID-19 outbreak. Hence, the proportion of patients with unplanned return visits within 72 h decreased. After the COVID-19 outbreak, people are now cautious whether they should return to the ED, as in the pre-pandemic situation, or just treat conservatively at home.

Building lexical networks: Preschoolers extract different types of information in cross-situational learning.

Children's everyday learning environment is semantically structured. For example, semantically related things (e.g., fork and spoon) usually co-occur in the same contexts. The current study examines the effects of semantically structured contexts on preschool-age children's (N = 65, 33 girls, age range: 52-68 months) use of statistical information to learn novel word-object mappings. Children were assigned into one of two conditions, in which objects from the same semantic category repeatedly co-occurred in the same trials (Same-category condition) or objects from different categories repeatedly co-occurred in the same trials (Different-categories condition). Children's word learning performance in the two conditions were comparable. However, their errors at test suggested that information extracted by children in the two conditions differed. Importantly, children in the Same-category condition extracted both statistical and semantic relationships from the stimuli.

Governmental public health in Taiwan.

A healthy and safe public health environment is a fundamental responsibility of government; achieving it requires collaboration across multiple sectors. Public health services include, for example, vaccination and quarantine for infectious diseases; health promotion, such as anti-smoking campaigns for noncommunicable diseases; and health insurance for universal health coverage. All these services require intersectoral actions in which the government must play a fundamental role, either partially or totally. The Taiwanese outlook on governmental public health infrastructure and professionalization of public health is given in this paper. It also describes the national governmental public health measures that were employed during the Covid-19 pandemic and discusses the challenges ahead for the country's governmental public health. Governmental public health is essential and should not be affected by changes in political forms or socioeconomic development. Instead, effective governmental public health will promote these developments while protecting citizens' right to health.

Action prediction during real-time parent-infant interactions.

Social interactions provide a crucial context for early learning and cognitive development during infancy. Action prediction-the ability to anticipate an observed action-facilitates successful, coordinated interaction and is an important social-cognitive skill in early development. However, current knowledge about infant action prediction comes largely from screen-based laboratory tasks. We know little about what infants' action prediction skills look like during real-time, free-flowing interactions with a social partner. In the current study, we used head-mounted eyetracking to quantify 9-month-old infants' visual anticipations of their parents' actions during free-flowing parent-child play. Our findings reveal that infants do anticipate their parents' actions during dynamic interactions at rates significantly higher than would be expected by chance. In addition, the frequency with which they do so is associated with child-led joint attention and hand-eye coordination. These findings are the first to reveal infants' action prediction behaviors in a more naturalistic context than prior screen-based studies, and they support the idea that action prediction is inherently linked to motor development and plays an important role in infants' social-cognitive development. A video abstract of this article can be viewed at https://www.youtube.com/watch?v=9HrmcicfiqE.

Lipidomics of children and adolescents exposed to multiple industrial pollutants.

BACKGROUND: There are limited studies on the lipidomics of children and adolescents exposed to multiple industrial pollutants. OBJECTIVES: In this study, we aimed to investigate lipid profile perturbations in 99 children and adolescents (aged 9-15) who lived in a polluted area surrounding the largest petrochemical complex in Taiwan. Previous studies have reported increased risks of acute and chronic diseases including liver dysfunctions and chronic kidney disease (CKD) in residents living in this area. METHODS: We measured urinary concentrations of 11 metals and metalloids and polycyclic aromatic hydrocarbons (PAHs) metabolite 1-hydroxypyrene (1-OHP) as exposure biomarkers, and urinary oxidative stress biomarkers and serum acylcarnitines as early health effect biomarkers. The association between individual exposure biomarkers and early health effect biomarkers were analyzed using linear regression, while association of combined exposure biomarkers with four oxidative stress biomarkers and acylcarnitines were analyzed using weighted quantile sum (WQS) regression. Lipid profiles were analyzed using an untargeted liquid chromatography mass spectrometry-based technique. "Meet-in-the-middle" approach was applied to identify potential lipid features that linked multiple industrial pollutants exposure with early health effects. RESULTS: We identified 15 potential lipid features that linked elevated multiple industrial pollutants exposure with three increased oxidative stress biomarkers and eight deregulated serum acylcarnitines, including one lysophosphatidylcholines (LPCs), four phosphatidylcholines (PCs), and two sphingomyelins (SMs) that were up-regulated in high exposure group compared to low exposure group, and two LPCs, four PCs, and two phosphatidylinositols (PIs) down-regulated in high exposure group compared to low exposure group. CONCLUSION: Our findings could provide information for understanding the health effects, including early indicators and biological mechanism identification, of children and adolescents exposed to multiple industrial pollutants during critical stages of development.

Parent-Child Joint Behaviors in Novel Object Play Create High-Quality Data for Word Learning.

This research takes a dyadic approach to study early word learning and focuses on toddlers' (N = 20, age: 17-23 months) information seeking and parents' information providing behaviors and the ways the two are coupled in real-time parent-child interactions. Using head-mounted eye tracking, this study provides the first detailed comparison of children's and their parents' behavioral and attentional patterns in two free-play contexts: one with novel objects with to-be-learned names (Learning condition) and the other with familiar objects with known names (Play condition). Children and parents in the Learning condition modified their individual and joint behaviors when encountering novel objects with to-be-learned names, which created clearer signals that reduced referential ambiguity and potentially facilitated word learning.

Strategies on locations of public access defibrillator: A systematic review.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a critical condition with poor outcomes. Although the survival rate increases in those who undergo defibrillation, the utility of on-time defibrillation among bystanders remained low. An evaluation of the deployment strategy for public access defibrillators (PADs) is necessary to increase their use and accessibility. This study was to conduct a systematic review for deployment strategies of PADs. METHODS: Two authors independently searched for articles published before October 2019 from PubMed, Embase, Web of Science, and Cochrane Library. An independent librarian provided the search strategy and assisted the literature research. We included articles that were focused on the main topic, but excluded those which were missing results or that used an unclear definition. The qualitative outcomes were the utility and OHCA coverage of PADs. We performed a qualitative analysis across the studies, but a quantitative analysis was not available due to the studies' heterogeneity in design and variety of outcomes. RESULTS: We eventually included 15 studies. Three strategies were presented: guidelines-based, grid-based, and landmark-based. The guidelines-based deployment was common fit for OHCA events. The grid-based method increased the use of bystander defibrillation 3-fold, and 30-day survival doubled. The top 3 landmarks in the landmark-based strategy were offices (18.6%), schools (13.3%), and sports facilities (12.9%). Utility of PADs might increase if we optimize PAD location by mathematical modeling and evaluation feedback. CONCLUSION: Three deployment strategies were presented. Although the optimal method could not be fully identified, a more efficient PAD deployment could benefit the population in terms of OHCA coverage and survival among patients with OHCA.

Association between prehospital time and outcome of trauma patients in 4 Asian countries: A cross-national, multicenter cohort study.

BACKGROUND: Whether rapid transportation can benefit patients with trauma remains controversial. We determined the association between prehospital time and outcome to explore the concept of the "golden hour" for injured patients. METHODS AND FINDINGS: We conducted a retrospective cohort study of trauma patients transported from the scene to hospitals by emergency medical service (EMS) from January 1, 2016, to November 30, 2018, using data from the Pan-Asia Trauma Outcomes Study (PATOS) database. Prehospital time intervals were categorized into response time (RT), scene to hospital time (SH), and total prehospital time (TPT). The outcomes were 30-day mortality and functional status at hospital discharge. Multivariable logistic regression was used to investigate the association of prehospital time and outcomes to adjust for factors including age, sex, mechanism and type of injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and prehospital interventions. Overall, 24,365 patients from 4 countries (645 patients from Japan, 16,476 patients from Korea, 5,358 patients from Malaysia, and 1,886 patients from Taiwan) were included in the analysis. Among included patients, the median age was 45 years (lower quartile [Q1]-upper quartile [Q3]: 25-62), and 15,498 (63.6%) patients were male. Median (Q1-Q3) RT, SH, and TPT were 20 (Q1-Q3: 12-39), 21 (Q1-Q3: 16-29), and 47 (Q1-Q3: 32-60) minutes, respectively. In all, 280 patients (1.1%) died within 30 days after injury. Prehospital time intervals were not associated with 30-day mortality. The adjusted odds ratios (aORs) per 10 minutes of RT, SH, and TPT were 0.99 (95% CI 0.92-1.06, p = 0.740), 1.08 (95% CI 1.00-1.17, p = 0.065), and 1.03 (95% CI 0.98-1.09, p = 0.236), respectively. However, long prehospital time was detrimental to functional survival. The aORs of RT, SH, and TPT per 10-minute delay were 1.06 (95% CI 1.04-1.08, p < 0.001), 1.05 (95% CI 1.01-1.08, p = 0.007), and 1.06 (95% CI 1.04-1.08, p < 0.001), respectively. The key limitation of our study is the missing data inherent to the retrospective design. Another major limitation is the aggregate nature of the data from different countries and unaccounted confounders such as in-hospital management. CONCLUSIONS: Longer prehospital time was not associated with an increased risk of 30-day mortality, but it may be associated with increased risk of poor functional outcomes in injured patients. This finding supports the concept of the "golden hour" for trauma patients during prehospital care in the countries studied.

What leads to coordinated attention in parent-toddler interactions? Children's hearing status matters.

Coordinated attention between children and their parents plays an important role in their social, language, and cognitive development. The current study used head-mounted eye-trackers to investigate the effects of children's prelingual hearing loss on how they achieve coordinated attention with their hearing parents during free-flowing object play. We found that toddlers with hearing loss (age: 24-37 months) had similar overall gaze patterns (e.g., gaze length and proportion of face looking) as their normal-hearing peers. In addition, children's hearing status did not affect how likely parents and children attended to the same object at the same time during play. However, when following parents' attention, children with hearing loss used both parents' gaze directions and hand actions as cues, whereas children with normal hearing mainly relied on parents' hand actions. The diversity of pathways leading to coordinated attention suggests the flexibility and robustness of developing systems in using multiple pathways to achieve the same functional end.

Metabolomics of Children and Adolescents Exposed to Industrial Carcinogenic Pollutants.

Studies on metabolomes of carcinogenic pollutants among children and adolescents are limited. We aim to identify metabolic perturbations in 107 children and adolescents (aged 9-15) exposed to multiple carcinogens in a polluted area surrounding the largest petrochemical complex in Taiwan. We measured urinary concentrations of eight carcinogen exposure biomarkers (heavy metals and polycyclic aromatic hydrocarbons (PAHs) represented by 1-hydroxypyrene), and urinary oxidative stress biomarkers and serum acylcarnitines as biomarkers of early health effects. Serum metabolomics was analyzed using a liquid chromatography mass spectrometry-based method. Pathway analysis and "meet-in-the-middle" approach were applied to identify potential metabolites and biological mechanisms linking carcinogens exposure with early health effects. We found 10 potential metabolites possibly linking increased exposure to IARC group 1 carcinogens (As, Cd, Cr, Ni) and group 2 carcinogens (V, Hg, PAHs) with elevated oxidative stress and deregulated serum acylcarnitines, including inosine monophosphate and adenosine monophosphate (purine metabolism), malic acid and oxoglutaric acid (citrate cycle), carnitine (fatty acid metabolism), and pyroglutamic acid (glutathione metabolism). Purine metabolism was identified as the possible mechanism affected by children and adolescents' exposure to carcinogens. These findings contribute to understanding the health effects of childhood and adolescence exposure to multiple industrial carcinogens during critical periods of development.

Parental Linguistic Input and Its Relation to Toddlers' Visual Attention in Joint Object Play: A Comparison Between Children with Normal Hearing and Children With Hearing Loss.

Parent-child interactions are multimodal, often involving coordinated exchanges of visual and auditory information between the two partners. The current work focuses on the effect of children's hearing loss on parent-child interactions when parents and their toddlers jointly played with a set of toy objects. We compared the linguistic input received by toddlers with hearing loss (HL) and their chronological age-matched (CA) and hearing age-matched (HA) normal-hearing peers. Moreover, we used head-mounted eye trackers to examine how different parental linguistic input affected children's visual attention on objects when parents either led or followed children's attention during joint object play. Overall, parents of children with HL provided comparable amount of linguistic input as parents of the two normal-hearing groups. However, the types of linguistic input produced by parents of children with HL were similar to the CA group in some ways and similar to the HA group in other ways. Interestingly, the effects of different types of linguistic input on extending the attention of children with HL qualitatively resembled the patterns seen in the CA group, even though the effects were less pronounced in the HL group. We discuss the implications of these results for our understanding of the reciprocal, dynamic, and multi-factored nature of parent-child interactions.

Global Oct4 target gene analysis reveals novel downstream PTEN and TNC genes required for drug-resistance and metastasis in lung cancer.

Overexpression of Oct4, a stemness gene encoding a transcription factor, has been reported in several cancers. However, the mechanism by which Oct4 directs transcriptional program that leads to somatic cancer progression remains unclear. In this study, we provide mechanistic insight into Oct4-driven transcriptional network promoting drug-resistance and metastasis in lung cancer cell, animal and clinical studies. Through an integrative approach combining our Oct4 chromatin-immunoprecipitation sequencing and ENCODE datasets, we identified the genome-wide binding regions of Oct4 in lung cancer at promoter and enhancer of numerous genes involved in critical pathways which promote tumorigenesis. Notably, PTEN and TNC were previously undefined targets of Oct4. In addition, novel Oct4-binding motifs were found to overlap with DNA elements for Sp1 transcription factor. We provided evidence that Oct4 suppressed PTEN in an Sp1-dependent manner by recruitment of HDAC1/2, leading to activation of AKT signaling and drug-resistance. In contrast, Oct4 transactivated TNC independent of Sp1 and resulted in cancer metastasis. Clinically, lung cancer patients with Oct4 high, PTEN low and TNC high expression profile significantly correlated with poor disease-free survival. Our study reveals a critical Oct4-driven transcriptional program that promotes lung cancer progression, illustrating the therapeutic potential of targeting Oc4 transcriptionally regulated genes.

Web Server for Peak Detection, Baseline Correction, and Alignment in Two-Dimensional Gas Chromatography Mass Spectrometry-Based Metabolomics Data.

Two-dimensional gas chromatography time-of-flight mass spectrometry (GC×GC/TOF-MS) is superior for chromatographic separation and provides great sensitivity for complex biological fluid analysis in metabolomics. However, GC×GC/TOF-MS data processing is currently limited to vendor software and typically requires several preprocessing steps. In this work, we implement a web-based platform, which we call GC2MS, to facilitate the application of recent advances in GC×GC/TOF-MS, especially for metabolomics studies. The core processing workflow of GC2MS consists of blob/peak detection, baseline correction, and blob alignment. GC2MS treats GC×GC/TOF-MS data as pictures and clusters the pixels as blobs according to the brightness of each pixel to generate a blob table. GC2MS then aligns the blobs of two GC×GC/TOF-MS data sets according to their distance and similarity. The blob distance and similarity are the Euclidean distance of the first and second retention times of two blobs and the Pearson's correlation coefficient of the two mass spectra, respectively. GC2MS also directly corrects the raw data baseline. The analytical performance of GC2MS was evaluated using GC×GC/TOF-MS data sets of Angelica sinensis compounds acquired under different experimental conditions and of human plasma samples. The results show that GC2MS is an easy-to-use tool for detecting peaks and correcting baselines, and GC2MS is able to align GC×GC/TOF-MS data sets acquired under different experimental conditions. GC2MS is freely accessible at http://gc2ms.web.cmdm.tw .

The unreliability of crackles: insights from a breath sound study using physicians and artificial intelligence.

BACKGROUND AND INTRODUCTION: In comparison to other physical assessment methods, the inconsistency in respiratory evaluations continues to pose a major issue and challenge. OBJECTIVES: This study aims to evaluate the difference in the identification ability of different breath sound. METHODS/DESCRIPTION: In this prospective study, breath sounds from the Formosa Archive of Breath Sound were labeled by five physicians. Six artificial intelligence (AI) breath sound interpretation models were developed based on all labeled data and the labels from the five physicians, respectively. After labeling by AIs and physicians, labels with discrepancy were considered doubtful and relabeled by two additional physicians. The final labels were determined by a majority vote among the physicians. The capability of breath sound identification for humans and AI was evaluated using sensitivity, specificity and the area under the receiver-operating characteristic curve (AUROC). RESULTS/OUTCOME: A total of 11,532 breath sound files were labeled, with 579 doubtful labels identified. After relabeling and exclusion, there were 305 labels with gold standard. For wheezing, both human physicians and the AI model demonstrated good sensitivities (89.5% vs. 86.0%) and good specificities (96.4% vs. 95.2%). For crackles, both human physicians and the AI model showed good sensitivities (93.9% vs. 80.3%) but poor specificities (56.6% vs. 65.9%). Lower AUROC values were noted in crackles identification for both physicians and the AI model compared to wheezing. CONCLUSION: Even with the assistance of artificial intelligence tools, accurately identifying crackles compared to wheezing remains challenging. Consequently, crackles are unreliable for medical decision-making, and further examination is warranted.