Objective: Various out-of-hospital cardiac arrest (OHCA) prognostication scores have been developed. However, the application of these scores is often limited owing to missing predictor variables. This study aimed to compare and validate various OHCA prognostication scores using simple imputation methods that can easily be applied in clinical situations. Methods: Adult patients presenting with OHCA with a sustained return of spontaneous circulation (ROSC) between October 2015 and June 2020 were the subjects for the analysis. We evaluated six OHCA prognostication scores: the ROSC after cardiac arrest (RACA) score, CaRdiac Arrest Survival Score (CRASS), NULL-PLEASE, predictive score (PS), cardiac arrest hospital prognosis (CAHP) score, and the OHCA score. For missing predictors, median imputation for continuous variables and mode imputation for categorical variables were performed before the analysis. We evaluated the discrimination and calibration powers of each prognostic score for good neurological recovery at discharge. The area under the receiver operating characteristic curve (AUC) was used to assess the discrimination power, and a calibration plot and the Hosmer-Lemeshow test were used to assess the calibration power. Results: Of the 12,321 patients, 5,191 were subjected to analysis. Among them, 924 (17.8%) had good neurological recovery. Certain predictors often had missing values-no-flow time 1,107 (21.3%), low-flow time 862 (16.6%), pH 1,104 (21.3%), lactate 1,820 (35.0%), and creatinine 2,257 (43.5%). After imputing the missing variables, the CAHP score showed the highest AUC (0.957; 95% confidence interval, 0.950-0.963), and the CRASS and PS also presented excellent discrimination power (AUC 0.914 and 0.942, respectively). However, the CAHP and NULL-PLEASE scores were well calibrated (Hosmer-Lemeshow test, P>0.05). Conclusion Among the six prognostic scores, the CAHP score showed the highest discrimination and calibration powers.

BACKGROUND AND PURPOSE: Thrombectomy within 24 hours can improve outcomes in selected patients with a clinical-infarct mismatch. We devised an easy-to-use visual estimation tool that allows infarct volume estimation in centers with limited resources. METHODS: We identified 1,031 patients with cardioembolic or large-artery atherosclerosis infarction on diffusion-weighted images (DWIs) obtained before recanalization therapy and within 24 hours of onset, and occlusion of the internal carotid or middle cerebral artery. Acute DWIs were mapped onto a standard template and used to create visual reference maps with known lesion volumes, which were then used in a validation study (with 130 cases) against software estimates of infarct volume. RESULTS: The DWI reference map chart comprises 144 maps corresponding to 12 different infarct volumes (0.5, 1, 2, 3, 5, 7, 9, 11, 13, 15, 17, and 19 mL) in each of 12 template slices (Montreal Neurological Institute z-axis –15 to 51 mm). Infarct volume in a patient is estimated by selecting a slice with a similar infarct size at the corresponding z-axis level on the reference maps and then adding up over all slices. The method yielded good correlations to software volumetrics and was easily learned by both experienced and junior physicians, with approximately 1 to 2 minutes spent per case. The sensitivity, specificity, and accuracy for detecting threshold infarct volumes ( < 21, < 31, and < 51 mL) were very high (all about >90%). CONCLUSIONS: We developed easy-to-use reference maps that allow prompt and reliable visual estimation of infarct volumes for triaging patients to thrombectomy in acute stroke.
Atherosclerosis ; Cerebral Infarction ; Decision Making ; Diffusion Magnetic Resonance Imaging ; Humans ; Infarction ; Medical Staff, Hospital ; Methods ; Middle Cerebral Artery ; Sensitivity and Specificity ; Stroke ; Thrombectomy

OBJECTIVE: High cholesterol level is a risk factor for coronary artery disease, and coronary artery disease is a major risk factor for out-of-hospital cardiac arrest (OHCA). However, the effect of cholesterol level on outcomes of OHCA has been poorly studied. This study aimed to determine the effect of cholesterol level on outcomes of OHCA.METHODS: This cross-sectional study used the CAPTURES (Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance) project database in Korea. Multivariable conditional logistic regression analysis was performed to estimate the effect of cholesterol level on outcomes in OHCA.RESULTS: In all, 584 cases of OHCA were analyzed; those with cholesterol levels <120 mg/dL were classified as having low total cholesterol (TC) (n=197), those with levels ranging from 120–199 mg/dL as middle TC (n=322), and those with ≥200 mg/dL as high TC (n=65). Compared to low TC, more patients with middle TC and high TC survived to discharge (9.1% vs. 22.0% and 26.2%, respectively, P=0.001). The good cerebral performance category also increased in that order (4.1 % vs. 14.6% and 23.1%, respectively, P≤0.001). Comparing middle TC and high TC with low TC, adjusted odds ratios (95% confidence intervals) were 1.97 (1.06 to 3.64) and 2.53 (1.08 to 5.92) for survival to discharge, respectively, and 2.53 (1.07 to 5.98) and 4.73 (1.63 to 13.71) for good neurological recovery, respectively.CONCLUSION: Higher cholesterol is associated with better outcomes in OHCA; cholesterol level is a good predictor of outcomes of OHCA.
Cholesterol ; Coronary Artery Disease ; Cross-Sectional Studies ; Heart Arrest ; Humans ; Korea ; Logistic Models ; Odds Ratio ; Out-of-Hospital Cardiac Arrest ; Risk Factors

OBJECTIVE: This study aimed to compare the demographic characteristics and trauma service structures and processes of hospitals in 15 countries across the Asia Pacific, and to provide baseline data for the integrated trauma database: the Pan-Asian Trauma Outcomes Study (PATOS).METHODS: Medical directors and emergency physicians at PATOS-participating hospitals in countries across the Asia Pacific were surveyed through a standardized questionnaire. General information, trauma care system data, and trauma emergency department (ED) outcomes at each hospital were collected by email and analyzed using descriptive statistics.RESULTS: Survey data from 35 hospitals across 15 countries were collected from archived data between June 2014 and July 2015. Designated trauma centers were identified as the highest hospital level for trauma patients in 70% of surveyed countries. Half of the hospitals surveyed had special teams for trauma care, and almost all prepared activation protocol documents for these teams. Most hospitals offered specialized trauma education programs, and 72.7% of hospitals had a hospital-based trauma registry. The total number of trauma patients visiting the ED across 25 of the hospitals was 300,376. The overall survival-to-discharge rate was 97.2%; however, it varied greatly between 85.1% and 99.7%. The difference between survival-to-discharge rates of moderate and severe injury groups was highest in Taiwan (41.8%) and lowest in Thailand (18.6%).CONCLUSION: Trauma care systems and ED outcomes vary widely among surveyed hospitals and countries. This information is useful to build further detailed, systematic platforms for trauma surveillance and evidence-based trauma care policies.
Asia ; Asian Continental Ancestry Group ; Cross-Sectional Studies ; Education ; Electronic Mail ; Emergencies ; Emergency Service, Hospital ; Epidemiology ; Humans ; Physician Executives ; Taiwan ; Thailand ; Trauma Centers

No abstract available.
Thrombectomy*

OBJECTIVE: This study aimed to achieve expert consensus for the development of strategies emergency medical services system (EMSS) after reunification of Korean using the Delphi method. METHODS: The Delphi study was performed through several rounds from January to February in 2017. Experts who have experiences of emergency medical support in North Korea and developing countries participated in the study. Respondents were asked to express their level of agreement following 7 categories: (1) emergency medical manpower, (2) communication system, (3) emergency facilities, (4) patient transfer system, (5) consumer participation and public education, (6) insurance system, (7) disaster planning. Score 1–3 was classified as disagreement, 4–6 as medium agreement, and 7–9 as agreement and consensus was considered being achieved when more than two thirds of respondents agreed in each question. RESULTS: Response rate were 80% in the first round and 75% in the second round. Consensus was achieved in emergency medical manpower, communication system, emergency facilities, patient transfer system, and disaster planning for the important factors immediately after reunification within 5 years. Consensus was achieved in emergency medical manpower, communication system, emergency facilities, patient transfer system, consumer participation and public education, and disaster planning for the prior factors when the reunification would happen rapidly without enough preparation. CONCLUSION: Consensus was achieved in emergency medical manpower, communication system, emergency facilities, patient transfer system, disaster planning for the essential EMSS elements. The consensus was expected to utilize as a basic data for the development of EMSS preparing for reunification.
Consensus* ; Consumer Participation ; Delphi Technique* ; Democratic People's Republic of Korea ; Developing Countries ; Disaster Planning ; Education ; Emergencies* ; Emergency Medical Services* ; Expert Testimony ; Insurance ; Korea* ; Methods ; Patient Transfer ; Public Health ; Surveys and Questionnaires

Development of a competence-based curriculum is important. This study aimed to develop competence assessment tools in emergency medicine and use it to assess competence of Cameroonian healthcare professionals. This was a cross-sectional, descriptive study. Through literature review, expert survey, and discrimination tests, we developed a self-survey questionnaire and a scenario-based competence assessment tool for assessing clinical knowledge and self-confidence to perform clinical practices or procedures. The self-survey consisted of 23 domains and 94 questionnaires on a 5-point Likert scale. Objective scenario-based competence assessment tool was used to validate the self-survey results for five life-threatening diseases presenting frequently in emergency rooms of Cameroon. Response rate of the self-survey was 82.6%. In this first half of competence assessment, knowledge of infectious disease had the highest score (4.6 ± 0.4) followed by obstetrics and gynecology (4.2 ± 0.6) and hematology and oncology (4.2 ± 0.5); in contrast, respondents rated the lowest score in the domains of disaster, abuse and assault, and psychiatric and behavior disorder (all of mean 2.8). In the scenario-based test, knowledge of multiple trauma had the highest score (4.3 ± 1.2) followed by anaphylaxis (3.4 ± 1.4), diabetic ketoacidosis (3.3 ± 1.0), ST-elevation myocardial infarction (2.5 ± 1.4), and septic shock (2.2 ± 1.1). Mean difference between the self-survey and scenario-based test was statistically insignificant (mean, −0.02; 95% confidence interval, −0.41 to 0.36), and agreement rate was 58.3%. Both evaluation tools showed a moderate correlation, and the study population had relatively low competence for specific aspects of emergency medicine and clinical procedures and skills.
Anaphylaxis ; Cameroon* ; Communicable Diseases ; Curriculum ; Delivery of Health Care* ; Developing Countries ; Diabetic Ketoacidosis ; Disasters ; Discrimination (Psychology) ; Emergencies* ; Emergency Medicine* ; Emergency Service, Hospital ; Gynecology ; Hematology ; Mental Competency* ; Multiple Trauma ; Myocardial Infarction ; Obstetrics ; Professional Competence ; Shock, Septic ; Surveys and Questionnaires

On page 47, the definition of stroke progression was erroneously described in the previous version of article.

Characteristics of stroke cases, acute stroke care, and outcomes after stroke differ according to geographical and cultural background. To provide epidemiological and clinical data on stroke care in South Korea, we analyzed a prospective multicenter clinical stroke registry, the Clinical Research Center for Stroke-Fifth Division (CRCS-5). Patients were 58% male with a mean age of 67.2+/-12.9 years and median National Institutes of Health Stroke Scale score of 3 [1-8] points. Over the 6 years of operation, temporal trends were documented including increasing utilization of recanalization treatment with shorter onset-to-arrival delay and decremental length of stay. Acute recanalization treatment was performed in 12.7% of cases with endovascular treatment utilized in 36%, but the proportion of endovascular recanalization varied across centers. Door-to-IV alteplase delay had a median of 45 [33-68] min. The rate of symptomatic hemorrhagic transformation (HT) was 7%, and that of any HT was 27% among recanalization-treated cases. Early neurological deterioration occurred in 15% of cases and were associated with longer length of stay and poorer 3-month outcomes. The proportion of mRS scores of 0-1 was 42% on discharge, 50% at 3 months, and 55% at 1 year after the index stroke. Recurrent stroke up to 1 year occurred in 4.5% of patients; the rate was higher among older individuals and those with neurologically severe deficits. The above findings will be compared with other Asian and US registry data in this article.
Asian Continental Ancestry Group ; Humans ; Korea ; Length of Stay ; Male ; National Institutes of Health (U.S.) ; Stroke ; Tissue Plasminogen Activator

Ingestion of puffer fish can result in severe and potentially lethal intoxication, referred to as tetrodotoxin intoxication. Tetrodotoxin is a potent neurotoxin well known for its ability to ability neuromuscular function. Tetrodotoxin is a specific and potent blocker of axonal sodium channel; it may block sodium channels in the axon of the neurons of the neurohypophysis, thereby inhibiting the release of vasopressin and causing diabetes insipidus neurotoxin. To our knowledge, previous report on diabetes insipidus causing tetrodotoxin is the only one case in Singapore. A married couple (69-year-old man and 57-year-old woman) ingested two green rough-backed puffer fish (Lagocephalus lunaris). They complained of paresthesia on perioral area and extremity and developed not only grade IV intoxication but also an increased urine output (4455 ml/day and 5035 ml/day), elevated serum sodium (157.4 mEq/L and 166.7 mEq/L) and elevated serum osmolality (324 mosmol/kg and 339 mosmol/kg), which suggested the development of diabetes insipidus. The administration of desmopressin nasal spray was successful in normalizing urine volume. Both were discharged on 20th and 18th hospital day, respectively, without any complications.
Axons ; Deamino Arginine Vasopressin ; Diabetes Insipidus ; Eating ; Extremities ; Neurons ; Osmolar Concentration ; Paresthesia ; Pituitary Gland, Posterior ; Sodium ; Sodium Channels ; Tetraodontiformes ; Tetrodotoxin ; Vasopressins