Gil Joon Suh

A trend in epidemiology and outcomes of out-of-hospital cardiac arrest by urbanization level: a nationwide observational study from 2006 to 2010 in South Korea.

BACKGROUND The goal of this study is to better understand the trend in epidemiological features and the outcomes of emergency medical service (EMS)-assessed out-of-hospital cardiac arrest (OHCA) according to the community urbanization level: metropolitan, urban, and rural. METHODS This study was performed within a nationwide EMS system with a single-tiered basic-to-intermediate service level and approximately 900 destination hospitals for eligible OHCA cases in South Korea (with 48 million people). A nationwide OHCA database, which included information regarding demographics, Utstein criteria, EMS, and hospital factors and outcomes, was constructed using the EMS run sheets of eligible cases who were transported by 119 EMS ambulances and followed by a medical record review from 2006 to 2010. Cases with an unknown outcome were excluded. The community urbanization level was categorized according to population size, with metropolitan areas (more than 500,000 residents), urban areas (100,000-500,000 residents), and rural areas (<100,000 residents). The primary end point was the survival to discharge rate. Age- and sex-adjusted survival rates (ASRs) and standardized survival ratios (SSRs) with 95% confidence intervals (CIs) were calculated compared to a standard population. The adjusted odds ratios (AORs) and 95% CIs for survival were calculated and adjusted for potential risk factors using stratified multivariable logistic regression analysis. RESULTS There were 97,291 EMS-assessed OHCAs with 73,826 (75.9%) EMS-treated cases analyzed, after excluding the patients with unknown outcome (N=4172). The standardized incidence rate increased from 37.5 in 2006 to 46.8 in 2010 per 100,000 person-years for EMS-assessed OHCAs, and the survival rate was 3.0% for EMS-assessed OHCAs (3.3% for cardiac etiology and 2.3% for non-cardiac etiology) and 3.6% for EMS-treated OHCAs. Significantly different trends were found by urbanization level for bystander CPR, EMS performance, and the level of the destination hospital. The ASRs for survival were significantly improved by year in the metropolitan areas (3.6% in 2006 to 5.3% in 2010) but remained low in the urban areas (1.4% in 2006 to 2.3% in 2010) and very low in the rural areas (0.5 in 2006 and 0.8 in 2010). The SSRs (95% CIs) in the metropolitan areas were 1.19 (1.06-1.34) in 2006 and 1.77 (1.64-1.92) in 2010, whereas the SSRs were observed to be less than 1.00 during the five-year period in both urban and rural areas. The AORs (95% CIs) for survival significantly increased to 1.42 (1.22-1.66) in the metropolitan areas and to 1.58 (1.18-2.11) in the urban areas while not increasing in the rural areas, compared to the level of each group of areas in 2006. CONCLUSIONS In this nationwide cohort study from 2006 to 2010, the standardized incidence rate and survival to discharge rate of EMS-assessed OHCAs increased annually in metropolitan and urban communities but did not increase in rural communities. Further investigations should be undertaken to improve the performance and outcomes in rural communities.

Epidemiology and outcomes from non-traumatic out-of-hospital cardiac arrest in Korea: A nationwide observational study ☆

OBJECTIVES We aimed to describe the epidemiological features and to determine the predictors for survival to discharge of non-traumatic out-of-hospital cardiac arrest (OHCA) in Korea. SUBJECTS AND METHODS A nationwide Utstein style OHCA database (2006-2007) was constructed from ambulance records and hospital medical record review. Cases were enrolled when they were non-traumatic OHCA with presumed cardiac aetiology. Using the population census (2005), we calculated age-gender standardized incidence rates (SIR) and mortality (SMR). We modelled a multivariate logistic regression analysis to determine the effect of risk factors on hospital outcomes. RESULTS The total number of EMS-assessed non-traumatic OHCA patients was 19045. The SIR was 20.9 (2006) and 22.2 (2007) per 100000 and survival-to-discharge rate was 2.3% for EMS-assessed non-traumatic OHCA, and was 3.5% for the resuscitation-attempted group. From a multivariate logistic regression analysis, witnessed arrest, and shorter basic life support (BLS) and EMS intervals turned out to be significant predictors of good outcome in the resuscitation-attempted group. CONCLUSION From a nationwide OHCA cohort, the incidence of EMS-assessed non-traumatic OHCA was found to be low. Survival-to-discharge rate in the resuscitation-attempted group was 3.5%, which was significantly associated with witnessed arrest, and shorter BLS and EMS intervals.

Pediatric out-of-hospital cardiac arrest in Korea: A nationwide population-based study☆☆☆

STUDY OBJECTIVES Our objective was to describe the incidence and demographics of pediatric out-of-hospital cardiac arrest (OHCA) in Korea. METHODS We identified non-traumatic OHCA patients aged less than 20 years from a Korean nationwide OHCA registry (2006-2007). Data from emergency medical service (EMS) run-sheets and hospital records were reviewed. We excluded cases with unknown hospital outcomes. Patient characteristics, treatment by EMS, and outcomes were compared by age groups: infant (<1 year), children (1-11 years), and adolescents (12-19 years). RESULTS A total of 971 patients including infants (n=299, 30.8%), children (n=305, 31.4%), and adolescents (n=367, 37.8%) met inclusion criteria. The incidence of pediatric OHCA was 4.2 per 100,000 person-years (67.1 in infants, 2.5 in children, and 3.5 in adolescents). The rate of cardiopulmonary resuscitation administered was 82.1% (infants 80.6%, children 82.0%, and adolescent 83.4%). The rate of applying automated external defibrillators and advanced airway management (endotracheal intubation or laryngeal mask airway), was only 4.1% and 2.5%, respectively. 7.4% showed ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in the initial ECG. Survival to hospital discharge for all pediatric OHCA was 4.9% (2.9% for infants, 4.7% for children, and 7.2% of adolescents). For EMS-treated pediatric OHCA or patients with VF or pulseless VT, the rate was 5.0% and 31.6%, respectively. CONCLUSION Incidence and hospital outcomes in pediatric OHCA in Korea were comparable to other population-based nationwide reports.

Cardiopulmonary resuscitation outcome of out-of-hospital cardiac arrest in low-volume versus high-volume emergency departments: An observational study and propensity score matching analysis

OBJECTIVE This study aimed to determine whether cardiopulmonary resuscitation (CPR) volume is associated with survival to discharge rate for out-of hospital cardiac arrest (OHCA) victims. METHODS This study was performed in an emergency medical service (EMS) system with single-tiered basic to intermediate service level. A nationwide OHCA cohort database from January 2006 to December 2007 was used and composed of hospital chart review and ambulance run sheet data. We enrolled data from the 410 emergency departments and excluded cases without available hospital outcome data. From sensitivity analysis, we decided cut-off value for the high volume (HV) versus low volume (LV) EDs. A matching process based on propensity score was used to equalize potential prognostic factors in both groups. The adjusted odds ratio (OR) and its 95% confidence interval (95% CI) for survival to admission and to discharge were calculated. RESULTS Of the 34,408 patients with OHCA, 20,457 (59.5%) were included except cases with unknown outcome (n=1284), traumatic cause (n=4894), no CPR attempt by EMS (n=7779), and cases transferred to non-ED facilities (n=3885). Overall survival to admission and to discharge was 10.9% and 3.4%, respectively. When we performed the sensitivity analysis for deciding the cut-off value for HV versus LV, the number was 68 per two years (sensitivity 67.0%, specificity 67.0%). Using propensity score matching, 3533 cases were randomly assigned to HV and LV group, respectively. The unadjusted and adjusted OR for survival to admission in HV was 1.35 (95% CI 1.19-1.54) and 1.44 (95% CI 1.24-1.66), respectively. The unadjusted and adjusted OR for survival to discharge was 1.71 (95% CI 1.36-2.14) and 1.81 (95% 1.43-2.30), respectively. CONCLUSIONS Emergency departments with high volumes of CPR cases showed significantly better outcomes for OHCA patients than those with low volumes in an EMS system with single-tiered basic to intermediate service level.

Epidemiologic Characteristics of Death by Poisoning in 1991-2001 in Korea

The purpose of this study was to investigate the epidemiologic characteristics of the death by poisoning in Korea. We recoded the Death Certificates Database by injury based on the short version of the International Classification of External Causes of Injuries (ICECI). We evaluated the mortality rate by total injury and poisoning, and analyzed the mortality rate by age, gender, year and month, toxic agent, and intent. Adjusted odds ratios were calculated to evaluate the effects of socioeconomic factors on suicidal poisoning death. The total number of death cases by injury was 346,656. The proportion of death cases by injury decreased from 13.53% of all death cases in 1991 to 11.89% in 2001. However, the mortality rate by poisoning increased rapidly from 1998, and then remained stable. The number of suicidal poisoning deaths has gradually increased, and its mortality rate was 6.41 (per 100,000) in 2001. Major toxic agents were pesticides and herbicides (50.90%) in 2001. Adjusted odds ratios of suicidal poisoning versus other poisonings showed significant differences in education attainment, region, and marital status. In conclusion, the mortality rate by poisoning has increased, and the proportion of suicidal poisoning also has increased compared to that of accidental poisoning.

Niacin attenuates lung inflammation and improves survival during sepsis by downregulating the nuclear factor-κb pathway*

Objectives:To examine whether niacin attenuates lung inflammation and improves survival during sepsis and to determine whether the beneficial effects of niacin are associated with downregulation of the nuclear factor (NF)-&kgr;B pathway. Design:Prospective laboratory study. Setting:University laboratory. Subjects:Male Sprague-Dawley rats (n = 119). Interventions:To induce endotoxemia in rats, lipopolysaccharide (Escherichia coli, O26:B6) at a dosage of 10 mg/kg was injected into a tail vein and 10 mins later, vehicle, a low dose of niacin (360 mg/kg), or a high dose of niacin (1180 mg/kg) was administered once through an orogastric tube, respectively. Measurements and Main Results:We observed the survival of the subjects for 72 hrs. At 6 hrs postlipopolysaccharide, we euthanized animals and measured cytoplasmic phosphorylated inhibitor &kgr;B-&agr; and inhibitor &kgr;B-&agr; expressions, nuclear NF-&kgr;B p65 expression, NF-&kgr;B p65 DNA-binding activity, tumor necrosis factor-&agr;, and interleukin-6 gene expressions and histologic damages in lung tissues. We also measured nicotinamide adenine dinucleotide, reduced nicotinamide adenine dinucleotide phosphate, reduced glutathione, and malondialdehyde levels in lung tissues. High dose of niacin suppressed NF-&kgr;B activation and proinflammatory cytokine gene expressions in lung tissues, reduced histologic lung damages, and improved survival in endotoxemic rats. Furthermore, it increased nicotinamide adenine dinucleotide, nicotinamide adenine dinucleotide phosphate, and glutathione levels and decreased malondialdehyde level in lung tissues. Conclusions:High dose of niacin attenuated lung inflammation, reduced histologic lung damages, and improved survival during sepsis in rats. These therapeutic benefits were associated with downregulation of the NF-&kgr;B pathway.

Glutamine attenuates acute lung injury by inhibition of high mobility group box protein-1 expression during sepsis.

Heat shock protein 70 (HSP70) is reported as the main factor responsible for the beneficial effects of glutamine (GLN) and as a negative regulator of high mobility group box protein-1 (HMGB-1) expression. Our aim was to determine whether GLN attenuates acute lung injury (ALI) by the inhibition of HMGB-1 expression during sepsis. Male Sprague-Dawley rats were subjected to caecal ligation and puncture (CLP) to induce sepsis. GLN or saline was administered through tail vein 1 h after CLP. Then, quercetin (Q), an inhibitor of HSP70, was utilised to assess the role of the enhanced HSP70. We observed the survival of the subjects. At 24 h post-CLP, we measured lung HSP70, phosphorylated heat shock factor-1 (HSF-1-p) and HMGB-1 expressions, NF-kappaB DNA-binding activity and ALI occurrence. We also measured serum HSP70, IL-6 and HMGB-1 concentrations. GLN improved survival during sepsis. In GLN-treated rats, lung HSP70 and HSF-1-p expressions were enhanced, lung HMGB-1 expression and NF-kappaB DNA-binding activity were suppressed, and ALI was attenuated. Furthermore, in GLN-administered rats, serum HSP70 concentration was higher, and serum IL-6 and HMGB-1 concentrations were lower than those in non-treated rats. Q inhibited the enhancement of HSP70 and HSF-1-p expressions and abrogated the GLN-mediated benefits. In conclusion, GLN attenuated ALI and improved survival by the inhibition of HMGB-1 expression during sepsis in rats. These benefits were associated with the enhancement of HSP70 expression by GLN.

Protective effects of ethyl pyruvate treatment on paraquat-intoxicated rats

Although, numerous studies have attempted to reduce the oxygen radical injury induced by the antioxidants in paraquat intoxication, these antioxidant therapies have showed few survival benefits. Ethyl pyruvate (EP) may function as an effective scavenger of oxygen radicals, an anti-inflammatory agent and an energy source in many ischemia reperfusion models. The aim of this study was to evaluate the antioxidant and anti-inflammatory effects of EP on the lung and the liver tissues in paraquat-intoxicated rats. Rats were randomly given either a low (2 mg/kg i.p.) or high (40 mg/kg i.p.) EP dose, 30 min before or 1 h after paraquat (50 mg/kg i.p.) administration, and subsequently killed at 6 and 24 h. Glutathione (GSH) and malondialdehyde (MDA) levels of the lungs and the livers, and plasma nitric oxide (NO) concentrations were measured. Pretreatment of EP significantly decreased the MDA level in the lung and the liver tissues. EP also significantly decreased plasma NO concentrations at 6 h. EP pretreatment, however, failed to show significant change in GSH concentration. In post-treatment of EP, MDA levels in the lung tissue and plasma NO levels were significantly decreased. In conclusion, EP decreased the lipid peroxidation and seemed to exert an anti-inflammatory action in the paraquat intoxication rat model.

Induced Hypothermia Attenuates the Acute Lung Injury in Hemorrhagic Shock

BACKGROUND In previous animal studies, induction of therapeutic hypothermia (HT) in hemorrhagic shock (HS) had beneficial effects on the hemodynamic and metabolic parameters and on the survival. However, the effect of induced HT on acute lung injury (ALI) in HS has not been investigated. We sought to determine the effects of HT on ALI in HS. METHODS Male Sprague-Dawley rats (350-390 g; n = 8 per group) were randomized to the normothermia (NT; 36-37 degrees C) group or the moderate HT (27-30 degrees C) group and were subjected to volume-controlled (2 mL/100 g weight) HS (90 minutes) followed by 90 minutes of resuscitation. ALI score, lung malondialdehyde content, and myeloperoxidase activity were measured. The expression of glycogen synthase kinase 3beta (GSK-3beta), phosphorylated GSK-3beta, inducible nitric oxide synthase (iNOS), heat shock protein (HSP) 72, and nuclear factor-kappaB (NF-kappaB) in the lung were compared. RESULTS ALI score, lung malondialdehyde content, and myeloperoxidase were lower in the HT group. GSK-3beta and iNOS gene expressions in lung tissue were significantly decreased in the HT group (p < 0.05). On the contrary, the expression of phosphorylated GSK-3beta was increased in the HT group (p < 0.001). HSP 72 was expressed in the HT group but not in the NT group. The activated p65 NF-kappaB levels in lung nuclear extract were significantly lower in the NT group (p = 0.03). CONCLUSIONS HT attenuates HS-induced ALI in rats by the modulation of GSK, HSP 72, iNOS, and NF-kappaB.

Therapeutic hypothermia attenuates acute lung injury in paraquat intoxication in rats

AIM OF THE STUDY Paraquat intoxication induces acute lung injury and numerous fatalities have been reported. The mechanism of toxic effect of paraquat is oxidative injury and inflammation. Therapeutic hypothermia has been known to have antioxidant and anti-inflammatory effects. This study was designed to evaluate the effect of therapeutic hypothermia on paraquat intoxication. METHODS Male Sprague-Dawley rats were given 50 mg/kg of paraquat intraperitoneally and divided into the normothermia (36-38°C) group and the hypothermia (30-32°C) group after 1h of paraquat administration. The hypothermia group underwent 2 h of hypothermia followed by 2 h of rewarming. In the survival study, mortality was observed for 24 h after paraquat administration. An in the second experiment, lung tissues and plasma were harvested at 6 h after paraquat administration. RESULTS The 12 h survival rate was significantly higher in the hypothermia group than in the normothermia group (100% vs. 50%, p<0.05), but survival rates for 24 h were not different. Acute lung injury score was lower in the hypothermia group than in the normothermia group (p<0.05). Thmalondialdehyde contents of lung tissues, plasma interleukin-6 and nitrite/nitrate concentrations were significantly decreased in the HT group compared to the NT group (p<0.05). CONCLUSION Therapeutic hypothermia delayed early mortality and attenuated acute lung injury in paraquat intoxication.