Ji Eun Hwang

Sodium bicarbonate administration during ongoing resuscitation is associated with increased return of spontaneous circulation

PURPOSE Sodium bicarbonate is frequently used for patients unresponsive to cardiopulmonary resuscitation (CPR). Its use may be associated with longer resuscitation duration as well as more severe metabolic acidosis. We applied a new analytical method based on a matched case-control study design to control for the potential confounders. BASIC PROCEDURES Out-of-hospital cardiac arrest patients resuscitated in an emergency department for at least 20 minutes, unless there was any return of spontaneous circulation (ROSC) within the time frame, were analyzed. Patients without ROSC for 20 minutes of CPR were matched to those with ROSC based on initial bicarbonate level categorized using cutoff points of 10, 15, 20, 25, and 30 mEq/L, and their observation durations were trimmed to match their pairs. The association between sodium bicarbonate and ROSC was examined using conditional logistic regression analysis. MAIN FINDINGS Two matched groups, one with ROSC and the other without (both n = 258), were generated. Sodium bicarbonate administration and its total cumulative dose were significantly associated with an increased ROSC, with odds ratios for ROSC of 1.86 (95% confidence interval [CI], 1.09-3.16; P = .022) and 1.18 (per 20 mEq; 95% CI, 1.04-1.33; P = .008), respectively. The positive associations remained unchanged after multivariable adjustment, with odds ratios for ROSC of 2.49 (95% CI, 1.33-4.65; P = .004) and 1.27 (95% CI, 1.11-1.47; P = .001), respectively. PRINCIPAL CONCLUSION Sodium bicarbonate administration during CPR in emergency department was associated with increased ROSC.

Effect of valproic acid combined with therapeutic hypothermia on neurologic outcome in asphyxial cardiac arrest model of rats

BACKGROUNDS Valproic acid (VPA) has been reported to have survival and neuroprotective effects in a cardiac arrest rat model. This study was designed to investigate the effect of VPA combined with therapeutic hypothermia (HT) in an asphyxial cardiac arrest rat model. METHODS Rats were subjected to 6 minutes of asphyxial cardiac arrest. Cardiopulmonary resuscitation was performed and then the randomly allocated to 1 of 4 groups (normal saline [NS]/normothermia [NT], VPA/NT, NS/HT, and VPA/HT). Hypothermia (32.5°C ± 0.5°C, 4 hours of HT and 2 hours of rewarming) or NT (37°C ± 0.5°C for 6 hours) was applied, and VPA (300 mg/kg) or NS was administered immediately after the return of spontaneous circulation. Neurologic deficit score was measured, and a tape removal test was performed for 3 days. Histologic injury of hippocampus was evaluated. RESULTS Valproic acid significantly improved neurologic deficit score at 48 and 72 hours in the NT-treated rats and at 72 hours in the HT-treated rats (all P < .05). Although the latency and success rate were not significantly different between the VPA/NT and NS/NT groups, the VPA/HT group showed significantly lower latency and higher success rates compared to the NS/HT group (P < .05). The histologic injury score in the hippocampal CA1 sector was significantly lower in the VPA/NT group than the NS/NT group (P < .05) and showed a tendency to be decreased in the VPA/HT group compared with the NS/HT group (P = .06). CONCLUSION In an asphyxial cardiac arrest rat model, administration of VPA improved neurologic outcomes and added a neuroprotective effect to HT.

Use of resuscitative endovascular balloon occlusion of the aorta in a patient with gastrointestinal bleeding

Resuscitative endovascular balloon occlusion of the aorta (REBOA) was developed for controlling intra-abdominal arterial bleeding before definitive bleeding control, and is commonly used in patients with ruptured abdominal aortic aneurysms. Although there is limited evidence for other uses of REBOA, we used REBOA in a patient with massive gastrointestinal bleeding. A 53-year-old man with hematochezia was admitted to our emergency department with an initial systolic blood pressure (SBP) of 83 mmHg. His SBP decreased to 40 mmHg in 10 minutes despite rapid fluid infusion. We decided to resuscitate the patient with REBOA in the emergency department and then move him to an intervention room after stabilization. After aortic occlusion, SBP abruptly increased from 57 to 108 mmHg, and the patient could be transferred to an intervention room. The patient was admitted to intensive care, but died of massive rebleeding 24 hours after admission to the emergency department.

External validation of the STONE score and derivation of the modified STONE score

OBJECTIVE The STONE score is a clinical prediction rule for the presence of uncomplicated ureter stones with a low probability of acutely important alternative findings. This study performed an external validation of the STONE score, focusing on the Korean population, and a derivation of the modified STONE score for better specificity and sensitivity. METHODS We retrospectively reviewed medical records of patients complaining of flank pain at a single emergency department from January 2013 to December 2014. Patients were categorized into 3 groups according to their STONE score. The prevalence of ureter stones and other alternative findings were calculated in each group. We derived a modified STONE score based on a multivariable analysis and performed an interval validation. RESULTS From the 700 patients included in the analysis, 555 patients (79%) had a ureter stone. The area under the receiver operating characteristic curve of the STONE score was 0.92. The sensitivity of the high stone score was 0.56. In the modified STONE score, nausea, vomiting, and racial predictors were substituted by C-reactive protein and previous stone history. The area under the receiver operating characteristic curve and sensitivity of the modified STONE score in the internal validation group significantly increased to 0.94 and 0.80, respectively. CONCLUSION The STONE score can be used to predict a ureter stone with a low probability of other alternative findings. The modified STONE score might increase the diagnostic performance in suspicious urinary stone cases. KEY POINTS We performed external validation of the STONE score and derivation of the modified STONE score. This scoring system could help the clinicians with radiation reducing decision making.

Prognostic value of pneumococcal urinary antigen test in community-acquired pneumonia

Background The pneumococcal urinary antigen test (UAT) has been known to improve sensitivity and specificity for the diagnosis of pneumococcal pneumonia. Associations of UAT results with prognosis in community acquired pneumonia (CAP) are not known. We hypothesized that positive UAT is associated with a good prognosis, and incorporation of UAT into CRB65 would improve its prognostic performance. Methods In this registry-based retrospective study, we analyzed CAP patients over a 10-year period beginning in April 2008. Patients who had UAT results were included in multivariable extended Cox-regression analyses to determine the association between UAT positivity and 30-day mortality. UAT results were incorporated for patients with a CRB65 score of 1 by subtracting 1 from the scoring system if the test was positive. The performance of the modified scoring systems was assessed with area under the receiver operating characteristic (AUROC) curves. Results Among 5145 CAP patients, total 2280 patients had UAT results and were included in analyses. A positive UAT result was associated with a good prognosis after a week of hospitalization (aHR, 0.14; p = 0.007). After modification of CRB65 using UAT results, positive and negative predictive values for 30-day mortality were increased from 7.7 to 8.3 (p<0.001) and 98.9 to 99.1 (p = 0.010). The AUROC increased from 0.73 to 0.75 (p<0.001). Conclusions Positive results on UAT could be considered as a good prognostic factor in CAP. UAT could be used as a useful tool in deciding whether to refer patients to the hospital, especially in moderate CAP with a CRB score of 1.

Intracellular formyl peptide receptor regulates naïve CD4 T cell migration

We found that formyl peptide receptor (FPR) 1 and FPR3 were expressed intracellularly and/or the nucleus of naïve CD4 T cell. Activation of naïve CD4 T cells with synthetic intracellular agonists dTAT-WKYMVm and CTP-WKYMVm for FPR members stimulated CD4 T cell migration via pertussis toxin-sensitive manner. Knockdown of FPR1, but not knockdown of FPR3, blocked dTAT-WKYMVm-induced naïve CD4 T cell migration. Stimulation of naïve CD4 T cells with dTAT-WKYMVm elicited the activation of ERK, p38 MAPK, and Akt. Activation of CD4 T cells with anti-CD3 and anti-CD28 antibodies caused surface expression of FPR1 and FPR3, but not FPR2. CD4 T cells isolated from sepsis patients expressed the three members of FPR family on their cell surface. Taken together, our results suggest that intracellular FPR in naïve CD4 T cells and surface FPRs in activated CD4 T cells might regulate immune responses by regulating CD4 T cell activity.

Incidence and risk factors of delayed intracranial hemorrhage in emergency department

Objectives This study was performed to identify the risk factors for delayed intracranial hemorrhage and develop a risk stratification system for disposition of head trauma patients with negative initial brain imaging. Methods The data source was National Health Insurance Service‐National Sample Cohort of Korea. We analyzed adult patients presenting to the ER from January 2004 to September 2012, who underwent brain imaging and discharged with or without short‐term observation no longer than two days. The primary outcome was defined as any intracranial bleeding within a month defined by a new appearance of any of the diagnostic codes for intracranial hemorrhage accompanied by a new claim for brain imaging(s) within a month of the index visit. We performed a multivariable logistic regression analysis and built a parsimonious model for variable selection to develop a simple scoring system for risk stratification. Results During the study period, a total of 19,723 head injury cases were identified from the cohort and a total of 149 cases were identified as having delayed intracranial hemorrhage within 30 days. In multivariable logistic regression model, old age, craniofacial fracture, neck injury, diabetes mellitus and hypertension were independent risk factors for delayed intracranial hemorrhage. We constructed the parsimonious model included age, craniofacial fracture and diabetes mellitus. The score showed area under the curve of 0.704 and positive predictive value of the score system was 0.014 when the score ≥ 2. Conclusions We found old age, associated craniofacial fracture, any neck injury, diabetes mellitus and hypertension are the independent risk factors of delayed intracranial hemorrhage.

Impact of bacteremia prediction rule in CAP: Before and after study

Objective: In cases of community acquired pneumonia (CAP), it has been known that blood cultures have low yields and rarely affect clinical outcomes. Despite many studies predicting the likelihood of bacteremia in CAP patients, those results have been rarely implemented in clinical practice, and use of blood culture in CAP is still increasing. This study evaluated impact of implementing a previously derived and validated bacteremia prediction rule. Methods: In this registry‐based before and after study, we used piecewise regression analysis to compare the blood culture rate before and after implementation of the prediction rule. We also compared 30‐day mortality, emergency department (ED) length of stay, time‐interval to initial antibiotics after ED arrival, and any changes to the antibiotics regimen as results of the blood cultures. In subgroup analysis, we compared two groups (with or without the use of the prediction rule) after implementation period, using propensity score matching. Results: Following the implementation, the blood culture rate declined from 85.5% to 78.1% (P = 0.003) without significant changes in 30‐day mortality and antibiotics regimen. The interval to initial antibiotics (231 min vs. 221 min, P = 0.362) and length of stay (1019 min vs. 954 min, P = 0.354) were not significantly changed. In subgroup analysis, the group that use the prediction rule showed 25 min faster antibiotics initiation (P = 0.002) and 48 min shorter length of stay (P = 0.007) than the group that did not use the rule. Conclusion: Implementation of the bacteremia prediction rule in CAP patients reduced the blood culture rate without affecting the 30‐day mortality and antibiotics regimen.