Kwang Je Baek

Lactic acidosis not hyperlactatemia as a predictor of inhospital mortality in septic emergency patients

Objective: To compare the prognostic abilities of lactic acidosis and hyperlactatemia and determine the influence of metabolic acidosis when attempting to predict the outcome of septic patients using serum lactate levels. Method: 126 patients with severe sepsis or septic shock were prospectively included in this study at an emergency department. Haemodynamic variables, simplified acute physiology score (SAPS) II, arterial blood gas studies and serum lactate levels were obtained at the time of presentation (0 h) and 4 h after presentation. The probability of mortality was calculated using SAPS II scores and compared with actual inhospital mortality at different serum lactate levels and arterial pH. Survival curves for lactic acidosis and severe hyperlactatemia were analysed using the Kaplan–Meier method. Results: The calculated probability of mortality decreased from 35.7% (95% CI 30.2 to 41.2) at presentation to 29.3% (95% CI 24.2 to 34.4) at 4 h post-presentation. 27.0% of patients (34) died in hospital. Arterial pH and SAPS II scores were independent factors for predicting mortality of septic patients, at 0 h and 4 h. Serum lactate levels were closely related to severity of illness and metabolic acidosis in septic patients. Patients with lactic acidosis had significantly higher inhospital mortality than patients with normal pH and normal lactate levels by Kaplan–Meier survival analysis as determined based on measurements made at 0 h and 4 h (p<0.001, p<0.001 by the log-rank test, respectively). No significant difference in survival was found between patients with hyperlactatemia and those with normal pH and serum lactate levels. Conclusion: Lactic acidosis not hyperlactatemia was found to predict inhospital mortality more exactly in severe sepsis and septic shock patients. The acid-base state should be considered when attempting to predict the outcome of septic patients using serum lactate levels.

A different rescuer changing strategy between 30:2 cardiopulmonary resuscitation and hands-only cardiopulmonary resuscitation that considers rescuer factors: A randomised cross-over simulation study with a time-dependent analysis

AIM To compare the time-dependent changes in the quality of chest compressions in 30:2 cardiopulmonary resuscitation (CPR) and hands-only cardiopulmonary resuscitation (HO-CPR) and to evaluate how individual rescuer factors affect the quality of chest compressions over time for both CPR techniques. METHODS Total 1028 adult hospital and university workers participated in CPR training programs including sessions of 30:2 CPR and HO-CPR. Tests of both CPR methods were performed in a random order using a manikin with Skill-Reporter™. Data were collected from 863 subjects. The time-dependent changes in chest compressions quality and the effects of individual rescuer factors (age, gender, body mass index (BMI), prior CPR training and experience) were analysed using the general linear model for a repeated-measures procedure. RESULTS In HO-CPR, the mean proportion of correct compressions depth (MPCD) decreased significantly throughout the time sectors following 20-40s (74.4-50.4% in 100-120 s) compared to 30:2 CPR (83.4-76.3% in 100-120 s) (p<0.0001). A significant decline of MPCD (MPCD<70%) was initially observed at 40-60s in HO-CPR, however, this pattern was not observed in 30:2 CPR. Individual rescuer factors minimally affected the time-dependent change in MPCD during 30:2 CPR. For HO-CPR, all rescuer factors except for male or obese/overweight (BMI≥25) were associated with a significant declines of MPCD, and these decline were usually observed from 40 to 60s. CONCLUSION Switching rescuers at an interval of 2-min is reasonable for 30:2 CPR. However, for HO-CPR switching rescuers every 1-min may be preferable except when rescuers are male or obese/overweight (BMI≥25).

Plasma neutrophil gelatinase-associated lipocalin as early biomarker for acute kidney injury in burn patients.

This study evaluated whether measurements of plasma neutrophil gelatinase-associated lipocalin (NGAL) can predict acute kidney injury (AKI) in adult burn patients, and assessed the use of this biomarker in risk stratification. We performed a prospective observational study of consecutive patients with major burns admitted to the burn center within 12 hours of injury. Samples for plasma NGAL assay were obtained three times (at admission, day 3, and day 7). The main outcome measures were occurrence of AKI based on Risk-Injury-Failure classification and mortality. A total 45 patients with burns injury were enrolled. There was a high prevalence (11 of 45, 24.4%) of AKI in burn patients. All patients with AKI developed AKI after hospital day 8. Multivariate logistic regression analysis demonstrated that burn size and abbreviated burn severity index were independent risk factors of AKI. Patients who developed AKI had significantly higher admission plasma NGAL levels, hospital day 3 NGAL levels, and hospital day 7 NGAL levels. Especially, hospital day 7 NGAL levels strongly correlated with AKI. For concentration in plasma NGAL at hospital day 7, the area under the receiver operating characteristic curve was 0.903, sensitivity was 87%, and specificity was 91% for a cutoff value of 125 ng/ml. The mean plasma NGAL at hospital day 7 of patients who died was significantly higher than that of patients who did not (485 ng/ml vs 111 ng/ml, P = .001). Plasma NGAL levels are early predictive biomarkers for AKI and its clinical outcomes after burn injury.

Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators ☆

AIM This study compared endotracheal intubation (ETI) performance during cardiopulmonary resuscitation (CPR) between direct laryngoscopy (DL) and video laryngoscopy (VL) (GlideScope(®)) by experienced intubators (>50 successful ETIs). METHODS This was a prospective randomized controlled study conducted in an emergency department between 2011 and 2013. Intubators who used DL or VL were randomly allocated to ETI during CPR. Data were collected from recorded video clips and rhythm sheets. The success, speed, complications, and chest compressions interruption were compared between the two devices. RESULTS Total 140 ETIs by experienced intubators using DL (n=69) and VL (n=71) were analysed. There were no significant differences between DL and VL in the ETI success rate (92.8% vs. 95.8%; p=0.490), first-attempt success rate (87.0% vs. 94.4%; p=0.204), and median time to complete ETI (51 [36-67] vs. 42 [34-62]s; p=0.143). In both groups, oesophageal intubation and dental injuries seldom occurred. However, longer chest compressions interruption occurred using DL (4.0 [1.0-11.0]s) compared with VL (0.0 [0.0-1.0]s) and frequent serious no-flow (interruption>10s) occurred with DL (18/69 [26.1%]) compared with VL (0/71) (p<0.001). For highly experienced intubators (>80 successful ETIs), frequent serious no-flow occurred in DL (14/55 [25.5%] vs. 0/57 in VL). CONCLUSIONS The ETI success, speed and complications during CPR did not differ significantly between the two devices for experienced intubators. However, the VL was superior in terms of completion of ETI without chest compression interruptions. TRIAL REGISTRATION Clinical Research Information Service (CRIS) in South Korea KCT0000849.

Effects of combination therapy of docetaxel with selenium on the human breast cancer cell lines MDA-MB-231 and MCF-7

Purpose The anticancer property and cytoprotective role of selenium in chemotherapy have been reported. However, the combination effects of selenium on chemotherapy for advanced breast cancer have not yet been clearly defined. The purpose of this study was to investigate the combined effects of selenium on chemotherapy using docetaxel on breast cancer cell lines. Methods Under adherent culture conditions, two breast cancer cell lines, MDA-MB-231 and MCF-7, were treated with docetaxel at 500pM and selenium at 100nM, 1µM, or 10µM. Changes in cell growth, cell cycle duration, and degree of apoptosis after 72 hours in each treated group were evaluated. Results In the MDA-MB-231 cells, the combination therapy group (docetaxel at 500pM plus selenium at 10µM) showed a significantly decreased percentage of cell growth (15% vs. 28%; P = 0.004), a significantly increased percentage of late apoptosis (63% vs. 26%; P = 0.001), and an increased cell cycle arrest in the G2/M phase (P = 0.001) compared with the solitary docetaxel therapy group. Isobologram analysis demonstrated the synergistic effect of the combination therapy in the MDA-MB-231 cells. However, in the MCF-7 cells, no significant differences in the percentage of cell growth apoptosis, the percentage of apoptosis, and the pattern of cell cycle arrest were noted between the combination therapy groups and the solitary docetaxel therapy group. Conclusion Our in vitro study indicated that the combination of selenium with docetaxel inhibits cell proliferation through apoptosis and cell arrest in the G2/M phase in MDA-MB-231 breast cancer cells.

Efficacy of the Disposcope endoscope, a new video laryngoscope, for endotracheal intubation in patients with cervical spine immobilisation by semirigid neck collar: comparison with the Macintosh laryngoscope using a simulation study on a manikin

Objective To evaluate whether endotracheal intubation in patients with cervical spine immobilisation by a semirigid neck collar is easier using the Disposcope endoscope (DE), a new video laryngoscope, than with the Macintosh laryngoscope (ML). Methods Sixty-eight medical interns who participated in a training programme for endotracheal intubation using the DE and ML were recruited to the randomised crossover trial 1 week after completing the training programme. In the trial, they used both the DE and the ML to perform intubation on a manikin wearing a semirigid neck collar. The time required to view the vocal cords and to complete intubation, successful endotracheal intubation, modified Cormack–Lehane classification (CL grade) and dental injury were recorded and analysed. Results The mean (SD) time to view the vocal cords was significantly shorter with the DE than with the ML (10.0 (7.0) vs 20.8 (18.9) s; p<0.0001). There were higher rates of CL grades 1 and 2a (69.1% and 22.1%) using the DE than with the ML (10.3% and 14.7%). All 68 participants had a higher rate of successful endotracheal intubation using the DE than using the ML (68 (100%) vs 47 (69.1%); p<0.0001). It took less time to complete endotracheal intubation with the DE than with the ML (p<0.0001). Conclusions In patients with cervical spine immobilisation by a semirigid neck collar, the DE may be a more effective device for endotracheal intubation than the ML.

Efficacy of various types of laryngoscope (direct, Pentax Airway Scope and GlideScope) for endotracheal intubation in various cervical immobilisation scenarios: a randomised cross-over simulation study

Objective To compare the efficacy of direct laryngoscopy (DL), Pentax Airway Scope (PAWS) and GlideScope video laryngoscope (GVL) systems for endotracheal intubation (ETI) in various cervical immobilisation scenarios: manual in-line stabilisation (MILS), Philadelphia neck collar (PNC) (moderate limit of mouth opening) and Stifneck collar (SNC) (severe limit of mouth opening). Design Randomised cross-over simulation study. Setting and Participants 35 physicians who had >30 successful ETI experiences at a tertiary hospital in Seoul, Korea. Primary and secondary outcome measures Participants performed ETI using PAWS, GVL and DL randomly in simulated MILS, PNC and SNC scenarios in our simulation centre. The end points were successful ETI and the time to complete ETI. In addition, modified Cormack-Lehane (CL) classification and pressure to teeth were recorded. Results In MILS, there were no significant differences in the rate of success of ETI between the three devices: 33/35(94.3%) for DL vs 32/35(91.4%) for GVL vs 35/35(100.0%) for PAWS; p=0.230). PAWS achieved successful ETI more quickly (19.8 s) than DL (29.6 s) and GVL (35.4 s). For the PNC scenario, a higher rate of successful ETI was achieved with GVL 33/35 (94.3%) than PAWS 29/35 (82.9%) or DL 25/35 (71.4%) (p=0.040). For the SNC scenario, a higher rate of successful ETI was achieved with GVL 28/35(80.0%) than with DL 14/35(40.0%) and PAWS 7/35(20.0%) (p<0.001). For the PNC and SNC scenarios, GVL provided a relatively good view of the glottis, but a frequent pressure to teeth occurred. Conclusions All three devices are suitable for ETI in MILS. DL is not suitable in both neck collar scenarios. PAWS showed faster intubations in MILS, but was not suitable in the SNC scenario. GVL is most suitable in all cervical immobilisation scenarios, but may cause pressure to teeth more frequently.

Value of plasma neutrophil gelatinase-associated lipocalin in predicting the mortality of patients with sepsis at the emergency department.

BACKGROUND Sepsis is a major cause of morbidity and mortality in the emergency department. This study aimed to evaluate the assessment of severity of sepsis by and prognostic value of plasma neutrophil gelatinase-associated lipocalin (NGAL) compared with other widely used biological markers of inflammation in patients with sepsis. METHODS NGAL, procalcitonin, and C-reactive protein values were measured in 470 patients with suspected sepsis, and the Mortality in Emergency Department Sepsis (MEDS) score was obtained for all enrolled subjects, who were followed for up to 28days. RESULTS The median plasma NGAL value was increased with sepsis severity according to the MEDS score. The plasma NGAL value was higher in nonsurvivors than in survivors. The area under the receiver operating characteristic curve of NGAL (0.797) was greater than that of procalcitonin (0.599) and MEDS score (0.774) in predicting 28-day hospital mortality. Multivariable logistic regression found that the plasma NGAL value was an independent predictor for hospital mortality in patients with sepsis. The plasma NGAL values were positively correlated with C-reactive protein and procalcitonin levels, and MEDS scores. CONCLUSIONS Plasma NGAL is a valuable biological marker in the assessment of severity and prediction of prognosis of patients with sepsis in the emergency department.

A Simple Audio-visual Prompt Device Can Improve CPR Performance

BACKGROUND An adjunct to assist cardiopulmonary resuscitation (CPR) might improve the quality of CPR performance. STUDY OBJECTIVES This study was conducted to evaluate whether a simple audio-visual prompt device improves CPR performance by emergency medical technicians (EMTs). METHODS From June 2008 to October 2008, 55 EMTs (39 men, mean age 34.9±4.8 years) participated in this study. A simple audio-visual prompt device was developed. The device generates continuous metronomic sounds for chest compression at a rate of 100 beats/min with a distinct 30(th) sound followed by two respiration sounds, each for 1 second. All EMTs were asked to perform a 2-min CPR series on a manikin without the device, and one 2-min CPR series with the device. RESULTS The average rate of chest compressions was more accurate when the device was used than when the device was not used (101.4±12.7 vs. 109.0±17.4/min, respectively, p=0.012; 95% confidence interval [CI] 97.2-103.8 vs. 104.5-113.5/min, respectively), and hands-off time during CPR was shorter when the device was used than when the device was not used (5.4±0.9 vs. 9.2±3.9 s, respectively, p<0.001; 95% CI 5.2-5.7 vs. 8.3-10.3 s, respectively). The mean tidal volume during CPR with the device was lower than without the device, resulting in the prevention of hyperventilation (477.6±60.0 vs. 636.6±153.4 mL, respectively, p<0.001; 95% CI 463.5-496.2 vs. 607.3-688.9 mL, respectively). CONCLUSION A simple audio-visual prompt device can improve CPR performance by emergency medical technicians.

Serum Procalcitonin: An Independent Predictor of Clinical Outcome in Health Care-Associated Pneumonia.

Background: Early prediction of the clinical outcomes for health care-associated pneumonia (HCAP) patients is challenging. Objectives: This is the first study to evaluate procalcitonin (PCT) as a predictor of outcomes in HCAP patients. Methods: We conducted an observational study based on data for HCAP patients prospectively collected between 2011 and 2014. Outcome variables were intensive care unit (ICU) admission and 30-day mortality. PCT was categorized into three groups: <0.5, 0.5-2.0, and >2.0 ng/ml. We analysed multiple variables including age, sex, comorbidities, clinical findings, and PCT group to assess their association with outcomes. Results: Of 245 HCAP patients, 99 (40.4%) were admitted to an ICU and 44 (18.0%) died within 30 days. The median PCT level was significantly higher in the ICU admission (1.19 vs. 0.4 ng/ml; p < 0.001) and 30-day mortality (3.3 vs. 0.4 ng/ml; p < 0.001) groups. In multivariate analysis, high PCT (>2.0 ng/ml) was strongly associated with ICU admission [odds ratio 3.734, 95% confidence interval (CI) 1.753-7.951; p = 0.001] and 30-day mortality (hazard ratio 2.254, 95% CI 1.250-5.340; p = 0.035). In receiver operating characteristic analysis, PCT had a poor discrimination power regarding ICU admission [0.695 of the area under the curve (AUC)] and a fair discrimination power regarding 30-day mortality in HCAP patients (0.768 of the AUC). Conclusions: High PCT on admission was strongly associated with ICU admission and 30-day mortality in HCAP patients. However, application of PCT alone seems to be limited to predicting outcomes.