Youngho Jin

Validation of modified early warning score using serum lactate level in community-acquired pneumonia patients. The National Early Warning Score–Lactate score ☆ ☆☆ ★ ★★ ☆☆☆

STUDY OBJECTIVE The aim of this study was to investigate the prognostic prediction power of a newly introduced early warning score modified by serum lactate level, the National Early Warning Score-Lactate (NEWS-L) score, among community-acquired pneumonia (CAP) patients. We also compared the NEWS-L score with the pneumonia severity index (PSI) and CURB-65. METHODS We designed a retrospective observational study and collected data on confirmed adult CAP patients who visited the study hospital between October 2013 and September 2014. Variables relevant to, the NEWS-L score, PSI, and CURB-65 were extracted from electronic medical records. Survival status at hospital discharge was determined in the same manner. The NEWS-L score was calculated as NEWS-L=NEWS+serum lactate level (mmol/L). The NEWS-L was divided into quartiles. The ability to predict mortality was assessed through area under the receiver operating characteristic curve analysis and calibration analysis. RESULTS A total of 553 patients were enrolled, and the inpatient mortality rate was 10.8% (n=60). Mortality rates increased incrementally in conjunction with the NEWS-L quartiles: first quartile, 2.2%; second quartile, 7.9%; third quartile, 9.6%; and fourth quartile, 23.9%. The area under the receiver operating characteristic curve of the NEWS-L score was 0.73 (95% confidence interval [CI], 0.66-0.80), which showed no significant difference from that of the PSI (0.68; 95% CI, 0.61-0.76; P=.28) and CURB-65 (0.66; 95% CI, 0.59-0.73; P=.06). CONCLUSIONS The newly introduced early warning score modified by serum lactate level, NEWS-L score, was comparable to PSI and CURB-65, for predicting inpatient mortality among adult CAP patients.

Predictive value of the National Early Warning Score–Lactate for mortality and the need for critical care among general emergency department patients ☆ ☆☆ ★

STUDY OBJECTIVES What is the predictive value of the National Early Warning Score-Lactate (NEWS-L) score for mortality and the need for critical care in general emergency department (ED) patients? METHODS In this retrospective cohort study, we enrolled all adult patients who visited the ED of an urban academic tertiary-care university hospital in South Korea over 2 consecutive months. The primary outcome was 2-day mortality. The secondary outcomes were the need for critical care (advanced airway use, vasopressor or inotropic agent use, intensive care unit admission) during an ED stay; 2-day composite outcome (2-day mortality and the need for critical care); 7-day mortality; and in-hospital mortality. RESULTS During the study period, 4624 adult patients visited the ED. Of these, 87 (1.9%) died within 2 days. In total, 481 patients (10.4%) required critical care during their ED stay. The 2-day composite outcome, 7-day mortality, and in-hospital mortality were 10.9% (503/4624), 2.5% (116/4624), and 3.9% (182/4624), respectively. The NEWS-L demonstrated excellent predictive value for 2-day mortality with an area under the receiver operating characteristic curve (AUROC) of 0.96 (95% confidence interval [CI], 0.94-0.98); this value was better than that of the NEWS alone (AUROC 0.94 [95% CI, 0.91-0.96], P=.002). The AUROC of the NEWS-L for the need for critical care was 0.83 (95% CI, 0.81-0.85); for the 2-day composite outcome, it was 0.84 (95% CI, 0.82-0.86); for 7-day mortality, it was 0.94 (95% CI, 0.92-0.96); and for in-hospital mortality, it was 0.87 (95% CI, 0.85-0.90). Logistic regression results confirmed that the ratio of the NEWS to the initial lactate level was 1:1. Similar results were obtained in the subgroup analyses (disease-infection, disease-vascular and heart, disease-others, and nondisease). The high-risk NEWS-L group (NEWS-L≥7, 9.4% of all patients) had an adjusted odds ratio of 28.67 (12.66-64.92) for 2-day mortality in the logistic regression model adjusted for basic characteristics. CONCLUSION The NEWS-L can provide excellent discriminant value for predicting 2-day mortality in general ED patients, and it has the best discriminant value regarding the need for critical care and composite outcomes. The NEWS-L may be helpful in the early identification of at-risk general ED patients.

Isolated bilateral vocal cord paralysis with intermediate syndrome after organophosphate poisoning

Introduction. Muscular weakness affecting predominantly the proximal limb muscles and neck flexors is the cardinal feature of intermediate syndrome with cranial nerve palsies occasionally accompanied. Following acute cholinergic phase of organophosphate poisoning (OPP), only a few isolated cases of vocal cord paralysis have been reported in the past. We describe a case of bilateral vocal cord paralysis which occurred in the wake of a clinical recovery from acute cholinergic crisis in OPP. Case report. A 32-year-old woman presented with severe cholinergic crisis after ingestion of an unknown amount of dichlorvos in a suicide attempt. The patient was improved from cholinergic crisis by administration of antidotes. On day 4, she complained of progressive dyspnea and dysphonia after removal of the endotracheal tube. Needle electromyography for neuromuscular confirmation was normal. However, laryngeal electromyography (LEMG) findings were consistent with bilateral laryngeal paralysis suggesting the vagus nerve involvement. Her vocal cord movements were restored to near normal with time and she was discharged on the 20th day after admission. Conclusions. Physicians should account for the neurotoxic effects of organophosphate poisoning during the first line management of exposed patients. Isolated bilateral vocal cord paralysis (BVCP) should be excluded as a cause, if dysphonia or respiratory distress occurs after extubation in patients with intermediate syndrome. LEMG in such cases can be an important diagnostic adjunct.

Diagnostic performance of initial serum albumin level for predicting in-hospital mortality among aspiration pneumonia patients

Purpose: The predictive value of serum albumin in adult aspiration pneumonia patients remains unknown. Methods: Using data collected during a 3‐year retrospective cohort of hospitalized adult patients with aspiration pneumonia, we evaluated the predictive value of serum albumin level at ED presentation for in‐hospital mortality. Results: 248 Patients were enrolled; of these, 51 cases died (20.6%). The mean serum albumin level was 3.4 ± 0.7 g/dL and serum albumin levels were significantly lower in the non‐survivor group than in the survivor group (3.0 ± 0.6 g/dL vs. 3.5 ± 0.6 g/dL). In the multivariable logistic regression model, albumin was associated with in‐hospital mortality significantly (adjusted odds ratio 0.30, 95% confidential interval (CI) 0.16–0.57). The area under the receiver operating characteristics (AUROC) for in‐hospital survival was 0.72 (95% CI 0.64–0.80). The Youden index was 3.2 g/dL and corresponding sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratio were 68.6%, 66.5%, 34.7%, 89.1%, 2.05 and 0.47, respectively. High sensitivity (98.0%) was shown at albumin level of 4.0 g/dL and high specificity (94.9%) was shown at level of 2.5 g/dL. Conclusion: Initial serum albumin levels were independently associated with in‐hospital mortality among adult patients hospitalized with aspiration pneumonia and demonstrated fair discriminative performance in the prediction of in‐hospital mortality.

Mean airway pressure and outcome of OHCA

We read with great interest the article by Chalkias et al.1 preenting the significant difference of mean airway pressure (mPaw) fter the onset of the third minute of CPR between survivors nd non-survivors. And I agree with their theory that the rise of ntrathoracic pressure can be transmitted equally to all intrathoacic structures thus it can squeeze out the pulmonary vessel, which ead to increment of forward blood flow and arterial oxygen partial ressure. This study would be a brilliant start up for the next study egarding the role of mPaw during CPR. However, I would like to propose some points regarding this tudy. The authors’ main finding is a difference in mPaw between urvivors and non-survivors after the onset of the third minute of PR. However, I can not find out any third minutes in the whole anuscript. Rather 2, 4, 6, 8, and 10 min were consistently used n tables and figures. I wish that authors reveal the ‘third minute’ ore specifically. Second, the authors reported that a mPaw value of 42.5 mbar ver the entire CPR was the point of maximizing both senitivity and specificity (Youden index). However, mPaw is 9.82 ± 5.01 mbar in return of spontaneous circulation (ROSC) atients (survivor in this study) and 23.61 ± 11.89 mbar in nonOSC patients (non-survivor in this study). The value of 42.5 mbar s substantially far away of mean value of mPaw, suggesting that 2.5 mbar could be an extreme end. Commonly extreme end could ot be the Youden index. Third, Fig. 3 in this study showed the area under the curve (AUC) alue of 0.668. However, it seems that AUC value of this graph

Does Lactate Ringer Matter or Sodium-Free Solution Matter?

A careful inspection of our article provides the answer for the first two queries. First, it is expected that percentage of infused fluids would present a certain degree of collinearity. We acknowledge this in the methods, and we have designed our principal component analysis (PCA) specifically in order to assess this issue. Our main focus was on whether the percentage of fluid infused as lactated Ringer (%LR) could be associated with worse outcomes. This is why our logistic regression model focused on %LR. Like saline, D5W is a solution with a strong ion difference (SID) of zero—in other words, the normal difference between Na and Cl found in blood plasma is not present in the solution. We were not surprised to see that this solution was not exempt of side effects in our PCA. comorbidities and diagnosis. It may not be so simple to conclude which solution is beneficial using data from a heterogeneous cohort. The authors have disclosed that they do not have any potential conflicts of interest.

Is a blood filled heart more susceptible to electric shock

Interestingly, Steinberg et al.1 reported different rates for the ermination of VF/VT (TOF) after electric shocks among the three hases of load distributing band-cardiopulmonary resuscitation LDB-CPR). Using a CIRC trial2 which compared manual chest comressions with the integrated use of mechanical LDB-CPR, the uthors analyzed the success rates of TOF with 244 first electric hocks and 685 up-to-three shocks categorized according to three DB compression cycle phases: compression, decompression and elaxation. The control group was shocked during a compression ause, in which LDB device stopped by the rescuer. In cases of rst shock, the TOF success rate was highest in the control group 69/80, 86%) followed by the decompression (18/23, 78%), relaxtion (29/39, 74%), and compression (41/57, 72%) phase groups. egarding up-to-three shocks, the results were similar: control roup (216/263, 82%), and decompression (45/58, 78%), relaxation 103/138, 75%) and compression (119/168, 71%) phase groups. here was a statistically significant difference between the conrol and compression groups. This was the first report to evaluate OF success rates among three phases in human. Although the physiological mechanism remains unknown, the uthors proposed two hypotheses for their findings. The first was change in the position and shape of the heart during the comression phase compared with during the decompression and elaxation phases. Because the placement of external defibrillaor pads is based on the normal anatomical location of the heart, hanges in the intrathoracic configuration during compression may ause a disturbance in the angle of the electrodes. The second was higher tetanic contraction induced by the combination of chest ompressions and electric shocks. In an animal model, tetanic conraction was almost doubled when the shock was delivered in the ompression phase compared with that in the decompression or elaxation phase.3 With due regard for the authors’ insights, we ropose third hypothesis. The electric impedance varies among tissues. The order of mpedance from the least resistant to the most resistant is as folows: nerves, blood, mucous membranes, muscle, dry skin, tendon, at tissue, and bone.4 Based on this physiological characteristic, we an deduce that a blood-filled (or blood-in) heart may be more suseptible to electric current than a blood-out heart. Venous blood ows into the heart during decompression phase, is maintained uring the relaxation phase, exits the heart during the compression hase. Therefore, the heart would be filled with blood (blood-filled eart) during the decompression and relaxation phases, and empied of blood (blood-out heart) during the compression phase. This ypothesis is another potential explanation for the results of the resent study.

Comprehensive interpretation of hyperglycemia and hyperosmolality on the clinical outcomes among ischemic stroke patients

BACKGROUND Hyperglycemia and hyperosmolality are associated with poor outcomes among acute ischemic stroke (AIS) patients. OBJECTIVES We evaluated the association between hyperglycemia and hyperosmolality, as a combination measure, with poor outcome among AIS patients. METHODS We conducted a retrospective study of AIS patients admitted to the study hospital emergency department between January and December 2014. Hyperglycemia was defined as serum glucose >144 mg/dL, and hyperosmolality was defined as a serum osmolality >295 mOsm/kg. After excluding hypoglycemia and hypoosmolality, the enrolled patients were classified into the following 4 subgroups: normoglycemia-normoosmolality, hyperglycemia-normoosmolality (HGNO), normoglycemia-hyperosmolality (NGHO), and hyperglycemia-normoosmolality (HGHO). The primary outcome was poor neurological status at 6 months, which was defined as a modified Rankin scale score ≥2. RESULTS Six hundred seven patients were included. The primary outcome was 336 (55.4%), and it was highest in the HGNO group (69.6%, 103/148), followed by the HGHO group (67.9%, 53/78), the NGHO group (57.3%, 43/75) and the normoglycemia-normoosmolality group (44.7%, 137/306). The multivariable logistic regression analysis revealed that HGNO and HGHO remained significant factors, with primary outcomes (adjusted odds ratio, 2.08; 95% confidence interval, 1.16-3.71) and 2.93 (1.45-5.91), respectively), whereas NGHO was not a significant factor. Cases of extremely high sodium levels were few in the NGHO and HGHO groups, whereas considerable cases of extremely high glucose level were observed in the HGHO group. CONCLUSION Hyperglycemia was associated with poor outcome, even after excluding the effect of hyperosmolality. However, hyperosmolality without hyperglycemia was not associated with poor outcome. An additive effect, likely reflecting severe hyperglycemia, was observed.