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ABSTRACT: AIM OF THE STUDY: Valproic acid (VPA) has been known to reduce neuronal injury, have anti-inflammatory and anti-apoptotic effects as a histone deacetylase (HDAC) inhibitor. Thus, this study was performed to investigate the effects of VPA on survival and neurological outcomes in an asphyxial cardiac arrest model of rats. METHODS: Male Sprague-Dawley rats were subjected to asphyxial cardiac arrest. For survival study, rats were subjected to 450seconds of asphyxial cardiac arrest. Cardiopulmonary resuscitation (CPR) was performed and then rats were blindly allocated to one of two groups (control group, n=10; VPA group, n=10). Valproic acid (300mg/Kg) or vehicle (normal saline) was administered via tail vein immediately after return of spontaneous circulation (ROSC) and observed for 72hours. For neurological outcome study, rats (n=7 for each group) were subjected to same experimental procedures except duration of cardiac arrest of 360seconds. Neurological deficit scale (NDS) score was measured every 24hours after ROSC for 72hours and was ranged from 0 (brain dead) to 80 (normal). Brain tissues were harvested at 72hours for evaluation of apoptotic injury and acetylation status of histone H3. RESULTS: In survival study, 2 rats in VPA group were excluded because cardiac arrest was not achieved in predetermined time. Thus, 10 rats were allocated to control group and 8 rats were allocated to VPA group. The survival rates at 72hours after cardiac arrest were significantly higher in VPA group than in control group (6/8 in VPA group, 3/10 rats in control group; log rank test, p<0.05). In neurological outcome study, all rats survived for 72hours and NDS at 72hour were significantly higher in VPA group than in control group (p<0.05). In brain tissues, expressions of acetylated histone H3 were not significantly different. However, expressions of cleaved caspase-3 were significantly lower in VPA group than in control group (p <0.05). CONCLUSION: VPA increased survival rates and improved neurologic outcome in asphyxial cardiac arrest model of rats while decreasing expressions of cleaved caspase-3.
Resuscitation 05/2013; · 3.60 Impact Factor
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ABSTRACT: OBJECTIVES: There are no guidelines regarding the hospitalization of female patients with acute pyelonephritis (APN); therefore, we performed a retrospective analysis to construct a clinical prediction model for hospital admission. METHODS: We conducted a retrospective analysis of a prospective database of women diagnosed as having APN in the emergency department between January 2006 and June 2012. Independent risk factors for admission were determined by multivariable logistic regression analysis in half of the patients in this database. The risk of admission was categorized into 5 groups. The internal and external validations were conducted using the remaining half of the patients and 192 independent patients, respectively. RESULTS: Independent risk factors for admission were age of 65 years or greater (odds ratio [OR], 2.62; 1 point), chill (OR, 2.40; 1 point), and the levels of segmented neutrophils greater than 90% (OR, 2.00; 1 point), serum creatinine greater than 1.5 mg/dL (OR, 2.41; 1 point), C-reactive protein greater than 10 mg/dL (OR, 2.37; 1 point), and serum albumin less than 3.3 g/dL (OR, 7.36; 2 points). The admission risk scores consisted of 5 categories, which were very low (0 points; 5.9%), low (1 point; 10.7%), intermediate (2 points; 20.7%), high (3-4 points; 51.9%), and very high (5-7 points; 82.8%) risk, showing an area under the curve of 0.770. The areas under the curve of the internal and external validation cohorts were 0.743 and 0.725, respectively. CONCLUSION: This model can provide a guideline to determine the admission of women with APN in the emergency department.
The American journal of emergency medicine 04/2013; · 1.54 Impact Factor
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Joonghee Kim,
Kyuseok Kim,
Sungmin Hong,
Bojun Kwon,
Il Dong Yun,
Byung Se Choi,
Cheolkyu Jung,
Jae Hyuk Lee, You Hwan Jo,
Taeyun Kim,
Joong Eui Rhee,
Soo Hoon Lee
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ABSTRACT: OBJECTIVE: Recent studies suggested quantitative analysis of diffusion-weighted magnetic resonance imaging as a promising tool for early prognostication of cardiac arrest patients. However, most of their methods involve significant manual image handling often subjective and difficult to reproduce. Therefore developing a computerized analysis method using easy-to-define characteristics would be useful. METHODS: Comatose out-of-hospital cardiac arrest (OHCA) patients who underwent brain MRI between Jan, 2008 and July, 2012 were identified from an OHCA registry. Apparent diffusion coefficient (ADC) axial images were analyzed using a program to detect and characterize clusters of low ADC pixels from six brain regions including frontal, occipital, parietal, rolandic and temporal and basal ganglia region. Identified clusters were ranked according to size, mean ADC and minimum ADC to assess the regional maximum cluster size (MCS), lowest mean ADC (LMEAN) and lowest minimum ADC (LMIN). Their power to predict poor outcome, defined as 6-month CPC 3 or higher, was assessed by contingency table analyses. RESULTS: 51 OHCA patients were eligible during the study period. The sensitivities of MCS, LMEAN and LMIN to detect poor outcome varied according to brain region from 62.5 to 90.0%, 50.0 to 72.5% and 42.5 to 82.5% with their specificities set to 100%, respectively. The MCS of occipital region showed most favorable test profile (sensitivity 90%, specificity 100%; AUROC 0.940, 95% confidence interval 0.874 to 1.000) CONCLUSION: The cluster-based computerized image analysis might be a simple but useful method for prediction of poor neurologic outcome. Future studies validating its prognostic performance are required.
Resuscitation 04/2013; · 3.60 Impact Factor
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ABSTRACT: OBJECTIVE: This study was performed to investigate the association of red cell distribution width (RDW) with 28-day mortality in patients with severe sepsis and septic shock. METHODS: We performed a retrospective analysis of patients with severe sepsis and septic shock. Patients' demographic data, comorbidities, the blood test results including RDW at admission to the emergency department, and Acute Physiologic and Chronic Health Evaluation II score were compared between 28-day survivors and nonsurvivors. Red cell distribution width was categorized into tertiles as 14% or less, 14.1% to 15.7%, and 15.8% or greater. Multivariate Cox proportional hazards regression analysis was performed to determine the risk factors for mortality. RESULTS: A total of 566 patients were included, and overall mortality was 29%. Red cell distribution width was significantly higher in nonsurvivors than in survivors, and the corresponding mortality of patients with an RDW of 14% or less, 14.1% to 15.7%, and 15.8% or greater was 13.1%, 30.1%, and 44.9%, respectively (P < .001). In Cox proportional hazards analysis, groups with higher RDW are independently associated with 28-day mortality compared with groups with an RDW of 14.0% or less: RDW 14.1% to 15.7% (hazard ratio, 1.66; 95% confidence interval [CI], 1.00-2.76) and RDW of 15.8% or greater (hazard ratio, 2.57; 95% CI, 1.53-4.34). The area under the receiver operating curve of RDW was 0.68 (95% CI, 0.63-0.72). CONCLUSION: Red cell distribution width is associated with 28-day mortality in patients with severe sepsis and septic shock.
The American journal of emergency medicine 02/2013; · 1.54 Impact Factor
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ABSTRACT: OBJECTIVE: Ketamine is used intramuscularly or intravenously as a sedative when repairing the skin lacerations of children in many emergency departments (EDs). Nitrous oxide (N2O) has the advantages of being a sedative agent that does not require a painful injection and that offers shallower levels of sedation and a rapid recovery of mental state. We evaluated the clinical usefulness of N2O compared with intravenous ketamine when used for the repair of lacerations in children in the ED. METHODS: From January to December 2009, we performed a prospective, randomized study at a single academic ED enrolling pediatric patients aged 3 to 10 years who needed primary repair of a laceration wound. The primary outcome was recovery time, which was defined as the time from completion of procedure to recovery of mental state. Other outcomes were sedation depth, pain scale, adverse effects, and satisfaction with sedation. RESULTS: There were 32 children who were randomly assigned. Recovery times were shorter in the N2O group compared with those in the ketamine group (median [interquartile range (IQR)], 0.0 minutes, [0.0-4.0 minutes] vs 21.5 minutes [12.5-37.5 minutes], P < 0.05). Sedation levels were deeper in the ketamine group than in the N2O group, but pain scales were comparable between groups. No difference was observed in the satisfaction scores by physicians, parents, or nurses. CONCLUSIONS: Nitrous oxide inhalation was preferable to injectable ketamine for pediatric patients because it is safe, allows for a faster recovery, maintains sufficient sedation time, and does not induce unnecessarily deep sedation.
Pediatric emergency care 11/2012; · 0.92 Impact Factor
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ABSTRACT: AIM OF STUDY: The effects of therapeutic hypothermia (HT) during experimental sepsis may be influenced by disease severity. We experimentally investigated the effect of therapeutic HT on varying disease severity in a septic rat model. MATERIALS AND METHODS: An adult male Sprague-Dawley rat model of intra-abdominal sepsis was used. To modify the disease severity, we used two different models; a moderate severe sepsis model (MSSM) and a severe septic shock model (SSSM). All rats were randomized to a hypothermia group (HT, 30-32°C) or a normothermia group (NT, 36-38°C) 1h after sepsis induction in each model. HT was maintained for 4h and rewarming was conducted for 2h. Survival time was recorded for up to 12h in the SSSM group and 24h in the MSSM group. Acute lung and liver injury, cytokine, and malondialdehyde (MDA) levels were investigated 7h after sepsis induction. Hemodynamic profiles were also evaluated. RESULTS: In the SSSM, there were survival benefits and reduced acute lung and liver injury with therapeutic HT. Therapeutic HT was also associated with significantly reduced levels of plasma interleukin-6 and tissue malondialdehyde (MDA) levels in the liver and lung compared with the NT group in the SSSM. There was a tendency for the mean arterial pressure to be higher in the HT group compared to the NT group in the SSSM. In MSSM, however, there was no such beneficial effect. CONCLUSION: In this rat model of severe septic shock, therapeutic HT showed beneficial effects. In contrast, therapeutic HT did not show protective effect in the moderate sepsis model.
Cytokine 09/2012; · 3.02 Impact Factor
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ABSTRACT: OBJECTIVE: We sought to investigate the prognostic implication of early coagulopathy represented by initial DIC score in out-of-hospital cardiac arrest (OHCA). METHODS: OHCA registry was analyzed to identify patients with ROSC without recent use of anticoagulant between 2008 and 2011. Patients were assessed for prehosptial factors, initial laboratory results and therapeutic hypothermia. Outcome variables were survival discharge, 6-month CPC and survival duration within the first week after ROSC. Logistic regression and Cox proportional hazards models were used for both univariable and multivariable analysis. RESULTS: Among 273 eligible patients, initial DIC score was available in 252 (92.3%). Higher DIC score was associated with increased inhospital death (odds ratio [OR], 1.89 per unit; 95% confidence interval [CI], 1.48-2.41) and unfavorable long-term outcome (6-month CPC 3-5; OR, 2.21 per unit; 95% CI, 1.60-3.05). The adjusted ORs for both outcomes were 1.61 (95% CI, 1.17-2.22) and 1.84 (95% CI, 1.26-2.67), respectively. We categorized DIC score in five groups as <3, 3, 4, 5 and >5 and analyzed differential mortality risk using Cox proportional hazards model. Compared with reference group (DIC score<3), the adjusted HR for early mortality in each remaining group was 1.96 (95% CI, 1.13-3.40), 2.26 (95% CI, 1.27-4.02), 2.77 (95% CI, 1.58-4.85) and 4.29 (95% CI, 2.22-8.30), respectively (p-trend<0.001). The area under the receiver operating characteristic of DIC score for prediction of unfavorable long-term outcome was 0.79 (95% CI, 0.69-0.88). CONCLUSION: Increased initial DIC score in OHCA was an independent predictor for poor outcomes and early mortality risk.
Resuscitation 09/2012; · 3.60 Impact Factor
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ABSTRACT: BACKGROUND: MRI-based prognostication of comatose cardiac arrest survivors has shown promising results. However, the technique has not been validated in patients treated with therapeutic hypothermia and it is unknown how it might add to NSE-based prognostication. We sought to evaluate the prognostic performance of regional apparent diffusion coefficient (ADC) in comatose out-of-hospital cardiac arrest (OHCA) patients treated with mild hypothermia and its added value to NSE-based prognostication. METHODS: An OHCA registry was analyzed to identify OHCA patients older than 15 who were treated with therapeutic hypothermia and underwent brain MRI between 2008 and 2011. Quantitative measurement of regional ADCs was performed by a radiologist blinded to the clinical outcome. RESULTS: Of the 43 eligible patients, 11 (18.6 %) achieved a good outcome (6-month CPC of 1 or 2). The regional ADC of the occipital cortex showed the highest discriminatory power with an area under the curve of receiver operating characteristic (AUROC) of 0.943 (95 % CI, 0.872-1.000) and predicted poor outcomes with a sensitivity of 90.6 % and a specificity of 100 %. The AUROC for NSE levels (48-h) was 0.911 (95 % CI, 0.801-1.000) which was significantly correlated with the regional ADC (Pearson's r = -0.674, p < .001). The ADC-based predictions identified an additional 5 (35.7 %) poor outcome patients out of 14 with 48-h NSE levels less than 78.9 ng/mL, which is the cutoff point suggested in a previous study. However, additional prognostic information was not provided when the 48-h NSE levels were >78.9 ng/mL. CONCLUSIONS: Regional ADC-based prognostication was accurate in OHCA patients who were treated with mild hypothermia. However, it only provided additional prognostic information when the 48-h NSE levels indicated a good prognosis (48-h NSE <78.9 ng/mL).
Neurocritical Care 08/2012; · 2.47 Impact Factor
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ABSTRACT: BACKGROUND: Red cell distribution width (RDW) is associated with mortality in both the general population and in patients with certain diseases. However, the relationship between RDW and mortality in patients with community-acquired pneumonia (CAP) is unknown. The objective of this study was to evaluate the association of RDW with mortality in patients with CAP. METHODS: We performed a retrospective analysis of a prospective registry database of patients with CAP. Red cell distribution width was organized into quartiles. The pneumonia severity index (PSI) and CURB-65 were calculated. The primary outcome was 30-day mortality. Secondary outcomes included the length of hospital stay, admission to the intensive care unit, vasopressor use, and the need for mechanical ventilation. RESULTS: A total of 744 patients were included. The PSI and CURB-65 were higher in patients with a high RDW. Multivariate logistic regression analysis identified higher categories of RDW, PSI, CURB-65, and albumin as statistically significant variables. Thirty-day mortality was significantly higher in patients with a higher RDW. Among the secondary outcomes, the length of hospital stay and vasopressor use were significantly different between the groups. In a Cox proportional hazard regression analysis, patients with higher categories of RDW exhibited increased mortality before and after adjustment of the severity scales. Receiver operating characteristics curves demonstrated improved mortality prediction when RDW was added to the PSI or CURB-65. CONCLUSION: Red cell distribution width was associated with 30-day mortality, length of hospital stay, and use of vasopressors in hospitalized patients with CAP. The inclusion of RDW improved the prognostic performance of the PSI and CURB-65.
The American journal of emergency medicine 08/2012; · 1.54 Impact Factor
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ABSTRACT: INTRODUCTION: The prophylactic coadministration of anticholinergics during dissociative sedation has been considered necessary to mitigate ketamine-associated hypersalivation. Given recent conflicting conclusions regarding adjunctive atropine, we compared the incidence of hypersalivation, degree of secretion, and related side effects with atropine or placebo as an adjunct to intravenous (IV) ketamine sedation for children. METHODS: This controlled trial randomized children, 1 to 10 years old, requiring ketamine sedation in a tertiary emergency department to receive 0.01 mg/kg of atropine or placebo, along with IV ketamine (2 mg/kg). A nurse rated preprocedure and postprocedure salivation on a 100-mm visual analog scale and recorded the frequency and nature of airway complications and interventions for hypersalivation. RESULTS: During 27 months, 140 patients were enrolled. Baseline characteristics did not differ between the 2 groups (P > .05). Secretion was significantly less in the atropine vs placebo group (mean visual analog scale score ± SD, 21.2 ± 13.1 [preprocedure] to 16.5 ± 9.9 [postprocedure] vs 22.4 ± 13.5 [preprocedure] to 27.0 ± 15.9 [postprocedure], respectively; P < .05). Visual analog scale scores greater than 50 were assigned to 7 (9.7%) of 72 and 1 (1.5%) of 68 patients in the placebo and atropine groups, respectively; these patients needed only medical procedures such as suction or airway repositioning. Heart rate was significantly higher in the atropine group compared with the placebo group (P < .05). There were no significant differences between the groups in terms of other adverse events. CONCLUSION: Atropine as an adjunct to IV ketamine sedation in children significantly reduced hypersalivation, without providing a clinical benefit.
The American journal of emergency medicine 06/2012; · 1.54 Impact Factor
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Jae Hyuk Lee,
Kyuseok Kim, You Hwan Jo,
Min A Kim,
Kwang Pil Rim,
Kyeong Won Kang,
Joong Eui Rhee,
Min Ji Lee,
Hyun Sook Lee,
Woon Yong Kwon,
Gil Joon Suh
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ABSTRACT: BACKGROUND: Therapeutic hypothermia has been proposed to protect organs in some diseases. However, the effect of therapeutic hypothermia on liver injury in sepsis is unknown. The aim of this study was to evaluate the effects of therapeutic hypothermia on liver injury in sepsis. METHODS: Male Sprague-Dawley rats underwent cecal ligation and incision (CLI). We randomly allocated rats into one of two groups 1 h after CLI: hypothermia (HT) and normothermia (NT). In the HT group, body temperature decreased to 32°C ± 0.5°C and was maintained 4 h, followed by rewarming to 37°C for 2 h. In the NT group, body temperature was maintained at 37°C ± 0.5°C throughout the experimental periods. At 7 h after CLI, we harvested blood and liver tissues and measured serum alanine aminotransferase and the histological liver injury score. We performed immunohistochemistry for cleaved caspase-3 and evaluated phosphorylation of Akt, GSK-3β and Bad with the Western blot assay. RESULTS: Serum alanine aminotransferase was significantly lower in the HT group than in the NT group (57.0 ± 6.0 IU/L versus 192.5 ± 92.5 IU/L; P = 0.028). The histological liver injury score was also significantly lower in the HT group than in the NT group (2.9 ± 0.5 versus 5.4 ± 0.6; P = 0.016). Phosphorylation of Akt, GSK-3β, and Bad was significantly increased in the HT group compared with the NT group (P < 0.001, P = 0.007, and P = 0.001, respectively). Hypothermia significantly mitigated expression of cleaved caspase-3 compared with the NT group (P = 0.032). CONCLUSIONS: Therapeutic hypothermia attenuated liver injury in a polymicrobial sepsis model of rats by enhancing the Akt signaling pathway and decreasing apoptosis.
Journal of Surgical Research 06/2012; · 2.25 Impact Factor
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ABSTRACT: AIM OF THE STUDY: N-acetylcysteine (NAC) has been investigated to attenuate organ injury in various experimental and clinical studies. However, results in hemorrhagic shock (HS) were controversial. We determined the effects of continuous administration of NAC on acute lung injury (ALI) and acute kidney injury (AKI) in HS model. METHODS: Twenty male Sprague-Dawley rats were used. Pressure controlled HS model defined by mean arterial pressure (MAP) 40±2mmHg for 90min followed by resuscitation and observation was used. Rats (n=10 per group) were randomized into 2 groups with NAC or dextrose. Intravenous NAC was given continuously from 15min after induction of HS to the end of observation period (2h). We measured serum IL-6, nitrite/nitrate concentration. NF-κB p65 DNA binding activity, expressions of cytoplasmic phosphorylated IκB-α (p-IκB-α) and IκB-α, malondialdehyde (MDA) and histopathological injury scores in lung and kidney were also evaluated. RESULTS: MAP did not show any difference during the study period. NAC decreased histopathologic scores in both lung and kidney. Lung and kidney MDA levels were significantly lower in the NAC group compared to control group. Serum nitrite/nitrate and IL-6 were also significantly lower in the NAC group. The levels of lung cytoplasmic p-IκB-α expression was mitigated by NAC, and NF-κB p65 DNA binding activity was also significantly decreased in the NAC group. CONCLUSIONS: Continuous infusion of NAC attenuated inflammatory response and acute lung and kidney injury after hemorrhagic shock in rats.
Resuscitation 06/2012; · 3.60 Impact Factor
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ABSTRACT: OBJECTIVE: This study was performed to evaluate whether heart-type fatty acid-binding protein (H-FABP) could predict 28-day mortality in patients with severe sepsis and septic shock. METHODS: We performed a prospective observational study and included consecutive patients with severe sepsis and septic shock. Patients' demographic data, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and the blood test results including H-FABP concentrations were compared between the 28-day survivors and nonsurvivors. The association between the concentration of H-FABP and survival was analyzed with multivariate logistic regression and Cox proportional hazards regression analyses. The prognostic performance of H-FABP was compared with those of the APACHE II score and albumin using the area under the receiver operating characteristic curve. RESULTS: Of the 99 patients, 38 (38%) died. The mortality rate increased with increasing H-FABP concentration. In multivariate logistic regression analyses, H-FABP greater than 40 ng/mL was an independent predictor of mortality compared with H-FABP less than 7 ng/mL (odds ratios, 9.23; 95% confidence interval, 1.29-65.86). By Cox proportional hazards analysis, H-FABP greater than 40 ng/mL was associated with a 5.57-fold increased risk for death during the 28-day follow-up period (hazard ratio, 5.57; 95% confidence interval, 1.20-25.80). The area under the receiver operating characteristic curve of H-FABP was 0.739 (95% confidence interval, 0.640-0.839), which was comparable with those of the APACHE II score and albumin. CONCLUSION: The H-FABP was an independent prognostic factor and could be a useful biomarker for 28-day mortality in patients with severe sepsis and septic shock.
The American journal of emergency medicine 03/2012; · 1.54 Impact Factor
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ABSTRACT: Post-resuscitation period is characterized by high early mortality due to post-cardiac arrest syndrome. Recent studies found that elevated red cell distribution width (RDW) is a strong predictor of mortality in critically ill patients. We investigated the prognostic significance of RDW in out-of-hospital cardiac arrest (OHCA) victims.
Analysis of emergency department OHCA registry extending from January 2007 to December 2010 was conducted. Patients with ROSC were assessed for Utstein predictors including sex, age, arrest location, presence of witness, bystander cardiopulmonary resuscitation, response time, initial rhythm and cause of arrest. RDW, hematocrit, white blood cell and platelet counts, blood urea nitrogen (BUN), creatinine and albumin were also obtained. Outcome variable was survival duration within 30 days. RDW was categorized in quartiles as <13.2%, 13.2% to 14.0%, 14.1% to 15.4% and >15.4%. Hazard ratios (HRs) were estimated using Cox-proportional hazard models in both univariate and multivariate analysis. All prognostic variables with their p value<0.1 in univariate analysis were used in multivariate analysis for adjustment.
Among 409 OHCA patients, 219 patients had ROSC. Highest RDW quartile (RDW>15.4%), female sex, older age, non-shockable initial rhythm, increased BUN and creatinine and decreased albumin, hematocrit and platelet count were associated with increased mortality in univariate analysis. In multivariate analysis, the highest RDW quartile was independently associated with all-cause mortality (HR=1.95; 95% CI 1.05-3.60; p=0.034) during 30-day post-resuscitation period. Other significant variables were age, initial rhythm and serum albumin.
Initial RDW is an independent predictor of all-cause mortality in post-resuscitation patients.
Resuscitation 02/2012; 83(10):1248-52. · 3.60 Impact Factor
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Jae Hyuk Lee,
Kyuseok Kim, You Hwan Jo,
Joong Eui Rhee,
Jung Chan Lee,
Kyung Su Kim,
Woon Yong Kwon,
Gil Joon Suh,
Hee Chan Kim,
Ho Il Yoon,
Sang Heon Park
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ABSTRACT: Glucose control is important in the management of critically ill patients. However, strict glucose control requires a large amount of nursing resources, especially in overcrowded emergency departments (EDs).
A continuous glucose monitoring system (CGMS) may be beneficial for glucose control in the ED. The objective of this study was to determine the test characteristics of CGMS in critically ill ED patients.
A prospective observational study of critically ill ED patients was conducted. During a patient's visit to the ED, a CGMS sensor measured their interstitial fluid glucose levels continuously. Capillary glucose was measured every hour and used for glucose control and as a reference value. CGMS values were recorded in real time and compared with capillary glucose values.
A total of 122 pairs of capillary and CGMS glucose values in 12 patients were analyzed. The correlation coefficient was 0.87, and Bland-Altman analysis showed that 117 pairs (95.9%) were within a 95% confidence interval. A Clarke Error Grid Analysis indicated an overall accuracy of 96.8% (Zones A and B). However, the mean absolute relative difference (MARD) was significantly higher in the hypoglycemic range than in a normo- or hyperglycemic range (p = 0.001). The sensitivity and positive predictive value of CGMS for detecting hypoglycemia were 33.3% and 16.7%, respectively. The CGMS specificity and negative predictive value were 95.8% and 98.3%, respectively. There was no linear correlation between MARD and body mass index, axillary temperature, inotrope score, and base deficit (all p-value >0.05).
CGMS demonstrated good clinical accuracy by Clarke Error Grid Analysis. There also was high agreement between CGMS and capillary glucose levels. However, CGMS demonstrated only limited real-time hypoglycemia detection ability in critically ill ED patients.
Journal of Emergency Medicine 10/2011; 43(2):251-7. · 1.31 Impact Factor
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ABSTRACT: To construct a simple model to predict bacteremia in women with uncomplicated acute pyelonephritis (APN) for the judicious use of blood cultures.
A prospective database including 735 women with uncomplicated APN at an academic urban emergency department was analyzed retrospectively. Independent risk factors were determined using multivariate logistic regression in two-thirds of patients. Cutoff values representing 10% and 30% of risk were selected for the stratification. This model was internally and externally validated using a remaining one-thirds of patients and 169 independent patients, respectively.
Independent risk factors were as follows: age ≥65 years (odds ratio [OR]=5.18, 4 points), vomiting (OR=2.40, 2 points), heart rate >110 beats/min (OR=2.35, 2 points), segmented neutrophils >90% (OR=3.17, 3 points), and urine WBC ≥50/HPF (OR=4.27, 4 points). Patients were stratified as low (points <4), intermediate (points, 4-6), or high risk (7≤ points). The areas under receiver operating characteristics curves were 0.707 and 0.792 in internal and external validation cohorts, respectively. The model stratified internal and external validation cohort into low (8.5% and 5.7%), intermediate (16.5% and 14.8%), and high risk of bacteremia (42.0% and 56.4%).
This model provides a useful tool to predict the risk of bacteremia, which can be helpful to decide whether to perform blood cultures and whether to admit the patient for the intravenous antibiotics in women with uncomplicated APN.
The Journal of infection 06/2011; 63(2):124-30. · 4.13 Impact Factor
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ABSTRACT: Abdominal contrast-enhanced computed tomography (A-CECT) is widely used in emergency departments despite the risk of contrast-induced nephropathy. We attempted to develop a risk stratification nomogram for nephropathy in patients receiving emergency A-CECT.
Seven hundred fifty patients who received emergency A-CECT between August 2003 and January 2007, with available serum creatinine (SCr) measurements before and after A-CECT were included. Nephropathy was defined as either an absolute increase of 0.5 mg/dL or greater (44 μmol/L) or a relative increase of 25% or more in the SCr from baseline. A nomogram was developed based on multivariate logistic regression analysis using clinical variables available before A-CECT. The model was internally validated with a bootstrapping method, and performance was assessed by area under the receiver operating characteristics curve (AUC) and calibration curve.
Nephropathy was observed in 34 of 750 patients. A nomogram was developed using age (odds ratio, 1.04 per 1-year increment) and baseline SCr (odds ratio, 2.51 per 1-mg/dL increment) as risk factors. Diagnostic accuracy of the model was fair by bias-corrected calibration plot. The AUC of the model was 0.794 (95% confidence interval, 0.734-0.854), and the AUC with bootstrapping samples of 200 repetitions was 0.794 (95% confidence interval, 0.737-0.851).
The risk of nephropathy after emergency A-CECT can be individually predicted by internally validated nomogram using clinical variables available before the procedure.
The American journal of emergency medicine 05/2011; 29(4):412-7. · 1.54 Impact Factor
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ABSTRACT: The prognostic role of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with community-acquired pneumonia (CAP) has not been evaluated. The aim of the present study was to investigate whether NT-proBNP level could predict mortality in hospitalised CAP patients.
We performed a structured medical record review of all hospitalised CAP patients from May 2003 to October 2006, and classified patients into the 30-day survival and non-survival group. Data included demographic and clinical characteristics, and laboratory findings including NT-proBNP levels. The APACHE II scores, PSI (pneumonia severity index) and CURB65 (confusion, urea, respiratory rate, blood pressure and aged 65 or more) scores were calculated. Comparisons between survivors and non-survivors were made with χ(2), non-parametric tests and logistic regression and ROC analysis were used to compare the ability of NT-proBNP (adjusted for age, heart failure and creatinine), APACHE II, PSI and CURB65 to predict mortality.
Of 502 patients, 61 (12.2%) died within 30 days. NT-proBNP levels were measured in 167 patients and were significantly higher in non-survivors compared to survivors (median 841.7 (IQR 267.1-3137.3) pg/ml vs 3658.0 (1863.0-7025.0) pg/ml, p=0.019). NT-proBNP was an independent predictor of mortality (adjusted OR 1.53; 95% CI 1.16 to 2.02, p=0.002). The AUC for NT-proBNP was 0.712 (95% CI, 0.613 to 0.812), which was comparable to those of PSI (0.749, p=0.531) and CURB65 (0.698, p=0.693), but inferior to that of APACHE II (0.831, p=0.037). Adding NT-proBNP to APACHE II, PSI and CURB65 did not significantly increase the AUCs, respectively.
NT-proBNP level is an independent predictor of mortality in hospitalised CAP patients. The performance of NT-proBNP level is comparable to those of PSI and CURB65 in predicting mortality.
Emergency Medicine Journal 02/2011; 28(2):122-7. · 1.44 Impact Factor
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Kyung Su Kim,
Hui Jai Lee,
Kyuseok Kim, You Hwan Jo,
Tae Yun Kim,
Jin Hee Lee,
Joong Eui Rhee,
Gil Joon Suh,
Mi Ran Kim,
Christopher C Lee,
Adam J Singer
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ABSTRACT: We hypothesized that when used in combination with cardiac troponins, heart-type fatty acid binding protein (H-FABP) would have greater diagnostic value than conventional markers for the early diagnosis of myocardial infarction (MI). Patients with typical chest pain at a single emergency department were consecutively enrolled. Initial blood samples were drawn for H-FABP, myoglobin, creatine kinase isoenzyme MB (CK-MB), and cardiac troponin-I (cTnI) measurements. MI was defined by serial cTnI measurements. To evaluate the adjunctive role of biochemical markers, we derived and compared logistic regression models predicting MI in terms of their discrimination (area under the receiver operating characteristics curve, AUC) and overall fit (Bayesian information criterion, BIC). Seventy-six of 170 patients were diagnosed as having MI. The AUC of cTnI, H-FABP, myoglobin, and CK-MB were 0.863, 0.827, 0.784, and 0.772, respectively. A logistic regression model using cTnI (P = 0.001) and H-FABP (P < 0.001) had the biggest AUC (0.900) and the best fit determined by BIC. Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of this model at 30% probability were 81.6%, 80.9%, 4.26, and 0.23, respectively. H-FABP has a better diagnostic value than both myoglobin and CK-MB as an adjunct to cTnI for the early diagnosis of MI.
Journal of Korean medical science 01/2011; 26(1):47-52. · 0.84 Impact Factor
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ABSTRACT: 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.
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.
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).
Therapeutic hypothermia delayed early mortality and attenuated acute lung injury in paraquat intoxication.
Resuscitation 01/2011; 82(4):487-91. · 3.60 Impact Factor
