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\"The Age of Doubt collects some of Pak Kyongni’s most famous works, including her 1955 debut and other stories featuring characters that would appear in her 21-volume epic, Toji. Many of Pak’s stories reflect her own turbulent experiences during the period following the Korean war and the various South Korean dictatorships throughout the twentieth century\"--Amazon.com.

The aim of this study was to compare out-of-hospital cardiac arrest (OHCA) outcomes before and after implementation of Smart Advanced Life Support (SALS) protocol incorporating changes in cardiopulmonary resuscitation (CPR) assistance and coaching by physicians via real-time video calls. A prospective before-and-after multi-regional observational study was conducted between January 2014 and December 2018. In January 2016, emergency medical service (EMS) providers adopted an integrated CPR coaching by physicians via real-time video call via SALS to treat patients with OHCA focusing on high-quality cardiopulmonary resuscitation. Propensity score matching was performed to match patients. Patients' outcomes using conventional protocol were then compared with those of patients using the SALS protocol. Among 26,349 OHCA cases, 2351 patients and 7261 patients were enrolled during the pre-intervention and the post-intervention periods, respectively. Multivariate analysis showed that SALS was independently associated with favorable neurological outcomes [odds ratio (OR): 2.20; 95% confidence interval (CI): 1.62–2.99]. A total of 2096 patients were propensity score-matched and the two groups were well balanced. In the matched cohort, the use of SALS protocol was still associated with increased prehospital return of spontaneous circulation (ROSC) (OR: 3.83, 95% CI: 2.80–5.26), survival to discharge (OR: 1.68; 95% CI: 1.20–2.34), and favorable neurological outcomes (OR: 1.83; 95% CI: 1.19–2.82). A multidisciplinary SALS protocol for the resuscitation of patients with OHCA was associated with increased prehospital ROSC, survival to discharge, and good neurologic outcomes compared with traditional resuscitation protocol.

Out-of-hospital cardiac arrest (OHCA) outcomes are unsatisfactory despite postcardiac arrest care. Early prediction of prognoses might help stratify patients and provide tailored therapy. In this study, we derived and validated a novel scoring system to predict hypoxic-ischemic brain injury (HIBI) and in-hospital death (IHD). We retrospectively analyzed Korean Hypothermia Network prospective registry data collected from in Korea between 2015 and 2018. Patients without neuroprognostication data were excluded, and the remaining patients were randomly divided into derivation and validation cohorts. HIBI was defined when at least one prognostication predicted a poor outcome. IHD meant all deaths regardless of cause. In the derivation cohort, stepwise multivariate logistic regression was conducted for the HIBI and IHD scores, and model performance was assessed. We then classified the patients into four categories and analyzed the associations between the categories and cerebral performance categories (CPCs) at hospital discharge. Finally, we validated our models in an internal validation cohort. Among 1373 patients, 240 were excluded, and 1133 were randomized into the derivation (n = 754) and validation cohorts (n = 379). In the derivation cohort, 7 and 8 predictors were selected for HIBI (0–8) and IHD scores (0−11), respectively, and the area under the curves (AUC) were 0.85 (95% CI 0.82–0.87) and 0.80 (95% CI 0.77–0.82), respectively. Applying optimum cutoff values of ≥6 points for HIBI and ≥7 points for IHD, the patients were classified as follows: HIBI (−)/IHD (−), Category 1 (n = 424); HIBI (−)/IHD (+), Category 2 (n = 100); HIBI (+)/IHD (−), Category 3 (n = 21); and HIBI (+)/IHD (+), Category 4 (n = 209). The CPCs at discharge were significantly different in each category (p < 0.001). In the validation cohort, the model showed moderate discrimination (AUC 0.83, 95% CI 0.79–0.87 for HIBI and AUC 0.77, 95% CI 0.72–0.81 for IHD) with good calibration. Each category of the validation cohort showed a significant difference in discharge outcomes (p < 0.001) and a similar trend to the derivation cohort. We presented a novel approach for assessing illness severity after OHCA. Although external prospective studies are warranted, risk stratification for HIBI and IHD could help provide OHCA patients with appropriate treatment.

Objectives: This study aimed to compare the predictive performance of the Korean Triage and Acuity Scale (KTAS) and the National Early Warning Score (NEWS) for serious adverse events (SAEs), including mortality and intensive care unit (ICU) admission, during emergency department (ED) stay. We also evaluated whether combining the two systems improves prediction accuracy. Methods: This retrospective study included adult patients (≥19 years) who presented to a university-affiliated ED between October and December 2024. KTAS and NEWS were assessed simultaneously at triage. NEWS2 was calculated retrospectively based on routinely documented vital signs and medical history without performing routine arterial blood gas analysis. The primary outcome was the occurrence of SAE during the ED stay. Predictive performance was evaluated using receiver operating characteristic (ROC) curves and the area under the curve (AUC), and logistic regression models were used to identify independent associations. Results: A total of 4216 patients were analyzed, of whom 255 (6.0%) experienced SAEs. All three scores—KTAS, NEWS and NEWS2—were independently associated with the occurrence of SAEs. The AUCs for KTAS, NEWS and NEWS2 were 0.75 (95% CI, 0.74–0.76), 0.73 (95% CI, 0.71–0.74) and 0.73 (95% CI, 0.71–0.74), respectively. Combining KTAS with NEWS or NEWS2 significantly improved predictive accuracy (AUC 0.81, 95% CI 0.79–0.82; p < 0.001). Conclusions: Both KTAS and NEWS/NEWS2 reliably predicted in-ED adverse outcomes, and their combination further enhanced prognostic performance. Integrating physiology-based early warning scores with structured triage systems may help identify high-risk ED patients earlier and optimize resource allocation.

Introduction: Kyushin is a widely used herbal medicine in East Asia for heart failure. Toad venom in present in Kyushin, which has positive inotropic effect as digitoxin. Case presentation: An 81-year-old, female patient presented with decreased mental status after overdose of Kyushin. The first electrocardiogram showed junctional tachycardia with 142/min, suddenly dropped to 27/min and followed by ventricular fibrillation. After one cycle of CPR, spontaneous circulation returned but junctional bradycardia, tachycardia, and ventricular fibrillation appeared. After six times of defibrillation, spontaneous circulation returned, and mechanical ventilator and transcutaneous pacing were applied. Plasma toxicology test revealed digitoxin 66.90 ng/mL by cloned enzyme donor immunoassay and digoxin 0.76 ng/mL by kinetic interaction of microparticles in solution immunoassay. After 8 h from presentation, the patient's mental status came to be alert, and then transcutaneous pacing was removed. Discussion: Cloned enzyme donor immunoassay has been reported to be highly cross-reactive with digoxin-like substances, which strongly supports bufotoxin to be responsible for arrhythmia of the patient. Conclusion: Poisoning of bufotoxin in Kyushin can cause cardiac arrhythmia, even arrest, but without digoxin-specific Fab, conventional therapy could be successful.

Objectives: The purpose of this study was to analyze the effect of cardiac arrest recognition by emergency medical dispatch on the pre-hospital advanced cardiac life support and to investigate the outcome of out-of-hospital cardiac arrest. Method: This study was conducted to evaluate the out-of-hospital cardiac arrest patients over 18 years of age, excluding trauma and poisoning patients, from 1 August 2015 to 31 July 2016. We investigated whether it was a cardiac-arrest recognition at dispatch. We compared the pre-hospital return of spontaneous circulation, the rate of survival admission and discharge, good neurological outcome, and also analyzed the time of securing vein, time of first epinephrine administration, and arrival time of paramedics. Results: A total of 3695 out-of-hospital cardiac arrest patients occurred during the study period, and 1468 patients were included in the study. Resuscitation rate by caller was significantly higher in the recognition group. The arrival interval between the first and second emergency service unit was shorter as 5.1 min on average, and the connection rate of paramedics and physicians before the arrival was 32.3%, which was significantly higher than that of the unrecognized group. The mean time required to first epinephrine administration was 13.1 min, which was significantly faster in the recognition group. However, there was no statistically significant difference between the two groups in patients with good neurological outcome, and rather the rate of return of spontaneous circulation and survival discharge was significantly higher in the non-recognition group. Conclusion: Although the recognition of cardiac arrest at dispatch does not directly affect survival rate and good neurological outcome, the activation of pre-hospital advanced cardiac life support and the shortening the time of epinephrine administration can increase pre-hospital return of spontaneous circulation. Therefore, effort to increase recognition by dispatcher is needed.

There is growing evidence that inflammation plays an important role in atherogenesis. Previous studies have shown that the concentration of peripheral inflammatory markers, particularly C-reactive protein (CRP), strongly correlates with stroke severity and independently predicts mortality and recurrent vascular events in patients with acute ischemic stroke. The aim of this study was to clarify the relationship between inflammatory markers and stroke severity by means of volumetric measurement of infarct size. From March 1, 2008, to February 28, 2009, 96 patients who had laboratory investigations and magnetic resonance imaging scans were included retrospectively in this study. Diffusion-weighted imaging (DWI) lesions were outlined using a semiautomatic threshold technique. Diffusion-weighted imaging lesion volumes were measured with MIPAV software (Medical Image Processing, Analysis and Visualization, version 4.1.1; National Institutes of Health, Bethesda, MD). The relationship between highly selective CRP (hs-CRP) levels and DWI infarct volume quartiles was examined. The mean age of patients was 66.9 years, and 50 patients (51.2%) were male. There was a significant correlation between hs-CRP and DWI volumes (Spearman ρ = 0.239, P = .010). The median hs-CRP values for successive volumes of DWI lesion quartiles (lowest to highest quartile) were as follows: 1.17, 1.14, 1.63, and 3.76 ( P = .029). Higher hs-CRP levels were associated with larger infarct volumes in patients with acute ischemic stroke. These results suggest that elevated hs-CRP levels, reflecting a large volume of infarct, may serve as a helpful serologic marker in the evaluation of severity of acute ischemic stroke.

It is often difficult to diagnose acute myocardial infarction (AMI) in patients who resuscitated after out-of-hospital cardiac arrest (OHCA) and had a delayed elevation in cardiac marker. This study explored whether elevations in cardiac marker were due to coronary artery occlusion or resulted from other causes. The study included 19 non–ST-segment elevation patients who resuscitated after OHCA and underwent delayed coronary angiography. We checked patients' serial creatine kinase–myocardial band (CK-MB) and troponin I (cTnI) levels on arrival and 6, 12, 24, 48, 72, and 96 hours postarrest. Based on the association of elevated cTnI and the results of their delayed angiographies, the patients were retrospectively divided into 2 groups: an AMI group (n = 5) and a non-AMI group (n = 14). We then analyzed the serial cardiac marker measurements in each group. Peak marker levels were significantly higher in the AMI group than in the non-AMI group (CK-MB, 177.0 ± 112.7 vs 66.4 ± 85.2 ng/mL; P = .033 and cTnI, 40.4 ± 14.5 vs 10.6 ± 13.5 ng/mL; P = .005). After adjusting for covariates, the peak and 6-, 12-, and 24-hour cTnI and 6-hour CK-MB were significantly different between the 2 groups (P = .005, P = .004, P = .005, P = .020, and P = .007). In the non-AMI group, 3 patients had cTnI values that were within the reference range at all of the evaluated times. Most patients had only low cTnI elevations that rapidly fell back to normal. The resuscitation of patients who experience sudden OHCA but do not have an AMI may lead to elevations of cardiac markers. However, these elevations are low and normalize early.

The association of body mass index with outcome in patients treated with targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) is unclear. The purpose of this study was to examine the effect of body mass index (BMI) on neurological outcomes and mortality in resuscitated patients treated with TTM after OHCA. This multicenter, prospective, observational study was performed with data from 22 hospitals included in the Korean Hypothermia Network KORHN-PRO registry. Comatose adult patients treated with TTM after OHCA between October 2015 and December 2018 were enrolled. The BMI of each patient was calculated and classified according to the criteria of the World Health Organization (WHO). Each group was analyzed in terms of demographic characteristics and associations with six-month neurologic outcomes and mortality after cardiac arrest (CA). Of 1,373 patients treated with TTM identified in the registry, 1,315 were included in this study. One hundred two patients were underweight (BMI <18.5 kg/m2), 798 were normal weight (BMI 18.5-24.9 kg/m2), 332 were overweight (BMI 25-29.9 kg/m2), and 73 were obese (BMI ≥ 30 kg/m2). The higher BMI group had younger patients and a greater incidence of diabetes and hypertension. Six-month neurologic outcomes and mortality were not different among the BMI groups (p = 0.111, p = 0.234). Univariate and multivariate analyses showed that BMI classification was not associated with six-month neurologic outcomes or mortality. In the subgroup analysis, the underweight group treated with TTM at 33°C was associated with poor neurologic outcomes six months after CA (OR 2.090, 95% CI 1.010-4.325, p = 0.047), whereas the TTM at 36°C group was not (OR 0.88, 95% CI 0.249-3.112, p = 0.843). BMI was not associated with six-month neurologic outcomes or mortality in patients surviving OHCA. However, in the subgroup analysis, underweight patients were associated with poor neurologic outcomes when treated with TTM at 33°C.

The aim of this study was to investigate the associative factors of rhabdomyolysis in patients with doxylamine overdose who had normal creatine phosphokinase levels at admission. This study included 169 patients who visited the emergency department of a tertiary teaching hospital after doxylamine overdose between January 1, 1998, and March 31, 2009. Demographic information, clinical variables, and laboratory data were investigated for the associative factors of rhabdomyolysis. Thirty-five (21%) of the 169 patients developed rhabdomyolysis. Patients who developed rhabdomyolysis differed from those who did not in the amount of doxylamine ingested, sex, heart rate, initial value of serum creatinine, and alanine aminotransferase. In the multivariate regression analysis, the only reliable predictors of rhabdomyolysis were the amount of doxylamine ingested ( P = .004) and heart rate ( P < .001). Observation and laboratory follow-up are required for patients with large reported ingestions or tachycardia on admission, even if their creatine phosphokinase levels were normal.