Investigating Associations Between Nonadherence to Guideline-Recommended Treatment of Pediatric Seizures and Adverse Outcomes: A Canadian Feasibility Study.

BACKGROUND: Emerging evidence suggests that nonadherence to treatment guidelines for seizures may affect patient outcomes. We examined the feasibility of conducting a larger investigation to test this hypothesis in the pediatric population. METHODS: We retrospectively reviewed charts of patients aged ≤18 years who presented with seizure to the emergency departments of two Ontario hospitals in 2019 to 2021. Patients were grouped by seizure duration (<5 minutes [n = 37], ≥5 minutes [n = 41]). We examined nonadherence to guideline-recommended treatment, adverse outcomes (hospitalization, length of stay, respiratory complications), and missing values for key variables. RESULTS: Of 78 patients, 34 (44%) did not receive guideline-recommended treatment. Nonadherence was similar in the two groups (<5 minutes: 46%; ≥5 minutes: 41%). Common deviations included administering an antiseizure medication (ASM) for seizures of less than five minutes (46%), a delay (>10 minutes) between the first and second ASM doses (50%), and use of a benzodiazepine for the third dose (45%). Hospitalizations were common in both seizure duration groups (∼90%), whereas respiratory complications were relatively rare. Time of seizure onset was missing in 51% of charts, and none contained the time of first contact with emergency services when patients were transported by ambulance. CONCLUSION: We found evidence of substantial nonadherence to guideline-recommended treatment of pediatric seizures. Medical records do not contain sufficient information to comprehensively investigate this issue. A multicenter prospective study is the most feasible option to examine the association between nonadherence to guideline-recommended treatment and patient outcomes.

Erratum to "Wolf Creek XVII Part 5: Mobile AEDs" [Resusc. Plus 16 (2023) 100500].

[This corrects the article DOI: 10.1016/j.resplu.2023.100500.].

An ecotoxicological assessment of a strigolactone mimic used as the active ingredient in a plant biostimulant formulation.

A risk assessment on the aquatic toxicity of the plant biostimulant strigolactone mimic (2-(4-methyl-5-oxo-2,5-dihydro-furan-2-yloxy)-benzo[de]isoquinoline-1,3-dione (SL-6) was performed using a suite of standardised bioassays representing different trophic groups and acute and chronic endpoints. In freshwater, three trophic groups of algae, crustacea and fish were used. Whilst in seawater, algae (unicellular and macroalgae), Crustacea and Mollusca were employed. In addition, the genotoxicity of SL-6 was determined with the comet assessment performed on unicellular marine algae, oysters, and fish embryos. This was the first time ecotoxicity tests have been performed on SL-6. In freshwater, the lowest LOEC was measured in the unicellular algae at 0.31 mg/L SL-6. Although, similar LOEC values were found for embryo malformations and impacts on hatching rate in zebrafish (LOEC 0.31-0.33 mg/L). Consistent malformations of pericardial and yolk sac oedemas were identified in the zebrafish embryos at 0.31 mg/L. In marine species, the lowest LOEC was found for both Tisbe battagliai mortality and microalgae growth at an SL-6 concentration of 1.0 mg/L. Significant genotoxicity was observed above control levels at 0.0031 mg/L SL-6 in the unicellular algae and 0.001 mg/L SL-6 in the oyster and zebrafish larvae. When applying the simple risk assessment, based on the lowest NOECs and appropriate assessment factors, the calculated predicted no effect concentration (PNEC), for the ecotoxicity and the genotoxicity tests were 1.0 µg/L and 0.01 µg/L respectively.

The American Heart Association Emergency Cardiovascular Care 2030 Impact Goals and Call to Action to Improve Cardiac Arrest Outcomes: A Scientific Statement From the American Heart Association.

Every 10 years, the American Heart Association (AHA) Emergency Cardiovascular Care Committee establishes goals to improve survival from cardiac arrest. These goals align with broader AHA Impact Goals and support the AHA's advocacy efforts and strategic investments in research, education, clinical care, and quality improvement programs. This scientific statement focuses on 2030 AHA emergency cardiovascular care priorities, with a specific focus on bystander cardiopulmonary resuscitation, early defibrillation, and neurologically intact survival. This scientific statement also includes aspirational goals, such as establishing cardiac arrest as a reportable disease and mandating reporting of standardized outcomes from different sources; advancing recognition of and knowledge about cardiac arrest; improving dispatch system response, availability, and access to resuscitation training in multiple settings and at multiple time points; improving availability, access, and affordability of defibrillators; providing a focus on early defibrillation, in-hospital programs, and establishing champions for debriefing and review of cardiac arrest events; and expanding measures to track outcomes beyond survival. The ability to track and report data from these broader aspirational targets will potentially require expansion of existing data sets, development of new data sets, and enhanced integration of technology to collect process and outcome data, as well as partnerships of the AHA with national, state, and local organizations. The COVID-19 (coronavirus disease 2019) pandemic, disparities in COVID-19 outcomes for historically excluded racial and ethnic groups, and the longstanding disparities in cardiac arrest treatment and outcomes for Black and Hispanic or Latino populations also contributed to an explicit focus and target on equity for the AHA Emergency Cardiovascular Care 2030 Impact Goals.

Wolf Creek XVII Part 5: Mobile AEDs.

Introduction: Millions of out-of-hospital cardiac arrests (OHCA) occur globally each year. Survival after OHCA can be improved with the use of automated external defibrillators (AED). The main strategy for facilitating bystander defibrillation has been fixed-location public access defibrillators (PADs). New strategies of mobile AEDs depart from the model of static PADs and have the potential to address known barriers to early defibrillation and improve outcomes. Methods: Mobile AEDs was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023, in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of cardiac arrest resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised, and ranked by all attendees to identify the top 5 for each category. Results: Top knowledge gaps center around understanding the impact of mobile AEDs on OHCA outcomes in various settings and the impact of novel AED technologies. Top barriers to translation include questionable public comfort/acceptance, financial/regulatory constraints, and a lack of centralized accountability. Top research priorities focus on understanding the impact of the mobile AED strategies and technologies on time to defibrillation and OHCA outcomes. Conclusion: This work informs research agendas, funding priorities and policy decisions around using mobile AEDs to optimize prehospital response to OHCA.

A recipe for plastic: Expert insights on plastic additives in the marine environment.

The production and consumption of plastic products had been steadily increasing over the years, leading to more plastic waste entering the environment. Plastic pollution is ubiquitous and comes in many types and forms. To enhance or modify their properties, chemical additives are added to plastic items during manufacturing. The presence and leakage of these additives, from managed and mismanaged plastic waste, into the environment are of growing concern. In this study, we gauged, via an online questionnaire, expert knowledge on the use, characteristics, monitoring and risks of plastic additives to the marine environment. We analysed the survey results against actual data to identify and prioritise risks and gaps. Participants also highlighted key factors for future consideration, including gaining a deeper understanding of the use and types of plastic additives, how they leach throughout the entire lifecycle, their toxicity, and the safety of alternative options. More extensive chemical regulation and an evaluation of the essentiality of their use should also be considered.

Do DOM quality and origin affect the uptake and accumulation of lipid-soluble contaminants in coastal filter feeders? An experimental simulation of teflubenzuron exposure to blue mussels.

The increased export of terrestrial dissolved organic matter (terrDOM) to coastal marine ecosystems may affect local filter feeders and the local food web via the altered uptake of organic material and associated contaminants. To compare terrDOM to marine DOM (marDOM) as contaminant vectors to coastal biota, we exposed blue mussels (Mytilus sp.) to the different DOM types in combination with teflubenzuron, a widely applied lipophilic aquaculture medicine targeting salmon lice (Lepeophtheirus salmonis). A 16-day exposure of the blue mussels to DOM and teflubenzuron was followed by a depuration phase of 20 days without teflubenzuron. We calculated teflubenzuron adsorption rates and bioaccumulation factors (BAF) using a Bayesian model, expecting teflubenzuron uptake to be greater with terrDOM than marDOM due to the higher prevalence of large amphipathic humic acids in terrDOM. Humic acids have strong absorption properties and are able to envelope lipophilic molecules. Thus, humic acids can function as an efficient contaminant vector when taken up by filter feeders. Although there were varying degrees of overlap, the mussels tended to accumulate higher amounts of teflubenzuron in the DOM treatments than in the seawater control (bioaccumulation factor [BAF] in seawater: median 106 L/kg; 2.5 %-97.5 % percentile: 69-160 L/kg). Contrary to expectations, mussels exposed to marDOM showed a trend toward more bioaccumulation of teflubenzuron than those exposed to terrDOM (BAF marine 144 L/kg; 102-221 L/kg versus BAF terrestrial: 121 L/kg; 82-186 L/kg). The highest teflubenzuron accumulation was observed with the 50:50 mixture of marDOM and terrDOM (BAF mix: 165 L/kg; 117-244 L/kg). The slight difference in DOM-type accumulation rates observed in this experiment-especially the accumulation rate of terrDOM compared to that of the seawater-only treatment type-was not considered environmentally relevant. Further studies are necessary to see if the observed trends transfer to complex environmental systems.

Small-angle strabismus detection by telemedicine in an experimental model.

PURPOSE: To evaluate the ability of observers to accurately detect strabismus using an alternate cover testing approach via telemedicine and to assess the effect of various factors related to video conditions on the accuracy rate. METHODS: Videos were made by the authors in which different angles of strabismus, up to 12Δ, were induced by prism and recorded using alternate cover testing. The videos were made under a variety of conditions that incorporated various head postures, lighting, fixation target position and motion, and viewing angle. The videos were shown to observers of varying levels of expertise. The accuracy of detecting the deviation was assessed and analyzed for statistical significance. RESULTS: The overall rate of detection was significantly affected by the angle of deviation, with 12Δ being correctly detected with 94% accuracy, 8Δ with 72% accuracy, and 4Δ with <50% accuracy. Esotropia and hypertropia were more accurately detected than exotropia for all angles tested. The level of training of the observer did not correlate with detection accuracy. However, accuracy was negatively affected by backlighting and movement of the fixation target during cover testing. CONCLUSIONS: Our data demonstrate that detection of even relatively small angles of strabismus can be accomplished with a high level of accuracy using telemedicine and an alternate cover testing strategy. For optimal results, it is important to consider conditions related to the fixation target and lighting.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation.

AIM OF THE REVIEW: Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS: The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS: There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS: All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Alpha globin gene copy number and incident ischemic stroke risk among Black Americans.

Introduction: People with African ancestry have greater stroke risk and greater heritability of stroke risk than people of other ancestries. Given the importance of nitric oxide (NO) in stroke, and recent evidence that alpha globin restricts nitric oxide release from vascular endothelial cells, we hypothesized that alpha globin gene (HBA) deletion would be associated with reduced risk of incident ischemic stroke. Methods: We evaluated 8,947 participants self-reporting African ancestry in the national, prospective Reasons for Geographic And Racial Differences in Stroke (REGARDS) cohort. Incident ischemic stroke was defined as non-hemorrhagic stroke with focal neurological deficit lasting ≥ 24 hours confirmed by the medical record or focal or non-focal neurological deficit with positive imaging confirmed with medical records. Genomic DNA was analyzed using droplet digital PCR to determine HBA copy number. Multivariable Cox proportional hazards regression was used to estimate the hazard ratio (HR) of HBA copy number on time to first ischemic stroke. Results: Four-hundred seventy-nine (5.3%) participants had an incident ischemic stroke over a median (IQR) of 11.0 (5.7, 14.0) years' follow-up. HBA copy number ranged from 2 to 6: 368 (4%) -α/-α, 2,480 (28%) -α/αα, 6,014 (67%) αα/αα, 83 (1%) ααα/αα and 2 (<1%) ααα/ααα. The adjusted HR of ischemic stroke with HBA copy number was 1.04; 95%CI 0.89, 1.21; p = 0.66. Conclusions: Although a reduction in HBA copy number is expected to increase endothelial nitric oxide signaling in the human vascular endothelium, HBA copy number was not associated with incident ischemic stroke in this large cohort of Black Americans.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation.

AIM OF THE REVIEW: Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS: The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS: There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS: All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Community Interventions for Out-of-Hospital Cardiac Arrest in Resource-Limited Settings: A Scoping Review Across Low, Middle, and High-Income Countries.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a major global health challenge, characterized by poor survival outcomes worldwide. Resource-limited settings are burdened with suboptimal emergency response and worse outcomes than high-resource areas. Engaging the community in the response to OHCA has the potential to improve outcomes, although an overview of community interventions in resource-limited settings has not been provided. OBJECTIVE: This review evaluated the scope of community-based OHCA interventions in resource-limited settings. METHODS: Literature searches in electronic databases (MEDLINE, EMBASE, Global Health, CINAHL, Cochrane Central Register of Controlled Clinical Trials) and grey literature sources were performed. Abstract screening, full-text review, and data extraction of eligible studies were conducted independently by two reviewers. The PCC (Population, Concept, and Context) framework was used to assess study eligibility. Studies that evaluated community-based interventions for laypeople (Population), targeting emergency response activation, cardiopulmonary resuscitation (CPR), or automated external defibrillator (AED) use (Concept) in resource-limited settings (Context) were included. Resource-limited settings were identified by financial pressures (low-income or lower-middle-income country, according to World Bank data on year of publication) or geographical factors (setting described using keywords indicative of geographical remoteness in upper-middle-income or high-income country). RESULTS: Among 14,810 records identified from literature searches, 60 studies from 28 unique countries were included in this review. Studies were conducted in high-income (n = 35), upper-middle-income (n = 2), lower-middle-income (n = 22), and low-income countries (n = 1). Community interventions included bystander CPR and/or AED training (n = 34), community responder programs (n = 8), drone-delivered AED networks (n = 6), dispatcher-assisted CPR programs (n = 4), regional resuscitation campaigns (n = 3), public access defibrillation programs (n = 3), and crowdsourcing technologies (n = 2). CPR and/or AED training were the only interventions evaluated in low-income, lower-middle-income, and upper-middle-income countries. CONCLUSIONS: Interventions aimed at improving the community response to OHCA in resource-limited settings differ globally. There is a lack of reported studies from low-income countries and certain continental regions, including South America, Africa, and Oceania. Evaluation of interventions other than CPR and/or AED training in low- and middle-income countries is needed to guide community emergency planning and health policies.

Accuracy of Self-Reported COVID-19 Vaccination Status Compared With a Public Health Vaccination Registry in Québec: Observational Diagnostic Study.

BACKGROUND: The accuracy of self-reported vaccination status is important to guide real-world vaccine effectiveness studies and policy making in jurisdictions where access to electronic vaccine registries is restricted. OBJECTIVE: This study aimed to determine the accuracy of self-reported vaccination status and reliability of the self-reported number of doses, brand, and time of vaccine administration. METHODS: This diagnostic accuracy study was completed by the Canadian COVID-19 Emergency Department Rapid Response Network. We enrolled consecutive patients presenting to 4 emergency departments (EDs) in Québec between March 24, 2020, and December 25, 2021. We included adult patients who were able to consent, could speak English or French, and had a proven COVID-19 infection. We compared the self-reported vaccination status of the patients with their vaccination status in the electronic Québec Vaccination Registry. Our primary outcome was the accuracy of the self-reported vaccination status (index test) ascertained during telephone follow-up compared with the Québec Vaccination Registry (reference standard). The accuracy was calculated by dividing all correctly self-reported vaccinated and unvaccinated participants by the sum of all correctly and incorrectly self-reported vaccinated and unvaccinated participants. We also reported interrater agreement with the reference standard as measured by unweighted Cohen κ for self-reported vaccination status at telephone follow-up and at the time of their index ED visit, number of vaccine doses, and brand. RESULTS: During the study period, we included 1361 participants. At the time of the follow-up interview, 932 participants reported at least 1 dose of a COVID-19 vaccine. The accuracy of the self-reported vaccination status was 96% (95% CI 95%-97%). Cohen κ for self-reported vaccination status at phone follow-up was 0.91 (95% CI 0.89-0.93) and 0.85 (95% CI 0.77-0.92) at the time of their index ED visit. Cohen κ was 0.89 (95% CI 0.87-0.91) for the number of doses, 0.80 (95% CI 0.75-0.84) for the brand of the first dose, 0.76 (95% CI 0.70-0.83) for the brand of the second dose, and 0.59 (95% CI 0.34-0.83) for the brand of the third dose. CONCLUSIONS: We reported a high accuracy of self-reported vaccination status for adult patients without cognitive disorders who can express themselves in English or French. Researchers can use self-reported COVID-19 vaccination data on the number of doses received, vaccine brand name, and timing of vaccination to guide future research with patients who are capable of self-reporting their vaccination data. However, access to official electronic vaccine registries is still needed to determine the vaccination status in certain susceptible populations where self-reported vaccination data remain missing or impossible to obtain. TRIAL REGISTRATION: Clinicaltrials.gov NCT04702945; https://clinicaltrials.gov/ct2/show/NCT04702945.

Intubation practices and outcomes for patients with suspected or confirmed COVID-19: a national observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN).

OBJECTIVE: Intubation practices changed during the COVID-19 pandemic to protect healthcare workers from transmission of disease. Our objectives were to describe intubation characteristics and outcomes for patients tested for SARS CoV-2 infection. We compared outcomes between patients testing SARS COV-2 positive with those testing negative. METHODS: We conducted a health records review using the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. We included consecutive eligible patients who presented to one of 47 EDs across Canada between March 1, 2020 and June 20, 2021, were tested for SARS-CoV-2 and intubated in the ED. The primary outcome was the proportion of patients experiencing a post-intubation adverse event during the ED stay. Secondary outcomes included first-pass success, intubation practices, and hospital mortality. We used descriptive statistics to summarize variables with subgroup differences examined using t tests, z tests, or chi-squared tests where appropriate with 95% CIs. RESULTS: Of 1720 patients with suspected COVID-19 who were intubated in the ED during the study period, 337 (19.6%) tested SARS-CoV-2 positive and 1383 (80.4%) SARS-CoV-2 negative. SARS-CoV-2 positive patients presented to hospital with lower oxygen levels than SARS-CoV-2 negative patients (mean pulse oximeter SaO2 86 vs 94%, p < 0.001). In total, 8.5% of patients experienced an adverse event post-intubation. More patients in the SARS-CoV-2 positive subgroup experienced post-intubation hypoxemia (4.5 vs 2.2%, p = 0.019). In-hospital mortality was greater for patients who experienced intubation-related adverse events (43.2 vs 33.2%, p = 0.018). There was no significant difference in adverse event-associated mortality by SARS-CoV-2 status. First-pass success was achieved in 92.4% of all intubations, with no difference by SARS-CoV-2 status. CONCLUSIONS: During the COVID-19 pandemic, we observed a low risk of adverse events associated with intubation, even though hypoxemia was common in patients with confirmed SARS-CoV-2. We observed high rates of first-pass success and low rates of inability to intubate. The limited number of adverse events precluded multivariate adjustments. Study findings should reassure emergency medicine practitioners that system modifications made to intubation processes in response to the COVID-19 pandemic do not appear to be associated with worse outcomes compared to pre-COVID-19 practices.

RéSUMé: OBJECTIF: Les pratiques d'intubation ont changé au cours de la pandémie de COVID-19 afin de protéger le personnel de santé contre la transmission de la maladie. Nos objectifs étaient de décrire les caractéristiques de l'intubation et les résultats pour les patients testés pour l'infection par le CoV-2 du SRAS. Nous avons comparé les résultats entre les patients testés positifs au SARS COV-2 et ceux testés négatifs. MéTHODES: Nous avons effectué un examen des dossiers de santé à l'aide du registre du Réseau canadien d'intervention rapide dans les services d'urgence pour la COVID-19 (RCIRSUC). Nous avons inclus les patients éligibles consécutifs qui se sont présentés à l'un des 47 services d'urgence du Canada entre le 1er mars 2020 et le 20 juin 2021, qui ont été testés pour le SRAS-CoV-2 et qui ont été intubés dans le service d'urgence. Le résultat principal était la proportion de patients ayant subi un événement indésirable après l'intubation pendant leur séjour aux urgences. Les critères de jugement secondaires comprenaient le succès du premier passage, les pratiques d'intubation et la mortalité hospitalière. Nous avons utilisé des statistiques descriptives pour résumer les variables avec des différences de sous-groupes examinées à l'aide de tests t, de tests z ou de tests du chi carré, le cas échéant, avec des IC à 95%. RéSULTATS: Sur les 1720 patients suspects de COVID-19 qui ont été intubés aux urgences pendant la période de l'étude, 337 (19,6%) ont été testés positifs au SARS-CoV-2 et 1383 (80,4%) négatifs au SARS-CoV-2. Les patients positifs au SRAS-CoV-2 se sont présentés à l'hôpital avec des niveaux d'oxygène inférieurs à ceux des patients négatifs pour le SRAS-CoV-2 (oxymètre de pouls moyen SaO2 86% contre 94%, p < 0,001). Au total, 8,5% des patients ont présenté un événement indésirable après l'intubation. Un plus grand nombre de patients du sous-groupe positif au SRAS-CoV-2 ont présenté une hypoxémie post-intubation (4,5% vs 2,2%, p = 0,019). La mortalité hospitalière était plus élevée chez les patients ayant subi des événements indésirables liés à l'intubation (43,2% vs 33,2%, p = 0,018). Il n'y avait pas de différence significative dans la mortalité associée aux événements indésirables selon le statut du SRAS-CoV-2. Le succès du premier passage a été obtenu dans 92,4% de toutes les intubations, sans différence selon le statut SARS-CoV-2 CONCLUSIONS: Pendant la pandémie de COVID-19, nous avons observé un faible risque d'événements indésirables associés à l'intubation, même si l'hypoxémie était fréquente chez les patients atteints de SRAS-CoV-2 confirmé. Nous avons observé des taux élevés de réussite du premier passage et des taux faibles d'incapacité à intuber. Le nombre limité d'événements indésirables a empêché les ajustements multivariés. Les résultats de l'étude devraient rassurer les praticiens de la médecine d'urgence que les modifications apportées aux processus d'intubation en réponse à la pandémie de COVID-19 ne semblent pas être associées à des résultats plus défavorables que les pratiques antérieures à la pandémie de COVID-19.

Alpha globin gene copy number and incident ischemic stroke risk among Black Americans.

Introduction: People with African ancestry have greater stroke risk and greater heritability of stroke risk than people of other ancestries. Given the importance of nitric oxide (NO) in stroke, and recent evidence that alpha globin restricts nitric oxide release from vascular endothelial cells, we hypothesized that alpha globin gene ( HBA) deletion would be associated with reduced risk of incident ischemic stroke. Methods: We evaluated 8,947 participants self-reporting African ancestry in the national, prospective Reasons for Geographic And Racial Differences in Stroke (REGARDS) cohort. Incident ischemic stroke was defined as non-hemorrhagic stroke with focal neurological deficit lasting ≥ 24 hours confirmed by the medical record or focal or non-focal neurological deficit with positive imaging confirmed with medical records. Genomic DNA was analyzed using droplet digital PCR to determine HBA copy number. Multivariable Cox proportional hazards regression was used to estimate the hazard ratio (HR) of HBA copy number on time to first ischemic stroke. Results: Four-hundred seventy-nine (5.3%) participants had an incident ischemic stroke over a median (IQR) of 11.0 (5.7, 14.0) years' follow-up. HBA copy number ranged from 2 to 6: 368 (4%) -α/-α, 2,480 (28%) -α/αα, 6,014 (67%) αα/αα, 83 (1%) ααα/αα and 2 (<1%) ααα/ααα. The adjusted HR of ischemic stroke with HBA copy number was 1.04; 95%CI 0.89, 1.21; p = 0.66. Conclusions: Although a reduction in HBA copy number is expected to increase endothelial nitric oxide signaling in the human vascular endothelium, HBA copy number was not associated with incident ischemic stroke in this large cohort of Black Americans.

Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society.

BACKGROUND: Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia. METHODS: Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used. RESULTS: Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality. CONCLUSION: We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis; Level IV.

Focused carotid ultrasound to predict major adverse cardiac events among emergency department patients with chest pain.

BACKGROUND AND OBJECTIVE: Point-of-care focused vascular ultrasound (FOVUS), an assessment of carotid artery plaque, predicts coronary artery disease in outpatients referred for coronary angiography. Our primary objective was to determine the diagnostic accuracy of sonographer-performed FOVUS to predict major adverse cardiac events (MACE) within 30 days among patients with suspected cardiac ischemia in the emergency department (ED). METHODS: We conducted a prospective cohort study of patients with chest pain presenting to a tertiary care ED who had an electrocardiogram and cardiac troponin testing. The primary outcome was a composite of death, acute myocardial infarction, or re-vascularization at 30 days. A sonographer performed FOVUS scans in consenting eligible subjects. Emergency physicians, blinded to the sonographer FOVUS result, performed a second FOVUS on some subjects. RESULTS: We recruited 326 subjects (age 62.1 ± 13.5 years; 166 (52%) men), 319 of whom completed an FOVUS scan by the sonographer. Of these, 198 (62%) had a positive FOVUS scan and 41 (13%) had a 30-day MACE. The sensitivity was 83% (95% CI 71-94%), specificity 41% (95% CI 36-47%), positive-likelihood ratio 1.41 (95% CI 1.19-1.68), and negative-likelihood ratio 0.41 (95% CI 0.23-0.75). Among 71 subjects also scanned by an emergency physician, the Kappa was 0.50 (95% CI 0.31-0.70), suggesting moderate agreement between sonographer and emergency physician on the determination of significant carotid plaque. CONCLUSIONS: The presence of carotid plaque on sonographer-performed FOVUS is associated with 30-day MACE in ED patients presenting with chest pain. The prognostic performance of FOVUS is not sufficient to support its use as a stand-alone risk stratification tool in the ED. Future work should investigate FOVUS in conjunction with validated clinical decision rules for chest pain and the impact of enhanced training and quality improvement in the conduct of FOVUS by emergency physicians. REGISTRATION: This study was registered at clinicaltrials.gov (NCT02947360).

RéSUMé: CONTEXTE ET OBJECTIF: L'échographie vasculaire focalisée au point de service (FOVUS), une évaluation de la plaque de l'artère carotide, prédit la maladie coronarienne chez les patients externes référés pour une coronarographie. Notre objectif principal était de déterminer la précision diagnostique du FOVUS réalisé par un échographiste pour prédire les événements cardiaques indésirables majeurs (MACE) dans les 30 jours chez les patients présentant une suspicion d'ischémie cardiaque aux urgences. MéTHODES: Nous avons mené une étude de cohorte prospective de patients souffrant de douleurs thoraciques se présentant à un service d'urgence de soins tertiaires et ayant subi un électrocardiogramme et un test de troponine cardiaque. L'issue primaire était un critère composite de décès, d'infarctus aigu du myocarde ou de revascularisation à 30 jours. Un échographiste a effectué des scans FOVUS chez les sujets éligibles consentants. Les médecins urgentistes, aveuglés par le résultat FOVUS de l'échographiste, ont effectué un deuxième FOVUS sur certains sujets. RéSULTATS: Nous avons recruté 326 sujets (âge 62,1 ± 13,5 ans; 166 (52%) hommes), dont 319 ont effectué un examen FOVUS par l'échographiste. Parmi ceux-ci, 198 (62%) avaient un scan FOVUS positif et 41 (13%) avaient un MACE de 30 jours. La sensibilité était de 83% (IC à 95% 71%-94%), la spécificité de 41% (IC à 95% 36%-47%), le rapport de vraisemblance positif de 1,41 (IC à 95% 1,19­1,68) et le rapport de vraisemblance négatif de 0,41 (IC à 95% 0,23­0,75). Parmi les 71 sujets également examinés par un médecin urgentiste, le Kappa était de 0,50 (IC à 95%: 0,31­0,70), ce qui suggère une concordance modérée entre l'échographiste et le médecin urgentiste pour la détermination de la plaque carotide significative. CONCLUSIONS: La présence d'une plaque carotidienne sur un FOVUS effectué par un échographiste est associée à la MACE à 30 jours chez les patients des urgences présentant des douleurs thoraciques. La performance pronostique du FOVUS n'est pas suffisante pour justifier son utilisation comme outil autonome de stratification du risque dans les urgences. Des travaux futurs devraient étudier le FOVUS en conjonction avec des règles de décision clinique validées pour la douleur thoracique et l'impact d'une formation renforcée et d'une amélioration de la qualité dans la conduite du FOVUS par les médecins urgentistes. ENREGISTREMENT: Cette étude a été enregistrée sur clinicaltrials.gov (NCT02947360).

Derivation and validation of a clinical decision rule to risk-stratify COVID-19 patients discharged from the emergency department: The CCEDRRN COVID discharge score.

Objective: To risk-stratify COVID-19 patients being considered for discharge from the emergency department (ED). Methods: We conducted an observational study to derive and validate a clinical decision rule to identify COVID-19 patients at risk for hospital admission or death within 72 hours of ED discharge. We used data from 49 sites in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) between March 1, 2020, and September 8, 2021. We randomly assigned hospitals to derivation or validation and prespecified clinical variables as candidate predictors. We used logistic regression to develop the score in a derivation cohort and examined its performance in predicting short-term adverse outcomes in a validation cohort. Results: Of 15,305 eligible patient visits, 535 (3.6%) experienced the outcome. The score included age, sex, pregnancy status, temperature, arrival mode, respiratory rate, and respiratory distress. The area under the curve was 0.70 (95% confidence interval [CI] 0.68-0.73) in derivation and 0.71 (95% CI 0.68-0.73) in combined derivation and validation cohorts. Among those with a score of 3 or less, the risk for the primary outcome was 1.9% or less, and the sensitivity of using 3 as a rule-out score was 89.3% (95% CI 82.7-94.0). Among those with a score of ≥9, the risk for the primary outcome was as high as 12.2% and the specificity of using 9 as a rule-in score was 95.6% (95% CI 94.9-96.2). Conclusion: The CCEDRRN COVID discharge score can identify patients at risk of short-term adverse outcomes after ED discharge with variables that are readily available on patient arrival.