Great Debates: Surgery or Watch and Wait After Total Neoadjuvant Therapy for Rectal Cancer.

Locally advanced rectal cancer has traditionally been treated with multimodal therapy including neoadjuvant chemoradiotherapy followed by surgical resection. More recent data suggests that in appropriate patients, total neoadjuvant treatment (TNT) makes it possible to adopt a "watch and wait" approach. Advocates for watch and wait argue that patients with a complete or near-complete clinical response to TNT have comparable overall and disease-free survival to their counterparts who undergo surgical resection, and also have a better quality of life, fewer complications, and potentially avoid a stoma. The dogma of surgery as regional curative intent therapy has been challenged by similar recurrence rates among those treated with total mesorectal excision (TME) and those treated with watch and wait. Furthermore, those who develop local recurrence in the watch and wait groups are equally salvageable, either by surgery, brachytherapy, or chemotherapy. While watch and wait is not appropriate in all patients, this manuscript highlights the benefits and drawbacks of both therapeutic modalities.

Amplifying Curcumin's Antitumor Potential: A Heat-Driven Approach for Colorectal Cancer Treatment.

Introduction: Peritoneal metastases from colorectal cancer (CRC) present a significant clinical challenge with poor prognosis, often unresponsive to systemic chemotherapy. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment approach for select patients. The use of curcumin, a natural compound with antitumor properties, in HIPEC is of interest due to its lower side effects compared to conventional drugs and potential for increased efficacy through direct delivery to the peritoneal cavity. Methods: An in vitro hyperthermic model was developed to simulate clinical HIPEC conditions. Three colon cancer cell lines (SK-CO-1, COLO205, SNU-C1) representing different genetic mutations (p53, KRAS, BRAF) were treated with either curcumin (25 µM) or mitomycin-C (1 µM) for 1, 2, or 3 hours. Post-treatment, cells were incubated at 37°C (normothermia) or 42°C (hyperthermia). Cell viability and proliferation were assessed at 24, 48 and 72 hours post-treatment using Annexin V/PI, MTT assay, trypan blue exclusion, and Hoffman microscopy. Results: Hyperthermia significantly enhanced the antitumor efficacy of curcumin, evidenced by a two-fold reduction in cell viability compared to normothermia across all cell lines. In the SNU-C1 cell line, which harbors a p53 mutation, mitomycin-C failed to significantly impact cell viability, unlike curcumin, suggesting mutation-specific differences in treatment response. Discussion: The findings indicate that hyperthermia augments the antitumor effects of curcumin in vitro, supporting the hypothesis that curcumin could be a more effective HIPEC agent than traditional drugs like mitomycin-C. Mutation-associated differences in response to treatments were observed, particularly in p53 mutant cells. While further studies are needed, these preliminary results suggest that curcumin in HIPEC could represent a novel therapeutic strategy for CRC patients with peritoneal metastases. This approach may offer improved outcomes with fewer side effects, particularly in genetically distinct CRC subtypes.

Adjuvant Radiotherapy for Surgically Resected Stage III Merkel Cell Carcinoma.

This case-control study evaluates whether adjuvant radiotherapy is associated with overall survival among patients with surgically resected stage III Merkel cell carcinoma.

The cognitive processes employed by undergraduate nursing OSCE assessors: A qualitative research study.

OBJECTIVES: The Objective Structured Clinical Examination (OSCE) is an assessment format commonly used to assess undergraduate nursing students. However, in spite of its prominence, relatively little research has been conducted into how OSCE assessors form judgements about student performances, and whether divergent processes of judgement formation have the potential to negatively impact the inter-rater reliability (IRR) of awarded scores. This qualitative study aimed to uncover the cognitive processes which assessors employ when assessing OSCE performances. DESIGN, SETTING, PARTICIPANTS: In order to investigate this, a convenience, purposive sample of 12 assessors watched four videos of students completing single-station OSCEs: two videos of blood pressure measurement, and two of naso-gastric tube insertion. METHODS: Assessors were asked to "think aloud" while watching the videos, and also participated in a semi-structured interview about their assessment practices. RESULTS: Thematic analysis of the qualitative data revealed three themes: observation, processing, and integration. Within each theme, a number of sub-themes were identified, which explain the cognitive mechanisms used by assessors when watching, judging and grading student performances. CONCLUSIONS: Notably, the presence of these mechanisms was not uniform across the sample, indicating that assessors utilise different approaches when viewing and interpreting the same performances. This has the potential to threaten the IRR of awarded scores, and thus the validity of decisions made on the basis of those scores.

Prostate Safety Events During Testosterone Replacement Therapy in Men With Hypogonadism: A Randomized Clinical Trial.

Importance: The effect of testosterone replacement therapy (TRT) on the risk of prostate cancer and other adverse prostate events is unknown. Objective: To compare the effect of TRT vs placebo on the incidences of high-grade prostate cancers (Gleason score ≥4 + 3), any prostate cancer, acute urinary retention, invasive prostate procedures, and pharmacologic treatment for lower urinary tract symptoms in men with hypogonadism. Design, Setting, and Participants: This placebo-controlled, double-blind randomized clinical trial enrolled 5246 men (aged 45-80 years) from 316 US trial sites who had 2 testosterone concentrations less than 300 ng/dL, hypogonadal symptoms, and cardiovascular disease (CVD) or increased CVD risk. Men with prostate-specific antigen (PSA) concentrations greater than 3.0 ng/mL and International Prostate Symptom Score (IPSS) greater than 19 were excluded. Enrollment took place between May 23, 2018, and February 1, 2022, and end-of-study visits were conducted between May 31, 2022, and January 19, 2023. Intervention: Participants were randomized, with stratification for prior CVD, to topical 1.62% testosterone gel or placebo. Main Outcomes and Measures: The primary prostate safety end point was the incidence of adjudicated high-grade prostate cancer. Secondary end points included incidence of any adjudicated prostate cancer, acute urinary retention, invasive prostate surgical procedure, prostate biopsy, and new pharmacologic treatment. Intervention effect was analyzed using a discrete-time proportional hazards model. Results: A total of 5204 men (mean [SD] age, 63.3 [7.9] years) were analyzed. At baseline, the mean (SD) PSA concentration was 0.92 (0.67) ng/mL, and the mean (SD) IPSS was 7.1 (5.6). The mean (SD) treatment duration as 21.8 (14.2) months in the TRT group and 21.6 (14.0) months in the placebo group. During 14 304 person-years of follow-up, the incidence of high-grade prostate cancer (5 of 2596 [0.19%] in the TRT group vs 3 of 2602 [0.12%] in the placebo group; hazard ratio, 1.62; 95% CI, 0.39-6.77; P = .51) did not differ significantly between groups; the incidences of any prostate cancer, acute urinary retention, invasive surgical procedures, prostate biopsy, and new pharmacologic treatment also did not differ significantly. Change in IPSS did not differ between groups. The PSA concentrations increased more in testosterone-treated than placebo-treated men. Conclusions and Relevance: In a population of middle-aged and older men with hypogonadism, carefully evaluated to exclude those at high risk of prostate cancer, the incidences of high-grade or any prostate cancer and other prostate events were low and did not differ significantly between testosterone- and placebo-treated men. The study's findings may facilitate a more informed appraisal of the potential risks of TRT. Trial Registration: ClinicalTrials.gov Identifier: NCT03518034.

Large Intestinal Obstruction and Perforation From Metastatic Merkel Cell Carcinoma: A Case Report.

Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine neoplasm of the skin that has a high propensity to metastasize. Abdominal metastases of MCC have been described previously though these are typically regional with nodal spread. We report the case of a 60-year-old man with a history of left upper extremity MCC who had resection, radiation therapy, and immunotherapy. He ultimately developed large bowel obstruction from metastatic intraperitoneal implants. A 6 cm mass at the descending colon was biopsied and proven to be metastatic MCC. The tumor eroded through the wall of the colon and perforated, requiring emergent colectomy for septic shock. Herein, we describe the first case of colonic perforation secondary to metastatic MCC. This case illustrates the importance of expedient and multifactorial management of patients with rapidly growing metastatic colonic tumors that are at risk for perforation.

Correction: Aboriginal artefacts on the continental shelf reveal ancient drowned cultural landscapes in northwest Australia.

[This corrects the article DOI: 10.1371/journal.pone.0233912.].

Primary School Students' Experiences using Minecraft Education during a National Project-Based Initiative: An Irish Study.

Minecraft Education is a digital game-based learning platform that is thought to support the development of twenty-first century competencies and skills. The purpose of this study is to explore primary students' experiences of using Minecraft Education during an innovative national project-based initiative. The initiative had two phases: 1) educational episodes for teachers and students on how to use the platform and 2) a national competition that required students to re-imagine a sustainable version of their community. We used a mixed-methods design with a sample of classes taking part in the initiative. First, third to sixth class students (N = 173) completed a survey that examined: 1) learning opportunities with Minecraft Education, 2) ease of use, 3) usefulness, and 4) enjoyment. Eight focus group interviews were then conducted with a subsample of sixth class students (n = 30). Students indicated that 1) there were good opportunities for learning with Minecraft Education, particularly for creativity and collaboration, 2) the platform was easy to use and useful and, 3) using Minecraft Education was enjoyable. Thematic analysis of the qualitative data identified five themes: 'collaboration', 'opportunities for creativity', 'immersive learning environment', 'student engagement', and 'technology and digital skills'. This research highlights the value of innovative project-based learning activities with Minecraft Education for supporting student learning.

Organ donation by children in Australia, 2000-2019: impact of the 2009 National Reform Program. A population-based registry data study.

OBJECTIVES: To assess the impact of the 2009 National Reform Program for organ donation in Australia on the number and characteristics of organ donors under 16 years of age. DESIGN, SETTING, PARTICIPANTS: Retrospective observational time series study; analysis of Australia and New Zealand Organ Donation (ANZOD) registry data for all consented potential deceased organ donors under 16 years of age during 2000-2019, and of numbers of donors aged 16 years or more reported in ANZOD annual reports. MAIN OUTCOME MEASURES: Difference between 2000-2008 (pre-reform) and 2009-2019 (reform period) in annual organ donor rates (donors per million population), by age group (under 16 years, 16 years or more), reported as incidence rate ratio (IRR). SECONDARY OUTCOMES: Differences in child donor characteristics during 2000-2008 and 2009-2019. RESULTS: During 2000-2019, 400 children under 16 years of age were consented potential deceased organ donors, of whom 374 were actual deceased donors (94%): 146 during 2000-2008, 228 during 2009-2019. The median annual rate was 3.3 (interquartile range [IQR], 3.0-4.3) actual donors per million population during 2000-2008 and 4.2 (IQR, 3.6-5.2) donors per million population during 2009-2019 (IRR, 1.15; 95% confidence interval [CI], 0.93-1.42). In contrast, the difference between the two periods was statistically significant for donors aged 16 years or more, rising from 11.7 (IQR, 11.2-11.8) to 19.9 (IQR, 18.3-24.4) actual donors per million population (IRR, 1.75; 95% CI, 1.66-1.85). The median age of actual organ donors under 16 was similar during 2000-2008 (11 years; IQR, 7-14 years) and 2009-2019 (10 years; IQR, 4-14 years), as was the proportion of donors in this age group under 10 kg (2000-2008: four of 146, 3%; 2009-2019: 14 of 228, 6%). CONCLUSIONS: Despite its overall effect on organ donation rates, the National Reform Program was not effective in increasing the numbers of donors under 16 years of age. Relying on broad initiatives for adult donors may not be appropriate for achieving this aim.

Effect of reverse shoulder arthroplasty humeral component retroversion on acromial strain.

INTRODUCTION: Acromion and scapular spine stress fractures can be catastrophic complications following reverse shoulder arthroplasty (RSA). A variety of host, implant, and technical factors have been identified that increase the risk of this complication. The glenoid component in particular has been closely evaluated for its impact on rates of stress fractures following RSA. The goal of this biomechanical study is to evaluate if humeral stem version has an impact on acromion and scapular spine strain after RSA. METHODS: Eight cadaveric specimens were tested on a custom dynamic shoulder frame. Commercially available RSA components were implanted with the humeral component inserted in 0° of retroversion. Acromion and scapular spine strain were measured at 0°, 30°, and 60° of abduction using strain rosettes secured to the acromion and scapular spine in the typical locations for Levy type II and type III stress fractures, respectively. The humeral stem was then removed and reimplanted in 30° of retroversion and the measurements were repeated. Student t test was performed to analyze the relationship between humeral stem version and acromion and scapular spine strain at various abduction angles. RESULTS: Strain at the both the acromion and scapular spine were found to have no significant difference at any abduction angle when comparing 0° and 30° version of the humeral stem. With 0° and 30° versions pooled together, there is significantly lower acromion and scapular spine strain at 60° of abduction when compared to 0° of abduction (strain at 0° abduction - strain at 60° abduction: acromion 313.1 µêœª; P = .0409, Scapular spine 304.9 µêœª; P = .0407). There was no significant difference in strain at either location when comparing 0° of abduction to 30° of abduction and when comparing 30° of abduction to 60° of abduction. CONCLUSIONS: This biomechanical study found no significant difference in scapular spine and acromion strain after RSA when comparing variations in humeral stem version. There does appear to be lower strain at both the acromion and scapular spine at 60° of abduction when compared to 0° of abduction regardless of stem version.

Natural Recombination among Type I Restriction-Modification Systems Creates Diverse Genomic Methylation Patterns among Xylella fastidiosa Strains.

Xylella fastidiosa is an important bacterial plant pathogen causing high-consequence diseases in agricultural crops around the world. Although as a species X. fastidiosa can infect many host plants, there is significant variability between strains regarding virulence on specific host plant species and other traits. Natural competence and horizontal gene transfer are believed to occur frequently in X. fastidiosa and likely influence the evolution of this pathogen. However, some X. fastidiosa strains are difficult to manipulate genetically using standard transformation techniques. Several type I restriction-modification (R-M) systems are encoded in the X. fastidiosa genome, which may influence horizontal gene transfer and recombination. Type I R-M systems themselves may undergo recombination, exchanging target recognition domains (TRDs) between specificity subunits (hsdS) to generate novel alleles with new target specificities. In this study, several conserved type I R-M systems were compared across 129 X. fastidiosa genome assemblies representing all known subspecies and 32 sequence types. Forty-four unique TRDs were identified among 50 hsdS alleles, which are arrayed in 31 allele profiles that are generally conserved within a monophyletic cluster of strains. Inactivating mutations were identified in type I R-M systems of specific strains, showing heterogeneity in the complements of functional type I R-M systems across X. fastidiosa. Genomic DNA methylation patterns were characterized in 20 X. fastidiosa strains and associated with type I R-M system allele profiles. Overall, these data suggest hsdS genes recombine among Xylella strains and/or unknown donors, and the resulting TRD reassortment establishes differential epigenetic modifications across Xylella lineages. IMPORTANCE Economic impacts on agricultural production due to X. fastidiosa have been severe in the Americas, Europe, and parts of Asia. Despite a long history of research on this pathogen, certain fundamental questions regarding the biology, pathogenicity, and evolution of X. fastidiosa have still not been answered. Wide-scale whole-genome sequencing has begun to provide more insight into X. fastidiosa genetic diversity and horizontal gene transfer, but the mechanics of genomic recombination in natural settings and the extent to which this directly influences bacterial phenotypes such as plant host range are not well understood. Genome methylation is an important factor in horizontal gene transfer and bacterial recombination that has not been comprehensively studied in X. fastidiosa. This study characterizes methylation associated with type I restriction-modification systems across a wide range of X. fastidiosa strains and lays the groundwork for a better understanding of X. fastidiosa biology and evolution through epigenetics.

A pilot study investigating feasibility of mainstreaming germline BRCA1 and BRCA2 testing in high-risk patients with breast and/or ovarian cancer in three tertiary Cancer Centres in Ireland.

In the Republic of Ireland (ROI), BRCA1/BRCA2 genetic testing has been traditionally undertaken in eligible individuals, after pre-test counselling by a Clinical Geneticist/Genetic Counsellor. Clinical Genetics services in ROI are poorly resourced, with routine waiting times for appointments at the time of this pilot often extending beyond a year. The consequent prolonged waiting times are unacceptable where therapeutic decision-making depends on the patient's BRCA status. "Mainstreaming" BRCA1/BRCA2 testing through routine oncology/surgical clinics has been implemented successfully in other centres in the UK and internationally. We aimed to pilot this pathway in three Irish tertiary centres. A service evaluation project was undertaken over a 6-month period between January and July 2017. Eligible patients, fulfilling pathology and age-based inclusion criteria defined by TGL clinical, were identified, and offered constitutional BRCA1/BRCA2 testing after pre-test counselling by treating clinicians. Tests were undertaken by TGL Clinical. Results were returned to clinicians by secure email. Onward referrals of patients with uncertain/pathogenic results, or suspicious family histories, to Clinical Genetics were made by the treating team. Surveys assessing patient and clinician satisfaction were sent to participating clinicians and a sample of participating patients. Data was collected with respect to diagnostic yield, turnaround time, onward referral rates, and patient and clinician feedback. A total of 101  patients underwent diagnostic germline BRCA1/BRCA2 tests through this pathway. Pathogenic variants were identified in 12 patients (12%). All patients in whom variants were identified were appropriately referred to Clinical Genetics. At least 12 additional patients with uninformative BRCA1/BRCA2 tests were also referred for formal assessment by Clinical Geneticist or Genetic Counsellor. Issues were noted in terms of time pressures and communication of results to patients. Results from a representative sample of participants completing the satisfaction survey indicated that the pathway was acceptable to patients and clinicians. Mainstreaming of constitutional BRCA1/BRCA2 testing guided by age- and pathology-based criteria is potentially feasible for patients with breast cancer as well as patients with ovarian cancer in Ireland.

Influence of reef isostasy, dynamic topography, and glacial isostatic adjustment on sea-level records in Northeastern Australia.

Understanding sea level during the peak of the Last Interglacial (125,000 yrs ago) is important for assessing future ice-sheet dynamics in response to climate change. The coasts and continental shelves of northeastern Australia (Queensland) preserve an extensive Last Interglacial record in the facies of coastal strandplains onland and fossil reefs offshore. However, there is a discrepancy, amounting to tens of meters, in the elevation of sea-level indicators between offshore and onshore sites. Here, we assess the influence of geophysical processes that may have changed the elevation of these sea-level indicators. We modeled sea-level change due to dynamic topography, glacial isostatic adjustment, and isostatic adjustment due to coral reef loading. We find that these processes caused relative sea-level changes on the order of, respectively, 10 m, 5 m, and 0.3 m. Of these geophysical processes, the dynamic topography predictions most closely match the tilting observed between onshore and offshore sea-level markers.

Do Not Attempt Resuscitation Order Rates in Hospitalized Patients With Heart Failure, Acute Myocardial Infarction, Chronic Obstructive Pulmonary Disease, and Pneumonia.

Background Descriptions of do not attempt resuscitation (DNAR) orders in heart failure (HF) are limited. We describe use of DNAR orders in HF hospitalizations relative to other common conditions, focusing on race. Methods and Results This was a retrospective study of all adult hospitalizations for HF, acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), and pneumonia from 2010 to 2016 using the California State Inpatient Dataset. Using a hierarchical multivariable logistic regression model with random effects for the hospital, we identified factors associated with DNAR orders for each condition. For racial variation, hospitals were divided into quintiles based on proportion of Black patients cared for. Our cohort comprised 399 816 HF, 190 802 AMI, 192 640 COPD, and 269 262 pneumonia hospitalizations. DNAR orders were most prevalent in HF (11.9%), followed by pneumonia (11.1%), COPD (7.9%), and AMI (7.1%). Prevalence of DNAR orders did not change from 2010 to 2016 for each condition. For all conditions, DNAR orders were more common in elderly people, women, and White people with significant site-level variation across 472 hospitals. For HF and COPD, hospitalizations at sites that cared for a higher proportion of Black patients were less likely associated with DNAR orders. For AMI and pneumonia, conditions such as dementia and malignancy were strongly associated with DNAR orders. Conclusions DNAR orders were present in 12% of HF hospitalizations, similar to pneumonia but higher than AMI and COPD. For HF, we noted significant variability across sites when stratified by proportion of Black patients cared for, suggesting geographic and racial differences in end-of-life care.

Potential organ donors with primary brain tumours: missed opportunities for donation and transplantation identified in Australian cohort study 2010-2015.

BACKGROUND: Potential organ donors with primary brain tumours (PBT) frequently donate, however some may be declined due to uncertainty about tumour classification or transmission risk to transplant recipients. We sought to describe transmission risk and donation outcome of potential donors with PBT, including identifying missed opportunities for transplantation, and any PBT transmission events. METHODS: We undertook a population-based cohort study in NSW of all potential donors 2010-2015. PBT potential donors were characterized according to tumour grade and transmission risk, and whether they donated organs. Data linkage was used to determine agreement of risk assessment of potential donors to that in the Biovigilance Register, and to identify any PBT transmissions. RESULTS: Of 2957 potential donors, 76 (3%) had PBTs. There was agreement of risk assessment in 44 (58%) cases. PBT potential donors had fewer comorbidities (1.6 vs. 2.1, P = 0.006) than non-PBT potential donors. Forty-eight (63%) potential donors were declined for non-PBT reasons, 18 (24%) were declined because of perceived PBT transmission risk and 10 (13%) donated. All PBT donors had WHO-I or -II tumours, and none had a ventriculo-pertioneal shunt. No transmission events occurred. CONCLUSION: Donors with WHO-I/II PBT appear to have minimal risk of tumour transmission in solid organ transplantation; it is reassuring that no PBT transmission occurred. There is evidence of risk aversion to referrals with WHO-III/IV tumours. There exists opportunity to improve potential donor risk assessment at the time of referral using integrated data sets, and to increase organ donation and transplantation rates through greater utilization of PBT referrals.

Assessment of telecommunicator cardiopulmonary resuscitation performance during out-of-hospital cardiac arrest using a standardized tool for audio review.

OBJECTIVE: Telecommunicator cardiopulmonary resuscitation (T-CPR) is a critical component of optimized out-of-hospital cardiac arrest (OHCA) care. We assessed a pilot tool to capture American Heart Association (AHA) T-CPR measures and T-CPR coaching by telecommunicators using audio review. METHODS: Using a pilot tool, we conducted a retrospective review of 911 call audio from 65 emergency medical services-treated out-of-hospital cardiac arrest (OHCA) patients. Data collection included events (e.g., OHCA recognition), time intervals, and coaching quality measures. We calculated summary statistics for all performance and quality measures. RESULTS: Among 65 cases, the patients' mean age was 64.7 years (SD: 14.6) and 17 (26.2%) were women. Telecommunicator recognition occurred in 72% of cases (47/65). Among 18 non-recognized cases, reviewers determined 12 (66%) were not recognizable based on characteristics of the call. Median time-to-recognition was 76 seconds (n = 40; IQR:39-138), while median time-to-first-instructed-compression was 198 seconds (n = 26; IQR:149-233). In 36 cases where coaching was needed, coaching on compression-depth occurred in 27 (75%); -rate in 28 (78%); and chest recoil in 10 (28%) instances. In 30 cases where repositioning was needed, instruction to position the patient's body flat occurred in 18 (60%) instances, on-back in 22 (73%) instances, and on-ground in 22 (73%) instances. CONCLUSIONS: Successful collection of data to calculate AHA T-CPR measures using a pilot tool for audio review revealed performance near AHA benchmarks, although coaching instructions did not occur in many instances. Application of this standardized tool may aid in T-CPR quality review.

The 2020 Pandemics: Lessons Learned in Academic Surgery and Beyond.

2020 was a significant year because of the occurrence of two simultaneous public health crises: the coronavirus pandemic and the public health crisis of racism brought into the spotlight by the murder of George Floyd. The coronavirus pandemic has affected all aspects of health care, particularly the delivery of surgical care, surgical education, and academic productivity. The concomitant public health crisis of racism and health inequality during the viral pandemic highlighted opportunities for action to address gaps in surgical care and the delivery of public health services. At the 2021 Academic Surgical Congress Hot Topics session on flexibility and leadership, we also explored how our military surgeon colleagues can provide guidance in leadership during times of crisis. The following is a summary of the issues discussed during the session and reflections on the important lessons learned in academic surgery over the past year.

The association of fire or police first responder initiated interventions with out of hospital cardiac arrest survival.

OBJECTIVE: Fire and police first responders are often the first to arrive in medical emergencies and provide basic life support services until specialized personnel arrive. This study aims to evaluate rates of fire or police first responder-initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, as well as their associated impact on out-of-hospital cardiac arrest (OHCA) outcomes. METHODS: We completed a secondary data analysis of the MI-CARES registry from 2014 to 2019. We reported rates of CPR initiation and AED use by fire or police first responders. Multilevel modeling was utilized to evaluate the relationship between fire/police first responder-initiated interventions and outcomes of interest: ROSC upon emergency department arrival, survival to hospital discharge, and good neurologic outcome. RESULTS: Our cohort included 25,067 OHCA incidents. We found fire or police first responders initiated CPR in 31.8% of OHCA events and AED use in 6.1% of OHCA events. Likelihood of sustained ROSC on ED arrival after CPR initiated by a fire/police first responder was not statistically different as compared to EMS initiated CPR (aOR 1.01, CI 0.93-1.11). However, fire/police first responder interventions were associated with significantly higher odds of survival to hospital discharge and survival with good neurologic outcome (aOR 1.25, 95% CI 1.08-1.45 and aOR 1.40, 95% CI 1.18-1.65, respectively). Similar associations were see when examining fire or police initiated AED use. CONCLUSIONS: Fire or police first responders may be an underutilized, potentially powerful mechanism for improving OHCA survival. Future studies should investigate barriers and opportunities for increasing first responder interventions by these groups in OHCA.

Newly diagnosed diabetes vs. pre-existing diabetes upon admission for COVID-19: Associated factors, short-term outcomes, and long-term glycemic phenotypes.

AIMS: High rates of newly diagnosed diabetes mellitus (NDDM) have been reported in association with coronavirus disease-2019 (COVID-19). Factors associated with NDDM and long-term glycemic outcomes are not known. METHODS: Retrospective review of individuals admitted with COVID-19 and diabetes mellitus (DM; based on labs, diagnoses, outpatient insulin use, or severe inpatient hyperglycemia) between March and September 2020, with follow-up through July 2021. RESULTS: Of 1902 individuals admitted with COVID-19, 594 (31.2%) had DM; 77 (13.0%) of these had NDDM. Compared to pre-existing DM, NDDM was more common in younger patients and less common in those of non-Hispanic White race/ethnicity. Glycemic parameters were lower and inflammatory markers higher in patients with NDDM. In adjusted models, NDDM was associated with lower insulin requirements, longer length of stay, and intensive care unit admission but not death. Of 64 survivors with NDDM, 36 (56.3%) continued to have DM, 26 (40.6%) regressed to normoglycemia or pre-diabetes, and 2 were unable to be classified at a median follow-up of 323 days. CONCLUSIONS: Diabetes diagnosed at COVID-19 presentation is associated with lower glucose but higher inflammatory markers and ICU admission, suggesting stress hyperglycemia as a major physiologic mechanism. Approximately half of such individuals experience regression of DM.