Understanding mentoring relationships between mentees, peer and senior mentors.

BACKGROUND: Mentoring relationships play a critical but poorly understood role in mentoring's overall success. To overcome these knowledge gaps, a study of mentee experiences in the Palliative Medicine Initiative, a structured research-based mentoring program, is proposed. The program's clearly described mentoring approach, competency-based mentoring stages and curated mentoring environment ensure a consistent mentoring experience. It provides a unique platform to study mentoring relationships longitudinally and its implications on professional identity formation. METHODOLOGY: The Tool Design Systematic Evidence-Based Approach methodology is used to map and employ current understanding. A review of recent reviews on mentoring processes, mentoring's effects, professional identity formation and professional identity formation assessment tools lay the foundation for the design of semi-structured interviews and mentoring diaries to evaluate the characteristics of successful mentoring relationships and mentoring's impact on professional identity formation. The data accrued from these tools were evaluated using this methodology whilst changes in professional identity formation were assessed using the Ring Theory of Personhood. RESULTS: The semi-structured interviews revealed four themes: stakeholders, mentoring stages, mentoring relationships and professional identity formation whilst the mentoring diaries revealed two: mentoring processes and mentoring relationships. Two final domains emerged - mentoring relationships and professional identity formation. CONCLUSIONS: The Palliative Medicine Initiative's structured stage-based mentoring approach, trained stakeholders, curated environment, assessment-directed and personalized mentoring support reveal seven developmental stages of mentoring relationships. These culminate in changes to the values, beliefs and principles that shape how mentees see, feel and act as professionals. These findings suggest that mentoring programs may help to further develop and fine-tune their professional identity formation.

Meta-analysis and systematic review: Prevalence, graft failure, mortality, and post-operative thrombosis in liver transplant recipients with pre-operative portal vein thrombosis.

AIMS: This study seeks to evaluate the association between pre-transplant portal vein thrombosis (PVT) and overall survival, graft failure, waitlist mortality, and post-operative PVT after liver transplantation. METHODS: A conventional pairwise meta-analysis between patients with and without pre-transplant PVT was conducted using hazard ratios or odds ratios where appropriate. RESULTS: Prevalence of preoperative PVT was 11.6% (CI 9.70-13.7%). Pre-operative PVT was associated with increased overall mortality (HR 1.45, 95% CI 1.27-1.65) and graft loss (HR 1.58, 95% CI 1.34-1.85). In particular, grade 3 (HR 1.59, 95% CI 1.00-2.51) and 4 (HR 2.24, 95% CI 1.45-3.45) PVT significantly increased mortality, but not grade 1 or 2 PVT. Patients with PVT receiving living donor (HR 1.54, 95% CI 1.24-1.91) and deceased donor (HR 1.52, 95% CI 1.21-1.92) liver transplantation had increased mortality, with no significant difference between transplant types (P = .13). Furthermore, pre-transplant PVT was associated with higher occurrence of post-transplant PVT (OR 5.06, 95% CI 3.89-6.57). Waitlist mortality was not significantly increased in patients with pre-transplant PVT. CONCLUSION: Graft failure, mortality, and post-operative PVT are more common in pre-transplant PVT patients, especially in grade 3 or 4 PVT. Prophylactic anticoagulation can be considered to reduce re-thrombosis and improve survival.

Cardiac arrest centres: what, who, when, and where?

PURPOSE OF REVIEW: Cardiac arrest centres (CACs) may play a key role in providing postresuscitation care, thereby improving outcomes in out-of-hospital cardiac arrest (OHCA). There is no consensus on CAC definitions or the optimal CAC transport strategy despite advances in research. This review provides an updated overview of CACs, highlighting evidence gaps and future research directions. RECENT FINDINGS: CAC definitions vary worldwide but often feature 24/7 percutaneous coronary intervention capability, targeted temperature management, neuroprognostication, intensive care, education, and research within a centralized, high-volume hospital. Significant evidence exists for benefits of CACs related to regionalization. A recent meta-analysis demonstrated clearly improved survival with favourable neurological outcome and survival among patients transported to CACs with conclusions robust to sensitivity analyses. However, scarce data exists regarding 'who', 'when', and 'where' for CAC transport strategies. Evidence for OHCA patients without ST elevation postresuscitation to be transported to CACs remains unclear. Preliminary evidence demonstrated greater benefit from CACs among patients with shockable rhythms. Randomized controlled trials should evaluate specific strategies, such as bypassing nearest hospitals and interhospital transfer. SUMMARY: Real-world study designs evaluating CAC transport strategies are needed. OHCA patients with underlying culprit lesions, such as those with ST-elevation myocardial infarction (STEMI) or initial shockable rhythms, will likely benefit the most from CACs.

A systematic scoping review of communication skills training in medical schools between 2000 and 2020.

BACKGROUND: Communication skills training (CST) remains poorly represented and prioritised in medical schools despite its importance. A systematic scoping review (SSR) of CST is proposed to better appreciate current variability in their structure, content, and assessment. This is to guide their future design in medical school curricula. METHODS: The Systematic Evidence-Based Approach (SEBA) was used to guide concurrent SSRs of teaching and assessment in CST. After independent database searches, concurrent thematic and content analysis of included articles were conducted separately. Resultant themes/categories were combined via the jigsaw perspective to provide a more holistic view of the data. These were then compared to tabulated summaries of the included articles to create funnelled domains. RESULTS: 52,300 papers were identified, 150 full-text articles included, and four funnelled domains were identified: Indications, Design, Assessment, and Barriers and Enablers of CST. CSTs confer numerous benefits to physicians and patients. It saw increased confidence, improved diagnostic capabilities and better clinical management, as well as greater patient satisfaction and treatment compliance. Skills may be divided into core, prerequisite competencies, and advanced skills pertinent to more challenging and nuanced scenarios - such as population or setting-specific situations. CST teaching and assessment modalities were found to align with Miller's Pyramid, with didactic teaching gradually infused with experiential approaches to enhance their understanding and integration. A plethora of CST frameworks, teaching and assessment methods were identified and are presented together. CONCLUSION: While variable in approach, content and assessment, CST in medical schools often employ stage-based curricula to instil competency-based topics of increasing complexity throughout medical school education. This process builds on the application of prior knowledge and skills, influencing practice and, potentially, the students' professional identity formation. In addition, the institution plays a critical role in overseeing training, ensuring longitudinal guidance and holistic assessments of the students' progress.

Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review.

BACKGROUND: Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method. METHODS: MEDLINE, Embase and the Cochrane Library were searched from inception to 15 June 2021. Randomised controlled trials comparing anaesthetic methods for the closed reduction of paediatric forearm fractures in the emergency setting were included. Two reviewers independently screened, collected data and assessed the risk of bias for the selected outcomes. The primary outcome was pain during reduction. Secondary outcomes included pain after reduction, adverse effects, satisfaction, adequacy of sedation/anaesthesia, success of reduction and resource use. RESULTS: 1288 records were screened and 9 trials, which studied 936 patients in total, were included. Four trials compared the main methods of anaesthesia. Within the same method of anaesthesia, one compared administrative routes, one compared procedural techniques, one compared different drugs, one compared the use of adjuncts and one compared different doses of the same drug. One study found better pain outcomes with infraclavicular blocks compared with procedural sedation and analgesia. Lidocaine was superior in analgesic effect to prilocaine in IVRA in one study. One study found lower pain scores with moderate-dose than low-dose lidocaine in IVRA. CONCLUSION: Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.

Controversies of colonic stenting in obstructive left colorectal cancer: a critical analysis with meta-analysis and meta-regression.

PURPOSE: After almost three decades since the first description of colonic stents, the controversies of its safe application continue to impede the readiness of adoption by clinicians for malignant left bowel obstruction. This review seeks to address some of the controversial aspects of stenting and its impact on surgical and oncological outcomes. METHODS: Medline, Embase, and CNKI were searched for articles employing SEMS for left colonic obstruction. Outcomes analyzed include success rates, complications, and long-term survival. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated. RESULTS: 36 studies were included with 2002 patients across seven randomized controlled trials and 29 observational studies. High technical (92%) and clinical (82%) success rates, and low rates of complications, including perforation (5%), were found. Those with > 8% perforation rates had poorer technical success rates than those with ≤ 8%, but there were no significant differences in 90-day in-hospital mortality and three and 5-year overall and disease-free survival. A significant increase was found in technical (RR = 1.094; CI, 1.041-1.149; p < 0.001) and clinical (RR = 1.158; CI, 1.064-1.259; p = 0.001) success rates when the duration between stenting and surgery was ≥ 2 weeks compared to < 2 weeks, but there were no significant differences in perforation rates, 90-day in-hospital mortality, and long-term survival. CONCLUSIONS: Colonic stenting is safe and effective with high success rates and low complication rates. However, outcomes of higher perforation rates and optimal timing from stent till surgery remain unclear, with only a few studies reporting on these outcomes, leaving areas for future research.

Incidence and Long-Term Outcomes of Acute Myocardial Infarction Among Survivors of Out-of-Hospital Cardiac Arrest.

BACKGROUND: Despite the increasing long-term survival after out-of-hospital cardiac arrest (OHCA), the risk of subsequent acute myocardial infarction (AMI) remains poorly understood. We aimed to determine the incidence, predictors, and long-term outcomes of AMI among survivors of OHCA. METHODS AND RESULTS: We assembled a retrospective cohort of 882 patients with OHCA who survived to 30 days or discharge from the hospital between 2010 and 2019. Survivors of OHCA had an increased risk of subsequent AMI, defined as AMI occurring 30 days after index OHCA or following discharge from the hospital after OHCA, compared with the general population when matched for age and sex (standardized incidence ratio, 4.64 [95% CI, 3.52-6.01]). Age-specific risks of subsequent AMI for men (standardized incidence ratio, 3.29 [95% CI, 2.39-4.42]) and women (standardized incidence ratio, 6.15 [95% CI, 3.27-10.52]) were significantly increased. A total of 7.2%, 8.3%, and 14.3% of survivors of OHCA had a subsequent AMI at 3 years, 5 years, and end of follow-up, respectively. Age at OHCA (hazard ratio [HR], 1.04 [95% CI, 1.02-1.06]) and past medical history of prior AMI, defined as any AMI preceding or during the index OHCA event (HR, 1.84 [95% CI, 1.05-3.22]), were associated with subsequent AMI, while an initial shockable rhythm was not (HR, 1.00 [95% CI, 0.52-1.94]). Survivors of OHCA with subsequent AMI had a higher risk of death (HR, 1.58 [95% CI, 1.12-2.22]) than those without. CONCLUSIONS: Survivors of OHCA are at an increased risk of subsequent AMI compared with the general population. Prior AMI, but not an initial shockable rhythm, increases this risk, while subsequent AMI predicts death. Preventive measures for AMI including cardiovascular risk factor control and revascularization may thus improve outcomes in selected patients with cardiac pathogenesis.

Long term survival and disease burden from out-of-hospital cardiac arrest in Singapore: a population-based cohort study.

Background: Understanding the long-term outcomes and disability-adjusted life years (DALY) after out-of-hospital cardiac arrest (OHCA) is important to understand the overall health and disease burden of OHCA respectively, but data in Asia remains limited. We aimed to quantify long-term survival and the annual disease burden of OHCA within a national multi-ethnic Asian cohort. Methods: We conducted an open cohort study linking the Singapore Pan-Asian Resuscitation Outcomes Study (PAROS) and the Singapore Registry of Births and Deaths from 2010 to 2019. We performed Cox regression, constructed Kaplan-Meier curves, and calculated DALYs and standardised mortality ratios (SMR) for each year of follow-up. Results: We analysed 802 cases. The mean age was 56.0 (SD 17.8). Most were male (631 cases, 78,7%) and of Chinese ethnicity (552 cases, 68.8%). At one year, the SMR was 14.9 (95% CI:12.5-17.8), decreasing to 1.2 (95% CI:0.7-1.8) at three years, and 0.4 (95% CI:0.2-0.8) at five years. Age at arrest (HR:1.03, 95% CI:1.02-1.04, p < 0.001), shockable presenting rhythm (HR:0.75, 95% CI:0.52-0.93, p = 0.015) and CPC category (HR:4.62, 95% CI:3.17-6.75, p < 0.001) were independently associated with mortality. Annual DALYs due to OHCA varied from 304.1 in 2010 to 849.7 in 2015, then 547.1 in 2018. Mean DALYs decreased from 12.162 in 2010 to 3.599 in 2018. Conclusions: OHCA survivors had an increased mortality rate for the first three years which subsequently normalised compared to that of the general population. Annual OHCA disease burden in DALY trended downwards from 2010 to 2018. Improved surveillance and OHCA treatment strategies may improve long-term survivorship and decrease its global burden. Funding: National Medical Research Council, Singapore, under the Clinician Scientist Award (NMRC/CSA-SI/0014/2017) and the Singapore Translational Research Investigator Award (MOH-000982-01).

Global prevalence of basic life support training: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Out-of-hospital cardiac arrest exerts a large disease burden, which may be mitigated by bystander cardiopulmonary resuscitation and automated external defibrillation. We aimed to estimate the global prevalence and distribution of bystander training among laypersons, which are poorly understood, and to identify their determinants. METHODS: We searched electronic databases for cross-sectional studies reporting the prevalence of bystander training from representative population samples. Pooled prevalence was calculated using random-effects models. Key outcome was cardiopulmonary resuscitation training (training within two-years and those who were ever trained). We explored determinants of interest using subgroup analysis and meta-regression. RESULTS: 29 studies were included, representing 53,397 laypersons. Among national studies, the prevalence of cardiopulmonary resuscitation training within two-years and among those who were ever trained, and automated external defibrillator training was 10.02% (95% CI 6.60 -14.05), 42.04% (95% CI 30.98-53.28) and 21.08% (95% CI 10.16-34.66) respectively. Subgroup analyses by continent revealed pooled prevalence estimates of 31.58% (95%CI 18.70-46.09), 58.78% (95%CI 42.41-74.21), 18.93 (95%CI 0.00-62.94), 64.97% (95%CI 64.00-65.93), and 50.56% (95%CI 47.57-53.54) in Asia, Europe, Middle East, North America, and Oceania respectively, with significant subgroup differences (p < 0.01). A country's income and cardiopulmonary resuscitation training (ever trained) (p = 0.033) were positively correlated. Similarly, this prevalence was higher among the highly educated (p<0.00001). CONCLUSIONS: Large regional variation exists in data availability and bystander training prevalence. Socioeconomic status correlated with prevalence of bystander training, and regional disparities were apparent between continents. Bystander training should be promoted, particularly in Asia, Middle East, and low-income regions. Data availability should be encouraged from under-represented regions.

The Role of Drones in Out-of-Hospital Cardiac Arrest: A Scoping Review.

Drones may be able to deliver automated external defibrillators (AEDs) directly to bystanders of out-of-hospital cardiac arrest (OHCA) events, improving survival outcomes by facilitating early defibrillation. We aimed to provide an overview of the available literature on the role and impact of drones in AED delivery in OHCA. We conducted this scoping review using the PRISMA-ScR and Arksey and O'Malley framework, and systematically searched five bibliographical databases (Medline, EMBASE, Cochrane CENTRAL, PsychInfo and Scopus) from inception until 28 February 2022. After excluding duplicate articles, title/abstract screening followed by full text review was conducted by three independent authors. Data from the included articles were abstracted and analysed, with a focus on potential time savings of drone networks in delivering AEDs in OHCA, and factors that influence its implementation. Out of the 26 included studies, 23 conducted simulations or physical trials to optimise drone network configuration and evaluate time savings from drone delivery of AEDs, compared to the current emergency medical services (EMS), along with 1 prospective trial conducted in Sweden and 2 qualitative studies. Improvements in response times varied across the studies, with greater time savings in rural areas. However, emergency call to AED attachment time was not reduced in the sole prospective study and a South Korean study that accounted for weather and topography. With growing interest in drones and their potential use in AED delivery spurring new research in the field, our included studies demonstrate the potential advantages of unmanned aerial vehicle (UAV) network implementation in controlled environments to deliver AEDs faster than current EMS. However, for these time savings to translate to reduced times to defibrillation and improvement in OHCA outcomes, careful evaluation and addressing of real-world delays, challenges, and barriers to drone use in AED delivery is required.

Association of High-Volume Centers With Survival Outcomes Among Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.

Importance: Although high volume of cases of out-of-hospital cardiac arrest (OHCA) is a key feature of cardiac arrest centers, which have proven survival benefit, the role of center volume as an independent variable associated with improved outcomes is unclear. Objective: To assess the association of high-volume centers with survival and neurological outcomes in nontraumatic OHCA. Data Sources: Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to October 11, 2021, for studies including adult patients with nontraumatic OHCA who were treated at high-volume vs non-high-volume centers. Study Selection: Randomized clinical trials, nonrandomized studies of interventions, prospective cohort studies, and retrospective cohort studies were selected that met the following criteria: (1) adult patients with OHCA of nontraumatic etiology, (2) comparison of high-volume with low-volume centers, (3) report of a volume-outcome association, and (4) report of outcomes of interest. At least 2 authors independently reviewed each article, blinded to each other's decision. Data Extraction and Synthesis: Data abstraction and quality assessment were independently conducted by 2 authors. Meta-analyses were performed for adjusted odds ratios (aORs) and crude ORs using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures: Survival and good neurological outcomes according to the Cerebral Performance Categories Scale at hospital discharge or 30 days. Results: A total of 16 studies involving 82 769 patients were included. Five studies defined high volume as 40 or more cases of OHCA per year; 3 studies defined high volume as greater than 100 cases of OHCA per year. All other studies differed in definitions. Survival to discharge or 30 days improved with treatment at high-volume centers, regardless of whether aORs (1.28 [95% CI, 1.00-1.64]) or crude ORs (1.43 [95% CI, 1.09-1.87]) were pooled. There was no association between center volume and good neurological outcomes at 30 days or hospital discharge in patients with OHCA (aOR, 0.96 [95% CI, 0.77-1.20]). Conclusions and Relevance: In this meta-analysis and systematic review, care at high-volume centers was associated with improved survival outcomes, even after adjustment for potential confounders, but was not associated with improved neurological outcomes for patients with nontraumatic OHCA. More studies evaluating the relative importance of center volume compared with other variables (eg, the availability of treatment modalities) associated with survival outcomes in patients with OHCA are required.

Long term risk of recurrence among survivors of sudden cardiac arrest: A systematic review and meta-analysis.

AIMS: With a growing number of survivors of sudden cardiac arrest globally, their natural disease progression is of interest. This systematic review and meta-analysis aimed to determine the risk of recurrence after sudden cardiac arrest and its associated risk factors. METHODS: Medline, Embase, Cochrane Library and Scopus were searched from inception to October 2021. Studies involving survivors of an out-of-hospital sudden cardiac arrest event of any non-traumatic aetiology were included. Meta-analyses of proportions using the random-effects model estimated the primary outcome of first recurrent sudden cardiac arrest incidence as well as secondary outcomes including cumulative incidence of recurrence at 1-year and incidence of second recurrence among survivors of first recurrence. A recurrent episode was defined as a sudden cardiac arrest that occurs 28 or more days after the index event. Subgroup and meta-regression analyses were conducted for predetermined variables. The Newcastle-Ottawa Scale was used to assess risk of bias for most studies. RESULTS: 35 studies of moderate to high quality comprising a total of 7186 survivors were analysed. The pooled incidence of first recurrence was 15.24% (32 studies; 95%CI, 11.01-19.95; mean follow-up time, 41.3 ± 29.3 months) and second recurrence was 35.03% (3 studies; 95%CI, 19.65-51.93; mean follow-up time, 161.1 ± 54.3 months). At 1-year, incidence of recurrence was 10.62% (3 studies; 95%CI, 0.25-30.42). Subgroup analyses found no significant difference (p = 0.204) between incidence of first recurrence published from 1975-1992 and 1993-2021, and between studies with mean follow-up time of <24 months, 24-48 months, and >48 months. On meta-regression, initial shockable rhythm increased incidence of first recurrence (p = 0.01). CONCLUSION: 15.24% of sudden cardiac arrest survivors experienced a recurrence, and of these, 35.03% experienced a second recurrence. Most recurrences occurred in the first year. Initial shockable rhythm increased this risk. Despite the limitations of inter-study heterogeneity, these findings can still guide intervention and follow-up of sudden cardiac arrest survivors.

Clustering of Environmental Parameters and the Risk of Acute Myocardial Infarction.

The association between days with similar environmental parameters and cardiovascular events is unknown. We investigate the association between clusters of environmental parameters and acute myocardial infarction (AMI) risk in Singapore. Using k-means clustering and conditional Poisson models, we grouped calendar days from 2010 to 2015 based on rainfall, temperature, wind speed and the Pollutant Standards Index (PSI) and compared the incidence rate ratios (IRR) of AMI across the clusters using a time-stratified case-crossover design. Three distinct clusters were formed with Cluster 1 having high wind speed, Cluster 2 high rainfall, and Cluster 3 high temperature and PSI. Compared to Cluster 1, Cluster 3 had a higher AMI incidence with IRR 1.04 (95% confidence interval 1.01-1.07), but no significant difference was found between Cluster 1 and Cluster 2. Subgroup analyses showed that increased AMI incidence was significant only among those with age ≥65, male, non-smokers, non-ST elevation AMI (NSTEMI), history of hyperlipidemia and no history of ischemic heart disease, diabetes or hypertension. In conclusion, we found that AMI incidence, especially NSTEMI, is likely to be higher on days with high temperature and PSI. These findings have public health implications for AMI prevention and emergency health services delivery during the seasonal Southeast Asian transboundary haze.

Variation in community and ambulance care processes for out-of-hospital cardiac arrest during the COVID-19 pandemic: a systematic review and meta-analysis.

Bystander cardiopulmonary resuscitation (BCPR), early defibrillation and timely treatment by emergency medical services (EMS) can double the chance of survival from out-of-hospital sudden cardiac arrest (OHCA). We investigated the effect of the COVID-19 pandemic on the pre-hospital chain of survival. We searched five bibliographical databases for articles that compared prehospital OHCA care processes during and before the COVID-19 pandemic. Random effects meta-analyses were conducted, and meta-regression with mixed-effect models and subgroup analyses were conducted where appropriate. The search yielded 966 articles; 20 articles were included in our analysis. OHCA at home was more common during the pandemic (OR 1.38, 95% CI 1.11-1.71, p = 0.0069). BCPR did not differ during and before the COVID-19 pandemic (OR 0.94, 95% CI 0.80-1.11, p = 0.4631), although bystander defibrillation was significantly lower during the COVID-19 pandemic (OR 0.65, 95% CI 0.48-0.88, p = 0.0107). EMS call-to-arrival time was significantly higher during the COVID-19 pandemic (SMD 0.27, 95% CI 0.13-0.40, p = 0.0006). Resuscitation duration did not differ significantly between pandemic and pre-pandemic timeframes. The COVID-19 pandemic significantly affected prehospital processes for OHCA. These findings may inform future interventions, particularly to consider interventions to increase BCPR and improve the pre-hospital chain of survival.

Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.

Background The role of cardiac arrest centers (CACs) in out-of-hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out-of-hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self-declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta-analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty-six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52-2.26]), even when including high-volume centers (aOR, 1.50 [95% CI, 1.18-1.91]) or including improved-care centers (aOR, 2.13 [95% CI, 1.75-2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59-2.32]), even when including high-volume centers (aOR, 1.74 [95% CI, 1.38-2.18]) or when including improved-care centers (aOR, 1.97 [95% CI, 1.71-2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm (P=0.006) and without prehospital return of spontaneous circulation (P=0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out-of-hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.

External validation of the Survival After ROSC in Cardiac Arrest (SARICA) score for predicting survival after return of spontaneous circulation using multinational pan-asian cohorts.

Aim: Accurate and timely prognostication of patients with out-of-hospital cardiac arrest (OHCA) who attain return of spontaneous circulation (ROSC) is crucial in clinical decision-making, resource allocation, and communication with family. A clinical decision tool, Survival After ROSC in Cardiac Arrest (SARICA), was recently developed, showing excellent performance on internal validation. We aimed to externally validate SARICA in multinational cohorts within the Pan-Asian Resuscitation Outcomes Study. Materials and methods: This was an international, retrospective cohort study of patients who attained ROSC after OHCA in the Asia Pacific between January 2009 and August 2018. Pediatric (age <18 years) and traumatic arrests were excluded. The SARICA score was calculated for each patient. The primary outcome was survival. We used receiver operating characteristics (ROC) analysis to calculate the model performance of the SARICA score in predicting survival. A calibration belt plot was used to assess calibration. Results: Out of 207,450 cases of OHCA, 24,897 cases from Taiwan, Japan and South Korea were eligible for inclusion. Of this validation cohort, 30.4% survived. The median SARICA score was 4. Area under the ROC curve (AUC) was 0.759 (95% confidence interval, CI 0.753-0.766) for the total population. A higher AUC was observed in subgroups that received bystander CPR (AUC 0.791, 95% CI 0.782-0.801) and of presumed cardiac etiology (AUC 0.790, 95% CI 0.782-0.797). The model was well-calibrated. Conclusion: This external validation study of SARICA demonstrated high model performance in a multinational Pan-Asian cohort. Further modification and validation in other populations can be performed to assess its readiness for clinical translation.

Air quality and the risk of out-of-hospital cardiac arrest in Singapore (PAROS): a time series analysis.

BACKGROUND: Previous studies have reported positive associations between out-of-hospital cardiac arrest (OHCA) and air pollutant concentrations, but there are inconsistencies across studies. We aimed to investigate the association between pollutant concentrations and the risk of OHCA in Singapore. METHODS: We did a time series analysis of all cases of OHCA in Singapore reported between July 1, 2010, and Dec 31, 2018, to the Pan-Asian Resuscitation Outcomes Study (PAROS), a prospective, population-based registry. Using multivariable fractional polynomial modelling, we investigated the immediate (day 0) and lagged (up to 5 days after exposure) association between 10 µg/m3 increases in concentrations of particulate matter with a diameter of 2·5 µm or smaller (PM2·5), particulate matter with a diameter of 10 µm or smaller (PM10), ozone (O3), nitrogen dioxide (NO2), and sulphur dioxide (SO2) and 1 mg/m3 increase in carbon monoxide (CO) and relative risk (RR) of OHCA. FINDINGS: We extracted data for 18 131 cases of OHCA. The median age of this cohort of cases was 65 years (IQR 56-80), 6484 (35·8%) were female, 11 647 (64·2%) were male, 12 270 (67·7%) were Chinese, 2873 (15·8%) were Malay, and 2010 (11·1%) were Indian. Every 10 µg/m3 increase in PM2·5 was associated with increased risk of OHCA (RR 1·022 [95% 1·002-1·043]) over the next 2 days, which decreased over the subsequent 3 days (3-5 days after exposure; 0·976 [0·955-0·998]). For PM10, O3, NO2, and SO2, we did not observe any associations between increased concentration and risk of OHCA on day 0 or cumulative risk over time (ie, at 0-1 days, 0-2 days, 0-3 days, 0-4 days, 0-5 days, and 3-5 days after exposure). For CO, we observed a cumulative decreased risk of OHCA across 0-5 days after exposure (0·876 [0·770-0·997]) and at days 3-5 after exposure (0·810 [0·690-0·949]). We observed effect modification of the association between increasing PM2·5 concentration and OHCA 0-2 days after exposure by cardiac arrest rhythm (non-shockable 1·027 [1·004-1·050] vs shockable 1·002 [0·956-1·051]) and location of OHCA (at home: 1·033 [1·008-1·057] vs not at home 0·955 [0·957-1·035]). In hypothetical modelling, the number of OHCA events associated with PM2·5 could be reduced by 8% with a 1 µg/m3 decrease in PM2·5 concentrations and by 30% with a 3 µg/m3 decrease in PM2·5 concentrations. INTERPRETATION: Increases in PM2·5 concentration were associated with an initial increased risk of OHCA and a subsequent reduced risk from 3-5 days after exposure, suggesting a short-term harvesting effect. A decrease in PM2·5 concentrations could reduce population demand for emergency health services. FUNDING: National Medical Research Council, Singapore, under the Clinician Scientist Award, Singapore and the Singapore Translational Research Investigator Award (MOH-000982-01).

A network meta-analysis of 12,116 individuals from randomized controlled trials in the treatment of depression after acute coronary syndrome.

BACKGROUND: Post-acute coronary syndrome (ACS) depression is a common but not well understood complication experienced by ACS patients. Research on the effectiveness of various therapies remains limited. Hence, we sought to conduct a network meta-analysis to assess the efficacy of different interventions for post-ACS depression in improving patient outcomes. METHODS AND FINDINGS: Three electronic databases were searched for randomised controlled trials describing different depression treatment modalities in post-ACS patients. Each article was screened based on inclusion criteria and relevant data were extracted. A bivariate analysis and a network meta-analysis was performed using risk ratios (RR) and standardized mean differences (SMD) for binary and continuous outcomes, respectively. A total of 30 articles were included in our analysis. Compared to standard care, psychosocial therapy was associated with the greatest reduction in depression scores (SMD:-1.21, 95% CI: -1.81 to -0.61, p<0.001), followed by cognitive behavioural therapy (CBT) (SMD: -0.75, 95% CI: -0.99 to -0.52, p<0.001), antidepressants (SMD: -0.73, 95% CI: -1.14 to -0.31, p<0.001), and lastly, combination therapy (SMD: -0.15, 95% CI: -0.28 to -0.03, p = 0.016). No treatment modalities was found to be more effective in reducing depression scores when compared to one another. Additional analysis showed that these treatment modalities did not have significant impact on the overall mortality, cardiac mortality and recurrent myocardial infarction. CONCLUSION: This network meta-analysis found that the treatment effect of the various psychological modalities on depression severity were similar. Future trials on psychological interventions assessing clinical outcomes and improvement in adherence to ACS-specific interventions are needed.