Association Between Emergency Medical Service Agency Intubation Rate and Intubation Success.

STUDY OBJECTIVE: Airway management is a crucial part of out-of-hospital care. It is not known if the rate of overall agency intubation attempts is associated with intubation success. We sought to evaluate the association between agency intubation attempt rate and intubation success using a national out-of-hospital database. METHODS: We conducted a retrospective secondary analysis of the ESO Data Collaborative from 2018 to 2019, and included all adult cases with an endotracheal intubation attempt. We calculated the number of intubations attempted per 100 responses, advanced life support responses, and transports for each agency. We excluded cases originating at health care facilities and outliers. We used multivariable logistic regression to evaluate the association between agency intubation attempt rate and 1) intubation success and 2) first-pass success. We adjusted for confounders. RESULTS: We included 1,005 agencies attempting 58,509 intubations. Overall, the intubation success rate was 78.8%, and the first-pass success rate was 68.5%. Per agency, the median rate of intubation attempts per 100 emergency medical service responses was 0.8 (interquartile range 0.6 to 1.1). Rates of intubation attempts per 100 responses (adjusted odds ratio [aOR] 1.7; 95% confidence interval [CI] 1.6 to 1.8), advanced life support responses (aOR 1.18; 95% CI 1.16 to 1.20), and transports (aOR 1.21; 95% CI 1.18 to 1.22) were all associated with intubation success. These relationships were similar for first-pass success but with smaller effect sizes. CONCLUSION: Higher agency rates of intubation attempts were associated with increased rates of intubation success and first-pass success.

The Epidemiology of Out-of-Hospital Pediatric Airway Management in the 2019 ESO Data Collaborative.

OBJECTIVES: Airway management is a fundamental skill that Emergency Medical Services (EMS) clinicians must be prepared to perform on patients of any age. We performed one of the first epidemiological studies of out-of-hospital pediatric airway management utilizing the ESO data set.METHODS: We used the 2019 ESO Data Collaborative public release research data set. We performed a descriptive analysis of all patients <18 years receiving at least one of the following airway management interventions: nasopharyngeal airway, oropharyngeal airway, non-invasive positive pressure ventilation (NIPPV), airway suctioning, bag-valve-mask ventilation (BVM), tracheal intubation (TI), supraglottic airway (SGA) or surgical airway placement. We determined the success rates for BVM, TI and SGA.RESULTS: Among 7,422,710 911 EMS activations, there were 346,912 pediatric encounters that resulted in patient care. Airway management occurred in 27,071 encounters (7,803 per 100,000 pediatric EMS patient care events). Use of BVM, intubation or supraglottic airway insertion occurred in 3,496 encounters (1,007 per 100,000 pediatric EMS patient care events). Ventilation with BVM occurred in 2,226 encounters (642 per 100,000 pediatric EMS patient care events), TI in 935 pediatric EMS patient care encounters (270 per 100,000 patient care encounters), and supraglottic airway insertion in 335 patient encounters (97 per 100,000 patient care encounters). Overall TI success was 71.4%, rapid sequence intubation success was 86.3%, and SGA success was 87.2%. Overall TI first pass success rate was 63.1%.CONCLUSIONS: In the ESO cohort, advanced airway management of children occurred in only 5.9 in 10,000 911 emergency encounters. Overall and first pass success rates for TI were low. These data provide contemporary perspectives of pediatric prehospital airway management in the United States.

Rural cardiac arrest care and outcomes in Texas.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) victims in rural communities have worse outcomes despite higher rates of bystander cardiopulmonary resuscitation (CPR) than urban communities. In this retrospective cohort study we attempt to evaluate selected aspects of the continuum of care, including post-arrest care, for rural OHCA victims, and we investigated factors that could contribute to rural areas having higher rates of bystander CPR. METHODS: We analyzed 2014-2020 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES) data for adult OHCAs. We linked TX-CARES data to census tract data and stratified OHCAs into urban and rural events. We created a mixed-model logistic regression to compare cardiac arrest characteristics, pre-hospital care, and post-arrest care between rural and urban settings. We adjusted for confounders and modeled census tract as a random intercept. We then compared different regression models evaluating the association between response time and bystander CPR. RESULTS: We included 1202 rural and 28,288 urban cardiac arrests. Comparing rural to urban OHCAs, rates of bystander CPR were significantly higher in rural communities (49.6% v 40.6%, aOR 1.3 95% CI 1.1-1.5). The median response time for rural (11.5 min) was longer than urban (7.3 min). The occurrence of an ambulance response time of <10 min was notably less common in rural communities when compared to urban areas (aOR 0.2, 95% CI 0.2-0.2). For post-arrest care the rates of percutaneous coronary intervention (PCI) were higher in rural than urban communities (aOR 1.7, 95% CI 1.01-2.8). The rates of AED and TTM were similar between urban and rural communities. Survival to hospital discharge was significantly lower in rural communities than urban communities (aOR 0.6, 95% CI 0.4-0.7). Although not significant, rural communities had lower rate of survival with a cognitive performance score (CPC) of 1 or 2 (aOR 0.7, 05% CI 0.6-1.003). We identified no association between response time and bystander CPR. CONCLUSION: Patients in rural areas of Texas have lower survival after OHCA compared to patients in urban areas, despite having significantly greater rates of bystander CPR and PCI. We did not find a link between response time and bystander CPR rates.

Time to Antiarrhythmic and Association with Return of Spontaneous Circulation in the United States.

INTRODUCTION: Recent clinical trials have failed to identify a benefit of antiarrhythmic administration during cardiac arrest. However, little is known regarding the time to administration of antiarrhythmic drugs in clinical practice or its impact on return of spontaneous circulation (ROSC). We utilized a national EMS registry to evaluate the time of drug administration and association with ROSC. METHODS: We utilized the 2018 and 2019 NEMSIS datasets, including all non-traumatic, adult 9-1-1 EMS activations for cardiac arrests with initial shockable rhythm and that received an antiarrhythmic. We calculated the time from 9-1-1 call to administration of antiarrhythmic. We excluded cases with erroneous time stamps. Stratified by initial antiarrhythmic (amiodarone and lidocaine), we created a mixed-effect logistic regression model evaluating the association between every 5-minute increase in time to antiarrhythmic and ROSC. We modeled EMS agency as a random intercept and adjusted for confounders. RESULTS: There were 449,630 adults, non-traumatic cardiac arrests identified with 11,939 meeting inclusion criteria. 9,236 received amiodarone and 1,327 received lidocaine initially. The median time in minutes to initial dose for amiodarone was 19.9 minutes (IQR 15.8-25.6) and for lidocaine was 19.5 minutes (IQR 15.2-25.4). Increasing time to initial antiarrhythmic was associated with decreased odds of ROSC for both amiodarone (aOR 0.9; 95% CI 0.9-0.94) and lidocaine (aOR 0.9; 95% CI 0.8-0.97). CONCLUSION: Time to administration of anti-arrhythmic medication varied, but most patients received the first dose of anti-arrhythmic drug more than 19 minutes after the initial 9-1-1 call. Longer time to administration of an antiarrhythmic in patients with an initial shockable rhythm was associated with decreased ROSC rates.

First Responder CPR and Survival Differences in Texas Minority and Lower Socioeconomic Status Neighborhoods.

INTRODUCTION: First responder (FR) cardiopulmonary resuscitation (CPR) is an important component of out-of-hospital cardiac arrest (OHCA) care. However, little is known about FR CPR disparities. METHODS: We linked the 2014-2021 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES) database to census tract data. We included non-traumatic OHCAs that were not witnessed by 9-1-1 responders and did not receive bystander CPR. We defined census tracts as having >50% of a race/ethnicity: White, Black, or Hispanic/Latino. We also stratified patients into quartiles based on socioeconomic status (SES): household income, high school graduation, and unemployment. We also combined race/ethnicity and income to create a total of five mixed strata, comparing lower income and minority census tracts to high income White census tracts. We created mixed model logistic regression models, adjusting for confounders and modeling census tract as a random intercept. Using the models, we compared FR CPR rates for census race/ethnicity (Black and Hispanic/Latino compared to White), and SES quartiles (2nd, 3rd, and 4th quartiles compared to 1st quartiles). Secondarily, we evaluated the association between FR CPR and survival for all strata. RESULTS: We included 21,966 OHCAs, and 57.4% had FR CPR. Evaluating the association between census tract characteristic and FR CPR, majority Black (aOR 0.30, 95% CI 0.22-0.41) had a lower bystander CPR rate when compared to majority White. The lowest income quartile had a lower rate of bystander CPR (aOR 0.80, 95% CI 0.65-0.98). The worst unemployment quartile was also associated with a lower rate of FR CPR (aOR 0.75, 95% CI 0.61-0.92). Combining race/ethnicity and income, middle income majority Black (30.0%; aOR 0.27, 95% CI 0.17-0.46) and low income >80% Black (31.8%; aOR 0.27, 95% CI 0.10-0.68) had lower rates of FR CPR in comparison to high income majority White. There were no associations between Hispanic or lower high school graduation and lower rates of FR CPR. We found no association between FR CPR and survival for all three strata. CONCLUSION: While we identified disparities in FR CPR in low SES and majority Black census tracts, we identified no association between FR CPR and survival in Texas.

Community Variations in Out-of-Hospital Cardiac Arrest Care and Outcomes in Texas.

Background: Large and unacceptable variation exists in cardiac resuscitation care and outcomes across communities. Texas is the second most populous state in the US with wide variation in community and emergency response infrastructure. We utilized the Texas-CARES registry to perform the first Texas state analysis of out-of-hospital cardiac arrest (OHCA) in Texas, evaluating for variations in incidence, care, and outcomes.Methods: We analyzed the Texas-CARES registry, including all adult, non-traumatic OHCAs from 1/1/2014 through 12/31/2018. We analyzed the incidence and characteristics of OHCA care and outcome, overall and stratified by community. Utilizing mixed models accounting for clustering by community, we characterized variations in bystander CPR, bystander AED in public locations, and survival to hospital discharge across communities, adjusting for age, gender, race, location of arrest, and rate of witnessed arrest (bystander and 911 responder witnessed).Results: There were a total of 26,847 (5,369 per year) OHCAs from 13 communities; median 2,762 per community (IQR 444-2,767, min 136, max 9161). Texas care and outcome characteristics were: bystander CPR (43.3%), bystander AED use (9.1%), survival to discharge (9.1%), and survival with good neurological outcomes (4.0%). Bystander CPR rate ranged from 19.2% to 55.0%, and there were five communities above and five below the adjusted 95% confidence interval. Bystander AED use ranged from 0% to 19.5%, and there was one community below the adjusted 95% confidence interval. Survival to hospital discharge ranged from 6.7% to 14.0%, and there were three communities above and two below the adjusted 95% confidence interval.Conclusion: While overall OHCA care and outcomes were similar in Texas compared to national averages, bystander CPR, bystander AED use, and survival varied widely across communities in Texas. These variations signal opportunities to improve OHCA care and outcomes in Texas.

Factors mediating community race and ethnicity differences in initial shockable rhythm for out-of-hospital cardiac arrests in Texas.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) patients from minoritized communities have lower rates of initial shockable rhythm, which is linked to favorable outcomes. We sought to evaluate the importance of initial shockable rhythm on OHCA outcomes and factors that mediate differences in initial shockable rhythm. METHODS: We performed a retrospective study of the 2013-2022 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES). Using census tract data, we stratified OHCAs into majority race/ethnicity communities: >50% White, >50% Black, and >50% Hispanic/Latino. We compared logistic regression models between community race/ethnicity and OHCA outcome: (1) unadjusted, (2) adjusting for bystander CPR (bCPR), and (3) adjusting for initial rhythm. Using structural equation modeling, we performed mediation analyses between community race/ethnicity, OHCA characteristics, and initial shockable rhythm. RESULTS: We included 22,730 OHCAs from majority White (21.1% initial shockable rhythm), 4,749 from majority Black (15.3% shockable), and 16,054 majority Hispanic/Latino (16.1% shockable) communities. Odds of favorable neurologic outcome were lower for majority Black (0.4 [0.3-0.5]) and Hispanic/Latino (0.6 [0.6-0.7]). While adjusting for bCPR minimally changed outcome odds, adjusting for shockable rhythm increased odds for Black (0.5 [0.4-0.5]) and Hispanic/Latino (0.7 [0.6-0.8]) communities. On mediation analysis for majority Black, the top mediators of initial shockable rhythm were public location (14.6%), bystander witnessed OHCA (11.6%), and female gender (5.7%). The top mediators for majority Hispanic/Latino were bystander-witnessed OHCA (10.2%), public location (3.52%), and bystander CPR (3.49%), CONCLUSION: Bystander-witnessed OHCA and public location were the largest mediators of shockable rhythm for OHCAs from minoritized communities.

Q selection for an electro-optical earth imaging system: theoretical and experimental results.

This paper explores practical design considerations for selecting Q for an electro-optical earth imaging system, where Q is defined as (λ FN) / pixel pitch. Analytical methods are used to show that, under imaging conditions with high SNR, increasing Q with fixed aperture cannot lead to degradation of image quality regardless of the angular smear rate of the system. The potential for degradation of image quality under low SNR is bounded by an increase of the detector noise scaling as Q. An imaging test bed is used to collect representative imagery for various Q configurations. The test bed includes real world errors such as image smear and haze. The value of Q is varied by changing the focal length of the imaging system. Imagery is presented over a broad range of parameters.

Geospatial Analysis of Prehospital Triage and Early Potential Preventable Traumatic Deaths.

Severely injured patients often depend on prompt prehospital triage for survival. This study aimed to examine the under-triage of preventable or potentially preventable traumatic deaths. A retrospective review of Harris County, TX, revealed 1848 deaths within 24 hours of injury, with 186 being preventable or potentially preventable (P/PP). The analysis evaluated the geospatial relationship between each death and the receiving hospital. Out of the 186 P/PP deaths, these were more commonly male, minority, and penetrating mechanisms when compared with NP deaths. Of the 186 PP/P, 97 patients were transported to hospital care, 35 (36%) were transported to Level III, IV, or non-designated hospitals. Geospatial analysis revealed an association between the location of initial injury and proximity to receiving Level III, IV, and non-designated centers. Geospatial analysis supports proximity to the nearest hospital as one of the primary reasons for under-triage.

Serial selection for invasiveness increases expression of miR-143/miR-145 in glioblastoma cell lines.

BACKGROUND: Glioblastoma multiforme (GBM) is the most common primary central nervous system malignancy and its unique invasiveness renders it difficult to treat. This invasive phenotype, like other cellular processes, may be controlled in part by microRNAs - a class of small non-coding RNAs that act by altering the expression of targeted messenger RNAs. In this report, we demonstrate a straightforward method for creating invasive subpopulations of glioblastoma cells (IM3 cells). To understand the correlation between the expression of miRNAs and the invasion, we fully profiled 1263 miRNAs on six different cell lines and two miRNAs, miR-143 and miR-145, were selected for validation of their biological properties contributing to invasion. Further, we investigated an ensemble effect of both miR-143 and miR-145 in promoting invasion. METHODS: By repeated serial invasion through Matrigel®-coated membranes, we isolated highly invasive subpopulations of glioma cell lines. Phenotypic characterization of these cells included in vitro assays for proliferation, attachment, and invasion. Micro-RNA expression was compared using miRCURY arrays (Exiqon). In situ hybridization allowed visualization of the regional expression of miR-143 and miR-145 in tumor samples, and antisense probes were used investigate in vitro phenotypic changes seen with knockdown in their expression. RESULTS: The phenotype we created in these selected cells proved stable over multiple passages, and their microRNA expression profiles were measurably different. We found that two specific microRNAs expressed from the same genetic locus, miR-143 and miR-145, were over-expressed in our invasive subpopulations. Further, we also found that combinatorial treatment of these cells with both antisense-miRNAs (antimiR-143 and -145) will abrogated their invasion without decreasing cell attachment or proliferation. CONCLUSIONS: To best of our knowledge, these data demonstrate for the first time that miR-143 and miR-145 regulate the invasion of glioblastoma and that miR-143 and -145 could be potential therapeutic target for anti-invasion therapies of glioblastoma patients.

The involvement of type IV pili and the phytochrome CphA in gliding motility, lateral motility and photophobotaxis of the cyanobacterium Phormidium lacuna.

Phormidium lacuna is a naturally competent, filamentous cyanobacterium that belongs to the order Oscillatoriales. The filaments are motile on agar and other surfaces and display rapid lateral movements in liquid culture. Furthermore, they exhibit a photophobotactic response, a phototactic response towards light that is projected vertically onto the area covered by the culture. However, the molecular mechanisms underlying these phenomena are unclear. We performed the first molecular studies on the motility of an Oscillatoriales member. We generated mutants in which a kanamycin resistance cassette (KanR) was integrated in the phytochrome gene cphA and in various genes of the type IV pilin apparatus. pilM, pilN, pilQ and pilT mutants were defective in gliding motility, lateral movements and photophobotaxis, indicating that type IV pili are involved in all three kinds of motility. pilB mutants were only partially blocked in terms of their responses. pilB is the proposed ATPase for expelling of the filament in type IV pili. The genome reveals proteins sharing weak pilB homology in the ATPase region, these might explain the incomplete phenotype. The cphA mutant revealed a significantly reduced photophobotactic response towards red light. Therefore, our results imply that CphA acts as one of several photophobotaxis photoreceptors or that it could modulate the photophobotaxis response.

Racial/ethnic and gender disparities of the impact of the COVID-19 pandemic in out-of-hospital cardiac arrest (OHCA) in Texas.

INTRODUCTION: Prior research shows a greater disease burden, lower BCPR rates, and worse outcomes in Black and Hispanic patients after OHCA. Female OHCA patients have lower rates of BCPR compared to men and other survival outcomes vary. The influence of the COVID-19 pandemic on OHCA incidence and outcomes in different health disparity populations is unknown. METHODS: We used data from the Texas Cardiac Arrest Registry to Enhance Survival (CARES). We determined the association of both prehospital characteristics and survival outcomes with the pandemic period in each study group through Pearson's χ2 test or Fisher's exact tests. We created mixed multivariable logistic regression models to compare odds of cardiac arrest care and outcomes between 2019 and 2020 for the study groups. RESULTS: Black OHCA patients (aOR = 0.73; 95% CI: 0.65 - 0.82) had significantly lower odds of BCPR compared to White OHCA patients, were less likely to achieve ROSC (aOR = 0.86; 95% CI: 0.74 - 0.99) or have a good CPC score (aOR = 0.47; 95% CI: 0.29 - 0.75). Compared to White patients with OHCA, Hispanic persons were less likely to have a field TOR (aOR = 0.86; 95% CI: 0.75 - 0.99) or receive BCPR (aOR = 0.78; 95% CI: 0.69 - 0.87). Female OHCA patients had higher odds of surviving to hospital admission compared to males (aOR = 1.29; 95% CI: 1.15 - 1.44). CONCLUSION: Many OHCA outcomes worsened for Black and Hispanic patients. While some aspects of care worsened for women, their odds of survival improved compared to males.

Video laryngoscopy for out of hospital cardiac arrest.

INTRODUCTION: Endotracheal intubation is an import component of out-of-hospital cardiac arrest (OHCA) resuscitation. In this analysis, we evaluate the association of video laryngoscopy (VL) with first pass success and return of spontaneous circulation (ROSC) using a national OHCA cohort. METHODS: We analyzed 2018 data from ESO Inc. (Austin, TX), a national prehospital electronic health record. We included all adult, non-traumatic cardiac arrests undergoing endotracheal intubation. We defined VL and direct laryngoscopy (DL) based on paramedic recorded intubation device. The primary outcomes were first pass success, ROSC, and sustained ROSC. Using multivariable, mixed models, we determined the association between VL and first pass success rate, ROSC, and sustained ROSC (survival to ED or ROSC in the field for greater than 20 min), fitting agency as a random intercept and adjusting for confounders. RESULTS: We included 22,132 patients cared for by 914 EMS agencies, including 5702 (25.7%) VL and 16,430 (74.2%) DL. Compared to DL, VL had a lower rate of bystander CPR, but other characteristics were similar between the groups. VL exhibited higher first pass success than DL (75.1% v 69.5%, p < .001). On mixed model analysis, VL was associated with a higher first pass success (OR 1.5, CI 1.3-1.6) but not ROSC (OR 1.1, CI 0.97-1.2) or sustained ROSC (OR 1.1, CI 0.9-1.2). CONCLUSION: While associated with higher FPS, VL was not associated with increased rate of ROSC. The role of VL in OHCA remains unclear.

Innovative Approaches to Emergency Medical Services Fellowship Challenges.

INTRODUCTION: Since the development of an Accreditation Council of Graduate Medical Education (ACGME)-accredited emergency medical services (EMS) fellowship, there has been little published literature on effective methods of content delivery or training modalities. Here we explore a variety of innovative approaches to the development and revision of the EMS fellowship curriculum. METHODS: Three academic, university-based ACGME-accredited EMS fellowship programs each implemented an innovative change to their existing training curricula. These changes included the following: a novel didactic curriculum delivery modality and evaluation; implementation of a distance education program to improve EMS fellows' rural EMS experiences; and modification of an existing EMS fellowship curriculum to train a non-emergency medicine physician. RESULTS: Changes made to each of the above EMS fellowship programs addressed unique challenges, demonstrating areas of success and promise for more generalized implementation of these curricula. Obstacles remain in tailoring the described curricula to the needs of each unique institution and system. CONCLUSION: Three separate curricula and program changes were implemented to overcome specific challenges and achieve educational goals. It is our hope that our shared experiences will enable others in addressing common barriers to teaching the EMS fellowship core content and share similar innovative approaches to educational challenges.

Continuous nondemolition measurement of the Cs clock transition pseudospin.

We demonstrate a weak continuous measurement of the pseudospin associated with the clock transition in a sample of Cs atoms. Our scheme uses an optical probe tuned near the D1 transition to measure the sample birefringence, which depends on the component of the collective pseudospin. At certain probe frequencies the differential light shift of the clock states vanishes, and the measurement is nonperturbing. In dense samples the measurement can be used to squeeze the collective clock pseudospin and has the potential to improve the performance of atomic clocks and interferometers.