Implementation of a National 5-Year Plan for Prehospital Emergency Care in Singapore and Impact on Out-of-Hospital Cardiac Arrest Outcomes From 2011 to 2016.

Background Outcomes of patients from out-of-hospital cardiac arrest (OHCA) vary widely globally because of differences in prehospital systems of emergency care. National efforts had gone into improving OHCA outcomes in Singapore in recent years including community and prehospital initiatives. We aimed to document the impact of implementation of a national 5-year Plan for prehospital emergency care in Singapore on OHCA outcomes from 2011 to 2016. Methods and Results Prospective, population-based data of OHCA brought to Emergency Departments were obtained from the Pan-Asian Resuscitation Outcomes Study cohort. The primary outcome was Utstein (bystander witnessed, shockable rhythm) survival-to-discharge or 30-day postarrest. Mid-year population estimates were used to calculate age-standardized incidence. Multivariable logistic regression was performed to identify prehospital characteristics associated with survival-to-discharge across time. A total of 11 465 cases qualified for analysis. Age-standardized incidence increased from 26.1 per 100 000 in 2011 to 39.2 per 100 000 in 2016. From 2011 to 2016, Utstein survival rates nearly doubled from 11.6% to 23.1% (P=0.006). Overall survival rates improved from 3.6% to 6.5% (P<0.001). Bystander cardiopulmonary resuscitation rates more than doubled from 21.9% to 56.3% and bystander automated external defibrillation rates also increased from 1.8% to 4.6%. Age ≤65 years, nonresidential location, witnessed arrest, shockable rhythm, bystander automated external defibrillation, and year 2016 were independently associated with improved survival. Conclusions Implementation of a national prehospital strategy doubled OHCA survival in Singapore from 2011 to 2016, along with corresponding increases in bystander cardiopulmonary resuscitation and bystander automated external defibrillation. This can be an implementation model for other systems trying to improve OHCA outcomes.

Therapeutic vaccination for chronic hepatitis B: A systematic review and meta-analysis.

Therapeutic vaccines may be promising treatments for chronic hepatitis B (CHB), but their clinical efficacy and safety are unclear. We conducted a systematic review of the evidence for the efficacy and safety of therapeutic vaccines in CHB patients. We searched PubMed, EMBASE and Google Scholar from 1990 until present and abstracts from EASL, APASL and AASLD from 2012 to 2017 and selected randomized controlled trials of CHB patients, comparing therapeutic vaccines with no treatment or standard of care. The Cochrane Risk of Bias tool v2.0 and GRADE method were used. Analyses were stratified by hepatitis B e antigen (HBeAg) status and the comparator (therapeutic vaccines vs no treatment, or therapeutic vaccines + standard of care vs standard of care). Efficacy outcomes were HBeAg seroconversion, hepatitis B virus DNA reduction and hepatitis B virus surface antigen (HBsAg) loss, measured at the end of treatment or end of follow-up. Effects were reported as risk differences with 95% confidence intervals using a random effects model. Fifteen studies were included. A wide variety of therapeutic vaccines were tested. For HBeAg clearance at the end of follow-up, when comparing therapeutic vaccines vs no therapy, RD = 0.01, 95% CI -0.05 to 0.07, and when comparing therapeutic vaccines + standard of care vs standard of care, RD = 0.03, 95% CI -0.03 to 0.09. For HBVDNA reduction at the end of follow-up, when comparing therapeutic vaccines vs no therapy, RD = -0.03, 95% CI -0.08 to 0.02, and when comparing therapeutic vaccines + standard of care, RD = 0.15, 95% CI 0.02-0.28. There were only a few studies on HBsAg loss, and hence, the findings were inconclusive. The only efficacy finding was HBVDNA reduction at the end of follow-up for therapeutic vaccines + standard of care vs standard of care; otherwise, therapeutic vaccines do not appear to be efficacious for the treatment of CHB, but were limited by few RCTs, suboptimal therapeutic vaccines and patient selection.

Impact of pharmacists' counseling on caregiver's knowledge in the management of pediatric atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a common skin condition in childhood. AD management can be complex, and caregivers may have inadequate information on the disease, aggravating factors, and management. Comprehensive therapeutic education has been closely associated with increased compliance and is recommended for all patients. There are, as yet, no studies on the impact of a pharmacist-led eczema counseling service. OBJECTIVES: The primary objective was to assess the impact of a pharmacist-led eczema counseling service on improving caregivers' knowledge. The secondary objective was to evaluate caregivers' satisfaction of the service and their confidence in handling the patient's condition after counseling. METHODS: This was a prospective, questionnaire-based observational study. After obtaining informed consent, caregivers were required to complete questionnaire A, containing items on demographics and knowledge assessment. Caregivers then underwent a counseling session by a dermatology-trained pharmacist. After counseling, caregivers were required to complete questionnaire B containing items on satisfaction and confidence level. A follow-up phone call was conducted after initial counseling session, during which knowledge-based questionnaire C would be completed. RESULTS: Data from 32 participants were included in the analysis. There was a significant improvement in caregivers' knowledge score after receiving counseling, with mean precounseling score of 8.38 ± 3.92 and mean postcounseling score of 13.88 ± 3.65 (P < 0.001). Majority was satisfied with the service and was confident in handling their child's condition. CONCLUSION: Pharmacist-led eczema counseling has a positive impact on caregiver's knowledge and can lead to improved compliance. The service was well received, although more time could be spent during the counseling.

Conversion to shockable rhythms during resuscitation and survival for out-of hospital cardiac arrest.

BACKGROUND: In out of hospital cardiac arrest (OHCA), the prognostic influence of conversion to shockable rhythms during resuscitation for initially non-shockable rhythms remains unknown. This study aimed to assess the relationship between initial and subsequent shockable rhythm and post-arrest survival and neurological outcomes after OHCA. METHODOLOGY: This was a retrospective analysis of all OHCA cases collected from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry in 7 countries in Asia between 2009 and 2012. We included OHCA cases of presumed cardiac etiology, aged 18-years and above and resuscitation attempted by EMS. We performed multivariate logistic regression analyses to assess the relationship between initial and subsequent shockable rhythm and survival and neurological outcomes. 2-stage seemingly unrelated bivariate probit models were developed to jointly model the survival and neurological outcomes. We adjusted for the clustering effects of country variance in all models. RESULTS: 40,160 OHCA cases met the inclusion criteria. There were 5356 OHCA cases (13.3%) with initial shockable rhythm and 33,974 (84.7%) with initial non-shockable rhythm. After adjustment of baseline and prehospital characteristics, OHCA with initial shockable rhythm (odds ratio/OR=6.10, 95% confidence interval/CI=5.06-7.34) and subsequent conversion to shockable rhythm (OR=2.00,95%CI=1.10-3.65) independently predicted better survival-to-hospital-discharge outcomes. Subsequent shockable rhythm conversion significantly improved survival-to-admission, discharge and post-arrest overall and cerebral performance outcomes in the multivariate logistic regression and 2-stage analyses. CONCLUSION: Initial shockable rhythm was the strongest predictor for survival. However, conversion to subsequent shockable rhythm significantly improved post-arrest survival and neurological outcomes. This study suggests the importance of early resuscitation efforts even for initially non-shockable rhythms which has prognostic implications and selection of subsequent post-resuscitation therapy.

Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS).

BACKGROUND: The Pan Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network (CRN) was established in collaboration with emergency medical services (EMS) agencies and academic centers in Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and UAE-Dubai and aims to report out-of-hospital cardiac arrests (OHCA) and provide a better understanding of OHCA trends in Asia. METHODS AND RESULTS: This is a prospective, international, multi-center cohort study of OHCA across the Asia-Pacific. Each participating country provided between 1.5 and 2.5 years of data from January 2009 to December 2012. All OHCA cases conveyed by EMS or presenting at emergency departments were captured. 66,780 OHCA cases were submitted to the PAROS CRN; 41,004 cases were presumed cardiac etiology. The mean age OHCA occurred varied from 49.7 to 71.7 years. The proportion of males ranged from 57.9% to 82.7%. Proportion of unwitnessed arrests ranged from 26.4% to 67.9%. Presenting shockable rhythm rates ranged from 4.1% to 19.8%. Bystander cardiopulmonary resuscitation (CPR) rates varied from 10.5% to 40.9%, however <1.0% of these arrests received bystander defibrillation. For arrests that were with cardiac etiology, witnessed arrest and VF, the survival rate to hospital discharge varied from no reported survivors to 31.2%. Overall survival to hospital discharge varied from 0.5% to 8.5%. Survival with good neurological function ranged from 1.6% to 3%. CONCLUSIONS: Survival to hospital discharge for Asia varies widely and this may be related to patient and system differences. This implies that survival may be improved with interventions such as increasing bystander CPR, public access defibrillation and improving EMS.