Age, sex, and pre-arrest comorbidities shape the risk trajectory of sudden cardiac death- Patterns highlighted by population data in Taiwan.

OBJECTIVES: Few reports have indicated the secular trend in the sudden cardiac death (SCD) incidence and pre-arrest comorbidities. This study aimed to comprehensively analyze the trend of SCD incidence and its association with pre-arrest comorbidities. METHODS: This population-based cohort study analyzed Taiwan's National Health Insurance (NHI) research database and identified SCD incidents by inspecting data from all emergency department visits from 2011 to 2018. The inclusion criteria were ICD-9:427.5 or 427.41, or ICD-10:I46.9, I46.8, or I46.2. Pre-existing comorbidities were confirmed based on medication use. Multivariable logistic regression was adopted with covariates age, sex, and pre-existing comorbidities. RESULTS: This study reviewed a total of 184,164,969 person-year records, and identified 92,138 SCD incidents. From 2011 to 2018, the SCD incidence rate increased from 36.3 to 55.4 per 100,000 enrollees in Taiwan. The top five pre-arrest comorbidities were stable, while the prevalence of chronic kidney disease rose significantly. Compared to those aged 20-29, enrollees aged >65 years had significantly higher odds of SCD (aOR:27.30, 95% CI:26.05-28.61). Higher odds of SCD were noted in the enrollees who had a seizure (aOR:2.24, 95% CI:2.12-2.38), parkinsonism (aOR:1.81, 95% CI:1.73-1.89), psychological disorders (aOR:1.59, 95% CI:1.56-1.62), diabetes mellitus (aOR:1.44, 95% CI:1.41-1.46), heart diseases (aOR:1.41, 95% CI:1.38-1.44). CONCLUSIONS: The incidence of SCD steadily increased in Taiwan from 2011 to 2018. Hypertension, diabetes mellitus, heart disease, psychological disorders, and arthritis were major pre-arrest comorbidities. Age is the most important risk factor for SCD. Further large-scaled population-based study that investigated in diverse ethnicities from countries in addition to Asians would be warranted.

A novel scale for triage assessment of frailty in the emergency department (ED-FraS): a prospective videotaped study.

BACKGROUND: Rapid recognition of frailty in older patients in the ED is an important first step toward better geriatric care in the ED. We aimed to develop and validate a novel frailty assessment scale at ED triage, the Emergency Department Frailty Scale (ED-FraS). METHODS: We conducted a prospective cohort study enrolling adult patients aged 65 years or older who visited the ED at an academic medical center. The entire triage process was recorded, and triage data were collected, including the Taiwan Triage and Acuity Scale (TTAS). Five physician raters provided ED-FraS levels after reviewing videos. A modified TTAS (mTTAS) incorporating ED-FraS was also created. The primary outcome was hospital admission following the ED visit, and secondary outcomes included the ED length of stay (EDLOS) and total ED visit charges. RESULTS: A total of 256 patients were included. Twenty-seven percent of the patients were frail according to the ED-FraS. The majority of ED-FraS was level 2 (57%), while the majority of TTAS was level 3 (81%). There was a weak agreement between the ED-FraS and TTAS (kappa coefficient of 0.02). The hospital admission rate and charge were highest at ED-FraS level 5 (severely frail), whereas the EDLOS was longest at level 4 (moderately frail). The area under the Receiver Operating Characteristic curve (AUROC) in predicting hospital admission for the TTAS, ED-FraS, and mTTAS were 0.57, 0.62, and 0.63, respectively. The ED-FraS explained more variation in EDLOS (R2 = 0.096) compared with the other two methods. CONCLUSIONS: The ED-Fras tool is a simple and valid screening tool for identifying frail older adults in the ED. It also can complement and enhance ED triage systems. Further research is needed to test its real-time use at ED triage internationally.

Chief complaints and computed tomography results in the emergency department: a three-year retrospective cohort study.

BACKGROUND: Computed tomography (CT) is frequently performed in the patients who admitted to the emergency department (ED), discharged but returned to ED within 72 h. It is unknown whether the main complaints of patients assist physicians to use CT effectively. This study aimed to find the association between chief complaints and the CT results. METHODS: This three-year retrospective cohort study was conducted in the ED of a tertiary medical center. Adult patients who returned to the ED after the index visit were included from 2019 to 2021. Demographics, pre-existing diseases, chief complaints, and CT region were recorded by independent ED physicians. A logistic regression model with an odds ratio (OR) and 95% confidence interval (CI) was used to determine the relationship between chief complaints and positive CT results. RESULTS: In total, 7,699 patients revisited ED after the index visit; 1,202 (15.6%) received CT. The top chief complaints in patients who received CT were abdominal pain, dizziness, and muscle weakness. Patients with abdominal pain or gastrointestinal symptoms had a significantly higher rate of positive abdominopelvic CT than those without it (OR 2.83, 95% CI 1.98-4.05, p < 0.001), while the central nervous system and cardiopulmonary chief complaints were not associated (or negatively associated) with new positive CT findings. CONCLUSION: Chief complaints of patients on revisit to the ED are associated with different yields of new findings when CT scans of the chest, abdomen and head are performed. Physicians should consider these differential likelihoods of new positive findings based on these data.

Differences in the characteristics and patterns of adult emergency department return visits before and after the coronavirus disease 2019 outbreak.

BACKGROUND: Data about changes in the characteristics of ED return visits before and after the COVID-19 outbreak are limited. This study aimed to report the differences on utility in ED return visits after the COVID-19 outbreak. METHODS: This retrospective cohort study was conducted from 2019 to 2020. Adult patients with ED return visits were included in the analysis. Variables including demographic characteristics, pre-comorbidities, triage levels, vital signs, chief complaints, management, and diagnosis were recorded and confirmed via a manual assessment. RESULTS: The proportion of patients with ED visits decreased by 23%. Hence, that of patients with ED return visits also reduced from 2580 to 2020 patients (22%) after the COVID-19 outbreak. The average age (60-57.8 years) of patients with return visits was significantly younger, and the proportion of female patients decreased remarkably. Further, the proportion of patients with chronic pre-existing diseases at the return visit significantly differed after the COVID-19 outbreak. The proportion of patients with chief complaints including dizziness, dyspnea, cough, vomiting, diarrhea, and chills during the return visits significantly differed before and after the COVID-19 pandemic. In the multivariable logistic regression model, age, high triage level were significantly associated with unfavorable outcome return visit. CONCLUSION: The use of services in the ED has changed since the COVID-19 outbreak. Hence, the proportion of patients with unplanned return visits within 72 h decreased. After the COVID-19 outbreak, people are now cautious whether they should return to the ED, as in the pre-pandemic situation, or just treat conservatively at home.

Pain trajectories in the emergency department: Patient characteristics and clinical outcomes.

BACKGROUND: Little is known about pain trajectories in the emergency department (ED), which could inform the heterogeneous response to pain treatment. We aimed to identify clinically relevant subphenotypes of pain resolution in the ED and their relationships with clinical outcomes. METHODS: This retrospective cohort study used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 733,398 ED visits over a 7-year period. We selected one ED visit per person and retrieved data including patient demographics, triage data, repeated pain scores evaluated on a numeric rating scale, pain characteristics, laboratory markers, and patient disposition. The primary outcome measures were hospitalization and ED revisit. RESULTS: 28,105 adult ED patients were included with a total of 154,405 pain measurements. Three distinct pain trajectory groups were identified: no pain (57.1%); moderate-to-severe pain, fast resolvers (17.9%); and moderate pain, slow resolvers (24.9%). The fast resolvers responded well to treatment and were independently associated with a lower risk of hospitalization (adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], 0.70-0.81). By contrast, the slow resolvers had lingering pain in the ED and were independently associated with a higher risk of ED revisit (aOR, 2.65; 95%CI, 1.85-3.69). This group also had higher levels of inflammatory markers, including a higher leukocyte count and a higher level of C-reactive protein. CONCLUSIONS: We identified three novel pain subphenotypes with distinct patterns in clinical characteristics and patient outcomes. A better understanding of the pain trajectories may help with the personalized approach to pain management in the ED.

Multivessel versus Culprit-Only Revascularization Strategies in Cardiac Arrest Survivors.

Background: Whether multivessel revascularization or culprit-only revascularization is more beneficial in cardiac arrest survivors with multivessel coronary artery disease remains unclear. We aimed to retrospectively evaluate whether multivessel or culprit-only revascularization following cardiac arrest was associated with a reduced incidence of in-hospital mortality. Methods: A total of 273 adult nontraumatic cardiac arrest survivors (aged ≥ 18 years) who underwent emergent coronary angiography (CAG) within 24 h following cardiac arrest were retrospectively recruited from three hospitals. Patients without definite coronary artery stenosis (n = 72), one-vessel stenosis (n = 74), or failed percutaneous coronary intervention (PCI; n = 37) were excluded. A total of 90 patients were enrolled for the final analysis and classified into multivessel (revascularization of more than one major vessel during the index CAG; n = 45) and culprit-only (revascularization of the infarct-related artery alone; n = 45) groups. Results: Twenty-five patients (55.6%) in the culprit-only group and 17 patients (37.8%) in the multivessel group failed to survive to discharge [adjusted hazard ratio (HR) = 0.47, 95% confidence interval (CI) = 0.24-0.95, p = 0.035]. The benefit of multivessel revascularization on survival was obvious among those with a prolonged cardiopulmonary resuscitation duration (> 10 min) (47.82% vs. 76.92%, adjusted HR = 0.27, 95% CI = 0.08-0.93, p = 0.03). No difference in neurological outcomes (favorable = cerebral performance category scores 1-2; poor = 3-5) between groups was observed (60.0% vs. 55.6%, adjusted OR = 1.22, 95% CI = 0.35-4.26, p = 0.753). Conclusions: Compared with culprit-only revascularization, multivessel revascularization was associated with lower in-hospital mortality among cardiac arrest survivors with multivessel lesions. Owing to the retrospective design and small sample size, the current study should be interpreted as observational and exploratory.

Strategies on locations of public access defibrillator: A systematic review.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a critical condition with poor outcomes. Although the survival rate increases in those who undergo defibrillation, the utility of on-time defibrillation among bystanders remained low. An evaluation of the deployment strategy for public access defibrillators (PADs) is necessary to increase their use and accessibility. This study was to conduct a systematic review for deployment strategies of PADs. METHODS: Two authors independently searched for articles published before October 2019 from PubMed, Embase, Web of Science, and Cochrane Library. An independent librarian provided the search strategy and assisted the literature research. We included articles that were focused on the main topic, but excluded those which were missing results or that used an unclear definition. The qualitative outcomes were the utility and OHCA coverage of PADs. We performed a qualitative analysis across the studies, but a quantitative analysis was not available due to the studies' heterogeneity in design and variety of outcomes. RESULTS: We eventually included 15 studies. Three strategies were presented: guidelines-based, grid-based, and landmark-based. The guidelines-based deployment was common fit for OHCA events. The grid-based method increased the use of bystander defibrillation 3-fold, and 30-day survival doubled. The top 3 landmarks in the landmark-based strategy were offices (18.6%), schools (13.3%), and sports facilities (12.9%). Utility of PADs might increase if we optimize PAD location by mathematical modeling and evaluation feedback. CONCLUSION: Three deployment strategies were presented. Although the optimal method could not be fully identified, a more efficient PAD deployment could benefit the population in terms of OHCA coverage and survival among patients with OHCA.

Serum lipids and risk of atherosclerosis in xanthelasma palpebrarum: A systematic review and meta-analysis.

BACKGROUND: The association between dyslipidemia and xanthelasma palpebrarum (XP) remains controversial, and no definite evidence has indicated atherosclerosis risk in patients with XP. OBJECTIVE: The present study was a systematic review and meta-analysis to elucidate the association of serum lipid profiles and risk of atherosclerotic diseases with XP. METHODS: We systematically searched for the eligible comparative studies published before April 15, 2019, in the databases of PubMed, Web of Science, Embase, and Cochrane Library. A random-effects model was used to calculate the standard mean difference with 95% confidence interval for each pooled estimate. RESULTS: The qualitative analyses included 15 case-control studies with 854 patients with XP. Compared with the controls, the patients with XP had significantly higher serum levels of total cholesterol and low-density lipoproteins, significantly higher apolipoprotein B levels, and relatively lower apolipoprotein A1 levels, and the carotid intima-media thickness was significantly higher. CONCLUSION: Patients with XP had significantly higher serum levels of atherogenic low-density lipoproteins and bore significantly higher risk of atherosclerosis than the controls. Careful monitoring and targeted intervention for prevention of cardiovascular diseases is essential for these patients.

Obesity is associated with poor prognosis in cardiogenic arrest survivors receiving coronary angiography.

BACKGROUND: The role of body mass index (BMI) in clinical outcomes in patients resuscitated from cardiac arrest (CA) has recently drawn attention. We evaluated the effect of BMI on the prognosis of patients successfully resuscitated from cardiogenic arrest. METHODS: This retrospective cohort study included 273 non-traumatic adult cardiogenic arrest survivors receiving coronary angiography after return of spontaneous circulation in three hospitals from January 2011 to September 2017. These patients were classified as underweight, normal-weight, overweight, and obese, based on BMI (<18.5; 18.5-24.9; 25.0-29.9; and ≥30 kg/m2, respectively). In-hospital mortality and poor neurological outcomes were compared among groups. RESULTS: The obese group had significantly higher rates of in-hospital mortality and poor neurological outcomes (cerebral performance scale = 3-5) than did the other groups (for underweight, normal-weight, overweight, and obese groups, in-hospital mortality rates were 38.5%, 29.8%, 39.0%, and 64.1%, respectively, p = 0.002; poor neurological outcomes were 53.9%, 43.8%, 47.0%, and 71.8%, respectively, p = 0.02). The obese group exhibited higher risks of in-hospital mortality and poor neurological outcomes than did the normal-weight group (in-hospital mortality: adjusted hazard ratio (aHR) = 5.21, 95% confidence interval (CI) 2.16-10.32, p < 0.001; poor neurological outcomes: aHR = 3.77, 95% CI 1.69-8.36, p = 0.002). CONCLUSION: Obesity was associated with higher risks of in-hospital mortality and poor neurological recovery.

Efficacy of Autologous Platelet-Rich Plasma Combined With Ablative Fractional Carbon Dioxide Laser for Acne Scars: A Systematic Review and Meta-Analysis.

BACKGROUND: Acne scars are common and challenging clinical complications of acne vulgaris. Ablative fractional carbon dioxide (CO2) laser is a well-established treatment for acne scars; however, some postlaser adverse effects have been noted. Autologous platelet-rich plasma (PRP) can improve tissue regeneration. Several studies have investigated the efficacy of combination therapy of CO2 laser and PRP for acne scars. OBJECTIVES: The authors sought to conduct a meta-analysis of the efficacy of PRP combined with ablative fractional CO2 laser for treating acne scars by examining clinical trial results. METHODS: A systematic review was performed by searching PubMed, Embase, Cochrane Library, and Web of Science, and a meta-analysis was conducted to assess the clinical outcomes after combination therapy of PRP and ablative fractional CO2 laser compared with laser alone. RESULTS: We identified 4 eligible studies for the meta-analysis, including 3 randomized controlled trials. Our results demonstrated that clinical improvement after combination therapy was significantly higher than that after laser alone (odds ratio = 2.992, P = 0.001). Regarding major side effects, patients who underwent combination therapy experienced significantly shorter duration of crust compared with CO2 laser alone (standard mean difference = -1.140, P < 0.001); relatively shorter durations of erythema and edema were also noted after combination therapy. Furthermore, patient satisfaction rates were significantly higher after combination therapy than after laser alone (odds ratio = 3.169, P = 0.002). CONCLUSIONS: The combination of autologous PRP and ablative fractional CO2 laser has synergistic positive effects on the clinical outcomes for acne scars and can accelerate the recovery of laser-damaged skin.

Outcome Analysis of Patients with Gallstone Disease Receiving Cholecystectomy: A Population-Based Cohort Study.

BACKGROUND/AIMS: Cholecystectomy is generally performed to treat patients with gallstone disease (GSD) in clinical practice. The present study aimed to investigate whether type 2 diabetes mellitus (T2DM) may influence the overall survival of GSD patients. METHODS: The National Health Insurance Research Database, a population-based registry data in Taiwan, was used to identify GSD patients from 2001 to 2008. The risk of cancers and effects of T2DM on the overall survival of GSD patients receiving cholecystectomy were estimated by hazards ratios (HRs) and 95% CIs using the Cox proportional hazard model. RESULTS: Among 392,028 eligible GSD patients, 81,971 underwent cholecystectomy, whereas 310,057 did not. After cholecystectomy, the HR for developing cancer was 1.14. The HR for the overall survival was 0.74-fold lower for patients who underwent cholecystectomy than that for patients who did not. GSD patients without T2DM who underwent cholecystectomy (0.78-fold lower risk) had a longer survival, whereas those with T2DM had shorter survival (1.64-fold higher risk without cholecystectomy and 1.13-fold higher risk with cholecystectomy) compared with those without T2DM who did not undergo cholecystectomy. CONCLUSIONS: Our major findings suggest that T2DM may worsen the prognosis of GSD patients after cholecystectomy, which provides useful insight into the treatment of T2DM among GSD patients in clinical settings.

Serous degeneration of bone marrow mimics spinal tumor.

OBJECTIVE: To present a rare case of serous degeneration of bone marrow which resembles primary spinal tumor or bony metastasis to spine. Serous degeneration of bone marrow or gelatinous marrow transformation is a rare disease characterized by focal marrow hypoplasia, fat atrophy, and accumulation of extracellular mucopolysaccharides abundant in hyaluronic acid. Few literature was reviewed and few clinical case was presented. METHODS: Two cases of serous marrow transformation were reported. RESULTS: In the first case, a 29-year-old man suffered from severe left buttock pain. Bone metastasis was impressed in radiology examinations. Percutaneous endoscopic lumbar discectomy was performed along with bone biopsy. In the second case, a 49-year-old man presented lower back pain with radiation to bilateral lower legs. Magnetic resonance imaging revealed a water-like signal lesion in sacrum. Serous marrow transformation was confirmed pathologically in both cases. CONCLUSION: To the best of our knowledge, a case of serous degeneration of bone marrow resembling malignancy has not been reported in the literature. In this report, two cases demonstrate serous transformation of bone marrow mimics spinal tumor.

The incidence, predictors, and causes of cardiac arrest in United States emergency departments.

Background: Emergency department cardiac arrest (EDCA) is a global public health challenge associated with high mortality rates and poor neurological outcomes. This study aimed to describe the incidence, risk factors, and causes of EDCA during emergency department (ED) visits in the U.S. Methods: This retrospective cohort study used data from the 2019 Nationwide Emergency Department Sample (NEDS). Adult ED visits with EDCA were identified using the cardiopulmonary resuscitation code. We used descriptive statistics and multivariable logistic regression, considering NEDS's complex survey design. The primary outcome measure was EDCA incidence. Results: In 2019, there were approximately 232,000 ED visits with cardiac arrest in the U.S. The incidence rate of EDCA was approximately 0.2%. Older age, being male, black race, low median household income, weekend ED visits, having Medicare insurance, and ED visits in non-summer seasons were associated with a higher risk of EDCA. Hispanic race was associated with a lower risk of EDCA. Certain comorbidities (e.g., diabetes and cancer), trauma centers, hospitals with a metropolitan and/or teaching program, and hospitals in the South were associated with a higher risk of EDCA. Depression, dementia, and hypothyroidism were associated with a lower risk of EDCA. Septicemia, acute myocardial infarction, and respiratory failure, followed by drug overdose, were the predominant causes of EDCA. Conclusions: Some patients were disproportionately affected by EDCA. Strategies should be developed to target these modifiable risk factors, specifically factors within ED's control, to reduce the subsequent disease burden.

Performance of Intra-arrest Echocardiography: A Systematic Review.

Introduction: Intra-arrest transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have been introduced in adult patients with cardiac arrest (CA). Whether the diagnostic performance of TTE or TEE is superior during resuscitation is unclear. We conducted a systematic review following PRISMA guidelines. Methods: We searched databases from PubMed, Embase, and Google Scholar and evaluated articles with intra-arrest TTE and TEE in adult patients with non-traumatic CA. Two authors independently screened and selected articles for inclusion; they then dual-extracted study characteristics and target conditions (pericardial effusion, aortic dissection, pulmonary embolism, myocardial infarction, hypovolemia, left ventricular dysfunction, and sonographic cardiac activity). We performed quality assessment using the Quality Assessment of Diagnostic Accuracy Studies Version 2 criteria. Results: A total of 27 studies were included: 14 studies with 2,145 patients assessed TTE; and 16 with 556 patients assessed TEE. A high risk of bias or applicability concerns in at least one domain was present in 20 studies (74%). Both TTE and TEE found positive findings in nearly one-half of the patients. The etiology of CA was identified in 13% (271/2,145), and intervention was performed in 38% (102/271) of patients in the TTE group. In patients who received TEE, the etiology was identified in 43% (239/556), and intervention was performed in 28% (68/239). In the TEE group, a higher incidence regarding the etiology of CA was observed, particularly for those with aortic dissection. However, the outcome of those with aortic dissection in the TEE group was poor. Conclusion: While TEE could identify more causes of CA than TTE, sonographic cardiac activity was reported much more in the TTE group. The impact of TTE and TEE on the return of spontaneous circulation and further survival was still inconclusive in the current dataset.

The interaction of sex and age on outcomes in emergency medical services-treated out-of-hospital cardiac arrest: A 5-year multicenter retrospective analysis.

Background: Studies have established that sex and age influence outcomes following out-of-hospital cardiac arrest (OHCA). However, a knowledge gap exists regarding their interaction. This study aimed to investigate the interaction of age and sex and how they cooperatively influence OHCA outcomes. Methods: This retrospective cohort study included adult, nontraumatic OHCA patients admitted to a university hospital and its affiliated hospitals in Taiwan from January 2017 to December 2021. Data including sex, age, body mass index, cardiac rhythm, and resuscitation information in the emergency department (ED) were collected from medical records. The study outcomes encompassed survival to intensive care unit (ICU) admission, survival to hospital discharge, and a favorable neurological outcome. Multivariable logistic regression was performed to estimate the influence of sex on study outcomes. Results: We analyzed a total of 2,826 eligible subjects categorized into three groups: young (18-44 years, 149 males and 57 females), middle-aged (45-64 years, 524 males and 188 females), and old (≥65 years, 1,049 males and 859 females). Analysis of the effects of sex according to age stratification showed that old males had higher odds for survival to ICU admission (OR: 1.49, 95% CI: 1.21-1.83) and favorable neurological outcomes (OR: 2.74, 95% CI: 1.58-4.76) than did old females. Analysis of the effects of age according to sex stratification revealed that old males had lower odds for survival to hospital discharge (OR: 0.33, 95% CI: 0.21-0.51) and favorable neurological outcomes (OR: 0.26, 95% CI: 0.16-0.43) than did young males. Old females also showed the same trend as males, with lower odds for survival to hospital discharge (OR: 0.37, 95% CI: 0.17-0.78) and favorable neurological outcomes (OR: 0.11, 95% CI: 0.05-0.25) than did young females. Conclusions: The interaction between sex and age in patients with OHCA results in diverse outcomes. Within the same sex, age demonstrated varying effects on distinct outcomes.