Vitamin D deficiency as a risk factor for sudden cardiac arrest: A multicenter case-control study.

BACKGROUND AND AIMS: Vitamin D is known to influence the risk of cardiovascular disease, which is a recognized risk factor for sudden cardiac arrest (SCA). However, the relationship between vitamin D and SCA is not well understood. Therefore, this study aims to investigate the association between vitamin D and SCA in out-of-hospital cardiac arrest (OHCA) patients compared to healthy controls. METHODS AND RESULTS: Using the Phase II Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES II) registry, a 1:1 propensity score-matched case-control study was conducted between 2017 and 2020. Serum 25-hydroxyvitamin D (vitamin D) levels in patients with OHCA (454 cases) and healthy controls (454 cases) were compared after matching for age, sex, cardiovascular risk factors, and lifestyle behaviors. The mean vitamin D levels were 14.5 ± 7.6 and 21.3 ± 8.3 ng/mL among SCA cases and controls, respectively. Logistic regression analysis was used adjusting for cardiovascular risk factors, lifestyle behaviors, corrected serum calcium levels, and estimated glomerular filtration rate (eGRF). The adjusted odds ratio (aOR) for vitamin D was 0.89 (95% confidence interval [CI] 0.87-0.91). The dose-response relationship demonstrated that vitamin D deficiency was associated with SCA incidence (severe deficiency, aOR 10.87, 95% CI 4.82-24.54; moderate deficiency, aOR 2.24, 95% CI 1.20-4.20). CONCLUSION: Vitamin D deficiency was independently and strongly associated with an increased risk of SCA, irrespective of cardiovascular and lifestyle factors, corrected calcium levels, and eGFR.

Characteristics and Outcomes of Traumatic Cardiac Arrests in the Pan-Asian Resuscitation Outcomes Study.

OBJECTIVE: Little is known about survival outcomes after traumatic cardiac arrest in Asia, or the association of Utstein factors with survival after traumatic cardiac arrests. This study aimed to describe the epidemiology and outcomes of traumatic cardiac arrests in Asia, and analyze Utstein factors associated with survival. METHODS: Traumatic cardiac arrest patients from 13 countries in the Pan-Asian Resuscitation Outcomes Study registry from 2009 to 2018 were analyzed. Multilevel logistic regression was performed to identify factors associated with the primary outcomes of survival to hospital discharge and favorable neurological outcome (Cerebral Performance Category (CPC) 1-2), and the secondary outcome of return of spontaneous circulation (ROSC). RESULTS: There were 207,455 out-of-hospital cardiac arrest cases, of which 13,631 (6.6%) were trauma patients aged 18 years and above with resuscitation attempted and who had survival outcomes reported. The median age was 57 years (interquartile range 39-73), 23.0% received bystander cardiopulmonary resuscitation (CPR), 1750 (12.8%) had ROSC, 461 (3.4%) survived to discharge, and 131 (1.0%) had CPC 1-2. Factors associated with higher rates of survival to discharge and favorable neurological outcome were arrests witnessed by emergency medical services or private ambulances (survival to discharge adjusted odds ratio (aOR) = 2.95, 95% confidence interval (CI) = 1.99-4.38; CPC 1-2 aOR = 2.57, 95% CI = 1.25-5.27), bystander CPR (survival to discharge aOR = 2.16; 95% CI 1.71-2.72; CPC 1-2 aOR = 4.98, 95% CI = 3.27-7.57), and initial shockable rhythm (survival to discharge aOR = 12.00; 95% CI = 6.80-21.17; CPC 1-2 aOR = 33.28, 95% CI = 11.39-97.23) or initial pulseless electrical activity (survival to discharge aOR = 3.98; 95% CI = 2.99-5.30; CPC 1-2 aOR = 5.67, 95% CI = 3.05-10.53) relative to asystole. CONCLUSIONS: In traumatic cardiac arrest, early aggressive resuscitation may not be futile and bystander CPR may improve outcomes.

Association between post-cardiac arrest treatments and clinical outcomes according to scene time interval in out-of-hospital cardiac arrest: Retrospective cross-sectional study.

BACKGROUND: Previous studies have reported that Post-Cardiac arrest (PCA) treatments including targeted temperature management (TTM), coronary reperfusion therapy (CRT), and extracorporeal membrane oxygenation (ECMO) are time-sensitive; however, there are no reports of the clinical outcomes of PCA treatment according to the scene time interval (STI). Our study aimed to investigated the clinical outcomes of PCA treatment according to the STI. METHODS: We used a Korean nationwide OHCA cohort database from January 2017 to December 2020. The inclusion criteria were all adult OHCA patients with a presumed cardiac etiology, bystander-witnessed arrest, and prehospital return of spontaneous circulation (ROSC). The outcomes were survival to discharge and good neurological recovery. The main exposure of interest was PCA treatment. We compared the outcomes using multivariable logistic regression, and interaction terms were included in the final model to assess whether the STI modified the effect of PCA treatment on clinical outcomes of OHCA. RESULTS: TTM and CRT were associated with high survival to discharge and good neurological recovery. In the interaction analysis, ECMO had an interaction effect with the STI on a good CPC among patients with OHCA [short STI (0 to 11 min) (1.16 (0.77-1.75)), middle STI (12 to 15 min) (0.66 (0.41-1.06)), and long STI (16 to 30 min) (0.59 (0.40-0.88)) (p for interaction <0.05)]. CONCLUSION: In adult bystander-witnessed patients with OHCA with prehospital ROSC, an STI of >16 min was a risk factor for poor neurological outcome in those patients who underwent ECMO.

The reverse shock index multiplied by Glasgow coma scale (rSIG) is predictive of mortality in trauma patients according to age.

OBJECTIVE: The role of reverse shock index multiplied Glasgow coma scale (rSIG) in patients post-trauma with traumatic brain injury (TBI) has not yet been defined well. Our study aimed to investigate the predictive performance of rSIG according to age group. METHOD: This is a prospective multi-national and multi-center cohort study using Pan-Asian Trauma Outcome Study registry in Asian-Pacific, conducted on patients post-trauma who visited participating hospitals. The main exposure was low rSIG measured at emergency department. The main outcome was in-hospital mortality. We performed multilevel logistic regression analysis to estimate the association low rSIG and study outcomes. Interaction analysis between rSIG and age group were also conducted. RESULTS: Low rSIG was significantly associated with an increase in in-hospital mortality in patients post-trauma with and without TBI (aOR (95% CI): 1.49 (1.04-2.13) and 1.71 (1.16-2.53), respectively). The ORs for in-hospital mortality differed according to the age group in patients post-trauma with TBI (1.72 (1.44-1.94) for the young group and 1.13 (1.07-1.52) for the old group; p < 0.05). CONCLUSION: Low rSIG is associated with an increase in in-hospital mortality in adult patients post-trauma. However, in patients with TBI, the prediction of mortality is significantly better in younger patient group.

Cystatin C and mortality risk in the general population: systematic review and dose response meta-analysis.

INTRODUCTION: Cystatin C has been identified as an independent predictor of all-cause and cardiovascular mortality in the general population. This meta-analysis to evaluate the association between serum cystatin C level and all-cause and cardiovascular mortality. We additionally conducted a dose-response analysis to examine a linear association between cystatin C and cardiovascular mortality. METHODS: PudMed and Embase databases were searched until January, 2021. All prospective cohort studies that reported a multivariate-adjusted risk estimated of all-cause and cardiovascular mortality for the highest compared with lowest cystatin C level were included. RESULTS: 13 prospective cohort studies, a total of 57,214 participants were included in this analysis. Meta-analysis indicated that the highest compared with lowest cystatin C level was associated with an increase of all-cause mortality (hazard ratio [HR]: 2.01; 95% confidence intervals [CI]: 1.60-2.53; I2=89%) and cardiovascular mortality (2.62 [1.96-3.51]; I2=52%). We found a significant log-linear dose-response association between cystatin C and cardiovascular mortality (p < 0.01). Every 0.1 mg/L increase in cystatin C level was associated with a 7.3% increased cardiovascular mortality. CONCLUSIONS: Elevated serum cystatin C is associated with an increased risk of all-cause and cardiovascular mortality in the general populations. Particularly, cystatin C level and cardiovascular mortality showed linear correlation.

Effect of implementation of multi-tier response system and prolonged on-scene resuscitation for out-of-hospital cardiac arrest.

INTRODUCTION: The purpose of this study was to explain the process and results of implementing a bundle of two cardiopulmonary resuscitation (CPR) programs in Gwang-ju metropolitan city and to determine whether the use of these programs improved the clinical outcomes for out-of-hospital cardiac arrest (OHCA) patients. METHODS: This was a before- and after-intervention study of the implementation of a bundle of two CPR programs in Gwang-ju. The main intervention was a multi-tier response (MTR) system, with an emphasis on prolonged on-scene resuscitation. The primary outcome was good neurological recovery, and secondary outcomes were survival to discharge and prehospital return of spontaneous circulation (ROSC). A multivariable logistic regression model was used to estimate the association between the study period and outcomes, after adjusting for potential confounders. Interaction analysis was conducted to determine whether the location of arrest and witness status modified the effect of the study period on the study outcomes. RESULTS: The adjusted odds ratios (AORs) for the intervention were 1.35 (0.96-1.90) for pre-hospital ROSC, 1.19 (0.49-2.86) for survival to discharge, and 3.45 (1.01-11.80) for good CPC. The AORs for good neurological recovery of the after-intervention period were 2.93 (0.73-11.77) for a private place, 4.82 (1.04-22.39) for a public place, 5.88 (1.47-23.57) for a witnessed arrest, and 1.49 (0.28-7.86) for a non-witnessed arrest. CONCLUSIONS: OHCA patients treated in the after-intervention period with the bundle of CPR programs including MTR and prolonged on-scene resuscitation showed better clinical outcomes, especially pre-hospital ROSC, and neurological recovery at hospital discharge than those treated in the before-intervention period.

Clinical outcomes according to intentionality of acute pesticide poisoning in South Korea: Retrospective observation study.

Objectives: To investigate if intentional pesticide intake could have different clinical outcomes compared to unintentional poisoning, and whether acute alcohol consumption correlated with intentional poisoning. METHODS: The retrospective observational study was conducted in South Korea and comprised data from the Emergency Department-based Injury In-depth Surveillance Registry of all adults with pesticide poisoning from 2009 to 2017. The primary outcome was overall mortality. Adjusted odds ratios with 95% confidence intervals of the exposures on clinical outcomes were calculated. Data was analysed using SAS 9.4. RESULTS: Among the 7,320 patients, intentional poisoning had higher odds of overall mortality (adjusted odds ratio: 1.88; 95% confidence interval: 1.56-2.25) and major adverse outcomes (adjusted odds ratio: 2.64; 95% confidence interval: 2.32-2.99), while acute alcohol consumption showed a higher incidence of intentional poisoning (adjusted odds ratio: 2.43; 95% confidence interval: 2.11-2.80). CONCLUSIONS: Intentional poisoning showed higher mortality rate and major adverse outcomes. It is important to consider host factors before poisoning, such as acute alcohol consumption, which may contribute to the clinical outcomes of pesticide poisoning cases.

Risk of hypertension on the incidence of out-of-hospital cardiac arrest.

Objectives: To analyse the effect of hypertension on the occurrence of out-of-hospital cardiac arrest, and to find out whether the effect is dependent on the use of anti-hypertensive drugs. METHODS: The case-control study used secondary data from the Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance project and comprised patients with presumed cardiac aetiology adult out-of-hospital cardiac arrest assessed by emergency medical service from 27 participating emergency departments from January 2016 to December 2017. Controls matched for age, gender and county were recruited from the Korea National Health and Nutrition Examination Survey database in a 4:1 ratio. Multivariate logistic regression analysis was used to analyse the effects of hypertension and the administration of anti-hypertensive medication on out-of-hospital cardiac arrest incidence. Data was analysed using SAS 9.4. RESULTS: Of the 7330 subjects, 1,466(20%) were patients and 5864(80%) were controls. Hypertension was found in 662(45.2%) patients and 3,190(54.4%) controls. Hypertension lowered the incidence of out-of-hospital cardiac arrest (adjusted odds ratio: 0.69 [95% confidence interval: 0.60-0.80]); in the medication group 0.64(0.55-0.75), and 1.12(0.83-1.49) in the non-medication group. CONCLUSIONS: Administration of anti-hypertensive medications in patients of hypertension may help reduce the incidence of out-of-hospital cardiac arrest. Active hypertension diagnosis and anti-hypertensive medications to reduce the incidence of out-of-hospital cardiac arrest is critical.

Interaction Effects between COVID-19 Outbreak and Community Income Levels on Excess Mortality among Patients Visiting Emergency Departments.

BACKGROUND: The objective of this study was to examine the effect of the coronavirus disease 2019 (COVID-19) outbreak on excess in-hospital mortality among patients who visited emergency departments (EDs) and to assess whether the excess mortality during the COVID-19 pandemic varies by community income level. METHODS: This is a cross-sectional study using the National Emergency Department Information System (NEDIS) database in Korea. The study population was defined as patients who visited all 402 EDs with medical conditions other than injuries between January 27 and May 31, 2020 (after-COVID) and for the corresponding time period in 2019 (before-COVID). The primary outcome was in-hospital mortality. The main exposure was the COVID-19 outbreak, and the interaction variable was county per capita income tax. We calculated the risk-adjusted in-hospital mortality rates by COVID-19 outbreak, as well as the difference-in-difference of risk-adjusted rates between the before-COVID and after-COVID groups according to the county income tax using a multilevel linear regression model with the interaction term. RESULTS: A total of 11,662,167 patients (6,765,717 in before-COVID and 4,896,450 in after-COVID) were included in the study with a 1.6% crude in-hospital mortality rate. The risk-adjusted mortality rate in the after-COVID group was higher than that in the before-COVID group (1.82% vs. 1.50%, difference: 0.31% [0.30 to 0.33]; adjusted odds ratio: 1.22 [1.18 to 1.25]). The excess in-hospital mortality rate of the after-COVID in the lowest quartile group of county income tax was significantly higher than that in the highest quartile group (difference-in-difference: 0.18% (0.14 to 0.23); P-for-interaction: < 0.01). CONCLUSION: During the COVID-19 pandemic, there was excess in-hospital mortality among patients who visited EDs, and there were disparities in excess mortality depending on community socioeconomic positions.

Interaction Effect Between Prehospital Mechanical Chest Compression Device Use and Post-Cardiac Arrest Care on Clinical Outcomes After Out-Of-Hospital Cardiac Arrest.

BACKGROUND: Prehospital application of a mechanical chest compression device (MCD) and post-cardiac arrest (PCA) care including coronary reperfusion therapy (CRT) or targeted temperature management (TTM) could affect the clinical outcome in out-of-hospital cardiac arrest (OHCA). OBJECTIVES: This study aimed to assess whether the effect of PCA care including CRT or TTM differs according to prehospital MCD use in patients with OHCA. METHODS: Adult OHCA cases with a presumed cardiac etiology and with survival to admission from 2016 to 2017 were enrolled from the Korean nationwide OHCA registry. The main exposures were CRT and TTM during PCA care. The primary outcome was good neurologic recovery defined by a cerebral performance category score of 1 or 2 at hospital discharge. We conducted interaction analyses between MCD use and PCA care including CRT or TTM. RESULTS: Four thousand three hundred sixty-six OHCA cases were enrolled and 7.9% underwent MCD application. TTM and CRT were performed in 11.2% and 17.9% of the study population. In the interaction analysis, the adjusted odds ratios of TTM and CRT for good neurologic recovery were 2.41 (1.90-3.06) and 3.40 (2.79-4.14) in patients without MCD use and 1.89 (0.97-3.68), and 1.54 (0.79-3.01) in patients with MCD use. CONCLUSIONS: The effect of PCA care on neurologic outcomes was different according to MCD use in OHCA. The association of good neurologic outcome and PCA care was not observed in the prehospital MCD use group compared with that in the MCD nonuse group.

Mechanical Chest Compression Device for Out-Of-Hospital Cardiac Arrest: A Nationwide Observational Study.

BACKGROUND: There are few studies on the use of a mechanical chest compression (meCC) device during transport in patients with out-of-hospital cardiac arrest (OHCA). OBJECTIVE: The aim of our study was to compare the performance of an meCC device with that of manual chest compression during transport after OHCA. METHODS: This study used data from the national cardiac arrest registry of patients with OHCA of presumed cardiac etiology. The primary exposure was the use of an meCC device by an Emergency Medical Services provider while transporting a patient to the emergency department. The primary endpoint was good cerebral performance category at discharge. We compared survival and neurologic outcomes between an meCC device group and a manual chest compression group. We also performed an interaction analysis to assess changes in study outcomes of meCC device use by the initial electrocardiogram (ECG) and transport time interval (TTI). RESULTS: Among 30,021 adult patients after OHCA with presumed cardiac etiology, an meCC device was used in 2357 (7.6%). After adjustment for possible confounders, there were no significant differences with respect to good neurologic recovery in the outcomes of patients who were treated with an meCC device and those who received manual chest compression (adjusted odds ratio [AOR] 0.66; 95% confidence interval [CI] 0.43-1.02) and survival to discharge (AOR 0.83; 95% CI 0.64-1.06). In the interaction model, the AOR of the meCC device study outcome did not interact with the initial ECG and TTI. CONCLUSIONS: The meCC device did not show better study outcomes than manual compression.

Effect of hypertension across the age group on survival outcomes in out-of-hospital cardiac arrest.

OBJECTIVE: There are few studies on the effects hypertension has on survival outcomes in out-of-hospital-cardiac arrest (OHCA) patients, although hypertension is a major risk factor for the incidence of cardiac arrest. This study aims to investigate whether hypertension is associated with survival outcomes in cardiac arrest patients across age groups. METHODS: This study was conducted using the national cardiac arrest registry of OHCA patients who survived to hospital admission from 2012 to 2016. The clinical histories of hypertension were obtained from patients' medical records. The endpoint was cerebral performance category (CPC) 1 and 2 (good CPC) and survival to discharge. Multivariable logistic regression analysis was performed on the data collected. The final model with an interaction term was evaluated to compare the effects of hypertension across age groups. RESULTS: A total 11,610 patients (61.0% hypertensive patients and 39.0% non-hypertensive patients) were included. The group over 80 years old with hypertension were more likely to have good neurologic recovery (AOR 2.53 [1.43-4.50]) and those under 65 years old with hypertension were more likely to survive to hospital discharge with statistical significance (AOR 1.19 [1.04-1.35]). CONCLUSIONS: Hypertension does not imply poor survival outcomes independently for all ages, as those over 80 years of age can have rather good neurological outcomes.

Cardiac arrest while exercising on mountains in national or provincial parks: A national observational study from 2012 to 2015.

BACKGROUND: Previous studies on cardiac arrest in mountainous areas were focused on environmental features such as altitude and temperature. However, those are limited to factors affecting the prognosis of patients after cardiac arrest. We analyzed the cardiac arrests in national or provincial parks located in the mountains and determined the factors affecting the prognosis of patients after cardiac arrest. METHODS: This study included all emergency medical service (EMS) treated patients over the age of 40 experiencing out-of-hospital cardiac arrests (OHCAs) of presumed cardiac etiology during exercise, between January 2012 and December 2015. The main focus of interest was the location of cardiac arrest occurrence (national mountain parks and provincial parks vs. other sites). The main outcome was survival to discharge and multivariable logistic regression was performed to adjust for possible confounding effects. RESULTS: A total 1835 patients who suffered a cardiac arrest while exercising were included. From these, 68 patients experienced cardiac arrest in national or provincial parks, and 1767 occurred in other locations. The unadjusted and adjusted ORs (95% CI) for a good cerebral performance scale (CPC) were 0.09 (0.01-0.63) and 0.08(0.01-0.56), survival discharges were 0.13(0.03-0.53) and 0.11 (0.03-0.48). CONCLUSIONS: Cardiac arrests occurring while exercising in the mountainous areas have worse prognosis compared to alternative locations.

The effectiveness of using magnetic resonance imaging in syncope patients visiting an emergency department: A case-control study.

OBJECTIVE: To evaluate the effectiveness of brain magnetic resonance imaging in excluding neurological causes in patients with syncope. METHODS: This retrospective, observational, cohort study was conducted at the Chonnam National University Hospital, Gwangju, South Korea, and comprised medical record of patients with syncope from January 2011 to February 2016. The ratio of abnormal findings, the characteristics of the patients who showed abnormal findings and the relationships between the presence of neurological problem and other clinical factors were analysed. SPSS 18 was used for statistical analysis. RESULTS: Of the 1,045 patients, 142(13.5%) underwent additional magnetic resonance imaging. The results showed that 15(10.6%) patients had abnormal findings indicating neurological problems; of them, 9(60%) showed vascular stenosis, 4(27%) showed cerebral infarction, and 2(13%) showed brain tumours. The neurological problems shown were significantly higher for older patients (p=0.006) and those with the underlying diseases of hypertension (p=0.014) and coronary artery disease (p=0.008). Of these patients in particular, age (p=0.036) and history of coronary artery disease (p=0.029) were significantly associated with abnormal findings in their magnetic resonance imaging. CONCLUSIONS: Although there are no specific neurological examinations or computed tomography findings currently used in patients with syncope in the emergency department, magnetic resonance imaging may be performed to exclude neurological causes in older patients as well as those with a history of coronary artery disease.

Interactions Between Depression, Alcohol Intake, and Smoking on the Risk of Acute Coronary Syndrome.

OBJECTIVE: Our study hypothesizes that the interaction between depression, alcohol intake, and smoking status can significantly influence the risk of acute coronary syndrome (ACS). We aim to investigate the magnitude of the association between depression and ACS risk and explore how alcohol intake and smoking status affect this association. METHODS: We used data from the Korean Genome and Epidemiology Study. The primary exposure of interest was the presence of depression, as measured using the Beck Depression Inventory score at baseline. The primary outcome was the occurrence of ACS observed in the biennial follow-up surveys. We used Cox proportional regression analysis to estimate the effect of depression on ACS incidence. We conducted interaction and joint effect analyses to explore the interactions between depression and health-related habits including alcohol intake and smoking with regard to ACS incidence. RESULTS: During 16 years of follow-up among 3,254 individuals, we documented 88 cases of new-onset ACS (2.2 cases per 1,000 personyears). We found no association between depression and ACS risk; furthermore, the effect of depression on ACS risk by alcohol intake and smoking status did not differ significantly. In the analysis to observe the joint effect of smoking and depression, the multivariate hazard ratios of ACS were 1.26 (95% confidence interval [CI], 0.67-2.36) for non-smoking and depression, 1.52 (95% CI, 0.83-2.82) for smoking and non-depression, and 2.79 (95% CI, 1.21-6.41) for smoking and depression compared with non-smoking and non-depression. CONCLUSION: Our study reveals the combined effect of depression and smoking on ACS risk, highlighting the potential benefits of concurrent interventions for both depression and smoking for cardiovascular health.

Sex disparity in stroke risk among patients with insomnia: a 19-year prospective cohort study.

STUDY OBJECTIVES: Considering the increased prevalence and more severe manifestations of insomnia among females along with established sex differences in ischemic stroke (IS) occurrence, this research aimed to examine the potential effects of the interaction between insomnia and sex on the incidence and outcome of IS. METHODS: We used data from the Korean Genome and Epidemiology Study (KoGES). The main exposure variables were insomnia history and sex. The main outcome was the occurrence of IS observed in biennial follow-up surveys. Cox proportional regression analysis was performed to estimate the effects of insomnia and sex on IS incidence. We also conducted interaction analysis to investigate the interaction effects between insomnia and sex on IS incidence. RESULTS: During 19 years of follow-up involving 8,933 individuals, we documented 370 cases of new-onset stroke (2.88 cases per 1,000 person-years). Cox proportional regression analysis showed that insomnia and female sex did not increase the risk of IS (HR: 1.13 [95% CI: 0.86-1.51] and HR: 0.86 [95% CI: 0.63-1.17], respectively). Interaction analysis demonstrated that stroke risk was increased only among females with insomnia (HR: 1.34 [95%: 1.05-1.80]) compared with those without insomnia. CONCLUSIONS: Our study highlights the significance of considering sex-specific factors when evaluating the relationship between insomnia and IS risk, particularly emphasizing the unique role of insomnia in IS risk among females.

Interaction Effect of Shift Work and Insomnia on Stroke Risk: A 19-Year Prospective Cohort Study in Korea.

OBJECTIVES: Our study aimed to investigate the association between shift work and stroke and determine whether this association varies depending on the presence of insomnia. METHODS: Utilizing the KoGES prospective cohort data, our primary exposure variables were shift work and insomnia. The occurrence of stroke was the main outcome of interest. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression analysis. An interaction analysis was conducted to assess the interaction of shift work and insomnia on stroke incidence. RESULTS: In the interaction analysis, shift work was significantly associated with stroke incidence only in groups with insomnia and an HR of 2.49 (1.02-6.11). CONCLUSIONS: Our study demonstrated that shift work was associated with a higher risk of stroke among the population with insomnia.

Recommendations on ambulance cardiopulmonary resuscitation in basic life support systems.

AIM: Cardiopulmonary resuscitation (CPR) during ambulance transport can be a safety risk for providers and can affect CPR quality. In many Asian countries with basic life support (BLS) systems, patients experiencing out-of-hospital cardiac arrest (OHCA) are routinely transported in ambulances in which CPR is performed. This paper aims to make recommendations on best practices for CPR during ambulance transport in BLS systems. METHODS: A panel consisting of 20 experts (including 4 North Americans) in emergency medical services (EMS) and resuscitation science was selected, and met over two days. We performed a literature review and selected 33 candidate issues in five core areas. Using Delphi methodology, the issues were classified into dichotomous (yes/no), multiple choice, and ranking questions. Primary consensus between experts was reached when there was more than 70% agreement. Questions with 60-69% agreement were made more specific and were submitted for a second round of voting. RESULTS: The panel agreed upon 24 consensus statements with more than 70% agreement (2 rounds of voting). The recommendations cover the following: length of time on the scene; advanced airway at the scene; CPR prior to transport; rhythm analysis and defibrillation during transport; prehospital interventions; field termination of resuscitation (TOR); consent for TOR; destination hospital; transport protocol; number of staff members; restraint systems; mechanical CPR; turning off of the engine for rhythm analysis; alternative CPR; and feedback for CPR quality. CONCLUSION: Recommendations for CPR during ambulance transport were developed using the Delphi method. These recommendations should be validated in clinical settings.

The off-hour effect on mortality in traumatic brain injury according to age group.

BACKGROUND: Traumatic brain injury (TBI) is a time-sensitive and life-threatening medical condition. We hypothesized that off-hours, which includes night-time, weekends, and holidays, may influence mortality in TBI. Our study aimed to evaluate if the off-hours effect influences mortality in patients with TBI and whether this effect is dependent on the age group. METHODS: This study included patients who experienced TBI and were admitted to Chonnam National University Hospital (CNUH) between 2017 to 2020. The main exposure was arrival time at the emergency department (ED) (off-hours vs. working hours). The main outcome was mortality at hospital discharge. Multivariable logistic regression analysis was conducted to estimate the effect size of off-hours on mortality compared to that of working hours. We performed an interaction analysis between ED admission time and age group on study outcomes. RESULTS: A total of 2086 patients with TBI with intracranial injury who were transported by EMS were enrolled in our registry. In the multivariable logistic regression analysis, there was no significant difference in mortality (AOR, 95% CI (1.05 [0.54-1.81]) in patients visiting the ED during off-hours. In the interaction analysis, the effect measure of ED admission during off-hours on mortality was significant among younger people (0-17 years: 1.16 [1.03-1.31]), compared to that in other age groups (18-64 years: 1.02 [0.48-2.39] and 65-100 years (0.99 [0.51-2.23])). CONCLUSIONS: In patients under 18 years old, admission during off-hours was associated with higher mortality at hospital discharge compared to admission during working-hours in patients with TBI with intracranial hemorrhage. EDs should be designed such that the same quality of emergency care is provided regardless of admission time.

Impact of cervical spine immobilization on clinical outcomes in traumatic brain injury patients according to prehospital mean arterial pressure: A multinational and multicenter observational study.

Cervical spine immobilization (CSI) has been considered an essential part of first aid management after severe trauma; however, the routine use of CSI for traumatic brain injury (TBI) patients is a matter of debate. The purpose of our study was to analyze the effect of CSI on the clinical outcomes of TBI patients and to analyze whether this effect depends on the prehospital mean arterial pressure (MAP) This was a prospective multi-national, multi-center cohort study using Pan-Asian trauma outcome study registry in Asian-Pacific, conducted on adult trauma patients. The main exposure was the implementation of CSI before hospital arrival. The main outcome was poor functional recovery at hospital discharge measured by the modified rankin scale. We performed multilevel logistic regression analysis to estimated the effect size of CSI for study outcomes. Interaction analysis between CSI and MAP on study outcomes were also conducted. CSI for TBI patients is significantly associated with an increased poor functional outcome (adjusted odd ratio, 95% confidence intervals: 1.23 [1.03 - 1.44]). The association of CSI with poor functional outcomes was maintained only in patients with decreased prehospital MAP (1.38 [1.14 - 1.56]), but not in patients with normal MAP (1.12 [0.93 - 1.24]) (P for interaction < .05). Routine use of CSI for patients with TBI, but without cervical spine injury, is associated with poor functional outcomes, but is significant only when the MAP, measured at the scene, was decreased.