Contamination of Blood Cultures From Arterial Catheters and Peripheral Venipuncture in Critically Ill Patients: A Prospective Multicenter Diagnostic Study.

BACKGROUND: Collecting blood cultures from indwelling arterial catheters is an attractive option in critically ill adult patients when peripheral venipuncture is difficult. However, whether the contamination proportion of blood cultures from arterial catheters is acceptable compared with that from venipuncture is inconclusive. RESEARCH QUESTION: Is contamination of blood cultures from arterial catheters noninferior to that from venipuncture in critically ill adult patients with suspected bloodstream infection? STUDY DESIGN AND METHODS: In this multicenter prospective diagnostic study conducted at five hospitals, we enrolled episodes of paired blood culture collection, each set consisting of blood drawn from an arterial catheter and another by venipuncture, were obtained from critically ill adult patients with cilinical indication. The primary measure was the proportion of contamination, defined as the number of false-positive results relative to the total number of procedures done. The reference standard for true bloodstream infection was blinded assessment by infectious disease specialists. We examined the noninferiority hypothesis that the contamination proportion of blood cultures from arterial catheters did not exceed that from venipuncture by 2.0%. RESULTS: Of 1,655 episodes of blood culture from December 2018 to July 2021, 590 paired blood culture episodes were enrolled, and 41 of the 590 episodes (6.9%) produced a true bloodstream infection. In blood cultures from arterial catheters, 33 of 590 (6.0%) were positive, and two of 590 (0.3%) were contaminated; in venipuncture, 36 of 590 (6.1%) were positive, and four of 590 (0.7%) were contaminated. The estimated difference in contamination proportion (arterial catheter - venipuncture) was -0.3% (upper limit of one-sided 95% CI, +0.3%). The upper limit of the 95% CI did not exceed the predefined margin of +2.0%, establishing noninferiority (P for noninferiority < .001). INTERPRETATION: Obtaining blood cultures from arterial catheters is an acceptable alternative to venipuncture in critically ill patients. CLINICAL TRIAL REGISTRATION: University Hospital Medical Information Network Center (UMIN-CTR); No.: UMIN000035392; URL: https://center6.umin.ac.jp/.

Comparison of mainstream end tidal carbon dioxide on Y-piece side versus patient side of heat and moisture exchanger filters in critically ill adult patients: a prospective observational study.

The purpose of the study was to investigate the accuracy of mainstream EtCO2 measurements on the Y-piece (filtered) side of the heat and moisture exchanger filter (HMEF) in adult critically ill patients, compared to that on the patient (unfiltered) side of HMEF. We conducted a prospective observational method comparison study between July 2019 and December 2019. Critically ill adult patients receiving mechanical ventilation with HMEF were included. We performed a noninferiority comparison of the accuracy of EtCO2 measurements on the two sides of HMEF. The accuracy was measured by the absolute difference between PaCO2 and EtCO2. We set the non-inferiority margin at + 1 mmHg in accuracy difference between the two sides of HMEF. We also assessed the agreement between PaCO2 and EtCO2 using Bland-Altman analysis. Among thirty-seven patients, the accuracy difference was - 0.14 mmHg (two-sided 90% CI - 0.58 to 0.29), and the upper limit of the CI did not exceed the predefined margin of + 1 mmHg, establishing non-inferiority of EtCO2 on the Y-piece side of HMEF (P for non-inferiority < 0.001). In the Bland-Altman analyses, 95% limits of agreement between PaCO2 and EtCO2 were similar on both sides of HMEF (Y-piece side, - 8.67 to + 10.65 mmHg; patient side, - 8.93 to + 10.67 mmHg). The accuracy of mainstream EtCO2 measurements on the Y-piece side of HMEF was noninferior to that on the patient side in critically ill adults. Mechanically ventilated adult patients could be accurately monitored with mainstream EtCO2 on the Y-piece side of the HMEF unless their tidal volume was extremely low.

Epinephrine administration for adult out-of-hospital cardiac arrest patients with refractory shockable rhythm: time-dependent propensity score-sequential matching analysis from a nationwide population-based registry.

AIMS: Little is known about the effect of prehospital epinephrine administration in out-of-hospital cardiac arrest (OHCA) patients with refractory shockable rhythm, for whom initial defibrillation was unsuccessful. METHODS AND RESULTS: This study using Japanese nationwide population-based registry included all adult OHCA patients aged ≥18 years with refractory shockable rhythm between January 2014 and December 2017. Patients with or without epinephrine during cardiac arrest were sequentially matched using a risk set matching based on the time-dependent propensity scores within the same minute. The primary outcome was 1-month survival. The secondary outcomes included 1-month survival with favourable neurological outcome (cerebral performance category scale: 1 or 2) and prehospital return of spontaneous circulation (ROSC). Of the 499 944 patients registered in the database during the study period, 22 877 were included. Among them, 8467 (37.0%) received epinephrine. After time-dependent propensity score-sequential matching, 16 798 patients were included in the matched cohort. In the matched cohort, positive associations were observed between epinephrine and 1-month survival [epinephrine: 17.3% (1454/8399) vs. no epinephrine: 14.6% (1224/8399); RR 1.22 (95% confidence interval, CI: 1.13-1.32)] and prehospital ROSC [epinephrine: 22.2% (1868/8399) vs. no epinephrine: 10.7% (900/8399); RR 2.07 (95% CI: 1.91-2.25)]. No significant positive association was observed between epinephrine and favourable neurological outcome [epinephrine: 7.8% (654/8399) vs. no epinephrine: 7.1% (611/8399); RR 1.13 (95% CI 0.998-1.27)]. CONCLUSION: Using the nationwide population-based registry with time-dependent propensity score-sequential matching analysis, prehospital epinephrine administration in adult OHCA patients with refractory shockable rhythm was positively associated with 1-month survival and prehospital ROSC.

Timing of Prehospital Advanced Airway Management for Adult Patients With Out-of-Hospital Cardiac Arrest: A Nationwide Cohort Study in Japan.

Background The timing of advanced airway management (AAM) on patient outcomes after out-of-hospital cardiac arrest has not been fully investigated. We evaluated the association between the timing of prehospital AAM and 1-month survival. Methods and Results We conducted a secondary analysis of a prospective, nationwide, population-based out-of-hospital cardiac arrest registry in Japan. We included emergency medical services-treated adult (≥18 years) out-of-hospital cardiac arrests from 2014 through 2017, stratified into initial shockable or nonshockable rhythms. Patients who received AAM at any minute after emergency medical services-initiated cardiopulmonary resuscitation underwent risk-set matching with patients who were at risk of receiving AAM within the same minute using time-dependent propensity scores. Eleven thousand three hundred six patients with AAM in shockable and 163 796 with AAM in nonshockable cohorts, respectively, underwent risk-set matching. For shockable rhythms, the risk ratios (95% CIs) of AAM on 1-month survival were 1.01 (0.89-1.15) between 0 and 5 minutes, 1.06 (0.98-1.15) between 5 and 10 minutes, 0.99 (0.87-1.12) between 10 and 15 minutes, 0.74 (0.59-0.92) between 15 and 20 minutes, 0.61 (0.37-1.00) between 20 and 25 minutes, and 0.73 (0.26-2.07) between 25 and 30 minutes after emergency medical services-initiated cardiopulmonary resuscitation. For nonshockable rhythms, the risk ratios of AAM were 1.12 (1.00-1.27) between 0 and 5 minutes, 1.34 (1.25-1.44) between 5 and 10 minutes, 1.39 (1.26-1.54) between 10 and 15 minutes, 1.20 (0.99-1.45) between 15 and 20 minutes, 1.18 (0.80-1.73) between 20 and 25 minutes, 0.63 (0.29-1.38) between 25 and 30 minutes, and 0.44 (0.11-1.69) after 30 minutes. Conclusions In this observational study, the timing of AAM was not statistically associated with improved 1-month survival for shockable rhythms, but AAM within 15 minutes after emergency medical services-initiated cardiopulmonary resuscitation was associated with improved 1-month survival for nonshockable rhythms.

Association Between Resuscitative Time on the Scene and Survival After Pediatric Out-of-Hospital Cardiac Arrest.

Background: The optimal timing for transporting pediatric patients with out-of-hospital cardiac arrest (OHCA) who do not achieve return of spontaneous circulation (ROSC) is unclear. Therefore, we assessed the association between resuscitation time on the scene and 1-month survival. Methods and Results: Data from the All-Japan Utstein Registry from 2013 through 2015 for 3,756 pediatric OHCA patients (age <18 years) who did not achieve ROSC prior to departing the scene were analyzed. Overall, the proportion of 1-month survival for on-scene resuscitation time <5, 5-9, 10-14, and ≥15 min was 13.6% (104/767), 10.2% (170/1,666), 8.6% (75/870), and 4.0% (18/453), respectively. Among specific age groups, the proportion of 1-month survival for on-scene resuscitation time of <5, 5-9, 10-14, and ≥15 min was 12.6% (54/429), 8.7% (59/680), 8.6% (23/267), and 6.8% (8/118), respectively, for patients aged 0 years; 16.4% (38/232), 11.0% (52/473), 11.9% (23/194), and 7.1% (6/85), respectively, for those aged 1-7 years; and 11.3% (12/106), 11.5% (59/513), 7.1% (29/409), and 1.6% (4/250), respectively, for those aged 8-17 years. Conclusions: Longer on-scene resuscitation was associated with decreased chance of 1-month survival among pediatric OHCA patients without ROSC. For patients aged <8 years, earlier departure from the scene, within 5 min, may increase the chances of 1-month survival. Conversely, for patients aged ≥8 years, continuing on-scene resuscitation for up to 10 min would be reasonable.

Pre-Hospital Administration of Epinephrine in Pediatric Patients With Out-of-Hospital Cardiac Arrest.

BACKGROUND: There is little evidence about pre-hospital advanced life support including epinephrine administration for pediatric out-of-hospital cardiac arrests (OHCAs). OBJECTIVES: This study aimed to assess the effect of pre-hospital epinephrine administration by emergency-medical-service (EMS) personnel for pediatric OHCA. METHODS: This nationwide population-based observational study in Japan enrolled pediatric patients age 8 to 17 years with OHCA between January 2007 and December 2016. Patients were sequentially matched with or without epinephrine during cardiac arrest using a risk-set matching based on time-dependent propensity score (probability of receiving epinephrine) calculated at each minute after initiation of cardiopulmonary resuscitation by EMS personnel. The primary endpoint was 1-month survival. Secondary endpoints were 1-month survival with favorable neurological outcome, defined as the cerebral performance category scale of 1 or 2, and pre-hospital return of spontaneous circulation (ROSC). RESULTS: During the study period, a total of 1,214,658 OHCA patients were registered, and 3,961 pediatric OHCAs were eligible for analyses. Of these, 306 (7.7%) patients received epinephrine and 3,655 (92.3%) did not receive epinephrine. After time-dependent propensity score-sequential matching, 608 patients were included in the matched cohort. In the matched cohort, there were no significant differences between the epinephrine and no epinephrine groups in 1-month survival (epinephrine: 10.2% [31 of 304] vs. no epinephrine: 7.9% [24 of 304]; risk ratio [RR]: 1.13 [95% confidence interval (CI): 0.67 to 1.93]) and favorable neurological outcome (epinephrine: 3.6% [11 of 304] vs. no epinephrine: 2.6% [8 of 304]; RR: 1.56 [95% CI: 0.61 to 3.96]), whereas the epinephrine group had a higher likelihood of achieving pre-hospital ROSC (epinephrine: 11.2% [34 of 304] vs. no epinephrine: 3.3% [10 of 304]; RR: 3.17 [95% CI: 1.54 to 6.54]). CONCLUSIONS: In this study, pre-hospital epinephrine administration was associated with ROSC, whereas there were no significant differences in 1-month survival and favorable neurological outcome between those with and without epinephrine.

Variation in survival after out-of-hospital cardiac arrest between receiving hospitals in Japan: an observational study.

OBJECTIVES: Patient outcomes after out-of-hospital cardiac arrest (OHCA) varies at multilevel (geographical regions, emergency medical service agencies and receiving hospitals) in the USA. However, it remains unclear whether there is a variation in patient outcomes after OHCA between relevant units of the healthcare system such as receiving hospitals in Japan. Therefore, we aimed to quantify the variation in patient outcomes after OHCA between receiving hospitals in Japan. DESIGN: Secondary analysis of the prospective multicentre OHCA registry. SETTING: The Japan Association for Acute Medicine OHCA Registry, a prospective multicentre OHCA registry, including 73 medical institutions in Japan. PARTICIPANTS: 9303 adults (≥18 years old) with OHCA of medical origin, treated at 67 hospitals from June 2014 to December 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was 1-month survival after OHCA. The secondary outcome was favourable functional status at 1 month, defined as cerebral performance category scale 1 or 2. We constructed a series of multivariable hierarchical logistic regression models predicting outcomes, accounting for patient-level variables and clustering of patients within hospitals. We evaluated the adjusted 1-month survival and functional outcome for each hospital, ranked hospitals for each outcome and calculated median ORs (MORs) to quantify the between-hospital variation in outcomes. RESULTS: The prevalence of 1-month survival after OHCA was 7.1% (663/9303) and that of favourable functional outcome was 3.6% (331/9303). After adjustment for patient-level factors, we observed variations in 1-month survival (range, 1.6%-13.8%; adjusted MOR 1.34; 95% CI 1.16 to 1.67) and favourable functional outcome (range, 0.7%-7.3%; adjusted MOR 1.53; 95% CI 1.10 to 2.24) between hospitals. CONCLUSIONS: We found substantial variations in patient outcomes after OHCA within a large group of hospitals in Japan, despite adjustment for patient factors that are known to be associated with different outcomes.

Prehospital advanced airway management for paediatric patients with out-of-hospital cardiac arrest: A nationwide cohort study.

BACKGROUND: Although prehospital advanced airway management (AAM) (i.e., endotracheal intubation [ETI] and insertion of supraglottic airways [SGA]) has been performed for paediatric out-of-hospital cardiac arrest (OHCA), the effect of AAM has not been fully studied. We evaluated the association between prehospital AAM for paediatric OHCA and patient outcomes. METHODS: We conducted an observational cohort study, using the All-Japan Utstein Registry between 2014 and 2016. We included paediatric patients (age <18 years) with OHCA. We calculated time-dependent propensity score at each minute after initiation of cardiopulmonary resuscitation by EMS providers, using a Fine-Gray regression model. We sequentially matched patients who received AAM during cardiac arrest to patients at risk of receiving AAM within the same minute (risk-set matching). The primary outcome was 1-month survival. Secondary outcome was 1-month survival with favourable functional status, defined as Cerebral Performance Category score of 1 or 2. RESULTS: We analysed 3801 paediatric patients with OHCA. 481 patients (12.7%) received AAM and 3320 (87.3%) did not. Among the 3801 analysed patients, 912 patients underwent risk-set matching. In the matched cohort, AAM was not associated with 1-month survival (AAM: 52/456 [11.4%] vs. no AAM: 44/456 [9.6%]; risk ratio [RR], 1.15 [95% CI, 0.76-1.73]; risk difference [RD], 1.5% [-3.0 to 6.1%]) or favourable functional status (AAM: 9/456 [2.0%] vs. no AAM: 10/456 [2.2%]; RR, 0.69 [95% CI, 0.26-1.79]; RD, -0.8% [-2.9 to 1.3%]). CONCLUSION: Among paediatric patients with OHCA, we found that prehospital AAM was not associated with 1-month survival or favourable functional status.

Methylxanthine use for acute asthma in the emergency department in Japan: a multicenter observational study.

AIM: Methylxanthines are no longer recommended for emergency department (ED) patients with acute asthma according to international guidelines. We aimed to describe the current methylxanthine use for acute asthma and to determine factors related to its use in the ED. METHODS: We undertook a multicenter retrospective study in 23 EDs across Japan. From each participating hospital, we randomly identified 60 ED patients aged 18-54 years with acute asthma from 2009 through 2011. We examined the associations of ED and patient characteristics with methylxanthine use by constructing a multivariable logistic regression model adjusting for a predefined set of ED- and patient-level factors. RESULTS: Among 1,380 patients, methylxanthines were used for 79 patients (5.7%, 95% confidence interval [CI], 4.6-7.0%). The proportion of methylxanthine treatment varied substantially among EDs, ranging from 0% to 26.1%. In the multivariable analysis, the number of annual ED patients with acute asthma (odds ratio [OR] per 100 increase in annual asthma patients, 0.12; 95% CI, 0.04-0.34; P < 0.001) and having a protocol for asthma treatment (OR 2.91; 95% CI, 1.06-8.00; P = 0.04) at the ED level, and systemic corticosteroid use (OR 6.39; 95% CI, 3.34-12.22; P < 0.001) at the patient level were associated with likelihood of methylxanthine use. CONCLUSIONS: In this multicenter study, approximately 6% of ED patients with acute asthma were treated with methylxanthines, with a wide variation across EDs. The number of annual ED patients with acute asthma was significantly associated with a lower likelihood of methylxanthine use, whereas having an ED asthma treatment protocol and systemic corticosteroid use in the ED were associated with a higher likelihood of methylxanthine treatment.

Association of prehospital oxygen administration and mortality in severe trauma patients (PROMIS): A nationwide cohort study.

Until now, we routinely administered oxygen to trauma patients in prehospital settings irrespective of whether oxygen delivery affected the prognosis. To determine the necessity of prehospital oxygen administration (POA) to trauma patients, we aimed to assess whether POA contributed to in-hospital mortality.This was a multicenter propensity-matched cohort study involving 172 major emergency hospitals in Japan. During 2004 to 2010, 70,683 patients with trauma aged ≥15 years were eligible for enrolment. The main outcome measures were survival until hospital discharge after POA, and propensity score analyses were used to adjust for patient factors and hospital site.Of 32,225 trauma patients, 19,985 (62.0%) were administered oxygen by the emergency medical services in prehospital settings and 12,240 (38.0%) did not receive oxygen. Overall, 29,555 patients (90.7%) survived till hospital discharge. In the multivariable unconditional logistic regression, POA had an odds ratio (OR) of 0.33 (95% confidence interval [CI], 0.30-0.37; P <.001) for favorable in-hospital mortality. Furthermore, there were significant differences in all the important variables between the POA and no POA groups (P <.001); therefore, we used propensity score matching analysis. After adjustment for the covariates of selected variables, we found that POA was not associated with a higher rate of survival after hospitalization (adjusted OR, 1.02; 95% CI, 0.99-1.04; P = .27). Even after adjustment for all covariates, POA did not improve in-hospital mortality (adjusted OR, 1.01; 95% CI, 0.99-1.03; P = .08).In this study, POA did not improve in-hospital mortality in trauma patients. However, further studies are needed to validate our results.

Use of prehospital qSOFA in predicting in-hospital mortality in patients with suspected infection: A retrospective cohort study.

BACKGROUND: The quick sequential organ failure assessment (qSOFA) score has recently been introduced to the emergency department (ED) and wards, and it predicted a higher number of deaths among patients with sepsis compared with baseline risk. However, studies about the application of the qSOFA score are limited in prehospital settings. Thus, this study aimed to assess the performance of prehospital qSOFA score in predicting the risk of mortality among patients with infection. METHODS: This single center, retrospective cohort study was conducted in a Japanese tertiary care teaching hospital between April 2016 and March 2017. We enrolled all consecutive adult patients transported to the hospital by ambulance and admitted to the ED due to a suspected infection. We calculated the prehospital qSOFA score using the first vital sign obtained at the scene by emergency medical service (EMS) providers. The primary outcome was in-hospital mortality. The Cox proportional hazards model was used to assess the association between prehospital qSOFA positivity and in-hospital mortality. RESULTS: Among the 925 patients admitted to the ED due to a suspected infection, 51.1% (473/925) were prehospital qSOFA-positive and 48.9% (452/925) were prehospital qSOFA-negative. The in-hospital mortality rates were 14.0% (66/473) in prehospital qSOFA-positive patients and 6.0% (27/452) in prehospital qSOFA-negative patients. The Cox proportional hazard regression model revealed a strong association between prehospital qSOFA score and in-hospital mortality (adjusted hazard ratio: 2.41, 95% confidence interval: 1.51-3.98; p <0.01). CONCLUSIONS: Among the patients with suspected infection who were admitted at the ED, a strong association was observed between the prehospital qSOFA score and in-hospital mortality. In order to use this score in clinical practice, future study is necessary to evaluate how infection is suspected in the prehospital arena.

Sex-Based Disparities in Receiving Bystander Cardiopulmonary Resuscitation by Location of Cardiac Arrest in Japan.

OBJECTIVE: To assess whether sex-based disparities occur by location of arrest in out-of-hospital cardiac arrest (OHCA) victims receiving bystander cardiopulmonary resuscitation (BCPR). PATIENTS AND METHODS: This secondary analysis of the All-Japan Utstein Registry included patients 18 years and older with OHCA of medical origin in public or residential locations, witnessed by bystanders, from January 1, 2013, through December 31, 2015. We assessed the likelihood of receiving BCPR based on sex differences and by arrest location. Sex-based disparities in receiving BCPR stratified by age and location were assessed via multivariable logistic regression analyses. RESULTS: During the study period, 373,359 OHCAs were registered, and 84,734 were eligible for analysis. Overall, 54.2% of women (3123 of 5766) and 57.0% of men (8672 of 15,213) received BCPR in public locations (P<.001), and 46.5% of women (11,263 of 24,216) and 44.0% of men (17,390 of 39,539) received BCPR in residential locations (P<.001). In the multivariable logistic regression analyses, there was no significant difference between the sexes in terms of who received BCPR in public locations (adjusted odds ratio [AOR], 0.99; 95% CI, 0.92-1.06), and women had a higher likelihood of receiving BCPR in residential locations (AOR, 1.08; 95% CI, 1.04-1.13). In public locations, women aged 18 to 64 years were less likely to receive BCPR (AOR, 0.86; 95% CI, 0.74-0.99), and when witnessed by a non-family member, women were less likely to receive BCPR regardless of age group. CONCLUSION: The reasons for this sex-based disparity should be better understood to facilitate public health interventions.

Pre-hospital advanced airway management for adults with out-of-hospital cardiac arrest: nationwide cohort study.

OBJECTIVE: To determine survival associated with advanced airway management (AAM) compared with no AAM for adults with out-of-hospital cardiac arrest. DESIGN: Cohort study between January 2014 and December 2016. SETTING: Nationwide, population based registry in Japan (All-Japan Utstein Registry). PARTICIPANTS: Consecutive adult patients with out-of-hospital cardiac arrest, separated into two sub-cohorts by their first documented electrocardiographic rhythm: shockable (ventricular fibrillation or pulseless ventricular tachycardia) and non-shockable (pulseless electrical activity or asystole). Patients who received AAM during cardiopulmonary resuscitation were sequentially matched with patients at risk of AAM within the same minute on the basis of time dependent propensity scores. MAIN OUTCOME MEASURES: Survival at one month or at hospital discharge within one month. RESULTS: Of the 310 620 patients eligible, 8459 (41.2%) of 20 516 in the shockable cohort and 121 890 (42.0%) of 290 104 in the non-shockable cohort received AAM during cardiopulmonary resuscitation. After time dependent propensity score sequential matching, 16 114 patients in the shockable cohort and 236 042 in the non-shockable cohort were matched at the same minute. In the shockable cohort, survival did not differ between patients with AAM and those with no AAM: 1546/8057 (19.2%) versus 1500/8057 (18.6%) (adjusted risk ratio 1.00, 95% confidence interval 0.93 to 1.07). In the non-shockable cohort, patients with AAM had better survival than those with no AAM: 2696/118 021 (2.3%) versus 2127/118 021 (1.8%) (adjusted risk ratio 1.27, 1.20 to 1.35). CONCLUSIONS: In the time dependent propensity score sequential matching for out-of-hospital cardiac arrest in adults, AAM was not associated with survival among patients with shockable rhythm, whereas AAM was associated with better survival among patients with non-shockable rhythm.

Bariatric surgery is associated with lower risk of acute care use for cardiovascular disease in obese adults.

AIMS: Studies have suggested relationships between obesity and cardiovascular disease (CVD) morbidity. However, little is known about whether substantial weight reduction affects the risk of CVD-related acute care use in obese patients with CVD. The objective of this study was to determine whether bariatric surgery is associated with decreased risk of CVD-related acute care use. METHODS AND RESULTS: We performed a self-controlled case series study of obese adults with CVD who underwent bariatric surgery, using population-based emergency department (ED), and inpatient samples in California, Florida, and Nebraska from 2005 to 2011. The primary outcome was ED visit or unplanned hospitalization for CVD. We used conditional logistic regression to compare the risk during sequential 12-month periods, using pre-surgery months 13-24 as the reference period. We identified 11 106 obese adults with CVD who underwent bariatric surgery. During the reference period, 20.6% [95% confidence interval (CI), 19.8-21.3%] of patients had an ED visit or unplanned hospitalization for CVD. The risk did not significantly change in the subsequent 12-month pre-surgery period [adjusted odds ratio (aOR) 0.98; 95% CI, 0.93-1.04; P = 0.42]. By contrast, in the first 12-month period after bariatric surgery, the risk significantly decreased (aOR 0.91; 95% CI, 0.86-0.96; P = 0.002). The risk remained reduced in the subsequent 13-24 months post-bariatric surgery (aOR 0.84; 95% CI, 0.79-0.89; P < 0.001). There was no reduction in the risk in separate obese populations that underwent non-bariatric surgery (i.e. cholecystectomy, hysterectomy). By CVD category, the risk of acute care use for coronary artery disease (CAD), heart failure (HF), and hypertension decreased after bariatric surgery, whereas that of dysrhythmia and venous thromboembolism transiently increased (Bonferroni corrected P < 0.05 for all comparisons). CONCLUSION: Bariatric surgery is associated with a lower risk of overall CVD-related ED visit or unplanned hospitalization. The decline was mainly driven by reduced risk of acute care use for CAD, HF, and hypertension after bariatric surgery.

Sex Differences in Receiving Layperson Cardiopulmonary Resuscitation in Pediatric Out-of-Hospital Cardiac Arrest: A Nationwide Cohort Study in Japan.

Background Layperson cardiopulmonary resuscitation ( CPR ) is a crucial intervention for patients with out-of-hospital cardiac arrest ( OHCA ). Although a sex disparity in receiving layperson CPR (ie, female patients were less likely to receive layperson CPR ) has been reported in adults, there are few data in the pediatric population, and we therefore investigated sex differences in receiving layperson CPR in pediatric patients with OHCA . Methods and Results From the All-Japan Utstein Registry, a prospective, nationwide, population-based OHCA database, we included pediatric patients (≤17 years) with layperson-witnessed OHCA from 2005 through 2015. The primary outcome was receiving layperson CPR . Patient sex was the main exposure. We fitted multivariable logistic regression models to examine associations between patient sex and receiving layperson CPR . We included a total of 4525 pediatric patients with layperson-witnessed OHCA in this study, 1669 (36.9%) of whom were female. Female patients received layperson CPR more often than male patients (831/1669 [49.8%] versus 1336/2856 [46.8%], P=0.05). After adjustment for age, time of day of arrest, year, witnesses persons, and dispatcher CPR instruction, the sex difference in receiving layperson CPR was not significant (adjusted odds ratio for female subjects 1.14, 95% CI, 0.996-1.31). Conclusions In a pediatric population, female patients with layperson-witnessed OHCA received layperson CPR more often than male patients. After adjustment for covariates, there was no significant association between patient sex and receiving layperson CPR .

Strongyloidiasis and Culture-Negative Suppurative Meningitis, Japan, 1993-2015.

Community-acquired Enterobacteriaceae infection and culture-negative meningitis are rare and atypical subtypes of meningitis in adults. Of 37 patients who had atypical suppurative meningitis during 1993-2015 in Okinawa, Japan, 54.5% had strongyloidiasis, of which 9.1% cases were hyperinfections and 3.0% dissemination. Strongyloidiasis should be considered an underlying cause of atypical suppurative meningitis.

Timing of advanced airway management by emergency medical services personnel following out-of-hospital cardiac arrest: A population-based cohort study.

BACKGROUND: Early prehospital advanced airway management (AAM) by emergency medical services (EMS) personnel has been intended to improve patient outcomes from out-of-hospital cardiac arrest (OHCA). However, few studies examine the effectiveness of early prehospital AAM. We investigated whether early prehospital AAM was associated with functionally favourable survival after adult OHCA. METHODS: We conducted a population-based cohort study of OHCA in Osaka, Japan, between 2005 and 2012. We included all consecutive, non-traumatic adult OHCA in which EMS personnel performed cardiopulmonary resuscitation (CPR) and AAM. Main exposure was time from CPR to AAM. Primary outcome was functionally favourable survival at one-month. As the primary analysis, we estimated adjusted odds ratio (OR) of time from CPR to AAM using multivariable logistic regression in the original cohort. In the secondary analysis, we divided the time from CPR to AAM into early (0-4 min) and late (5-29 min). We calculated propensity scores (PS) for early AAM and performed PS-matching. RESULTS: We included 27,471 patients who received prehospital AAM by EMS personnel. In this original cohort, time from CPR to AAM was inversely associated with functionally favourable survival (adjusted OR 0.90 for one-increment of minute, 95% confidence interval [CI] 0.87-0.94). In the PS-matched cohort of 17,022 patients, early AAM, compared to late AAM, was associated with functionally favourable survival: 2.2% vs 1.4%; adjusted OR 1.58 (95% CI 1.24-2.02). CONCLUSIONS: Earlier prehospital AAM by EMS personnel was associated with functionally better survival among adult patients who received AAM.

Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest.

STUDY OBJECTIVE: We seek to determine the effect of intraosseous over intravenous vascular access on outcomes after out-of-hospital cardiac arrest. METHODS: This secondary analysis of the Resuscitation Outcomes Consortium Prehospital Resuscitation Using an Impedance Valve and Early Versus Delayed (PRIMED) study included adult patients with nontraumatic out-of-hospital cardiac arrests treated during 2007 to 2009, excluding those with any unsuccessful attempt or more than one access site. The primary exposure was intraosseous versus intravenous vascular access. The primary outcome was favorable neurologic outcome on hospital discharge (modified Rankin Scale score ≤3). We determined the association between vascular access route and out-of-hospital cardiac arrest outcome with multivariable logistic regression, adjusting for age, sex, initial emergency medical services-recorded rhythm (shockable or nonshockable), witness status, bystander cardiopulmonary resuscitation, use of public automated external defibrillator, episode location (public or not), and time from call to paramedic scene arrival. We confirmed the results with multiple imputation, propensity score matching, and generalized estimating equations, with study enrolling region as a clustering variable. RESULTS: Of 13,155 included out-of-hospital cardiac arrests, 660 (5.0%) received intraosseous vascular access. In the intraosseous group, 10 of 660 patients (1.5%) had favorable neurologic outcome compared with 945 of 12,495 (7.6%) in the intravenous group. On multivariable regression, intraosseous access was associated with poorer out-of-hospital cardiac arrest survival (adjusted odds ratio 0.24; 95% confidence interval 0.12 to 0.46). Sensitivity analyses revealed similar results. CONCLUSION: In adult out-of-hospital cardiac arrest patients, intraosseous vascular access was associated with poorer neurologic outcomes than intravenous access.

Regional variation in functional outcome after out-of-hospital cardiac arrest across 47 prefectures in Japan.

BACKGROUND: Although prior work reported regional variation in survival after out-of-hospital cardiac arrest (OHCA), mechanisms of the variation have not been fully investigated. We sought to evaluate regional variation in favourable functional outcome after OHCA across 47 prefectures in Japan as our primary aim. We also evaluated the associations between favourable functional outcome and the numbers of basic life support (BLS) providers and public access automated external defibrillators (AEDs) within each prefecture as our secondary aim. METHODS: Using the All-Japan Utstein Registry, a nationwide prospective, population-based OHCA database, we identified 97,408 patients with OHCA of medical origin across 47 prefectures in 2014. Primary outcome was 1-month survival with favourable functional outcome, defined as Cerebral Performance Category (CPC) scale 1 or 2. We fitted multivariable hierarchical logistic regression models (patients nested within prefectures) to adjust for potential confounding factors at patient- and prefecture-level and clustering of patients within prefectures. We calculated median odds ratios (ORs) from the hierarchical models to quantify the outcome variation at prefecture-level. We also evaluated the associations between OHCA outcome and the numbers of BLS providers and public access AEDs within each prefecture, using the hierarchical models. RESULTS: A total of 2246 patients (2.3%) had 1-month survival with favourable functional outcome. The unadjusted rates of 1-month survival with favourable functional outcome in each prefecture ranged from 1.1% to 4.1% (median OR = 1.29; 95% credible interval, 1.20-1.40) and the adjusted rates varied from 0.9% to 3.5% (median OR = 1.34; 95% credible interval, 1.24-1.48). We observed no associations between 1-month survival with favourable functional outcome and the numbers of BLS providers (correlation coefficient = -0.25; 95% confidence interval [CI], -0.50 to 0.04; p = 0.09) and public access AEDs (correlation coefficient = -0.27; 95% CI, -0.51 to 0.02; p = 0.07) within prefectures. CONCLUSIONS: We found substantial regional variation in favourable functional outcome after OHCA of medical origin that was not explained by the numbers of BLS providers and public access AEDs within each prefecture.