A comparison between intraosseous and intravenous access in patients with out-of-hospital cardiac arrest: A retrospective cohort study.

INTRODUCTION: The optimal vascular access for patients with out-of-hospital cardiac arrest (OHCA) remains controversial. Increasing evidence supports intraosseous (IO) access due to faster medication administration and higher first-attempt success rates compared to intravenous (IV) access. However, the impact on patient outcomes has been inconclusive. METHODS: This retrospective cohort study in Taoyuan City, Taiwan, from January 1, 2019, to December 31, 2022, included patients aged ≥18 years with non-traumatic OHCA resuscitated by emergency medical technician paramedics (EMT-Ps) with either IVs or IOs for final vascular access. The exclusion criteria were cardiac arrest en route to the hospital and resuscitation during the coronavirus pandemic (from May 1, 2022, to October 31, 2022). The primary and secondary outcomes were sustained ROSC (≥2 h) and cerebral performance category (CPC) 1-2, respectively. Univariate logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CI) for the primary analysis. Multivariable logistic regression was employed, with variables selected based on a p-value of <0.05 in the univariate analysis. The survival benefits of different insertion sites and subgroups like general ambulance teams (with a composition that includes fewer EMT-Ps and limited experience in using IO access) were also analyzed. RESULTS: A total of 2003 patients were enrolled; 1602 received IV access and 401 IO access. The median patient age was 70 years, and most were male (66.6%). Compared to patients receiving IV access, the adjusted odds ratios (aORs) for primary and secondary outcomes in patients with IOs were 0.83 (95% confidence interval [CI], 0.61-1.11; p = 0.20) and 0.96 (95% CI, 0.39-2.40; p = 0.93), respectively. Different insertion sites showed no outcome differences. In the subgroups of females and patients resuscitated by general ambulance teams, the aORs for sustained ROSC were 0.55 (95% CI, 0.33-0.92; p = 0.02) and 0.62 (95% CI, 0.41-0.94; p = 0.02), respectively. CONCLUSIONS: For patients with OHCA resuscitated by EMT-Ps, IO access was comparable to IV access regarding patient outcomes. However, in females and patients resuscitated by general ambulance teams, IV access might be favorable.

Persistent hiccups as a rare presenting symptom of empyema: a case report.

BACKGROUND: Empyema is uncommon owing to antibiotic use but still affects patient health if not treated. Hiccups as the initial symptom of empyema are rare; however, empyema should be considered if a patient has persistent hiccups with unexplained fever. CASE PRESENTATION: We present a case of persistent hiccups, left upper quadrant abdominal pain, and fever on day 1, and total left lung white-out and empyema on day 3. The hiccups resolved gradually after antibiotic treatment and surgical decortication. CONCLUSIONS: Clinicians should consider the possibility of empyema and conduct a chest computed tomography study if unexplained fever and persistent hiccups coexist.

Emergency Medical Services in Taiwan: Past, Present, and Future.

This review assessed the development of Taiwan's emergency medical services (EMS) and focused on the optimizing initiatives of the EMS systems, the current state of Taiwan's EMS system, EMS benchmarks in different regions of Taiwan, EMS response during the coronavirus disease 2019 (COVID-19) pandemic, and future design. In the past decade, there has been a noticeable increase in prehospital services, numerous optimizing initiatives to improve patient prognosis, and the medical oversight model. Taiwan's current EMS system, including the dispatch system, out-of-hospital cardiac arrest (OHCA) patient management, time-sensitive critical illness in prehospital settings, and disaster response, has undergone significant improvements. These improvements have been demonstrated to have a measurable impact on patient outcomes, as supported by medical literature. Each region in Taiwan has developed a unique EMS system with local characteristics, such as the implementation of the Global Resuscitation Alliance 10 steps for OHCA-related quality control, hearing automated external defibrillator program, a five-level prehospital triage system, an island-hopping strategy for patients with major trauma, dispatcher-assisted teamwork for OHCA resuscitation, and optimized prehospital care for acute coronary syndrome patients. In response to the COVID-19 pandemic from 2019 to 2023, Taiwan's EMS implemented measures to combat the outbreak such as interagency collaboration to obtain patient's personal information, to optimize prehospital management initiatives, and to provide financial compensation and personal insurance for emergency medical technicians. The areas that need focus include integrating prehospital and in-hospital information to build a national-level database (One-Stop Emergency Management), increasing public awareness of first responders and emergency casualty care, and evolving the EMS system by incorporating private EMS system, initiating school-based education of paramedicine, and legally recognizing paramedics as medical and health care personnel. By improving these areas, we can better prepare for the future and ensure that Taiwan's EMS system continues to provide high-quality care to those in need.

The effect of point-of-care ultrasound on length of stay and mortality in patients with chest pain/dyspnea.

PURPOSE: This study aims to investigate the effects of point-of-care ultrasound (PoCUS) on length of stay (LOS) and mortality in hemodynamically stable patients with chest pain/dyspnea. MATERIALS AND METHODS: The prospective study was conducted from June 2020 to May 2021. A convenience sample of adult non-traumatic patients with chest pain/dyspnea was included and evaluated by PoCUS. The primary outcome was the relationship between the door-to-PoCUS time and LOS/mortality categorized by the ST-segment elevation (STE) and non-STE on the initial electrocardiogram. The diagnostic accuracy of PoCUS was computed, compared to the final diagnosis. RESULTS: A total of 465 patients were included. 3 of 18 patients with STE had unexpected cardiac tamponade and 1 had myocarditis with pulmonary edema. PoCUS had a minimal effect on LOS and mortality in patients with STE. In the non-STE group, the shorter door-to-PoCUS time was associated with a shorter LOS (coefficient, 1.26±0.47, p=0.008). After categorizing the timing of PoCUS as 30, 60, 90, and 120 minutes, PoCUS had a positive effect, especially when performed within 90 minutes of arrival, on LOS of less than 360 minutes (OR, 2.42, 95% CI, 1.61-3.64) and patient survival (OR, 3.32, 95% CI, 1.14-9.71). The overall diagnostic performance of PoCUS was 96.6% (95% CI, 94.9-98.2%), but lower efficacy occurred in pulmonary embolism and myocardial infarction. CONCLUSION: The use of PoCUS was associated with a shorter LOS and less mortality in patients with non-STE, especially when performed within 90 minutes of arrival. Although the effect on patients with STE was minimal, PoCUS played a role in discovering unexpected diagnoses.

PKD2 founder mutation is the most common mutation of polycystic kidney disease in Taiwan.

Autosomal Dominant polycystic kidney disease (ADPKD) is the most common inherited adult kidney disease. Although ADPKD is primarily caused by PKD1 and PKD2, the identification of several novel causative genes in recent years has revealed more complex genetic heterogeneity than previously thought. To study the disease-causing mutations of ADPKD, a total of 920 families were collected and their diagnoses were established via clinical and image studies by Taiwan PKD Consortium investigators. Amplicon-based library preparation with next-generation sequencing, variant calling, and bioinformatic analysis was used to identify disease-causing mutations in the cohort. Microsatellite analysis along with genotyping and haplotype analysis was performed in the PKD2 p.Arg803* family members. The age of mutation was calculated to estimate the time at which the mutation occurred or the founder arrived in Taiwan. Disease-causing mutations were identified in 634 families (68.9%) by detection of 364 PKD1, 239 PKD2, 18 PKHD1, 7 GANAB, and 6 ALG8 pathogenic variants. 162 families (17.6%) had likely causative but non-diagnostic variants of unknown significance (VUS). A single PKD2 p.Arg803* mutation was found in 17.8% (164/920) of the cohort in Taiwan. Microsatellite and array analysis showed that 80% of the PKD2 p.Arg803* families shared the same haplotype in a 250 kb region, indicating those families may originate from a common ancestor 300 years ago. Our findings provide a mutation landscape as well as evidence that a founder effect exists and has contributed to a major percentage of the ADPKD population in Taiwan.

Earlier point-of-care ultrasound, shorter length of stay in patients with acute flank pain.

BACKGROUND: The effects of early integration of point-of-care ultrasound (PoCUS) into patient care are uncertain. This study aims to investigate the effects of early PoCUS on patients with acute flank pain. METHODS: Adult non-traumatic patients with acute flank pain receiving PoCUS were enrolled. Expert physicians reviewed the medical records and made the "final diagnosis" for the cause of acute flank pain. The primary outcome was the relationship between the door to ultrasound (US) time and length of stay (LOS). The secondary outcomes included the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the sonographic diagnosis, compared with the final diagnosis. RESULTS: Eight hundred and eighty-eight patients were included in the analysis. Patients receiving early PoCUS (≤120 min) had a shorter LOS (128 vs. 217 min, p < 0.0001). Patients in the late POCUS group (> 120 min) had a trend to receive more CT scans. The disease distribution, sensitivity, specificity, PPV, and NPV were similar in patients receiving early or late PoCUS for target diagnoses. After adjusting for the confounders, early PoCUS (OR, 2.77, 95% CIs, 1.93-3.98) had a positive impact on shorter LOS. In addition, the effect of early PoCUS became more prominent (OR, 4.91, 95% CIs, 3.39-7.13) on LOS in less than 3 h. CONCLUSIONS: Early integration of PoCUS is significantly related to shorter LOS in patients with acute flank pain without increasing morbidity and mortality. Our results suggested "PoCUS early" in these patients to possibly alleviate emergency department crowding. Trial registration NCT04149041 at the ClinicalTrial.gov.

Ultrasound in postresuscitation care: a narrative review.

The efficacy of ultrasound (US) in real-time differential diagnosis and guiding further treatment decisions has been well demonstrated in prearrest conditions and during resuscitation. Evidence is limited regarding the application of US in postresuscitation care. Most of the patients following resuscitation remain comatose, and the requirement for transportation to other examination rooms increases their risk of injury. US can be performed at the bedside with high accessibility and timeliness without radiation. This narrative review provides an overview of current evidence regarding the application of US in identifying the cause of cardiac arrest (CA), hemodynamic monitoring, and prognostication in postresuscitation care. For identifying the cause of CA, cardiac US is mainly used to detect regional wall motion abnormality. However, postarrest myocardial dysfunction would confound the sonographic findings that a combination of electrocardiograms and biomarkers besides the cardiac US could improve the positive predictive value of coronary artery disease. For hemodynamic monitoring, left ventricular outlet tract velocity time integral has the best performance in predicting fluid responsiveness in conjunction with the passive leg raising test. The RUSH protocol assists in determining the subtypes of shock with high sensitivity and specificity in hypovolemic, cardiogenic, or obstructive shock. Evidence regarding the application of US for prognostication is still limited, and further evaluation should be needed.

Effect of Placement of a Supraglottic Airway Device vs Endotracheal Intubation on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest in Taipei, Taiwan: A Cluster Randomized Clinical Trial.

Importance: Prehospital advanced airway management with either initial endotracheal intubation (ETI) or initial supraglottic airway (SGA) insertion in patients with out-of-hospital cardiac arrest (OHCA) remains controversial. Objective: To compare the effectiveness of ETI and SGA in patients with nontraumatic OHCA. Design, Setting, and Participants: The Supraglottic Airway Device vs Endotracheal intubation (SAVE) trial was a multicenter cluster randomized clinical trial conducted in Taipei City, Taiwan. Individuals aged 20 years or older who experienced nontraumatic OHCA requiring advanced airway management and were treated by participating emergency medical service agencies were enrolled from November 11, 2016, to December 31, 2019. The final day of follow-up was February 19, 2020. Interventions: Four advanced life support ambulance teams were divided into 2 randomization clusters, with each cluster assigned to either ETI or SGA in a biweekly period. Main Outcomes and Measures: The primary outcome of the SAVE trial was sustained return of spontaneous circulation (ROSC) (≥2 hours) after resuscitation. Secondary outcomes included prehospital ROSC, survival to hospital discharge, and favorable neurologic outcome, defined as a cerebral performance category score less than or equal to 2. Prespecified subgroups and the association between time to advanced airways were explored. Per protocol and intention-to-treat analysis were performed. Results: A total of 936 patients (517 in the ETI group and 419 in the SGA group) were included in the primary analysis (median age, 77 [IQR, 62-85] years; 569 men [60.8%]). The first-attempt airway success rates were 77% with ETI (n = 413) and 83% with SGA (n = 360). Sustained ROSC was 26.9% (n = 139) in the ETI group vs 25.8% (n = 108) in the SGA group. The odds ratio of sustained ROSC was 1.02 (95% CI, 0.98-1.06) in the ETI group vs SGA group. The odds ratio of ETA vs SGA was 1.04 (95% CI, 1.02-1.07) for prehospital ROSC, 1.00 (95% CI, 0.94-1.06) for survival to hospital discharge, and 0.99 (95% CI, 0.94-1.03) for cerebral performance category scores less than or equal to 2. Conclusions and Relevance: In this randomized clinical trial, among patients with OHCA, initial airway management with ETI did not result in a favorable outcome of sustained ROSC compared with SGA device insertion. Trial Registration: ClinicalTrials.gov Identifier: NCT02967952.

Use of Opioids and Outcomes of Pneumonia: Results From the US Nationwide Inpatient Sample.

BACKGROUND: Opioids have been shown to increase risk of pneumonia among susceptible population. However, the effect of opioid abuse on the outcome of pneumonia has not been evaluated at the population level. We aimed to compare the outcomes of pneumonia among patients with opioid use disorder and patients without substance use disorder using a large population database. METHODS: We assembled a pneumonia cohort composed of 11,186,564 adult patients from the National Inpatient Sample (NIS; 2005-2014). Patients with opioid disorder were identified using the International Classification of Diseases, 9th Revision, Clinical Modification codes. We compared health-related and economic outcomes between patients with and without opioid disorders using propensity score matching (PSM) analysis to balance baseline differences. The survival differences between two groups of patients were assessed using a Cox proportional hazard model. We further explored the possibility of effect modification by interaction analyses in different populations. RESULTS: After PSM, patients with opioid use disorder were at increased risk of ventilator use (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.08 to 1.38, p = 0.0014) and associated with increased length of hospital stay by 0.59 days (95% CI: 0.35 to 0.83, p < 0.001), compared with those without substance use disorder. Patients with opioid use also had higher daily (228.00 USD, 95% CI: 180.51 to 275.49, p < 0.001) and total (1,875.72 USD, 95% CI: 1,259.63 to 2,491.80, p < 0.001) medical costs. Subgroup analyses showed similar results. CONCLUSIONS: Compared with patients without any drug dependence, patients with opioid use disorders had increased risk of complications and resource utilization. This study adds evidence for increased risk for pneumonia complications in the growing patients with opioid use disorders.

Comparing Effectiveness of Initial Airway Interventions for Out-of-Hospital Cardiac Arrest: A Systematic Review and Network Meta-analysis of Clinical Controlled Trials.

STUDY OBJECTIVE: We compare effectiveness of different airway interventions during cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest. METHODS: We systematically searched the PubMed and EMBASE databases from their inception through August 2018 and selected randomized controlled trials or quasi randomized controlled trials comparing intubation, supraglottic airways, or bag-valve-mask ventilation for treating adult out-of-hospital cardiac arrest patients. We performed a network meta-analysis along with sensitivity analyses to investigate the influence of high intubation success rate on meta-analytic results. RESULTS: A total of 8 randomized controlled trials and 3 quasi randomized controlled trials were included in the network meta-analysis: 7,361 patients received intubation, 7,475 received supraglottic airway, and 1,201 received bag-valve-mask ventilation. The network meta-analysis indicated no differences among these interventions for survival or neurologic outcomes at hospital discharge. Rather, network meta-analysis suggested that supraglottic airway improved the rate of return of spontaneous circulation compared with intubation (odds ratio 1.11; 95% confidence interval 1.03 to 1.20) or bag-valve-mask ventilation (odds ratio 1.35; 95% confidence interval 1.11 to 1.63). Furthermore, intubation improved the rate of return of spontaneous circulation compared with bag-valve-mask ventilation (odds ratio 1.21; 95% confidence interval 1.01 to 1.44). The sensitivity analyses revealed that the meta-analytic results were sensitive to the intubation success rates across different out-of-hospital care systems. CONCLUSION: Although there were no differences in long-term survival or neurologic outcome among these airway interventions, these system-based comparisons demonstrated that supraglottic airway was better than intubation or bag-valve-mask ventilation and intubation was better than bag-valve-mask ventilation in improving return of spontaneous circulation. The intubation success rate greatly influenced the meta-analytic results, and therefore these comparison results should be interpreted with these system differences in mind.

Reverse epithelial-mesenchymal transition contributes to the regain of drug sensitivity in tyrosine kinase inhibitor-resistant non-small cell lung cancer cells.

Tyrosine kinase inhibitors (TKIs) are currently the first-line treatment for non-small cell lung cancer (NSCLC) patients with epidermal growth factor receptor (EGFR) mutations. These patients receive platinum-based chemotherapy as the second-line treatment after they develop resistance to TKIs. Many patients regain sensitivity to the TKIs used in the first-line treatment after the failure of chemotherapy. However, the molecular mechanism for the regain of TKI sensitivity is largely unknown. In this study, we established gefitinib-resistant PC9 and HCC827 cell lines, which did not harbor the EGFR T790M mutation and MET amplification but exhibited the epithelial-mesenchymal transition (EMT) phenotype. Overexpression of EMT inducers, Snail or Slug, in the parental lines promoted their resistance to gefitinib. The gefitinib-resistant cell lines regained their sensitivity to gefitinib and displayed reverse EMT phenotypes after long-term culture in gefitinib-free culture medium. Blockage of reverse EMT by stable expression of Snail or Slug prevented the regain of TKI sensitivity. In conclusion, reverse EMT is one of the major mechanisms for the regain of TKI sensitivity in TKI-resistant NSCLC cells, suggesting that the development of small molecules targeting the EMT process may prolong the efficacy of TKIs in NSCLC patients with EGFR mutations.