Emergency Medical Retrieval Services in Remote Indigenous Islands: Experiences in Lanyu, Taiwan.

Emergency medical retrieval services (EMRS) in remote Indigenous islands is rarely investigated. We analyzed the characteristics of patients who underwent EMRS in Lanyu, an offshore island of Taiwan, from January 1, 2014 to December 31, 2021. The need for EMRS for Lanyu Indigenous residents (N=132, 3.83‰) was almost 1.5-fold and 100-fold for non-Indigenous residents (N=16, 2.64‰) and tourists (N=40, 0.04‰), respectively. The resident group had a longer hospitalization (12.0 ± 12.9 vs. 5.9 ± 11.7 days, p=.007). The tourist group had more near-drowning or decompression sickness (44.0% vs. 3.0%, p<.001) and secondary transfers (20.0% vs. 5.4%, p=.003). All the patients (N=12) that required multiple retrievals were Lanyu Indigenous residents. The Lanyu Indigenous residents, compared with the non-Indigenous residents, had fewer admissions to intensive care units (47.7% vs. 80.0%) and more in-hospital mortalities (10.6% vs. 0.0%). Multifaceted approaches should be initiated to improve the health care system in remote Indigenous islands.

Clinical performance of ultrasonic backscatter parametric and nonparametric statistics in detecting early hepatic steatosis.

Diagnosis of early hepatic steatosis would allow timely intervention. B-mode ultrasound imaging was in question for detecting early steatosis, especially with a variety of concomitant parenchymal disease. This study aimed to use the surgical specimen as a reference standard to elucidate the clinical performance of ultrasonic echogenicity and backscatter parametric and nonparametric statistics in real-world scenarios. Ultrasound radio-frequency (RF) signals of right liver lobe and patient data were collected preoperatively. Surgical specimen was then used to histologically determine staging of steatosis. A backscatter nonparametric statistic (h), a known backscatter parametric statistic, i.e., the Nakagami parameter (m), and a quantitative echo intensity (env) were calculated. Among the 236 patients included in the study, 93 were grade 0 (<5% fat) and 143 were with steatosis. All the env, m and h statistics had shown significant discriminatory power of steatosis grades (AUC = 0.643-0.907 with p-value < 0.001). Mann-Whitney U tests, however, revealed that only the backscatter statistics m and h were significantly different between the groups of grades 0 and 1 steatosis. The two-way ANOVA showed a significant confounding effect of the elevated ALT on env (p-value = 0.028), but no effect on m or h. Additionally, the severe fibrosis was found to be a significant covariate for m and h. Ultrasonic signals acquired from different scanners were found linearly comparable.

Patient stratification based on the risk of severe illness in emergency departments through collaborative machine learning models.

OBJECTIVES: Emergency department (ED) overcrowding presents a global challenge that inhibits prompt care for critically ill patients. Traditional 5-level triage system that heavily rely on the judgment of the triage staff could fail to detect subtle symptoms in critical patients, thus leading to delayed treatment. Unlike previous rivalry-focused approaches, our study aimed to establish a collaborative machine learning (ML) model that renders risk scores for severe illness, which may assist the triage staff to provide a better patient stratification for timely critical cares. METHODS: This retrospective study was conducted at a tertiary teaching hospital. Data were collected from January 2015 to October 2022. Demographic and clinical information were collected at triage. The study focused on severe illness as the outcome. We developed artificial neural network (ANN) models, with or without utilizing the Taiwan Triage and Acuity Scale (TTAS) score as one of the predictors. The model using the TTAS score is termed a machine-human collaborative model (ANN-MH), while the model without it is referred to as a machine-only model (ANN-MO). The predictive power of these models was assessed using the area under the receiver-operating-characteristic (AUROC) and the precision-recall curves (AUPRC); their sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and F1 score were compared. RESULTS: The study analyzed 668,602 ED visits from 2015 to 2022. Among them, 278,724 visits from 2015 to 2018 were used for model training and validation, while 320,201 visits from 2019 to 2022 were for testing model performance. Approximately 2.6% of visits were by severely ill patients, whose TTAS scores ranged from 1 to 5. The ANN-MH model achieved a testing AUROC of 0.918 and AUPRC of 0.369, while for the ANN-MO model the AUROC and AUPRC were 0.909 and 0.339, respectively. Based on these metrics, the ANN-MH model outperformed the ANN-MO model, and both surpassed human triage classification. Subgroup analyses further highlighted the models' capability to identify higher-risk patients within the same triage level. CONCLUSIONS: The traditional 5-level triage system often falls short, leading to under-triage of critical patients. Our models include a score-based differentiation within a triage level to offer advanced risk stratification, thereby promoting patient safety.

Sex Differences in the Role of Multimorbidity on Poststroke Disability: The Taiwan Stroke Registry.

BACKGROUND AND OBJECTIVES: Multimorbidity is common in patients who experience stroke. Less is known about the effect of specific multimorbidity patterns on long-term disability in patients with stroke. Furthermore, given the increased poststroke disability frequently seen in female vs male patients, it is unknown whether multimorbidity has a similar association with disability in both sexes. We assessed whether specific multimorbidity clusters were associated with greater long-term poststroke disability burden overall and by sex. METHODS: In the Taiwan Stroke Registry, an ongoing nationwide prospective registry, patients with first-ever ischemic stroke were enrolled; this analysis is restricted to those individuals surviving to at least 6 months poststroke. Using a hierarchical clustering approach, clusters of prestroke multimorbidity were generated based on 16 risk factors; the algorithm identified 5 distinct clusters. The association between clusters and 12-month poststroke disability, defined using the modified Rankin Scale (mRS), was determined using logistic regression models, with additional models stratified by sex. The longitudinal association between multimorbidity and functional status change was assessed using mixed-effects models. RESULTS: Nine-thousand eight hundred eighteen patients with first-ever ischemic stroke were included. The cluster with no risk factors was the reference, "healthier" risk group (N = 1,373). Patients with a cluster profile of diabetes, peripheral artery disease (PAD), and chronic kidney disease (CKD) (N = 1882) had significantly greater disability (mRS ≥ 3) at 1 month (OR [95% CI] = 1.36 [1.13-1.63]), 3 months (OR [95% CI] = 1.27 [1.04-1.55]), and 6 months (OR [95% CI] = 1.30 [1.06-1.59]) but not at 12 months (OR [95% CI] = 1.16 [0.95-1.42]) than patients with a healthier risk factor profile. In the sex-stratified analysis, the associations with this risk cluster remained consistent in male patients (OR [95% CI] = 1.42 [1.06-1.89]) at 12 months, who also had a higher comorbidity burden, but not in female patients (OR [95% CI] = 0.95 [0.71-1.26]), who had higher proportions of severe strokes and severe disability (p-interaction = 0.04). DISCUSSION: Taiwanese patients with multimorbidity, specifically the concurrent presence of diabetes, PAD, and CKD, had higher odds of a worse functional outcome in the first 6 months poststroke. Clusters of multimorbidity may be less informative for long-term disability in female patients. Further studies should evaluate other mechanisms for worse disability in female patients poststroke.

Comparison of Outpatient Department-Referred and Self-Referred Patients in the Emergency Department.

BACKGROUND: Patients present to emergency departments (EDs) from a variety of backgrounds, which may help inform decision making. OBJECTIVE: This study investigated the clinical characteristics and outcomes of outpatient department (OPD)-referred patients and self-referred patients in the ED. METHODS: We selected nontrauma ED adult patients from a tertiary teaching hospital in Taiwan between August 1, 2020, and October 31, 2020. The acuity levels were determined by dichotomizing the triage classification scores. After propensity score matching, we compared the hospitalization, mortality, and length of ED stay of OPD-referred and self-referred patients. We categorized the patients into "emergency" or "urgent" subgroups according to their triage information and then analyzed the effects of different severity levels. Statistical significance was set at p < 0.05. RESULTS: A total of 564 OPD-referred and 11,959 self-referred patients were included. After propensity score matching, the OPD-referred patients (n = 564), compared with self-referred patients (n = 564), had a higher admission rate (49.8% vs. 28.9%; p < 0.001; odds ratio [OR] 2.44). Among the emergency subgroup patients, there was no significant difference between OPD-referred patients (n = 131) and self-referred patients (n = 138) regarding the admission rate (p = 0.257) or the mortality rate (p = 0.253). Among the urgent subgroup patients, OPD-referred patients (n = 433), compared with self-referred patients (n = 426), had a significantly higher admission rate (46.0% vs. 20.2%; p < 0.001; OR 3.36), but not mortality rate (2.1% vs. 0.5%; p = 0.064). Regarding the length of ED stay, OPD-referred and self-referred patients had a significant difference only in the "urgent and discharged" subgroup (5.8 vs. 2.3 h; p < 0.001). CONCLUSIONS: OPD-referred ED patients might have more severe and complex conditions and need comprehensive care management.

Association between Conversion to Shockable Rhythms and Survival with Favorable Neurological Outcomes for Out-of-Hospital Cardiac Arrests.

BACKGROUND: The initial cardiac rhythm in out-of-hospital cardiac arrest (OHCA) portends different prognoses and affects treatment decisions. Initial shockable rhythms are associated with good survival and neurological outcomes but there is conflicting evidence for those who initially present with non-shockable rhythms. The aim of this study is to evaluate if OHCA with conversion from non-shockable (i.e., asystole and pulseless electrical activity) rhythms to shockable rhythms compared to OHCA remaining in non-shockable rhythms is associated with better survival and neurological outcomes. METHOD: OHCA cases from the Pan-Asian Resuscitation Outcomes Study registry in 13 countries between January 2009 and February 2018 were retrospectively analyzed. Cases with missing initial rhythms, age <18 years, presumed non-medical cause of arrest, and not conveyed by emergency medical services were excluded. Multivariable logistic regression analysis was performed to evaluate the relationship between initial and subsequent shockable rhythm, survival to discharge, and survival with favorable neurological outcomes (cerebral performance category 1 or 2). RESULTS: Of the 116,387 cases included. 11,153 (9.6%) had initial shockable rhythms and 9,765 (8.4%) subsequently converted to shockable rhythms. Japan had the lowest proportion of OHCA patients with initial shockable rhythms (7.3%). For OHCA with initial shockable rhythm, the adjusted odds ratios (aOR) for survival and good neurological outcomes were 8.11 (95% confidence interval [CI] 7.62-8.63) and 15.4 (95%CI 14.1-16.8) respectively. For OHCA that converted from initial non-shockable to shockable rhythms, the aORs for survival and good neurological outcomes were 1.23 (95%CI 1.10-1.37) and 1.61 (95%CI 1.35-1.91) respectively. The aORs for survival and good neurological outcomes were 1.48 (95%CI 1.22-1.79) and 1.92 (95%CI 1.3 - 2.84) respectively for initial asystole, while the aOR for survival in initial pulseless electrical activity patients was 0.83 (95%CI 0.71-0.98). Prehospital adrenaline administration had the highest aOR (2.05, 95%CI 1.93-2.18) for conversion to shockable rhythm. CONCLUSION: In this ambidirectional cohort study, conversion from non-shockable to shockable rhythm was associated with improved survival and neurologic outcomes compared to rhythms that continued to be non-shockable. Continued advanced resuscitation may be beneficial for OHCA with subsequent conversion to shockable rhythms.

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.

Effect of crew ratio of advanced life support-trained personnel on patients with out-of-hospital cardiac arrest: A systematic review and meta-analysis.

BACKGROUND/PURPOSE: This review aimed to investigate the effect of crew ratios of on-scene advanced life support (ALS)-trained personnel on patients with out-of-hospital cardiac arrest (OHCA). METHODS: We systematically searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials databases from the inception date until September 30, 2022, for eligible studies. Two reviewers independently screened the studies for relevance, extracted data, and quality. We compared the effect of the ratio of on-scene ALS-trained personnel >50 % to those with a ratio ≤50 % among prehospital personnel on the clinical outcomes of OHCA patients. The primary outcome was survival-to-discharge and secondary outcomes were any return of spontaneous circulation (ROSC), sustained ROSC (≥2 h), and favourable neurological outcome at discharge (cerebral performance category scores: 1 or 2). Pooled odds ratios (ORs) were calculated, and the certainty of evidence was assessed. RESULTS: From 10,864 references, we identified four non-randomised studies, including 16,475 patients. Two studies were performed in Japan and two in Taiwan. There were significant differences in survival-to-discharge (OR: 1.24, 95 % confidence interval [CI]: 1.07-1.44, I2: 7 %), any ROSC (OR:1.22, 95 % CI: 1.04-1.43, I2: 74 %) and sustained ROSC (OR: 1.39, 95 % CI: 1.16-1.65, I2: 40 %), but insignificant differences in favourable neurological outcome at discharge. The overall certainty of evidence was rated as very low for all outcomes. CONCLUSION: Prehospital ALS care with a ratio of on-scene ALS-trained personnel >50 % could improve OHCA patient outcomes than crew ratios ≤50 %. Further studies are required to reach a robust conclusion.

Triage body temperature and its influence on patients with acute myocardial infarction.

BACKGROUND: Fever can occur after acute myocardial infarction (MI). The influence of body temperature (BT) after hospital arrival on patients with acute MI has rarely been investigated. METHODS: Patients who were diagnosed with acute MI in the emergency department (ED) of a tertiary teaching hospital between 1 January 2020 and 31 December 2020 were enrolled. Based on the tympanic temperature obtained at the ED triage, patients were categorized into normothermic (35.5°C-37.5°C), hypothermic (< 35.5°C), or hyperthermic (> 37.5°C) groups. The primary outcome was in-hospital cardiac arrest (IHCA), while the secondary outcomes were adverse events. Statistical significance was set at p < 0.05. RESULTS: There were 440 enrollees; significant differences were found among the normothermic (n = 369, 83.9%), hypothermic (n = 27, 6.1%), and hyperthermic (n = 44, 10.0%) groups in the triage respiratory rate (median [IQR]) (20.0 [4.0] cycles/min versus 20.0 [4.0] versus 20.0 [7.5], p = 0.009), triage heart rate (88.0 [29.0] beats/min versus 82.0 [28.0] versus 102.5 [30.5], p < 0.001), presence of ST-elevation MI (42.0% versus 66.7% versus 31.8%, p = 0.014), need for cardiac catheterization (87.3% versus 85.2% versus 72.7%, p = 0.034), initial troponin T level (165.9 [565.2] ng/L versus 49.1 [202.0] versus 318.8 [2002.0], p = 0.002), peak troponin T level (343.8 [1405.9] ng/L versus 218.7 [2318.2] versus 832.0 [2640.8], p = 0.003), length of ICU stay (2.0 [3.0] days versus 3.0 [8.0] versus 3.0 [9.5], p = 0.006), length of hospital stay (4.0 [4.5] days versus 6.0 [15.0] versus 10.5 [10.8], p < 0.001), and infection during hospitalization (19.8% versus 29.6% versus 63.6%, p < 0.001) but not in IHCA (7.6% versus 14.8% versus 11.4%, p = 0.323) or any adverse events (50.9% versus 48.1% versus 63.6%, p = 0.258). Multivariable analysis showed no significant association of triage BT with IHCA or any major complication. CONCLUSION: Triage BT did not show a significant association with IHCA or adverse events in patients with acute MI. However, triage BT could be associated with different clinical presentations and should warrant further investigation.

Scrub Typhus Complicated With Fulminant Perimyocarditis.

A 62-year-old woman with no systemic disease presented to the emergency department (ED) with acute febrile illness for three days. During her ED course, she developed respiratory distress and refractory cardiogenic shock with ST-elevation on electrocardiography. No occluded coronary vessel was found in angiography, and perimyocarditis was impressed. The serum indirect immunofluorescence assay was positive for scrub typhus. Hemopericardium and subsequently intracranial hemorrhage occurred on the 4th hospital day even under intensive care, and the patient expired. Perimyocarditis is a rare but fatal complication of scrub typhus. Through this case report, we aim to convey the genuine possibility that a fulminant perimyocarditis may occur in a previously healthy adult as a potential complication of scrub typhus. By recognizing the risk factors of scrub typhus-related myocarditis, an ED physician can maintain a high index of suspicion for the cardiac complication and intervene in a timely manner.

Prediction of Contaminated Areas Using Ultraviolet Fluorescence Markers for Medical Simulation: A Mobile Phone Application Approach.

The use of ultraviolet fluorescence markers in medical simulations has become popular in recent years, especially during the COVID-19 pandemic. Healthcare workers use ultraviolet fluorescence markers to replace pathogens or secretions, and then calculate the regions of contamination. Health providers can use bioimage processing software to calculate the area and quantity of fluorescent dyes. However, traditional image processing software has its limitations and lacks real-time capabilities, making it more suitable for laboratory use than for clinical settings. In this study, mobile phones were used to measure areas contaminated during medical treatment. During the research process, a mobile phone camera was used to photograph the contaminated regions at an orthogonal angle. The fluorescence marker-contaminated area and photographed image area were proportionally related. The areas of contaminated regions can be calculated using this relationship. We used Android Studio software to write a mobile application to convert photos and recreate the true contaminated area. In this application, color photographs are converted into grayscale, and then into black and white binary photographs using binarization. After this process, the fluorescence-contaminated area is calculated easily. The results of our study showed that within a limited distance (50-100 cm) and with controlled ambient light, the error in the calculated contamination area was 6%. This study provides a low-cost, easy, and ready-to-use tool for healthcare workers to estimate the area of fluorescent dye regions during medical simulations. This tool can promote medical education and training on infectious disease preparation.

Impact of the Emergency Procedure Zone on Emergency Care.

Background: Emergency department (ED) overcrowding is a public health crisis that affects patient care quality. Space management in the ED can affect patient flow dynamics and clinical practice. We proposed a novel design of the "emergency procedure zone" (EPZ). The purpose of the EPZ was to provide an isolated area for clinical practice and procedure teaching, to ensure a secure area with adequate equipment and monitors, and safeguard patient privacy and safety. This study aimed to analyze the impact of the EPZ on procedural practice and patient flow dynamics. Methods: This study was conducted at the ED of a tertiary teaching hospital in Taiwan. Data were collected from 1 March 2019 to 31 August 2020 (pre-EPZ period) and from 1 November 2020 to 30 April 2022 (post-EPZ period). Statistical analyses were performed using IBM SPSS Statistics software. This study focused on the number of procedures and length of stay in the emergency department (LOS-ED). Variables were analyzed using the chi-square test and Mann-Whitney U test. Statistical significance was defined as p < 0.05. Results: There were 137,141 (pre-EPZ period) and 118,386 (post-EPZ period) ED visits recorded during this period. The post-EPZ period showed a significant increase in central venous catheter insertion, chest tube or pigtail placement, arthrocentesis, lumbar puncture, and incision and drainage procedures (p < 0.001). For patients who were directly discharged from the ED, the post-EPZ period also had a higher percentage of ultrasound studies performed in the ED and a shorter LOS-ED for patients who were directly discharged from the ED (p < 0.001). Conclusions: The establishment of an EPZ in the ED has a positive impact on procedural efficiency. The EPZ improved diagnosis and disposition efficiency, shortened the length of stay, and provided benefits such as improved management, patient privacy, and teaching opportunities.

Preparation of Medical Supply for Prehospital Emergencies and Disasters: An Internet-Based Simulation Drill.

Background: Mass casualties caused by natural disasters and man-made events may overwhelm local emergency medical services and healthcare systems. Logistics is essential to a successful emergency medical response. Drills have been used in disaster preparedness to validate plans, policies, procedures, and agreements, and identify resource gaps. The application of the internet to facilitate the conduct of exercise was still limited. This study aimed to investigate the optimal preparation of medical supplies by medical emergency response teams (MERTs) during emergencies and disasters using an internet-based drill. Methods: An internet-based drill based on real-life mass casualty incidents (MCIs) was developed and conducted in Taiwan from June 2017 to July 2018. The drill involved an MCI with 50 events delivered under two scenarios: (1) reduced transfer capacity and well-functioning local healthcare facilities (emergency module); (2) severely reduced transfer capacity and dysfunctional local healthcare facilities (disaster module). For each event, medical supplies commonly prepared by local MERTs in Taiwan were listed in structured questionnaires and participants selected the supplies they would use. Results: Forty-three senior medical emergency responders participated in the survey (responding rate of 47.3%). Resuscitation-related supplies increased from emergency to disaster module (e.g., intubation from 9.1% to 13.9%; dopamine from 3.2% to 5.0%; all p < 0.001). In the subgroup analysis of events with life-threatening injuries, the utilization of resuscitation-related supplies (e.g., intubation from 46.6% to 65.3%; p < 0.001) remained higher in the disaster than in the emergency module. Compared to emergency medical technicians, physicians and nurses are more likely to use intravenous/intramuscular analgesics. Conclusions: The severity of scenarios and the professional background of emergency responders have a different utilization of medical supplies in the simulation drill. The internet-based drill may contribute to optimizing the preparedness of medical response to prehospital emergencies and disasters.

Optimal deployment of automated external defibrillators in a long and narrow environment.

AIM OF THE STUDY: Public access to automated external defibrillators (AEDs) plays a key role in increasing survival outcomes for patients with out-of-hospital cardiac arrest. Based on the concept of maximizing "rescue benefit" of AEDs, we aimed to propose a systematic methodology for optimizing the deployment of AEDs, and develop such strategies for long and narrow spaces. METHODS: We classified the effective coverage of an AED in hot, warm, and cold zones. The AEDs were categorized, according to their accessibility, as fixed, summonable, or patrolling types. The overall rescue benefit of the AEDs were evaluated by the weighted size of their collective hot zones. The optimal strategies for the deployment of AEDs were derived mathematically and numerically verified by computer programs. RESULTS: To maximize the overall rescue benefit of the AEDs, the AEDs should avoid overlapping with each other's coverage as much as possible. Specific rules for optimally deploying one, two, or multiple AEDs, and various types of AEDs are summarized and presented. CONCLUSION: A methodology for assessing the rescue benefit of deployed AEDs was proposed, and deployment strategies for maximizing the rescue benefit of AEDs along a long, narrow, corridor-like, finite space were derived. The strategies are simple and readily implementable. Our methodology can be easily generalized to search for optimal deployment of AEDs in planar areas or three-dimensional spaces.

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.

Predicting Bacteremia among Septic Patients Based on ED Information by Machine Learning Methods: A Comparative Study.

INTRODUCTION: Bacteremia is a common but life-threatening infectious disease. However, a well-defined rule to assess patient risk of bacteremia and the urgency of blood culture is lacking. The aim of this study is to establish a predictive model for bacteremia in septic patients using available big data in the emergency department (ED) through logistic regression and other machine learning (ML) methods. MATERIAL AND METHODS: We conducted a retrospective cohort study at the ED of National Cheng Kung University Hospital in Taiwan from January 2015 to December 2019. ED adults (≥18 years old) with systemic inflammatory response syndrome and receiving blood cultures during the ED stay were included. Models I and II were established based on logistic regression, both of which were derived from support vector machine (SVM) and random forest (RF). Net reclassification index was used to determine which model was superior. RESULTS: During the study period, 437,969 patients visited the study ED, and 40,395 patients were enrolled. Patients diagnosed with bacteremia accounted for 7.7% of the cohort. The area under the receiver operating curve (AUROC) in models I and II was 0.729 (95% CI, 0.718-0.740) and 0.731 (95% CI, 0.721-0.742), with Akaike information criterion (AIC) of 16,840 and 16,803, respectively. The performance of model II was superior to that of model I. The AUROC values of models III and IV in the validation dataset were 0.730 (95% CI, 0.713-0.747) and 0.705 (0.688-0.722), respectively. There is no statistical evidence to support that the performance of the model created with logistic regression is superior to those created by SVM and RF. DISCUSSION: The advantage of the SVM or RF model is that the prediction model is more elastic and not limited to a linear relationship. The advantage of the LR model is that it is easy to explain the influence of the independent variable on the response variable. These models could help medical staff identify high-risk patients and prevent unnecessary antibiotic use. The performance of SVM and RF was not inferior to that of logistic regression. CONCLUSIONS: We established models that provide discrimination in predicting bacteremia among patients with sepsis. The reported results could inspire researchers to adopt ML in their development of prediction algorithms.

Design, fabrication, and validation of an aberration-free integral imaging system for 3D reconstruction.

Optical design for reducing aberrations of the micro-lens-array-based integral imaging system is challenging. A design process combining the sequential and non-sequential modes of optical design software is proposed. The process is verified by a system assembled on a coordinate measuring machine with errors of several micrometers. Differences in the modulation transfer function, measured by the slanted-edge method, are less than 0.02 between the paraxial and off-axial regions. Reconstructed images of a U.S. quarter-dollar coin with different refocusing depths show the synthesized defocusing. The estimated depth map and depth-based reconstructed image show the rough shape of the coin.

High Thermal Resistance of Epoxy/Cyanate Ester Hybrids Incorporating an Inorganic Double-Decker-Shaped Polyhedral Silsesquioxane Nanomaterial.

In this study, we prepared a difunctionalized cyanate ester double-decker silsesquioxane (DDSQ-OCN) cage with a char yield and thermal decomposition temperature (Td) which were both much higher than those of a typical bisphenol A dicyanate ester (BADCy, without the DDSQ cage) after thermal polymerization. Here, the inorganic DDSQ nanomaterial improved the thermal behavior through a nano-reinforcement effect. Blending the inorganic DDSQ-OCN cage into the epoxy resin improved its thermal and mechanical stabilities after the ring-opening polymerization of the epoxy units during thermal polymerization. The enhancement in the physical properties arose from the copolymerization of the epoxy and OCN units to form the organic/inorganic covalently bonded network structure, as well as the hydrogen bonding of the OH groups of the epoxy with the SiOSi moieties of the DDSQ units. For example, the epoxy/DDSQ-OCN = 1/1 hybrid, prepared without Cu(II)-acac as a catalyst, exhibited a glass transition temperature, thermal decomposition temperature (Td), and char yield (166 °C, 427 °C, and 51.0 wt%, respectively) that were significantly higher than those obtained when applying typical organic curing agents in the epoxy resin. The addition of Cu(II)-acac into the epoxy/BADCy and epoxy/DDSQ-OCN hybrids decreased the thermal stability (as characterized by the values of Td and the char yields) because the crosslinking density and post-hardening also decreased during thermal polymerization; nevertheless, it accelerated the thermal polymerization to a lower curing peak temperature, which is potentially useful for real applications as epoxy molding compounds.

A full-face mask for protection against respiratory infections.

BACKGROUND: Aerosols and droplets are the transmission routes of many respiratory infectious diseases. The COVID-19 management guidance recommends against the use of nebulized inhalation therapy directly in the emergency room or in an ambulance to prevent possible viral transmission. The three-dimensional printing method was used to develop an aerosol inhalation treatment mask that can potentially prevent aerosol dispersion. We conducted this utility validation study to understand the practicability of this new nebulizer mask system. RESULTS: The fit test confirmed that the filter can efficiently remove small particles. The different locations of the mask had an excellent fit with a high pressure making a proper face seal usability. The full-face mask appeared to optimize filtration with pressure and is an example of materials that perform well for improvised respiratory protection using this design. The filtering effect test confirmed that the contamination of designated locations could be protected when using the mask with filters. As in the clinical safety test, a total of 18 participants (10 [55.6%] females; aged 33.1 ± 0.6 years) were included in the final analysis. There were no significant changes in SPO2, EtCO2, HR, SBP, DBP, and RR at the beginning, 20th, 40th, or 60th minutes of the test (all p >.05). The discomfort of wearing a mask increased slightly after time but remained within the tolerable range. The vision clarity score did not significantly change during the test. The mask also passed the breathability test. CONCLUSION: The results of our study showed that this mask performed adequately in the fit test, the filtering test, and the clinical safety test. The application of a full-face mask with antiviral properties, together with the newly designed shape of a respirator that respects the natural curves of a human face, will facilitate the production of personal protective equipment with a highly efficient filtration system. METHODS: We conducted three independent tests in this validation study: (1) a fit test to calculate the particle number concentration and its association with potential leakage; (2) a filtering effect test to verify the mask's ability to contain aerosol spread; and (3) a clinical safety test to examine the clinical safety, comfortableness, and visual clarity of the mask.

Adequacy of care during interfacility transfer in Taiwan: A pilot study.

BACKGROUND/PURPOSE: Interfacility transfer (IFT) in Asian communities is seldom discussed. We aimed to describe the characteristics of IFT in Taiwan and to explore the adequacy of care during transfer. METHODS: A retrospective, cross-sectional, descriptive study was conducted using standardized, paper-based interfacility ambulance transfer records between 1 January 2018 and 31 January 2018 from Tainan City, Taiwan. The mode of patient care needed was classified as advanced life support (ALS) or basic life support (BLS) cares based on clinical conditions. ALS providers were defined as physicians and EMT-Paramedics, while BLS providers were defined as nurse practitioners, nurses, EMT-1s and EMT-2s. RESULTS: Of the 377 (227 [60.2%] were >65 years old; 219 [58.1%] were male) IFTs enrolled in the final analysis, 210 (55.7%) patients met the ALS transfer criteria, with poor consciousness (n = 158), tachypnea (n = 17), tachycardia (n = 5), bradycardia (n = 7), hypertension (n = 12), hypotension (n = 13), hypoxia (n = 4), endotracheal intubation (n = 18), a tracheostomy (n = 25), a precipitous labor (n = 1), and after resuscitation for out-of-hospital cardiac arrest (n = 10) or in-hospital cardiac arrest (n = 3). None of the patients who required ALS care had adequate ambulance staffing. Of the 167 BLS IFTs, 9 (5.4%) patients deteriorated and required ALS care during transportation, which included worsened consciousness (n = 2), tachycardia (n = 1), hypertension (n = 2), hypotension (n = 1), and hypoxia (n = 3). The rates of deterioration during BLS-transferals from the emergency departments, general wards, nursing facilities, and unknown areas were 4.8%, 4.7%, 7.7%, and 7.1%, respectively (p = 0.93). CONCLUSION: The patient care during IFT in Taiwan is inadequate currently and should warrant attention.