Outcome prediction of cardiac arrest with automatically computed gray-white matter ratio on computed tomography images.

BACKGROUND: This study aimed to develop an automated method to measure the gray-white matter ratio (GWR) from brain computed tomography (CT) scans of patients with out-of-hospital cardiac arrest (OHCA) and assess its significance in predicting early-stage neurological outcomes. METHODS: Patients with OHCA who underwent brain CT imaging within 12 h of return of spontaneous circulation were enrolled in this retrospective study. The primary outcome endpoint measure was a favorable neurological outcome, defined as cerebral performance category 1 or 2 at hospital discharge. We proposed an automated method comprising image registration, K-means segmentation, segmentation refinement, and GWR calculation to measure the GWR for each CT scan. The K-means segmentation and segmentation refinement was employed to refine the segmentations within regions of interest (ROIs), consequently enhancing GWR calculation accuracy through more precise segmentations. RESULTS: Overall, 443 patients were divided into derivation N=265, 60% and validation N=178, 40% sets, based on age and sex. The ROI Hounsfield unit values derived from the automated method showed a strong correlation with those obtained from the manual method. Regarding outcome prediction, the automated method significantly outperformed the manual method in GWR calculation (AUC 0.79 vs. 0.70) across the entire dataset. The automated method also demonstrated superior performance across sensitivity, specificity, and positive and negative predictive values using the cutoff value determined from the derivation set. Moreover, GWR was an independent predictor of outcomes in logistic regression analysis. Incorporating the GWR with other clinical and resuscitation variables significantly enhanced the performance of prediction models compared to those without the GWR. CONCLUSIONS: Automated measurement of the GWR from non-contrast brain CT images offers valuable insights for predicting neurological outcomes during the early post-cardiac arrest period.

Association between independent practice time and patient outcomes in the emergency department: a retrospective study of residents in three urban hospitals in Taiwan.

BACKGROUND: The purpose of the study was to investigate the relationship between the independent practice time of residents and the quality of care provided in the Emergency Department (ED) across three urban hospitals in Taiwan. The study focused on non-pediatric and non-obstetric complaints, aiming to provide insights into the optimal balance between resident autonomy and patient safety. METHODS: A comprehensive retrospective study was conducted using de-identified electronic health records (EHRs) from the hospital's integrated medical database (iMD) from August 2015 to July 2019. The independent practice time was defined as the duration from the first medical order by a resident to the first modifications by the attending physician. The primary outcome was revisits to the ED within 72 h following discharge. Statistical analysis was conducted using RStudio and pyGAM. RESULTS: The study identified several factors associated with shorter independent practice times (< 30 minutes), including older patient age, male sex, higher body temperature, higher heart rate, lower blood pressure, and the presence of certain comorbidities. Residents practicing independently for 30-120 minutes were associated with similar adjusted odds of patient revisits to the ED (OR 1.034, 95% CI 0.978-1.093) and no higher risk of 7-day mortality (OR 0.674, 95% CI 0.592-0.767) compared to the group with less autonomy. However, independent practice times exceeding 120 minutes were associated with higher odds of revisiting the ED within 72 h. For the group with 120-210 minutes of independent practice time, the OR was 1.113 (95% CI: 1.025-1.208, p = 0.011). For the group with > 210 minutes, the OR was 1.259 (95% CI: 1.094-1.449, p = 0.001), indicating an increased risk of adverse outcomes as the independent practice time increasing. CONCLUSIONS: The study concludes that while providing residents an independent practice time between 30 to 120 minutes may be beneficial, caution should be exercised when this time exceeds 120 minutes. The findings underscore the importance of optimal supervision in enhancing patient care quality and safety. Further research is recommended to explore the long-term effects of different levels of resident autonomy on patient outcomes and the professional development of the residents themselves.

The Effectiveness of Online-Only Blended Cardiopulmonary Resuscitation Training: Static-Group Comparison Study.

BACKGROUND: Basic life support (BLS) education is essential for improving bystander cardiopulmonary resuscitation (CPR) rates, but the imparting of such education faces obstacles during the outbreak of emerging infectious diseases, such as COVID-19. When face-to-face teaching is limited, distance learning-blended learning (BL) or an online-only model-is encouraged. However, evidence regarding the effect of online-only CPR training is scarce, and comparative studies on classroom-based BL (CBL) are lacking. While other strategies have recommended self-directed learning and deliberate practice to enhance CPR education, no previous studies have incorporated all of these instructional methods into a BLS course. OBJECTIVE: This study aimed to demonstrate a novel BLS training model-remote practice BL (RBL)-and compare its educational outcomes with those of the conventional CBL model. METHODS: A static-group comparison study was conducted. It included RBL and CBL courses that shared the same paradigm, comprising online lectures, a deliberate practice session with Little Anne quality CPR (QCPR) manikin feedback, and a final assessment session. In the main intervention, the RBL group was required to perform distant self-directed deliberate practice and complete the final assessment via an online video conference. Manikin-rated CPR scores were measured as the primary outcome; the number of retakes of the final examination was the secondary outcome. RESULTS: A total of 52 and 104 participants from the RBL and CBL groups, respectively, were eligible for data analysis. A comparison of the 2 groups revealed that there were more women in the RBL group than the CBL group (36/52, 69.2% vs 51/104, 49%, respectively; P=.02). After adjustment, there were no significant differences in scores for QCPR release (96.9 vs 96.4, respectively; P=.61), QCPR depth (99.2 vs 99.5, respectively; P=.27), or QCPR rate (94.9 vs 95.5, respectively; P=.83). The RBL group spent more days practicing before the final assessment (12.4 vs 8.9 days, respectively; P<.001) and also had a higher number of retakes (1.4 vs 1.1 times, respectively; P<.001). CONCLUSIONS: We developed a remote practice BL-based method for online-only distant BLS CPR training. In terms of CPR performance, using remote self-directed deliberate practice was not inferior to the conventional classroom-based instructor-led method, although it tended to take more time to achieve the same effect. TRIAL REGISTRATION: Not applicable.

Post-resuscitation diastolic blood pressure is a prognostic factor for outcomes of cardiac arrest patients: a multicenter retrospective registry-based analysis.

BACKGROUND: Post-resuscitation hemodynamic level is associated with outcomes. This study was conducted to investigate if post-resuscitation diastolic blood pressure (DBP) is a favorable prognostic factor. METHODS: Using TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry, we recruited adult patients who received targeted temperature management in nine medical centers between January 2014 and September 2019. After excluding patients with extracorporeal circulation support, 448 patients were analyzed. The first measured, single-point blood pressure after resuscitation was used for analysis. Study endpoints were survival to discharge and discharge with favorable neurologic outcomes (CPC 1-2). Multivariate analysis, area under the receiver operating characteristic curve (AUC), and generalized additive model (GAM) were used for analysis. RESULTS: Among the 448 patients, 182 (40.7%) patients survived, and 89 (19.9%) patients had CPC 1-2. In the multivariate analysis, DBP > 70 mmHg was an independent factor for survival (adjusted odds ratio [aOR] 2.16, 95% confidence interval [CI, 1.41-3.31]) and > 80 mmHg was an independent factor for CPC 1-2 (aOR 2.04, 95% CI [1.14-3.66]). GAM confirmed that DBP > 80 mmHg was associated with a higher likelihood of CPC 1-2. In the exploratory analysis, patients with DBP > 80 mmHg had a significantly higher prevalence of cardiogenic cardiac arrest (p = 0.015) and initial shockable rhythm (p = 0.045). CONCLUSION: We found that DBP after resuscitation can predict outcomes, as a higher DBP level correlated with cardiogenic cardiac arrest.

Characteristics, prognostic factors, and chronological trends of out-of-hospital cardiac arrests with shockable rhythms in Taiwan - A 7-year observational study.

BACKGROUND: The study aimed to explore the characteristics, predictors, and chronological trends of outcomes for adult out-of-hospital cardiac arrests (OHCAs) with shockable rhythms. METHODS: A 7-year, community-wide observational study using an Utstein-style registry was conducted. Patients who were not transported, those who experienced trauma and those who lacked electronic electrocardiography data were excluded; those with initial shockable rhythms of ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) were included. Outcomes were survival of discharge (SOD) and favorable neurological status (CPC 1-2). The outcome predictors, chronological trends, and their relationship with system interventions were analyzed. RESULTS: Of the 1544 shockable OHCAs (incidence 12.6%) included, 97.6% had VF and 2.4% had pVT. VF showed better outcomes than pVT. Predictors for both outcomes (SOD; CPC 1-2) were chronological change (adjusted odds ratio [aOR]: 1.133; 1.176), younger age (aOR: 0.973; 0.967), shorter response time (aOR: 0.998; 0.999), shorter scene time (aOR: 0.999; 0.999), witnessed collapse (aOR: 1.668; 1.670), and bystander cardiopulmonary resuscitation (BCPR) (aOR: 1.448; 1.576). Predictors for only SOD were public location (aOR: 1.450) and successful prehospital defibrillation (aOR: 3.374). The use of the supraglottic airway was associated with adverse outcomes. Chronologically with system interventions, BCPR rate, the proportion of shockable OHCA, and improved neurological outcomes increased over time. CONCLUSION: The incidence of shockable OHCA remained low in Asian community. VF showed better outcomes than pVT. Over time, the incidence of shockable rhythm, BCPR rate and patient outcomes did improve with health system interventions. The number of prehospital defibrillations did not predict outcomes.

Predicting the Mortality and Readmission of In-Hospital Cardiac Arrest Patients With Electronic Health Records: A Machine Learning Approach.

BACKGROUND: In-hospital cardiac arrest (IHCA) is associated with high mortality and health care costs in the recovery phase. Predicting adverse outcome events, including readmission, improves the chance for appropriate interventions and reduces health care costs. However, studies related to the early prediction of adverse events of IHCA survivors are rare. Therefore, we used a deep learning model for prediction in this study. OBJECTIVE: This study aimed to demonstrate that with the proper data set and learning strategies, we can predict the 30-day mortality and readmission of IHCA survivors based on their historical claims. METHODS: National Health Insurance Research Database claims data, including 168,693 patients who had experienced IHCA at least once and 1,569,478 clinical records, were obtained to generate a data set for outcome prediction. We predicted the 30-day mortality/readmission after each current record (ALL-mortality/ALL-readmission) and 30-day mortality/readmission after IHCA (cardiac arrest [CA]-mortality/CA-readmission). We developed a hierarchical vectorizer (HVec) deep learning model to extract patients' information and predict mortality and readmission. To embed the textual medical concepts of the clinical records into our deep learning model, we used Text2Node to compute the distributed representations of all medical concept codes as a 128-dimensional vector. Along with the patient's demographic information, our novel HVec model generated embedding vectors to hierarchically describe the health status at the record-level and patient-level. Multitask learning involving two main tasks and auxiliary tasks was proposed. As CA-mortality and CA-readmission were rare, person upsampling of patients with CA and weighting of CA records were used to improve prediction performance. RESULTS: With the multitask learning setting in the model learning process, we achieved an area under the receiver operating characteristic of 0.752 for CA-mortality, 0.711 for ALL-mortality, 0.852 for CA-readmission, and 0.889 for ALL-readmission. The area under the receiver operating characteristic was improved to 0.808 for CA-mortality and 0.862 for CA-readmission after solving the extremely imbalanced issue for CA-mortality/CA-readmission by upsampling and weighting. CONCLUSIONS: This study demonstrated the potential of predicting future outcomes for IHCA survivors by machine learning. The results showed that our proposed approach could effectively alleviate data imbalance problems and train a better model for outcome prediction.

Attitude and behavior toward bystander cardiopulmonary resuscitation during COVID-19 outbreak.

BACKGROUND: Outbreaks of emerging infectious diseases, such as COVID-19, have negative impacts on bystander cardiopulmonary resuscitation (BCPR) for fear of transmission while breaking social distancing rules. The latest guidelines recommend hands-only cardiopulmonary resuscitation (CPR) and facemask use. However, public willingness in this setup remains unknown. METHODS: A cross-sectional, unrestricted volunteer Internet survey was conducted to assess individuals' attitudes and behaviors toward performing BCPR, pre-existing CPR training, occupational identity, age group, and gender. The raking method for weights and a regression analysis for the predictors of willingness were performed. RESULTS: Among 1,347 eligible respondents, 822 (61%) had negative attitudes toward performing BCPR. Healthcare providers (HCPs) and those with pre-existing CPR training had fewer negative attitudes (p < 0.001); HCPs and those with pre-existing CPR training and unchanged attitude showed more positive behaviors toward BCPR (p < 0.001). Further, 9.7% of the respondents would absolutely refuse to perform BCPR. In contrast, 16.9% would perform BCPR directly despite the outbreak. Approximately 9.9% would perform it if they were instructed, 23.5%, if they wore facemasks, and 40.1%, if they were to perform hands-only CPR. Interestingly, among the 822 respondents with negative attitudes, over 85% still tended to perform BCPR in the abovementioned situations. The weighted analysis showed similar results. The adjusted predictors for lower negative attitudes toward BCPR were younger age, being a man, and being an HCP; those for more positive behaviors were younger age and being an HCP. CONCLUSIONS: Outbreaks of emerging infectious diseases, such as COVID-19, have negative impacts on attitudes and behaviors toward BCPR. Younger individuals, men, HCPs, and those with pre-existing CPR training tended to show fewer negative attitudes and behaviors. Meanwhile, most individuals with negative attitudes still expressed positive behaviors under safer measures such as facemask protection, hands-only CPR, and available dispatch instructions.

Comparison of Chest Compression Quality between Transfer Sheet and Stretcher Use for Transporting out-of-Hospital Cardiac Arrest Patients in a High-Rise Building - A Randomized and Open-Label Cross-over Design.

OBJECTIVES: Stretchers are commonly used for transporting cardiac arrest patients, but their use may be limited in confined spaces, like elevators. Use of transfer sheet as an alternative has not been explored. We aimed to compare manual chest compression quality between these two methods. Methods: In this prospective, open-label, randomized cross-over manikin study, the subjects included emergency medical technicians who were assigned to 12 three-person crews. Scenarios included transport of a cardiac arrest in a high-rise building and elevator using transfer sheet (TS) and stretchers adjusted to 45° (S45) and 90° (S90). Chest compression quality was measured using a recording manikin and that before (on-scene phase) and after (transport phase) the manikin moved via transfer sheet or stretcher were compared. Results: The final analysis included 72 simulation runs. Chest compression quality did not differ among the groups in the on-scene phase. In the transport phase, the transfer sheet group provided greater mean compression depth (54.4 ± 4.2 vs 39.6 ± 7.2 mm, p < 0.01 and 54.4 ± 4.2 vs 40.6 ± 8.3 mm, p < 0.01, respectively) than stretchers of S45 and S90, and higher percentage of deep-enough compression (TS: 51.0 [23.8-74.8]% vs S45: 19.5 [5.8-29.5]%, p < 0.01) than the S45 group. Transfer sheet use showed a trend of lower percentages of full recoil (TS: 40.0 [12.8-64.5]% vs S45: 70.5 [47.0-79.8]% vs S90: 52.5 [25.3-76.0]%, p = 0.09). Chest compression fraction, compressions with correct hand position, and mean compression rates did not differ between groups in the transport phase. The TS group showed shorter time intervals of simulation start-to-first-compression (TS: 13.9 [12.4-15.1] sec vs S90: 15.9 [13.3-16.4] sec, p = 0.04) and total run time (TS: 145.7 [135.1-151.4] sec vs S90: 160.0 [151.9-175.4] sec, p < 0.01) than the S90 group. Conclusion: In this simulation, using transfer sheet outperform using stretcher for transporting cardiac arrest patients from high-rise buildings. Rescuers need to be aware of full chest recoil.

Pentoxifylline decreases post-operative intra-abdominal adhesion formation in an animal model.

BACKGROUND: Intra-abdominal adhesions develop after nearly every abdominal surgery, commonly causing female infertility, chronic pelvic pain, and small bowel obstruction. Pentoxifylline (PTX) is a methylxanthine compound with immunomodulatory and antifibrotic properties. The aim of this study was to investigate whether PTX can reduce post-operative intra-abdominal adhesion formation via collagen deposition, tissue plasminogen activator (tPA) level, inflammation, angiogenesis, and fibrosis. METHODS: Seventy male BALB/c mice were randomized into one of three groups: (1) sham group without peritoneal adhesion model; (2) peritoneal adhesion model (PA group); (3) peritoneal adhesion model with PTX (100 mg/kg/day i.p.) administration was started on preoperative day 2 and continued daily (PA + PTX group). On postoperative day 3 and day 7, adhesions were assessed using the Lauder scoring system. Parietal peritoneum was obtained for histological evaluation with hematoxylin and eosin (HE) and picrosirius red staining. Fibrinolysis was analyzed by tPA protein levels in the peritoneum by ELISA. Immunohistological analysis was also conducted using markers for angiogenesis (ki67+/CD31+), inflammation (F4/80+) and fibrosis (FSP-1+ and α-SMA+). All the comparisons were made by comparing the PA group with the PTX treated PA group, and p < 0.05 was considered statistically significant. RESULTS: Intra-abdominal adhesions were markedly reduced by PTX treatment. Compared with the PA group, PTX treatment had lower adhesion scores than the PA group on both day 3 and day 7 (p < 0.05). Histological evaluations found that PTX treatment reduced collagen deposition and adhesion thickening. ELISA analysis showed that PTX treatment significantly increased the level of tPA in the peritoneum. In addition, in the immunohistological analysis, PTX treatment was found to significantly decrease the number of ki67+/CD31+ cells at the site of adhesion. Finally, we also observed that in the PTX treated group, there was a reduction in the expression of F4/80+, FSP-1+, and α-SMA+ cells at the site of adhesion. CONCLUSION: PTX may decrease intra-abdominal adhesion formation via increasing peritoneal fibrinolytic activity, suppressing angiogenesis, decreasing collagen synthesis, and reducing peritoneal fibrosis. Our findings suggest that PTX can be used to decrease post-operative intra-abdominal adhesion formation.