Factors Mediating Community Race and Ethnicity Differences in Initial Shockable Rhythm for Out-of-Hospital Cardiac Arrests in Texas.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) patients from minoritized communities have lower rates of initial shockable rhythm, which is linked to favorable outcomes. We sought to evaluate the importance of initial shockable rhythm on OHCA outcomes and factors that mediate differences in initial shockable rhythm. METHODS: We performed a retrospective study of the 2013-2022 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES). Using census tract data, we stratified OHCAs into majority race/ethnicity communities: >50% White, >50% Black, and >50% Hispanic/Latino. We compared logistic regression models between community race/ethnicity and OHCA outcome: 1) unadjusted, 2) adjusting for bystander CPR (bCPR), and 3) adjusting for initial rhythm. Using structural equation modeling, we performed mediation analyses between community race/ethnicity, OHCA characteristics, and initial shockable rhythm. RESULTS: We included 22,730 OHCAs from majority White (21.1% initial shockable rhythm), 4,749 from majority Black (15.3% shockable), and 16,054 majority Hispanic/Latino (16.1% shockable) communities. Odds of favorable neurologic outcome were lower for majority Black (0.4 [0.3-0.5]) and Hispanic/Latino (0.6 [0.6-0.7]). While adjusting for bCPR minimally changed outcome odds, adjusting for shockable rhythm increased odds for Black (0.5 [0.4-0.5]) and Hispanic/Latino (0.7 [0.6-0.8]) communities. On mediation analysis for majority Black, the top mediators of initial shockable rhythm were public location (14.6%), bystander witnessed OHCA (11.6%), and female gender (5.7%). The top mediators for majority Hispanic/Latino were bystander-witnessed OHCA (10.2%), public location (3.52%), and bystander CPR (3.49%), CONCLUSION: Bystander-witnessed OHCA and public location were the largest mediators of shockable rhythm for OHCAs from minoritized communities.

Rural cardiac arrest care and outcomes in Texas.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) victims in rural communities have worse outcomes despite higher rates of bystander cardiopulmonary resuscitation (CPR) than urban communities. In this retrospective cohort study we attempt to evaluate selected aspects of the continuum of care, including post-arrest care, for rural OHCA victims, and we investigated factors that could contribute to rural areas having higher rates of bystander CPR. METHODS: We analyzed 2014-2020 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES) data for adult OHCAs. We linked TX-CARES data to census tract data and stratified OHCAs into urban and rural events. We created a mixed-model logistic regression to compare cardiac arrest characteristics, pre-hospital care, and post-arrest care between rural and urban settings. We adjusted for confounders and modeled census tract as a random intercept. We then compared different regression models evaluating the association between response time and bystander CPR. RESULTS: We included 1202 rural and 28,288 urban cardiac arrests. Comparing rural to urban OHCAs, rates of bystander CPR were significantly higher in rural communities (49.6% v 40.6%, aOR 1.3 95% CI 1.1-1.5). The median response time for rural (11.5 min) was longer than urban (7.3 min). The occurrence of an ambulance response time of <10 min was notably less common in rural communities when compared to urban areas (aOR 0.2, 95% CI 0.2-0.2). For post-arrest care the rates of percutaneous coronary intervention (PCI) were higher in rural than urban communities (aOR 1.7, 95% CI 1.01-2.8). The rates of AED and TTM were similar between urban and rural communities. Survival to hospital discharge was significantly lower in rural communities than urban communities (aOR 0.6, 95% CI 0.4-0.7). Although not significant, rural communities had lower rate of survival with a cognitive performance score (CPC) of 1 or 2 (aOR 0.7, 05% CI 0.6-1.003). We identified no association between response time and bystander CPR. CONCLUSION: Patients in rural areas of Texas have lower survival after OHCA compared to patients in urban areas, despite having significantly greater rates of bystander CPR and PCI. We did not find a link between response time and bystander CPR rates.

Prehospital Ultrasound: Nationwide Incidence from the NEMSIS Database.

OBJECTIVE: We sought to describe prehospital ultrasound (PHUS) use and trends in PHUS utilization over time using a national database. METHODS: Using the 2018 - 2021 National Emergency Medical Services Information System databases, we identified those EMS activations where PHUS was performed. We evaluated the association between year and number of PHUS exams performed using univariable and multivariable regression analysis. Analysis was performed on the overall group and various subgroups. RESULTS: In total, there were 148,709,000 EMS activations by 13,899 agencies over the 4 years. Of these, 3,291 unique activations (0.002%) involved PHUS, performed by 71 EMS agencies (0.5%). The annual rate of ultrasound evaluations per 1 million EMS activations significantly increased over the study period: 5.2 in 2018, 14.8 in 2019, 18.6 in 2020, and 38.9 in 2021 (p < 0.01). The number of agencies performing PHUS each year increased over the study period from 11 in 2018 to 54 in 2021 (p < 0.05). Each year after 2018 had an increased odds of PHUS use demonstrated with logistic regression (p < 0.01). PHUS was used in each US census region, and paramedics performed most of the PHUS exams (75.5%). We identified 1,060 out-of-hospital cardiac arrest, 820 trauma, and 427 respiratory PHUS cases. These three cohorts accounted for 70.1% of all PHUS cases. CONCLUSION: Prehospital ultrasound use in the United States increased significantly over the study period, but remains exceedingly rare. The performance of PHUS was recorded throughout the United States, with paramedics performing the majority of PHUS studies included in this database.

First Responder CPR and Survival Differences in Texas Minority and Lower Socioeconomic Status Neighborhoods.

INTRODUCTION: First responder (FR) cardiopulmonary resuscitation (CPR) is an important component of out-of-hospital cardiac arrest (OHCA) care. However, little is known about FR CPR disparities. METHODS: We linked the 2014-2021 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES) database to census tract data. We included non-traumatic OHCAs that were not witnessed by 9-1-1 responders and did not receive bystander CPR. We defined census tracts as having >50% of a race/ethnicity: White, Black, or Hispanic/Latino. We also stratified patients into quartiles based on socioeconomic status (SES): household income, high school graduation, and unemployment. We also combined race/ethnicity and income to create a total of five mixed strata, comparing lower income and minority census tracts to high income White census tracts. We created mixed model logistic regression models, adjusting for confounders and modeling census tract as a random intercept. Using the models, we compared FR CPR rates for census race/ethnicity (Black and Hispanic/Latino compared to White), and SES quartiles (2nd, 3rd, and 4th quartiles compared to 1st quartiles). Secondarily, we evaluated the association between FR CPR and survival for all strata. RESULTS: We included 21,966 OHCAs, and 57.4% had FR CPR. Evaluating the association between census tract characteristic and FR CPR, majority Black (aOR 0.30, 95% CI 0.22-0.41) had a lower bystander CPR rate when compared to majority White. The lowest income quartile had a lower rate of bystander CPR (aOR 0.80, 95% CI 0.65-0.98). The worst unemployment quartile was also associated with a lower rate of FR CPR (aOR 0.75, 95% CI 0.61-0.92). Combining race/ethnicity and income, middle income majority Black (30.0%; aOR 0.27, 95% CI 0.17-0.46) and low income >80% Black (31.8%; aOR 0.27, 95% CI 0.10-0.68) had lower rates of FR CPR in comparison to high income majority White. There were no associations between Hispanic or lower high school graduation and lower rates of FR CPR. We found no association between FR CPR and survival for all three strata. CONCLUSION: While we identified disparities in FR CPR in low SES and majority Black census tracts, we identified no association between FR CPR and survival in Texas.

Piloting a Layperson Prehospital Care System in Rural Uganda.

INTRODUCTION: In many low-income countries, basic prehospital Emergency Medical Services (EMS) remain under-developed, resulting in significant delays or the complete inability to access care. STUDY OBJECTIVE: The purpose of this study was to analyze the effectiveness of a layperson EMS training targeting motorcycle taxi (boda) drivers in a rural region of Uganda. METHODS: Fifty (50) adult boda drivers from Masindi, Uganda were selected for a one-day training course including lectures and simulation. Course content covered basic prehospital skills and transport. Participants were given a first responder kit at completion of the course. Understanding of material was assessed prior to training, immediately after course completion, and four months from the initial course using the same ten question test. Test means were analyzed using a standard linear regression model. At the four-month follow up, all 50 boda drivers participated in semi-structured small group qualitative interviews regarding their perception of the course and experiences implementing course skills in the community. Boda drivers were asked to complete a brief form on each patient transported during the study period. For patients transported to Masindi Kitara Medical Center (MKMC), hospital trauma registry data were analyzed. RESULTS: Trainees showed both knowledge acquisition and retention with pre-test scores of 21.8% improving to 48.0% at course completion and 57.7% at the four-month follow up. Overall, participant's scores increased by an average of 35% from the pre-test to the second post-test (P <.001). A total of 69 patient forms were completed on transported patients over the initial four-month period. Ninety-five percent (95%) of these were injured patients, and motorcycle crash was the predominant mechanism of injury (48% of injuries). Eight patients were transported to MKMC, but none of these patients were recorded in the hospital trauma registry. Major barriers identified through semi-structured interviews included harassment by police, poor road conditions, and lack of basic resources for transport. Ninety-four percent (94%) of trainees strongly agreed that the training was useful. Total costs were estimated at $3,489 USD, or $69 per trainee. CONCLUSION: Motorcycle taxi drivers can be trained to provide basic prehospital care in a short time and at a low cost. While there is much enthusiasm for additional training and skill acquisition from this cohort, the sustainability and scalability of such programs is still in question.

Geospatial Analysis of Prehospital Triage and Early Potential Preventable Traumatic Deaths.

Severely injured patients often depend on prompt prehospital triage for survival. This study aimed to examine the under-triage of preventable or potentially preventable traumatic deaths. A retrospective review of Harris County, TX, revealed 1848 deaths within 24 hours of injury, with 186 being preventable or potentially preventable (P/PP). The analysis evaluated the geospatial relationship between each death and the receiving hospital. Out of the 186 P/PP deaths, these were more commonly male, minority, and penetrating mechanisms when compared with NP deaths. Of the 186 PP/P, 97 patients were transported to hospital care, 35 (36%) were transported to Level III, IV, or non-designated hospitals. Geospatial analysis revealed an association between the location of initial injury and proximity to receiving Level III, IV, and non-designated centers. Geospatial analysis supports proximity to the nearest hospital as one of the primary reasons for under-triage.

Disparities in Prehospital Non-Traumatic Pain Management.

Introduction: While prior research has identified racial disparities in prehospital analgesia for traumatic pain, little is known about non-traumatic pain. Using a national prehospital dataset, we sought to evaluate for racial and ethnic disparities in analgesia given by EMS for non-traumatic pain.Methods: We analyzed the 2018 and 2019 data from the ESO Data Collaborative, a collection of de-identified prehospital electronic health records from nearly 1,300 participating EMS agencies in the US. We included all transported, adult, non-traumatic encounters with a primary or secondary impression of a pain complaint, and we stratified encounters based on race and ethnicity as recorded by the EMS clinicians. We performed a mixed model analysis, modeling EMS agency as a random intercept and adjusting for age, sex, pain location, level of service, location of incident, and highest pain score. With non-Hispanic White patients as the reference group, we then evaluated the association between race/ethnicity and receiving any pain medication (acetaminophen, non-steroidal anti-inflammatories, or opioids), receiving opioid pain medication, and receiving pain medication within 20 minutes of EMS arrival.Results: We included 1,035,486 patients; 67.5% non-Hispanic White, 26.8% Black, 4.9% Hispanic, 0.5% Asian, 0.1% Native Hawaiian or Other Pacific Islander, and 0.2% American Indian or Alaska Native patients. 4.7% of patients received pain medications. Compared to White patients (5.1%), Black patients were less likely to receive pain medication (3.3%, aOR 0.7; 95% CI 0.7-0.7) and Hispanics were more likely to receive pain medication (7.6%, aOR 1.5; 95% CI 1.4-1.6). Black patients were also less likely to receive opioids (1.8% for Black v 3.0% for White, aOR 0.7; 95% CI 0.6-0.7), while Hispanic patients were more likely to receive opioids (4.9%, aOR 1.4; 95% CI 1.3-1.5). The odds of receiving pain medication within 20 minutes was lower for Black patients (aOR 0.9; 95% CI 0.8-0.95) but no different for Hispanic patients (aOR 1.0; 95% CI 0.9-1.1), when compared to White patients.Conclusion: Pain medication administration is uncommon for non-traumatic pain complaints. While Black patients were less likely than White patients to receive pain medications and receive pain medication within 20 minutes, Hispanics were more likely to receive pain medications.

The impact of COVID-19 on incidence and outcomes from out-of-hospital cardiac arrest (OHCA) in Texas.

INTRODUCTION: Emerging research demonstrates lower rates of bystander cardiopulmonary resuscitation (BCPR), public AED (PAD), worse outcomes, and higher incidence of OHCA during the COVID-19 pandemic. We aim to characterize the incidence of OHCA during the early pandemic period and the subsequent long-term period while describing changes in OHCA outcomes and survival. METHODS: We analyzed adult OHCAs in Texas from the Cardiac Arrest Registry to Enhance Survival (CARES) during March 11-December 31 of 2019 and 2020. We stratified cases into pre-COVID-19 and COVID-19 periods. Our prehospital outcomes were bystander cardiopulmonary resuscitation (BCPR), public AED use (PAD), sustained ROSC, and prehospital termination of resuscitation (TOR). Our hospital survival outcomes were survival to hospital admission, survival to hospital discharge, good neurological outcomes (CPC Score of 1 or 2) and Utstein bystander survival. We created a mixed effects logistic regression model analyzing the association between the pandemic on outcomes, using EMS agency as the random intercept. RESULTS: There were 3619 OHCAs (45.0% of overall study population) in 2019 compared to 4418 (55.0% of overall study population) in 2020. Rates of BCPR (46.2% in 2019 to 42.2% in 2020, P < 0.01) and PAD (13.0% to 7.3%, p < 0.01) decreased. Patient survival to hospital admission decreased from 27.2% in 2019 to 21.0% in 2020 (p < 0.01) and survival to hospital discharge decreased from 10.0% in 2019 to 7.4% in 2020 (p < 0.01). OHCA patients were less likely to receive PAD (aOR = 0.5, 95% CI [0.4, 0.8]) and the odds of field termination increased (aOR = 1.5, 95% CI [1.4, 1.7]). CONCLUSIONS: Our study adds state-wide evidence to the national phenomenon of long-term increased OHCA incidence during COVID-19, worsening rates of BCPR, PAD use and survival outcomes.

COVID-19 Acute Respiratory Distress Syndrome and Pulmonary Embolism: A Case Report of Nebulized Nitroglycerin and Systemic Thrombolysis For Right Ventricular Failure.

BACKGROUND: Acute respiratory compromise caused by complications of COVID-19, such as acute respiratory distress syndrome (ARDS) or thromboembolic disease, is a complex syndrome with unique challenges in treatment. Management often requires time and intensive care through a multiprofessional, multispecialty approach. Initial management is particularly challenging within the limited-resource environment of the emergency department (ED). The emergency physician's toolbox of treatments with reasonably rapid onset remains limited to respiratory support, prone positioning, steroids, and anticoagulation. CASE REPORT: We present a case of a patient with COVID-19 complicated by ARDS and bilateral pulmonary emboli with severe right ventricular dysfunction and systemic hypotension treated with nebulized nitroglycerin and systemic thrombolytic therapy in the ED. Serial evaluation of right ventricular function using point of care ultrasound over the next 2 h showed improvement of function with both agents as well as improvement in the patient's respiratory rate and work of breathing. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case describes a novel use of a widely available medication for patients with COVID-19-induced right ventricular dysfunction. Nebulized nitroglycerin may be an option to improve right ventricular function when other inhaled pulmonary vasodilators are not available in the initial ED setting. © 2021 Elsevier Inc.

Enantioselective Radical Construction of 5-Membered Cyclic Sulfonamides by Metalloradical C-H Amination.

Both arylsulfonyl and alkylsulfonyl azides can be effectively activated by the cobalt(II) complexes of D2-symmetric chiral amidoporphyrins for enantioselective radical 1,5-C-H amination to stereoselectively construct 5-membered cyclic sulfonamides. In addition to C-H bonds with varied electronic properties, the Co(II)-based metalloradical system features chemoselective amination of allylic C-H bonds and is compatible with heteroaryl groups, producing functionalized 5-membered chiral cyclic sulfonamides in high yields with high enantioselectivities. The unique profile of reactivity and selectivity of the Co(II)-catalyzed C-H amination is attributed to its underlying stepwise radical mechanism, which is supported by several lines of experimental evidence.

Synthesis, pharmacological characterization, and structure-activity relationship studies of small molecular agonists for the orphan GPR88 receptor.

GPR88 is an orphan G-protein-coupled receptor (GPCR) enriched in the striatum. Genetic deletion and gene expression studies have suggested that GPR88 plays an important role in the regulation of striatal functions and is implicated in psychiatric disorders. The signal transduction pathway and receptor functions of GPR88, however, are still largely unknown due to the lack of endogenous and synthetic ligands. In this paper, we report the synthesis of a GPR88 agonist 2-PCCA and its pure diastereomers, which were functionally characterized in both transiently and stably expressing GPR88 HEK293 cells. 2-PCCA inhibited isoproterenol-stimulated cAMP accumulation in a concentration-dependent manner in cells expressing GPR88 but not in the control cells, suggesting that the observed cAMP inhibition is mediated through GPR88 and that GPR88 is coupled to Gαi. 2-PCCA did not induce calcium mobilization in GPR88 cells, indicating no Gαq-mediated response. A structure-activity relationship (SAR) study of 2-PCCA was also conducted to explore the key structural features for GPR88 agonist activity.

Quantifying and comparing torsional strains after olecranon plating.

PURPOSE: Any torsion experienced at a fracture site will directly translate into shearing forces and has been regarded as detrimental to healing. The purpose of this study was to determine which plating system currently on the market controls torsional forces about comminuted olecranon fractures most effectively. METHODS: Five olecranon plates (Acumed, Synthes-SS, Synthes-Ti, ITS/US Implants and Zimmer) were implanted to stabilise a simulated comminuted fracture pattern in 50 fresh-frozen, cadaveric elbows. All specimens were evaluated by dual energy X-ray absorptiometry (DXA) scan to determine bone density. Three-dimensional displacement analysis was conducted to assess fragment motion through physiologic cyclic arcs of motion. The specimens were cycled through progressive physiologic loads (0.18-5.6 kg). Movements of the fragments were statistically compared amongst the different implants using one-way analysis of variance (ANOVA) and Tukey Honestly Significant Difference (HSD) post hoc comparisons with a critical significance level of α=0.05. RESULTS: DXA bone mineral densities (BMDs) ranged from 0.465 to 0.927, with an average of 0.714. The Acumed, Synthes-SS, Synthes-Ti and Zimmer plates allowed <1° of torsion up to 1.6 kg of load. The differences between these plates at this load were not statistically significant. The ITS/US Implants plate, however, allowed significantly more torsion above loads of 2.6 kg (p=0.045) compared with all other plates. The ITS/US Implants plate allowed over 2° of torsion at 2.6 kg (p=0.012), and nearly 3° at 3.6 kg (p=0.045). The Zimmer plate consistently allowed more torsion than the Acumed plate or either of the Synthes plates, but the differences were not statistically significant. CONCLUSION: Regardless of which olecranon plate is used, the authors recommend limiting postoperative rehabilitation loads to below 1.6 kg in an effort to minimise the detrimental effects of torsion on healing. If loads over 1.6 kg are anticipated, the authors recommend the use of the Acumed plate or either of the Synthes plates.

Comparison of olecranon plate fixation in osteoporotic bone: do current technologies and designs make a difference?

OBJECTIVES: The purpose of this study is to determine if recent innovations in olecranon plates have any advantages in stabilizing osteoporotic olecranon fractures. METHODS: Five olecranon plates (Acumed, Synthes-SS, Synthes-Ti, US Implants/ITS, and Zimmer) were implanted to stabilize a simulated comminuted fracture pattern in 30 osteoporotic cadaveric elbows. Specimens were randomized by bone mineral density per dual-energy x-ray absorptiometry scan. Three-dimensional displacement analysis was conducted to assess fragment motion through physiological cyclic arcs of motion and failure loading, which was statistically compared using one-way analysis of variance and Tukey honestly significant difference post hoc comparisons with a critical significance level of α = 0.05. RESULTS: Bone mineral density ranged from 0.546 g/cm to 0.878 g/cm with an average of 0.666 g/cm. All implants limited displacement of the fragments to less than 3 mm until sudden, catastrophic failure as the bone of the proximal fragment pulled away from the implant. The maximum load sustained by all osteoporotic specimens ranged from 1.6 kg to 6.6 kg with an average of 4.4 kg. There was no statistical difference between the groups in terms of cycles survived and maximum loads sustained. CONCLUSIONS: Cyclic physiological loading of osteoporotic olecranon fracture fixation resulted in sudden, catastrophic failure of the bone-implant interface rather than in gradual implant loosening. Recent plate innovations such as locking plates and different screw designs and positions appear to offer no advantages in stabilizing osteoporotic olecranon fractures. Surgeons may be reassured that the current olecranon plates will probably adequately stabilize osteoporotic fractures for early motion in the early postoperative period, but not for heavy activities such as those that involve over 4 kg of resistance.