Video-stylet vs. channeled hyperangulated videolaryngoscope: Efficacy in simulated Ludwig's angina randomized cadaver trial.

INTRODUCTION: Ludwig's angina (LA) is a life-threatening infection that can affect the floor of the mouth and neck, potentially causing serious airway obstruction. In such cases, rescue airway management and oxygenation can be challenging due to swelling of the mouth floor, trismus, and limited mouth opening. The aim of this study was to assess the efficacy of the Trachway video-stylet (VS) and Pentax AWS hyperangulated videolaryngoscope with channel (HAVL-C) compared to the standard geometric video-laryngoscope (SGVL, Macintosh 3, Trachway) in simulating Ludwig's angina with cadavers. METHODS: Three fresh frozen cadavers were prepared with varying degrees of difficulty to simulate the airway conditions of patients with LA, including mouth floor swelling, restricted mouth opening, and trismus. Fifty-five second-year resident physicians from various specialties participated in the study and received training in airway management using SGVL, VS, and HAVL-C devices. Participants were randomly assigned to intubate simulated LA with cadavers using the three devices in a random order, and intubation times and success rates were recorded. Participants also rated the difficulty of intubation using a visual analogue scale (VAS) score. The primary outcome assessed the first-pass intubation success or failure, while the secondary outcomes measured the intubation time and subjective difficulty using a visual analogue scale with different laryngoscopes. RESULTS: The success rates for intubation within 90 s were 40% for SGVL, 82% for VS, and 76% for HAVL-C. VS and HAVL-C had significantly higher success rates than SGVL, with hazard ratios of 3.4 and 2.7, and 95% confidence intervals (CI) of 2.0-5.7 and 1.6-4.6, p < 0.001, respectively. The odds ratios of successful intubation for VS and HAVL-C were 8.1 and 6.3, respectively, with a 95% CI of 3.7-17.8 and 2.4-16.7, p < 0.001, compared to SGVL. The VAS score was significantly correlated with intubation success rate and time. CONCLUSIONS: In cases of LA, the use of VS and HAVL-C is preferable over SGVL. These findings suggest that using VS and HAVL-C can improve intubation success rates and reduce intubation time in patients with LA.

Continuous aerosol monitoring and comparison of aerosol exposure based on smoke dispersion distance and concentrations during oxygenation therapy.

This study evaluated the aerosol exposure risks while using common noninvasive oxygenation devices. A simulated mannequin was designed to breathe at a minute ventilation of 20 L/min and used the following oxygen-therapy devices: nasal cannula oxygenation (NCO) at 4 and 15 L/min, nonrebreathing mask (NRM) at 15 L/min, simple mask at 6 L/min, combination of NCO at 15 L/min and NRM at 15 L/min, high-flow nasal cannula (HFNC) at 50 L/min, and flush rate NRM. Two-dimension of the dispersion distance and the aerosol concentrations were measured at head, trunk, and foot around the mannequin for over 10 min. HFNC and flush-rate NRM yielded the longest dispersion distance and highest aerosol concentrations over the three sites of the mannequin than the other oxygenation devices and should use with caution. For flow rates of < 15 L/min, oxygenation devices with mask-like effects, such as NRM or NCO with NRM, decreased aerosol dispersion more effectively than NCO alone or a simple mask. In the upright position, the foot area exhibited the highest aerosol concentration regardless of the oxygenation device than the head-trunk areas of the mannequin. Healthcare workers should be alert even at the foot side of the patient while administering oxygenation therapy.

Multi-disciplinary management of type 1 and 2 skin tears using a silver-based hydrofiber dressing.

Skin tear is a common problem encountered in the emergency department. If it is not properly managed, it can lead to wound infection, skin necrosis and a need for further surgical intervention and skin grafting. Current management is to cleanse the wound, replace the thin skin tear followed by coverage with a dressing that is inducive for wound healing. Several dressings have been suggested for the coverage of these wounds. But, up to now, there has been no mention of the use of a silver-based hydrofiber dressing in the management of this condition. The objective of this study was to explore the use of a silver-based hydrofiber dressing for the management of paper-thin skin tears. We retrospectively reviewed all patients with Type 1 or 2 skin tears that had undergone management using a silver-based hydrofiber dressing between October 2019 and October 2020. Demographic data and medical history was obtained by retrospective chart review. Data that was collected included: age, sex, comorbid illnesses, defect location, defect size, complications, number of times the silver-based hydrofiber dressing was replaced and the number of days required to achieve complete wound healing. A total of 65 patients were included in the study. There were 42 males and 23 females. There were 28 patients whose age was greater then 85 years old, of which 14 patients were over 90 years old. The mean number of outpatient visits was 2. The mean defect size was 33 cm2 (range 1 cm × 1 cm to 18 × 10 cm). The mean number of days required for total wound healing was 13 days (range 7-21). We did not encounter any patients that required further surgical debridement or split-thickness skin grafting. The use of a silver-based hydrofiber dressing was well tolerated by the elderly population as it provided an easy, efficient, economical and effective form of management of skin tears. We suggest that a silver-based hydrofiber dressing can be used as a first-line treatment method for type 1 and 2 skin tears.

A comparative analysis of aerosol exposure and prevention strategies in bystander, pre-hospital, and inpatient cardiopulmonary resuscitation using simulation manikins.

To evaluate aerosol exposure risk and prevention strategies during bystander, pre-hospital, and inpatient cardiopulmonary resuscitation (CPR). This study compared hands-only CPR, CPR with a surgical or N95 mask, and CPR with a non-rebreather mask at 15 L/min. 30:2 compression-ventilation ratio CPR was tested with face-mask ventilation (FMV), FMV with a high efficiency particulate air (HEPA) filter; supraglottic airway (SGA), SGA with a surgical mask, SGA with a HEPA filter, or SGA with both. Continuous CPR was tested with an endotracheal tube (ET), ET with a surgical mask, a HEPA filter, or both. Aerosol concentration at the head, trunk, and feet of the mannequin were measured to evaluate exposure to CPR personnel. Hands-only CPR with a surgical or N95 face mask coverings and ET tube ventilation CPR with filters showed the lowest aerosol exposure among all study groups, including CPR with NRM oxygenation, FMV, and SGA ventilation. NRM had a mask effect and reduced aerosol exposure at the head, trunk, and feet of the mannequin. FMV with filters during 30:2 CPR reduced aerosol exposure at the head and trunk, but increased at the feet of the mannequin. A tightly-sealed SGA when used with a HEPA filter, reduced aerosol exposure by 21.00-63.14% compared with a loose-fitting one. Hands-only CPR with a proper fit surgical or N95 face mask coverings is as safe as ET tube ventilation CPR with filters, compared with CPR with NRM, FMV, and SGA. FMV or tight-sealed SGA ventilation with filters prolonged the duration to achieve estimated infective dose of SARS-CoV-2 2.4-2.5 times longer than hands-on CPR only. However, a loose-fitting SGA is not protective at all to chest compressor or health workers standing at the foot side of the victim, so should be used with caution even when using with HEPA filters.

Using a chatbot to reduce emergency department visits and unscheduled hospitalizations among patients with gynecologic malignancies during chemotherapy: A retrospective cohort study.

Background: A chatbot is an automatic text-messaging tool that creates a dynamic interaction and simulates a human conversation through text or voice via smartphones or computers. A chatbot could be an effective solution for cancer patients' follow-up during treatment, and could save time for healthcare providers. Objective: We conducted a retrospective cohort study to evaluate whether a chatbot-based collection of patient-reported symptoms during chemotherapy, with automated alerts to clinicians, could decrease emergency department (ED) visits and hospitalizations. A control group received usual care. Methods: Self-reporting symptoms were communicated via the chatbot, a Facebook Messenger-based interface for patients with gynecologic malignancies. The chatbot included questions about common symptoms experienced during chemotherapy. Patients could also use the text-messaging feature to speak directly to the chatbot, and all reported outcomes were monitored by a cancer manager. The primary and secondary outcomes of the study were emergency department visits and unscheduled hospitalizations after initiation of chemotherapy after diagnosis of gynecologic malignancies. Multivariate Poisson regression models were applied to assess the adjusted incidence rate ratios (aIRRs) for chatbot use for ED visits and unscheduled hospitalizations after controlling for age, cancer stage, type of malignancy, diabetes, hypertension, chronic renal insufficiency, and coronary heart disease. Result: Twenty patients were included in the chatbot group, and 43 in the usual-care group. Significantly lower aIRRs for chatbot use for ED visits (0.27; 95% CI 0.11-0.65; p = 0.003) and unscheduled hospitalizations (0.31; 95% CI 0.11-0.88; p = 0.028) were noted. Patients using the chatbot approach had lower aIRRs of ED visits and unscheduled hospitalizations compared to usual-care patients. Conclusions: The chatbot was helpful for reducing ED visits and unscheduled hospitalizations in patients with gynecologic malignancies who were receiving chemotherapy. These findings are valuable for inspiring the future design of digital health interventions for cancer patients.

Compromised cardiopulmonary resuscitation quality due to regurgitation during endotracheal intubation: a randomised crossover manikin simulation study.

BACKGROUND: Regurgitation is a complication common during cardiopulmonary resuscitation (CPR). This manikin study evaluated the effect of regurgitation during endotracheal intubation on CPR quality. METHODS: An airway-CPR manikin was modified to regurgitate simulated gastric contents into the oropharynx during chest compression during CPR. In total, 54 emergency medical technician-paramedics were assigned to either an oropharyngeal regurgitation or clean airway scenario and then switched to the other scenario after finishing the first. The primary outcomes were CPR quality metrics, including chest compression fraction (CCF), chest compression depth, chest compression rate, and longest interruption time. The secondary outcomes were intubation success rate and intubation time. RESULTS: During the first CPR-intubation sequence, the oropharyngeal regurgitation scenario was associated with a significantly lower CCF (79.6% vs. 85.1%, P < 0.001), compression depth (5.2 vs. 5.4 cm, P < 0.001), and first-pass success rate (35.2% vs. 79.6%, P < 0.001) and greater longest interruption duration (4.0 vs. 3.0 s, P < 0.001) than the clean airway scenario. During the second and third sequences, no significant difference was observed in the CPR quality metrics between the two scenarios. In the oropharyngeal regurgitation scenario, successful intubation was independently and significantly associated with compression depth (hazard ratio = 0.47, 95% confidence interval, 0.24-0.91), whereas none of the CPR quality metrics were related to successful intubation in the clean airway scenario. CONCLUSION: Regurgitation during endotracheal intubation significantly reduces CPR quality. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05278923 , March 14, 2022.

Ultrasound-Guided Femoral Nerve Block in Geriatric Patients with Hip Fracture in the Emergency Department.

Background and Objectives: Systemic analgesics, including opioids, are commonly used for acute pain control in traumatic hip fracture patients in the emergency department (ED). However, their use is associated with high rates of adverse reactions in the geriatric population. As such, the aim of this study was to investigate the impact of lidocaine-based single-shot ultrasound-guided femoral nerve block (USFNB) on the standard care for acute pain management in geriatric patients with traumatic hip fracture in the ED. Methods: This retrospective, single-center, observational study included adult patients aged ≥60 years presenting with acute traumatic hip fracture in the ED between 1 January 2017 and 31 December 2020. The primary outcome measure was the difference in the amount of opioid use, in terms of morphine milligram equivalents (MME), between lidocaine-based single-shot USFNB and standard care groups. The obtained data were evaluated through a time-to-event analysis (time to meaningful pain relief), a time course analysis, and a multivariable analysis. Results: Overall, 607 adult patients (USFNB group, 66; standard care group, 541) were included in the study. The patients in the USFNB group required 80% less MME than those in the standard care group (0.52 ± 1.47 vs. 2.57 ± 2.53, p < 0.001). The multivariable Cox proportional hazards regression models showed that patients who received USFNB achieved meaningful pain relief 2.37-fold faster (hazard ratio (HR) = 2.37, 95% confidence intervals (CI) = 1.73−3.24, p < 0.001). Conclusions: In geriatric patients with hip fractures, a lidocaine-based single-shot USFNB can significantly reduce opioid consumption and provide more rapid and effective pain reduction.

The Aerosol-Generating Effect Among Noninvasive Positive Pressure Ventilation, High-Flow Nasal Cannula, Nonrebreather Mask, Nasal Cannula, and Ventilator-Assisted Preoxygenation.

STUDY OBJECTIVE: To evaluate aerosol dispersion and exposure risk during oxygenation therapy among health care personnel. METHODS: This study compared the aerosol dispersion effect produced through continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), BiPAP with face coverings, a high-flow nasal cannula (HFNC) with face coverings, nasal cannula oxygenation (NCO) at 15 L/min with face coverings, nonrebreather mask (NRM), and ventilator-assisted preoxygenation (VAPOX) during oxygenation therapy at a minute ventilation of 10 L/min and 20 L/min. The length and width of aerosol dispersion were recorded, and aerosol concentrations were then detected at a mannequin's head, trunk, and feet. RESULTS: The average length dispersion distance of CPAP was 47.12 cm (SD, 12.56 cm), of BiPAP was 100.13 cm (SD, 6.03 cm), of BiPAP with face coverings was 62.20 cm (SD, 8.46 cm), of HFNC with face coverings was 67.09 cm (SD, 12.74 cm); of NCO with face coverings was 85.55 cm (SD, 7.28 cm); and of NRM was 63.08 cm (SD, 15.33 cm); VAPOX showed no visible dispersion. The aerosol concentrations at the feet under CPAP and at the head under BiPAP were significantly higher than those observed without an oxygen device. Compared with no oxygen device, the aerosol concentration with HFNC was higher at the mannequin's head, trunk, and feet; whereas it was lower with VAPOX and NRM. Moreover, when translated to the number of virus particles required to infect medical personnel (Nf), VAPOX took more time to achieve Nf than other devices. CONCLUSION: Strong flow from the oxygenation devices resulted in increased aerosol concentrations. CPAP at the feet side, BiPAP at the head side, HFNC, and NCO with face coverings significantly increase aerosol exposure and should be used with caution. Aerosol concentrations at all positions were lower with NRM and VAPOX.

Correction: A Novel mHealth Approach for a Patient-Centered Medication and Health Management System in Taiwan: Pilot Study.

[This corrects the article DOI: 10.2196/mhealth.9987.].

Optic nerve sheath diameter changes at high altitude and in acute mountain sickness: meta-regression analyses.

BACKGROUND/AIMS: To assess changes in optic nerve sheath diameter (ONSD) at high altitude and in acute mountain sickness (AMS). METHODS: Cochrane Library, EMBASE, Google Scholar and PubMed were searched for articles published from their inception to 31st of July 2020. Outcome measures were mean changes of ONSD at high altitude and difference in ONSD change between subjects with and without AMS. Meta-regressions were conducted to investigate the relation of ONSD change to altitude and time spent at that altitude. RESULTS: Eight studies with 248 participants comparing ONSD from sea level to high altitude, and five studies with 454 participants comparing subjects with or without AMS, were included. ONSD increased by 0.14 mm per 1000 m after adjustment for time (95% CI: 0.10 to 0.18; p<0.01). Restricted cubic spline regression revealed an almost linear relation between ONSD change and time within 2 days. ONSD was greater in subjects with AMS (mean difference=0.47; 95% CI: 0.14 to 0.80; p=0.01; I2=89.4%). CONCLUSION: Our analysis shows that ONSD changes correlate with altitude and tend to increase in subjects with AMS. Small study number and high heterogeneity are the limitations of our study. Further large prospective studies are required to verify our findings.

High-Grade B-Cell Lymphoma (HGBL) with MYC and BCL2 and/or BCL6 Rearrangements Is Predominantly BCL6-Rearranged and BCL6-Expressing in Taiwan.

This study investigated the epidemiological and clinical peculiarities of BCL2 and BCL6 rearrangement in patients with high grade B-cell lymphoma (HGBL) from Taiwan, compared with data from Western countries. Two hundred and eighty-two DLBCL cases from Taipei Medical University-affiliated hospitals (n = 179) and Tri-Service General Hospital (n = 103) were enrolled for this study. From the 282, 47 (16.7%) had MYC translocation; 24 of these harbored concurrent BCL2 and/or BCL6 translocation (double-hit, DH or triple-hit, TH). Twelve DH-HGBL cases had simultaneous MYC and BCL6 translocations, 8 harbored MYC and BCL2 rearrangement, while the remaining 4 patients exhibited TH. Together, 66.7% of DH/TH-HGBL patients were BCL6 rearrangement positive. Among these BCL6-rearranged DH/TH-HGBL patients, only 6 (37.5%) overexpressed MYC and BCL6 proteins simultaneously, indicating that MYC-BCL6 co-overexpression may not be plausible surrogate biomarker for screening BCL6-rearranged DH-HGBL. By the end of year 5, all patients with TH-HGBL, BCL2 DH-HGBL and all but one BCL6 DH-HGBL cases had expired or were lost to follow-up. Progression-free survival (PFS) was longer for the non-DH/TH-HGBL group compared with the DH/TH-HGBL group. While the patients with BCL2 DH-HGBL were lost to follow-up by day 800, their remaining TH-HGBL and BCL6 DH-HGBL peers exhibited very poor PFS, regardless of age strata. More so, patients with BCL6 rearrangement were 5.5-fold more likely associated with extranodal involvement compared with their BCL2-rearranged peers. Moreover, ~60.0% of the BCL6-rearranged DH-HGBL cases were non-GCB, suggesting that including screening for BCL6 rearrangement in patients with the non-GCB phenotype may aid medical decision-making and therapeutic strategy. Contrary to contemporary data from western countries, 2 in every 3 patients with DH/TH-HGBL in Taiwan harbor BCL6 rearrangement. Consistent with present findings, we recommend mandatory screening for BCL6 rearrangement in patients with aggressive HGBL in Taiwan.

Comparing the effectiveness of negative-pressure barrier devices in providing air clearance to prevent aerosol transmission.

PURPOSE: To investigate the effectiveness of aerosol clearance using an aerosol box, aerosol bag, wall suction, and a high-efficiency particulate air (HEPA) filter evacuator to prevent aerosol transmission. METHODS: The flow field was visualized using three protective device settings (an aerosol box, and an aerosol bag with and without sealed working channels) and four suction settings (no suction, wall suction, and a HEPA filter evacuator at flow rates of 415 liters per minute [LPM] and 530 LPM). All 12 subgroups were compared with a no intervention group. The primary outcome, aerosol concentration, was measured at the head, trunk, and foot of a mannequin. RESULTS: The mean aerosol concentration was reduced at the head (p < 0.001) but increased at the feet (p = 0.005) with an aerosol box compared with no intervention. Non-sealed aerosol bags increased exposure at the head and trunk (both, p < 0.001). Sealed aerosol bags reduced aerosol concentration at the head, trunk, and foot of the mannequin (p < 0.001). A sealed aerosol bag alone, with wall suction, or with a HEPA filter evacuator reduced the aerosol concentration at the head by 7.15%, 36.61%, and 84.70%, respectively (99.9% confidence interval [CI]: -4.51-18.81, 27.48-45.73, and 78.99-90.40); trunk by 70.95%, 73.99%, and 91.59%, respectively (99.9% CI: 59.83-82.07, 52.64-95.33, and 87.51-95.66); and feet by 69.16%, 75.57%, and 92.30%, respectively (99.9% CI: 63.18-75.15, 69.76-81.37, and 88.18-96.42), compared with an aerosol box alone. CONCLUSIONS: As aerosols spread, an airtight container with sealed working channels is effective when combined with suction devices.

Is the Yale Global Tic Severity Scale a valid tool for parent-reported assessment in the paediatric population? A prospective observational study in Taiwan.

OBJECTIVE: The Yale Global Tic Severity Scale (YGTSS) is the most commonly used clinician-rated evaluation tool for Tourette syndrome (TS), with established reliability and validity. This study aims to determine whether the YGTSS is a valid parent-reported assessment in the TS population. DESIGN: A prospective cohort study. SETTING: A major medical centre in Taiwan. METHODS: A total of 594 patients were enrolled. A revised traditional Chinese version of the YGTSS was made available to parents via Google docs. Parents were encouraged to complete the YGTSS the day before each outpatient clinic visit. At each visit, a paediatric neurology fellow also administered the YGTSS assessment. We investigated whether differences in scores between physicians and parents changed as the number of parent evaluations increased. The results of the physician assessments were also taken as the expert standard for evaluating the sensitivity and specificity of the parent-reported assessments was conducted for the same visit. RESULTS: The differences in the YGTSS scores between participants and physicians were small. The mean difference in the total assessment score was 4.15 points. As the number of times the parent evaluation was performed increased, the difference between the parent and physician scores decreased. Discrimination of moderate-to-severe attacks was good using the parent-assessed YGTSS (area under the receiver operating characteristic curve, 0.858; 95% CI 0.839 to 0.876). The sensitivity for detecting a moderate-to-severe attack by YGTSS parent assessment was 79.7% (95% CI 76.6 to 82.8), and the specificity was 91.8% (95% CI 89.9 to 93.7). CONCLUSION: The parent-reported YGTSS is a promising tool for TS assessment, demonstrating good discriminative ability for disease severity, with user precision increasing with experience.

The evaluation of a better intubation strategy when only the epiglottis is visible: a randomized, cross-over mannequin study.

BACKGROUND: The Cormack-Lehane (C-L) grade III airway is considered to be a challenging airway to intubate and is associated with a poor intubation success rate. The purpose of this study was to investigate whether the holding position, shapes, bend angles of the endotracheal tube (ET) and the stylet-assisted lifting of the epiglottis could improve the success rate of intubation. METHODS: Thirty-two participants, 26 physicians, 2 residents, and 4 nurse practitioners, with 12.09 ± 5.38 years of work experience in the emergency department and more than 150 annual intubation events, were enrolled in this randomized, cross-over mannequin study. We investigated the effects of straight-to-cuff ET shapes with 35° and 50° bend angles, banana-shaped ET with longitudinal distances of 28 cm and 26 cm, two methods of holding the ET (either on the top or in the middle), and lifting or not the epiglottis, on the intubation duration, its success rate, and its subjective difficulty. The aim of the study is to provide optimized intubation strategies for difficult airway with C-L IIb or III grades, when the inlet of the trachea cannot be visualized. RESULTS: The two groups that lifted the epiglottis using the stylets, in bend angles of 35° and 50°, had the shortest duration of intubation (23.75 ± 14.24 s and 20.72 ± 6.90 s, hazard ratios 1.54 and 1.85 with 95% confidence intervals [95% CI] of 1.01-2.34 and 1.23-2.78, respectively) and a 100% success rate in intubations. In the survival analysis, lifting of the epiglottis was the only significant factor (p < 0.0001, 95% CI 1.34-2.11) associated with the success rate of intubation. CONCLUSIONS: The use of the epiglottic lift as an adjunctive technique can facilitate the intubation and improve its success rate without increasing procedure difficulty, in C-L III airway, when only the epiglottis is seen. TRIAL REGISTRATION: ClinicalTrials Registry ( https://clincaltrials.gov , identifier NCT03366311).

The incidence and risk factors of hepatic veno-occlusive disease after hematopoietic stem cell transplantation in Taiwan.

Hepatic veno-occlusive disease (VOD) is a potentially fatal complication of hematopoietic stem cell transplantation (HSCT). We conducted this study to investigate the incidence and risk factors of hepatic VOD for patients receiving HSCT in Taiwan. We retrospectively analyzed the data from a nationwide registry for patients receiving HSCT, which was collected by the Taiwan Society of Blood and Marrow Transplantation. The data collection period was from 2009 to 2014. A total 2345 patients were reviewed and 39 patients among them were diagnosed as having hepatic VOD. The cumulative incidence of hepatic VOD in the whole cohort of 2345 patients was 1.66%. In multivariate analysis, disease diagnosis of myelodysplastic syndrome, chronic HCV infection, condition regimens of bulsulfan intravenously administered, and antithymocyte immunoglobulin were independent factors to predict higher risk of hepatic VOD. The overall mortality rate for patients with hepatic VOD was 79%. Patients with hepatic VOD had significant worse survival outcomes when compared with those without hepatic VOD (P = 0.00063). In conclusion, although the incidence is low, hepatic VOD remains a serious complication after HSCT in Taiwan. The findings of this study could be the basis for developing prophylactic or early treatment strategies for hepatic VOD.

Autologous stem cell transplantation in multiple myeloma: Post-transplant outcomes of Taiwan Blood and Marrow Transplantation Registry.

BACKGROUND/PURPOSE: Multiple myeloma (MM) is a monoclonal plasma cell malignancy. The primary choice of treatment for MM is induction therapy followed by autologous stem cell transplantation (ASCT). This study aimed to analyze the treatment efficacy of ASCT in a Taiwanese cohort and evaluate possible prognostic factors. METHODS: From the database of the Taiwan Blood and Marrow Transplantation registry, data on 396 patients with MM who underwent ASCT were reviewed. RESULTS: The average age of participants was 54.8 years, and there were more men than women (57.6% vs. 42.4%). Most patients were diagnosed with IgG-type myeloma (52.4%), followed by IgA-type (23.2%) and light-chain type (21.4%). Patients with Durie Salmon Staging System (DSS) III disease accounted for 61.9% of the study cohort, while 23.7% had stage II and 14.4% had stage I disease. The median progression-free survival (PFS) and overall survival (OS) after ASCT were 46.5 months and 70.4 months, respectively. DSS III was a poor prognostic factor affecting both PFS and OS with a duration of 35.9 months and 69.0 months, respectively, compared with the other two stages (p = 0.006 and p = 0.03, respectively). In addition, patients with better treatment response before ASCT had better PFS and OS compared with those who did not show a response (both p < 0.0001). The overall incidence of organ toxicities associated with transplantation was low. CONCLUSION: In conclusion, our cohort showed that myeloma patients with early DSS and better treatment response before ASCT had better long-term survival outcomes.

Comparison of the validity of checklist assessment in cardiac arrest simulations with an app in an academic hospital in Taiwan: a retrospective observational study.

INTRODUCTION: Robust assessment is a crucial component in Advanced Cardiac Life Support (ACLS) training to determine whether participants have achieved learning objectives with little or no variation in their overall outcomes. This study aimed to evaluate resuscitation performance by real-time logs. We hypothesised that instructors may not be able to evaluate time-sensitive parameters, namely, chest compression fraction, time to initiating chest compression and time to initiating defibrillation accurately in a subjective manner. METHODS: Video records and formal checklist-based test results of Megacode scenarios for the ACLS certification examination at several hospitals in Taipei were examined. For the study interest, three time-sensitive parameters were measured via video review assisted by a mobile phone application, and were used for evaluation. We evaluated if the pass/fail results made by instructors via checklists were correlated with these parameters. RESULTS: A total of 185 Megacode scenarios were eligible for the final analysis. Among the three parameters, good chest compression fraction was statistically significant with a higher OR of passing (OR=3.65; 95% CI 1.36 to 9.91; p=0.01). In 112 participants with one parameter that did not meet the criteria, 25 were graded as fail, making the specificity 22.3% (95% CI 15.0% to 31.2%). CONCLUSIONS: Visual observation of cardiopulmonary resuscitation performance is not accurate when evaluating time-sensitive parameters. Objective results should be offered for training outcome evaluation, and also for feedback to participants.

Ginkgo biloba extract for prevention of acute mountain sickness: a systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: Trials of ginkgo biloba extract (GBE) for the prevention of acute mountain sickness (AMS) have been published since 1996. Because of their conflicting results, the efficacy of GBE remains unclear. We performed a systematic review and meta-analysis to assess whether GBE prevents AMS. METHODS: The Cochrane Library, EMBASE, Google Scholar and PubMed databases were searched for articles published up to 20 May 2017. Only randomised controlled trials were included. AMS was defined as an Environmental Symptom Questionnaire Acute Mountain Sickness-Cerebral score ≥0.7 or Lake Louise Score ≥3 with headache. The main outcome measure was the relative risk (RR) of AMS in participants receiving GBE for prophylaxis. Meta-analyses were conducted using random-effects models. Sensitivity analyses, subgroup analyses and tests for publication bias were conducted. RESULTS: Seven study groups in six published articles met all eligibility criteria, including the article published by Leadbetter et al, where two randomised controlled trials were conducted. Overall, 451 participants were enrolled. In the primary meta-analysis of all seven study groups, GBE showed trend of AMS prophylaxis, but it is not statistically significant (RR=0.68; 95% CI 0.45 to 1.04; p=0.08). The I2 statistic was 58.7% (p=0.02), indicating substantial heterogeneity. The pooled risk difference (RD) revealed a significant risk reduction in participants who use GBE (RD=-25%; 95% CI, from a reduction of 45% to 6%; p=0.011) The results of subgroup analyses of studies with low risk of bias, low starting altitude (<2500 m), number of treatment days before ascending and dosage of GBE are not statistically significant. CONCLUSION: The currently available data suggest that although GBE may tend towards AMS prophylaxis, there are not enough data to show the statistically significant effect of GBE on preventing AMS. Further large randomised controlled studies are warranted.