Prognostic implication of out-of-hospital cardiac arrest in patients with cardiogenic shock and acute myocardial infarction

ObjectivesTo compare outcome in patients with acute myocardial infarction (MI) and cardiogenic shock (CS) presenting with and without out-of-hospital cardiac arrest (OHCA).BackgroundDespite general improvement in outcome after acute MI, CS remains a leading cause of death in acute MI patients with a high 30-day mortality rate. OHCA on top of cardiogenic shock may further increase mortality in these patients resulting in premature withdrawal of supportive therapy, but this is not known.Methods and resultsIn a retrospective study from 2008 to 2013, 248 consecutive patients admitted alive to a tertiary centre with the diagnosis of CS and acute MI were enrolled, 118 (48%) presented with OHCA and 130 (52%) without (non-OHCA patients). Mean lactate level at admission was significantly higher in OHCA patients compared with non-OCHA patients (9 mmol/l (SD 6) vs. 6 mmol/l (SD 4) p < 0.0001). Co-morbidities were more prevalent in the non-OHCA group. By univariate analysis age (Hazard ratio (HR) = 1.02 [CI 1.00–1.03], p = 0.01) and lactate at admission (HR = 1.06 [CI 1.03–1.09], p < 0.001), but not OHCA (HR = 1.1 [CI 0.8–1.4], p = NS) was associated with mortality. In multivariate analysis, only age (HR = 1.02 [CI 1.01–1.04], p = 0.003) and lactate level at admission (HR = 1.06 [1.03–1.09], p < 0.001) were independent predictors of mortality. One-week mortality was 63% in the OHCA group and 56% in the non-OHCA group, p = NS.ConclusionOHCA is not an independent predictor of mortality in patients with acute MI complicated by cardiogenic shock. This should encourage active intensive treatment of CS patients regardless of OHCA.     

Higher achieved mean arterial pressure during therapeutic hypothermia is not associated with neurologically intact survival following cardiac arrest

IntroductionTo determine if higher achieved mean arterial blood pressure (MAP) during treatment with therapeutic hypothermia (TH) is associated with neurologically intact survival following cardiac arrest.MethodsRetrospective analysis of a prospectively collected cohort of 188 consecutive patients treated with TH in the cardiovascular intensive care unit of an academic tertiary care hospital.ResultsNeurologically intact survival was observed in 73/188 (38.8%) patients at hospital discharge and in 48/162 (29.6%) patients at a median follow up interval of 3 months. Patients in shock at the time of admission had lower baseline MAP at the initiation of TH (81 versus 87 mmHg; p = 0.002), but had similar achieved MAP during TH (80.3 versus 83.7 mmHg; p = 0.11). Shock on admission was associated with poor survival (18% versus 52%; p < 0.001). Vasopressor use among all patients was common (84.6%) and was not associated with increased mortality. A multivariable analysis including age, initial rhythm, time to return of spontaneous circulation, baseline MAP and achieved MAP did not demonstrate a relationship between MAP achieved during TH and poor neurological outcome at hospital discharge (OR 1.28, 95% CI 0.40–4.06; p = 0.87) or at outpatient follow up (OR 1.09, 95% CI 0.32–3.75; p = 0.976).ConclusionWe did not observe a relationship between higher achieved MAP during TH and neurologically intact survival. However, shock at the time of admission was clearly associated with poor outcomes in our study population. These data do not support the use of vasopressors to artificially increase MAP in the absence of shock. There is a need for prospective, randomized trials to further define the optimum blood pressure target during treatment with TH.     

Obesity and the Emergency Short Stay Unit

ObjectivesTo evaluate the health service requirements of obese patients admitted to an Emergency Short Stay Unit (ESSU) and specifically compare length of stay (LOS), failure of ESSU management, and rates of investigations and allied health interventions among obese and non-obese patients.MethodsA prospective cohort study, using convenience sampling was conducted. The body mass index (BMI) of participants was calculated and those with a BMI of ⩾30 were allocated to the obese group, and those that had a BMI of <30 to the non-obese group. Data collected included demographics, admission diagnosis, time and date of ESSU admission and discharge, discharge disposition, radiological investigations, and referrals made to allied health personnel during ESSU admission.ResultsThere were 262 patients that were recruited sub-grouped into 127 (48.5%) obese participants and 135 (51.5%) non-obese participants with similar sex and diagnostic category distributions. The mean LOS in ESSU was similar – 11.5 h (95% CI: 9.9–13.1) for obese patients and, 10.2 h (95% CI: 8.8–11.6) for non-obese patients (p = 0.21). Failure rates of ESSU management, defined as inpatient admission to hospital, were also similar with 29 (22.8%) obese patients admitted to hospital compared to 25 (18.5%) non-obese patients (p = 0.39). Plain X-ray requests were significantly higher among obese patients (71.6 vs 53.3%; p = 0.002), as was the rate of allied health interventions (p = 0.001).ConclusionThere was no significant difference in inpatient admission rates or LOS between obese and non-obese patients managed in the ESSU. Provisions for increased rate of investigations and allied health interventions for obese patients may facilitate timely assessment and disposition from ESSU.     

Timing of palliative care team referrals for inpatients receiving rapid response services: A retrospective pilot study in a US hospital

Background/objectivesResearch indicates up to one-third of rapid response team calls relate to end-of-life symptoms. The CriSTAL criteria were developed as a screening tool to identify high risk of death within three months. The primary purpose of this pilot study was to investigate the timing of palliative care referrals in patients receiving rapid response team services, and patients’ CriSTAL criteria score on admission. The potential feasibility of using the CriSTAL tool to stimulate earlier Palliative Care Team (PCT) referral served as an underlying goal, and investigation of a relationship between specific CriSTAL criteria and the prediction of in-hospital death was a secondary objective.DesignA retrospective chart review of rapid response calls made in 2015 was used to identify patient risk of death on admission based on the CriSTAL criteria. The presence and timing of PCT referral as well as patient survival status to hospital discharge were documented for comparison.Setting/participantsA sample of 183 charts from 584 inpatients involved in over 600 RRT events recorded in 2015. The study was undertaken in a 676-bed teaching hospital in the Midwestern U.S.Methods/resultsNinety-one patients died during the hospital stay while 92 patients from the 493 individuals who survived were randomly selected for full analysis. Applying CriSTAL criteria to the 141 individuals aged 50 years or older indicated that frailty (OR = 1.43, 95%CI 1.08–1.89, p = 0.012), being a male (OR = 3.14; 95%CI 1.40–7.05, p = 0.006), and the presence of two or more comorbidities (OR = 3.71, 95%CI 1.67–8.24, p = 0.001) were the most significant predictors of in-hospital death after adjusting for age. A CriSTAL score of 6 was the optimal cut-off for high-risk of in-hospital death. Palliative care consultations within the high-risk population occurred for 45.2% of the deceased and 40.4% of the survivors. Consultation often occurred within two days of the RRT event and many patients (46.8%) died within one day of the consultation.ConclusionA positive relationship was found between the CriSTAL score, palliative care referral, and in-hospital mortality in patients who received RRT services. The study indicates a need for earlier PCT referral, showcases the potential to identify high risk of in-hospital death upon admission and supports the feasibility of using the CriSTAL criteria tool to encourage earlier PCT referrals.     

Prophylactic antibiotics are associated with a lower incidence of pneumonia in cardiac arrest survivors treated with targeted temperature management

IntroductionProphylactic antibiotics (PRO) reduce the incidence of early-onset pneumonia in comatose patients with structural brain injury, but have not been examined in cardiac arrest survivors undergoing targeted temperature management (TTM). We investigated the effect of PRO on the development of pneumonia in that population.MethodsWe conducted a retrospective cohort study comparing patients treated with PRO to those not receiving PRO (no-PRO) using Northern Hypothermia Network registry data. Cardiac arrest survivors ≥18 years of age with a GCS < 8 at hospital admission and treated with TTM at 32–34 °C were enrolled in the registry. Differences were analyzed in univariate analyses and with logistic regression models to evaluate independent associations of clinical factors with incidence of pneumonia and good functional outcome.Results416 of 1240 patients (33.5%) received PRO. Groups were similar in age, gender, arrest location, initial rhythm, and time from collapse to return of spontaneous circulation. PRO patients had less pneumonia (12.6% vs. 54.9%, p < 0.001) and less sepsis (1.2 vs. 5.7%, p < 0.001) compared to no-PRO patients. ICU length of stay (98 vs. 100 h, p = 0.2) and incidence of a good functional outcome (41.1 vs. 36.6%, p = 0.19) were similar between groups. Backwards stepwise logistic regression demonstrated PRO were independently associated with a lower incidence of pneumonia (OR 0.09, 95% 0.06–0.14, p < 0.001) and a similar incidence of good functional outcome.ConclusionsProphylactic antibiotics were associated with a reduced incidence of pneumonia but a similar rate of good functional outcome.     

Prevalence of gastric parietal cell antibodies and intrinsic factor antibodies in primary biliary cirrhosis

BackgroundWe investigated the prevalence of antibodies against gastric parietal cells (GPA), intrinsic factor antibodies (IFA) and the presence of pernicious anemia in a large cohort of primary biliary cirrhosis (PBC) patients as similar data is missing.Methods157 PBC patients and 357 controls (73 with autoimmune hepatitis (AIH), 35 primary sclerosing cholangitis (PSC), 45 HBV, 37 HCV, 36 alcoholic liver disease (ALD), 35 non-alcoholic fatty liver disease (NAFLD) and 96 healthy) were investigated for IgG-isotype-specific GPA and IFA by ELISAs and vitamin-B₁₂ levels by a microparticle enzyme immunoassay.ResultsThe detection of IgG-GPA was significantly higher in PBC (31.8%) compared to AIH (10.9%; p = 0.001), PSC (0%; p = 0.000), HCV (13.5%; p = 0.01), HBV (13.3%; p = 0.006), ALD (8.3%; p = 0.004), NAFLD (11.4%; p = 0.003) and healthy (10.4%; p = 0.001). IgG-IFA were detected in 12% of GPA-positive PBC patients and in none of the other liver diseases or in healthy (p = 0.001). This reactivity was significantly associated with lower vitamin-B₁₂ levels compared to those with an IFA-negative test (p = 0.025).ConclusionsA significant proportion of PBC patients had IgG-GPA and IFA compared to controls. IgG-IFA were detected only in GPA-positive PBC patients and associated with lower vitamin-B₁₂ levels compared to those with an IFA-negative test.     

Relation between riboflavin,flavin mononucleotide and flavin adenine dinucleotide concentrations in plasma and red cells in patients with critical illness

BackgroundThere is some evidence that the relationship between plasma and red cell vitamin B2 concentrations is perturbed in the critically ill patient. The aim of the present study was to examine the longitudinal interrelationships between riboflavin, flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD) in plasma and red cells in patients with critical illness.MethodsRiboflavin, FMN and FAD concentrations were measured, by HPLC, in plasma and red cells in healthy subjects (n = 119) and in critically ill patients (n = 125) on admission and on follow-up.ResultsOn admission, compared with the controls, critically ill patients had significantly higher plasma riboflavin and FMN concentrations (p < 0.001) and lower median plasma FAD concentrations (p < 0.001). In the red cell, FAD concentrations were significantly lower in critically ill patients (p < 0.001). In healthy subjects, plasma riboflavin was directly associated with both plasma FMN (r_s = 0.55, p < 0.001) and plasma FAD (r_s = 0.49, p < 0.001). Red cell riboflavin was directly associated with red cell FMN (r_s = 0.52, p < 0.001) but not red cell FAD. In the critically ill patients, plasma riboflavin was not significantly associated with either plasma FMN or FAD. Red cell riboflavin was directly associated with red cell FMN (r_s = 0.79, p < 0.001) and red cell FAD (r_s = 0.72, p < 0.001). Longitudinal measurements (n = 60) were similar.ConclusionsThe relationship between plasma riboflavin, FMN and FAD was significantly perturbed in critical illness. This effect was less pronounced in red cells. Therefore, red cell FAD concentrations are more likely to be a reliable measure of status in the critically ill patient.     

Mortality and neurological outcome in the elderly after target temperature management for out-of-hospital cardiac arrest

AimTo assess older age as a prognostic factor in patients resuscitated from out-of-hospital-cardiac arrest (OHCA) and the interaction between age and level of target temperature management.Methods and results950 patients included in the target temperature management (TTM) trial were randomly allocated to TTM at 33 or 36 °C for 24 h. We assessed survival and cerebral outcome (cerebral performance category, CPC and modified Rankin scale, mRS) using age as predictor, dividing patients into 5 age groups: ≤65 (median), 66–70, 71–75, 76–80 and >80 years of age. Shockable rhythm decreased with higher age groups, p = 0.001, the same was true for ST segment elevation on ECG at admission, p < 0.01. Increasing age was associated with a higher mortality rate (HR = 1.04 per year, 95% CI = 1.03–1.06, p < 0.001) after adjusting for confounders. Octogenarians had an increased mortality (HR = 3.5, CI: 2.5–5.0, p < 0.001) compared to patients ≤65 years of age. Favorable vs. unfavorable outcome measured by CPC and mRS in survivors was different between age groups with adverse outcomes more prevalent in higher age groups (CPC: p = 0.04, mRS: p = 0.001). The interaction between age and target temperature allocation was not statistically significant for either mortality or neurological outcome.ConclusionIncreasing age is associated with significantly increased mortality after OHCA, but mortality rate is not influenced by level of target temperature. Risk of poor neurological outcome also increases with age, but is not modified by level of target temperature.     

Actual and perceived nursing workload and the complexity of patients with total hip arthroplasty

BackgroundLittle is known about the relation between patient complexity and nursing care of total hip arthroplasty (THA) patients. To improve patient care and hospital logistics, the aim of this study is to gain insight into the relation between patient complexity and the nursing staff's actual and perceived workload at an orthopedic ward during admission for a THA.DesignProspective cohort study of 45 THA patients in the year 2014. Duration and type of nursing care activities were recorded during the first postoperative morning. A questionnaire was used to analyze the perceived workload of the nursing staff. Both actual and perceived workload were analyzed for their relation with patient complexity, expressed in the American Society of Anesthesiologists (ASA) score, Charlson comorbidity index (CCI), Katz Activities of Daily Life score (Katz-ADL) and Body Mass Index (BMI).ResultsNo relation was found between actual workload and measures for patient complexity. The perceived workload of the nursing staff was related to two complexity measures: ASA (r = 0.71; p < 0.001) and CCI (r = 0.65; p = 0.002).ConclusionPatient comorbidity is related to the perceived workload of the nursing staff during admission for a THA. Patient complexity is not related to actual workload. This study gives a first insight into the relation between patient comorbidity and nursing staff workload, to try to improve staffing numbers at the ward as well as patient care in the process.     

Identification of Seniors at Risk (ISAR) in the emergency room: A prospective study

IntroductionThe Identification of Seniors at Risk (ISAR) is one of the most frequently utilized risk screening tools in emergency departments (ED). The goal of this study was to evaluate the predictive validity of the ISAR screening tool for adverse outcomes in an ED.MethodsThis was a prospective single-center observational study in a Portuguese urban university hospital ED, and included 402 older adults (OA). After triage, baseline sociodemographic and clinic data were collected by the researcher and the ISAR was administered. Baseline ISAR, adverse outcomes (ED revisits and hospital admission) at 30 (early) and 180 (late) days were evaluated.ResultsISAR screening showed that 308 (76.62%) OAs were at risk (cutoff ≥ 2). High-risk patients were more like to be older, take more medication, have urgent or very urgent ED visits and have longer ED lengths of stay. The high-risk group were more likely to demonstrate both early (OR = 2.43, 95% CI 1.35–4.35, p < 0.01) and late returns to the ED (AO = 1.70, 95% CI 1.04–2.79, p < 0.05). The ISAR did not predict any significant variable for hospital admission in 30 or 180 days.DiscussionThe ISAR predicted returns to EDs at 30 and 180 days for OAs at risk, but was unable to predict early or late hospital readmission.     

The predictive value of NT-proBNP and hs-TnT for risk of death in cardiac surgical patients

BackgroundEuropean System for Cardiac Operative Risk Evaluation II (EuroSCORE II) is used for risk stratification before cardiac surgery, but whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hs-TnT) may add prognostic information to EuroSCORE II is not known.MethodsPreoperative (n = 640) and postoperative (n = 629) blood samples were available from cardiac surgical patients with 961-day follow-up (FINNAKI Heart study; cohort #1). The accuracy of a parsimonious risk model with NT-proBNP measurements was also tested in 90 patients with respiratory failure after cardiac surgery (FINNALI study; cohort #2).ResultsSixty-one patients (9.5%) died during follow-up in cohort #1. Preoperative NT-proBNP and hs-TnT concentrations correlated (rho = 0.58; p < 0.001) and were higher in non-survivors compared to survivors: median 2027 (Q1-3 478-5387) vs. 373 (134–1354) ng/L [NT-proBNP] and 39 (16–191) vs. 13 (8–32) ng/L [hs-TnT]; p < 0.001 for both. Preoperative NT-proBNP concentrations were associated with time to death after adjustment for EuroSCORE II (HR [_lnNT-proBNP] 1.33 [95% CI 1.08–1.64]), p = 0.008 and reclassified patients on top of EuroSCORE II (net reclassification index 0.39 [95% CI 0.14–0.64], p = 0.003). Pre- and postoperative NT-proBNP concentrations were closely correlated (rho = 0.80, p < 0.001) and postoperative NT-proBNP concentrations were also associated with long-term mortality after adjustment for EuroSCORE II. A parsimonious risk model that included age, creatinine clearance, chronic pulmonary disease, and NT-proBNP measurements provided comparable prognostic accuracy as EuroSCORE II in cohort #1 and #2 for risk of long-term mortality. hs-TnT measurements did not add to NT-proBNP measurementsConclusionNT-proBNP measurements could improve and simplify risk prediction in cardiac surgical patients.     

Mayo Registry for Telemetry Efficacy in Arrest (MR TEA) study: An analysis of code status change following cardiopulmonary arrest

IntroductionCode status discussions are important during a hospitalization, yet variation in its practice exists. No data have assessed the likelihood of patients to change code status following a cardiopulmonary arrest.MethodsA retrospective review of all patients that experienced a cardiopulmonary arrest between May 1, 2008 and June 30, 2014 at an academic medical center was performed. The proportion of code status modifications to do not resuscitate (DNR) from full code was assessed. Baseline clinical characteristics, resuscitation factors, and 24-h post-resuscitation, hospital, and overall survival rates were compared between the two subsets.ResultsA total of 157 patients survived the index event and were included. One hundred and fifteen (73.2%) patients did not have a change in code status following the index event, while 42 (26.8%) changed code status to DNR. Clinical characteristics were similar between subsets, although patients in the change to DNR subset were older (average age 67.7 years) compared to the full code subset (average age 59.2 years; p = 0.005). Patients in the DNR subset had longer overall resuscitation efforts with less attempts at defibrillation. Compared to the DNR subset, patients that remained full code demonstrated higher 24-h post-resuscitation (n = 108, 93.9% versus n = 32, 76.2%; p = 0.001) and hospital (n = 50, 43.5% versus n = 6, 14.3%; p = 0.001) survival rates. Patients in the DNR subset were more likely to have neurologic deficits on discharge and shorter overall survival.ConclusionsPatient code status wishes do tend to change during critical periods within a hospitalization, adding emphasis for continued code status evaluation.     

Association Between Cardiovascular Autonomic Functions and Time to Death in Patients With Terminal Hepatocellular Carcinoma

ContextA better time-to-death (TTD) prediction can facilitate decision-making processes related to plans for providing effective end-of-life care for patients in hospice wards.ObjectiveTo explore the association of cardiovascular autonomic functions with TTD in patients with terminal hepatocellular carcinoma.MethodsA prospective study was conducted with 33 patients with hepatocellular carcinoma recruited from the hospice ward of a regional hospital in Chiayi county, Taiwan. Serum creatinine, serum glutamate oxaloacetate transaminase, serum glutamate pyruvate transaminase, blood urea nitrogen (BUN), and serum albumin were measured on the admission day. Cardiovascular autonomic functions were evaluated by frequency-domain measures of heart rate variability (HRV) on admission.ResultsTTD was significantly associated with total spectrum power (TP) (r = 0.55, P = 0.001) and high frequency (HF power) (r = 0.44, P = 0.010) of HRV measurement. The accuracy of within-one-week TTD prediction was 67% for TP and HF power. The accuracy of within-two-week TTD prediction was 82% for TP and 73% for HF. In addition, TTD of the patients was also significantly associated with serum creatinine (r = ?0.42, P = 0.015), serum albumin (r = ?0.46, P = 0.007), and BUN (r = ?0.44, P = 0.010).ConclusionThis is the first study to evaluate the association between cardiovascular autonomic functions and TTD in patients with terminal hepatocellular carcinoma. The inclusion of HRV measurement in prognostic models may improve accuracy in TTD prediction and, hence, facilitate medical decision making in hospice care.     

Outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) following refractory pediatric cardiac arrest in the intensive care unit

AimTo describe our experience using extracorporeal cardiopulmonary resuscitation (ECPR) in resuscitating children with refractory cardiac arrest in the intensive care unit (ICU) and to describe hospital survival and neurologic outcomes after ECPR.MethodsA retrospective chart review of a consecutive case series of patients requiring ECPR from 2001 to 2006 at Arkansas Children's Hospital. Data from medical records was abstracted and reviewed. Primary study outcomes were survival to hospital discharge and neurological outcome at hospital discharge.ResultsDuring the 6-year study period, ECPR was deployed 34 times in 32 patients. 24 deployments (73%) resulted in survival to hospital discharge. Twenty-eight deployments (82%) were for underlying cardiac disease, 3 for neonatal non-cardiac (NICU) patients and 3 for paediatric non-cardiac (PICU) patients. On multivariate logistic regression analysis, only serum ALT (p-value = 0.043; OR, 1.6; 95% confidence interval, 1.014–2.527) was significantly associated with risk of death prior to hospital discharge. Blood lactate at 24 h post-ECPR showed a trend towards significance (p-value = 0.059; OR, 1.27; 95% confidence interval, 0.991–1.627). The Hosmer–Lemeshow tests (p-value = 0.178) suggested a good fit for the model. Neurological evaluation of the survivors revealed that there was no change in PCPC scores from a baseline of 1–2 in 18/24 (75%) survivors.ConclusionsECPR can be used successfully to resuscitate children following refractory cardiac arrest in the ICU, and grossly intact neurologic outcomes can be achieved in a majority of cases.     

The influence of age and chronic medical conditions on neurological outcomes in out of hospital cardiac arrest

AimIt is unknown whether older patients with out of hospital cardiac arrest (OHCA) have worse outcomes because of aging itself, or because age can be a marker for overall health status. We aimed to study the prognostic utility of age and pre-arrest comorbidities.MethodsWe conducted a retrospective cohort study, reviewing electronic health records of all adults treated for non-traumatic OHCA in the University of Michigan Emergency Department (N = 588). Primary covariates included age, Charlson Comorbidity Index (CCI), and a combined Charlson-age index. The primary dichotomized outcome was favorable neurological outcome (cerebral performance category, 1–2), evaluated by logistic regressions.ResultsDementia (p = 0.01), witnessed arrest (p = 0.03), bystander CPR (p < 0.001), presenting rhythm (p < 0.001), and mild therapeutic hypothermia (p < 0.001) were associated with the primary outcome. Increasing age (unadjusted OR for each decade of life, 95% CI: 0.78, 0.70–0.88; adjusted 0.79, 0.67–0.94) was negatively associated with likelihood of a favorable neurological outcome. CCI and combined Charlson-age index significantly predicted outcome in the unadjusted, but not adjusted analysis. Composite variables were stronger predictors in patients with shockable than non-shockable presenting rhythms (interaction terms: age and rhythm [p = 0.004], CCI and rhythm [p = 0.01]).ConclusionAge, but not CCI, was significantly associated with less favorable neurological outcomes in patients with OHCA after adjusting important covariates. Age appears to be an independent predictor of prognosis rather than a marker for comorbidity.     

Urban and rural differences in out-of-hospital cardiac arrest in Ireland

BackgroundMore than a third of Ireland's population lives in a rural area, defined as the population residing in all areas outside clusters of 1500 or more inhabitants. This presents a challenge for the provision of effective pre-hospital resuscitation services. In 2012, Ireland became one of three European countries with nationwide Out-of-Hospital Cardiac Arrest (OHCA) register coverage. An OHCA register provides an ability to monitor quality and equity of access to life-saving services in Irish communities.AimTo use the first year of national OHCAR data to assess differences in the occurrence, incidence and outcomes of OHCA where resuscitation is attempted and the incident is attended by statutory Emergency Medical Services between rural and urban settings.MethodsThe geographical coordinates of incident locations were identified and co-ordinates were then classified as ‘urban’ or ‘rural’ according to the Irish Central Statistics Office (CSO) definition.Results1798 OHCA incidents were recorded which were attended by statutory Emergency Medical Services (EMS) and where resuscitation was attempted. There was a higher percentage of male patients in rural settings (71% vs. 65%; p = 0.009) but the incidence of male patients did not differ significantly between urban and rural settings (26 vs. 25 males/100,000 population/year p = 0.353). A higher proportion of rural patients received bystander cardiopulmonary resuscitation (B-CPR) 70% vs. 55% (p ≤ 0.001), and had defibrillation attempted before statutory EMS arrival (7% vs. 4% (p = 0.019), respectively). Urban patients were more likely to receive a statutory EMS response in 8 min or less (33% vs. 9%; p ≤ 0.001). Urban patients were also more likely to be discharged alive from hospital (6% vs. 3%; p = 0.006) (incidence 2.5 vs. 1.1/100,000 population/year; p ≤ 0.001).Multivariable analysis of survival showed that the main variable of interest i.e. urban vs. rural setting was also independently associated with discharge from hospital alive (OR 3.23 (95% CI 1.43–7.31)).ConclusionThere are significant disparities in the incidence of resuscitation attempts in urban and rural areas. There are challenges in the provision of services and subsequent outcomes from OHCA that occur outside of urban areas requiring novel and innovative solutions. An integrated community response system is necessary to improve metrics around OHCA response and outcomes in rural areas.     

NASCAR pit-stop model improves delivery room and admission efficiency and outcomes for infants <27 weeks’ gestation

AimTo evaluate a new process based on teamwork in a manner similar to the race car pit stop on organization and efficiency during the “Golden Hours” for extremely preterm infants.MethodsA team designed an improved process focused on checklists, preparation, assigning roles, and best practices, for the care of infants <27 weeks’ gestation in the delivery room (DR) through admission to the neonatal intensive care unit (NICU). Clinical outcomes 2 years before and after implementation were analyzed. A survey was administered to NICU staff prior to and 14 months after implementation. The survey assessed organization and efficiency in the DR and during the admission process of the target population.ResultsThere were 62 inborn infants prior to and 90 infants after implementation with overall survival of 90.3% and 86.6%, respectively (p = 0.61). Infants were more stable on admission with a mean arterial blood pressure equal to or greater than their gestational age in the post intervention group compared to the pre-cohort (76% vs 57%, p = 0.02) and discharged home at a lower mean postmenstrual age (39.0 ± 2.2 vs 40.1 ± 3.5 weeks, p = 0.04) The survey demonstrated improvement in assessment of roles being clearly defined in the DR and in the organization and the efficiency both in the DR and during the NICU admission (p < 0.05).ConclusionsA systematic approach to the care of the <27 weeks’ gestation neonate increased staff perception of improved organization and efficiency in the DR through admission processes and improved outcomes.     

The impact of health literacy on health outcomes in individuals with chronic pain: a cross-sectional study

ObjectiveTo establish if health literacy (HL) is linked to poorer outcomes and behaviours in patients with chronic pain.DesignA prospective cross-sectional observational study.SettingMultidisciplinary out-patient pain clinics in three university teaching hospitals.PatientsNew patients (n = 131) referred to the pain clinic with a history of chronic pain (>12 weeks).MethodsA questionnaire was distributed to chronic pain patients attending their first appointment. Those eligible for inclusion were newly referred patients who had pain lasting longer than three months. The questionnaire comprised the following sections: demographics, chronic pain status and disease-related knowledge, quality of life (SF-36), beliefs (Beliefs About Pain Control Questionnaire), and a validated HL tool (Newest Vital Sign).ResultsOf the 131 participants recruited, 54% had inadequate HL. The group was subsequently stratified according to HL level. In bivariate analysis, inadequate HL was associated with older age (p < 0.001), being unemployed or retired (p = 0.005), less education (p < 0.001), lower income, increased comorbidities (p = 0.038), being less likely to utilise allied health services (p = 0.001), poorer disease-related knowledge (p = 0.002), and poorer beliefs about pain (p < 0.05). In multivariate analysis, disease-related knowledge (OR 2.5, 95%CI 1.0 to 6.3, p = 0.05) and beliefs about pain (B = −2.3, S.E = 0.9, p = 0.01) remained independently associated with HL.ConclusionInadequate HL is prevalent in chronic pain patients, and may impact on the development of certain characteristics necessary for effective self-management.     

Acid-base disturbances in acute poisoning and their association with survival

PurposeThe purpose was to investigate the association between acid-base disturbances and mortality in acute poisoning.Materials and methodsWe performed a retrospective cross-sectional exploratory study on all acutely poisoned patients older than 12 years who had been admitted to the main tertiary toxicology hospital in Tehran between March and August 2010.ResultsOf a total of 1167 patients (median age = 25 years, 50.9% male), 98 died (74.5% male). Psychotropic medications were the most common cause of poisoning (36.5%), whereas narcotics and psychodysleptics were the most common cause of death (23.5%). Mixed respiratory alkalosis and metabolic acidosis with normal pH were the most common acid-base status (333, 28.5%). However, patients with primary metabolic acidosis and respiratory compensation had significantly higher mortality (31 cases, 18.8%). Logistic regression analysis identified age (odds ratio [OR], 1.051; 95% confidence interval [CI], 1.031-1.070; P < .001), intensive care unit admission (OR, 12.405; 95% CI, 7.178-21.440; P < .001), consciousness level (OR, 1.752; 95% CI, 1.301-2.359; P < .001), hospitalization period (OR, 1.1361; 95% CI, 1.079-1.195; P < .001), severe metabolic acidosis (OR, 6.016; 95% CI, 1.647-21.968; P = .007), and primary respiratory alkalosis (OR, 5.579; 95% CI, 1.353-23.001; P = .017) as death predictors during hospitalization (P < .001).ConclusionOn-arrival acid-base status predicts survival and can be used in prognostication of the poisoned patients.