Nearly 6000 hospitalized children in the United States receive cardiopulmonary resuscitation (CPR) annually. Little is known about whether the survival of these children is influenced by the time of ...the event (eg, nighttime or weekends). Differences in survival could have important implications for hospital staffing, training, and resource allocation.
To determine whether outcomes after pediatric in-hospital cardiac arrests differ during nights and weekends compared with days/evenings and weekdays.
This study included a total of 354 hospitals participating in the American Heart Association's Get With the Guidelines-Resuscitation registry from January 1, 2000, to December 12, 2012. Index cases (12 404 children) from all children younger than 18 years of age receiving CPR for at least 2 minutes were included. Data analysis was performed in December 2014 and June 2016. We aggregated hourly blocks of time, using previously defined time intervals of day/evening and night, as well as weekend. Multivariable logistic regression models were used to examine the effect of independent variables on survival to hospital discharge. We used a combination of a priori variables based on previous literature (including age, first documented rhythm, location of event in hospital, extracorporeal CPR, and hypotension as the cause of arrest), as well as variables that were identified in bivariate generalized estimating equation models, and maintained significance of P ≤ .15 in the final multivariable models.
The primary outcome measure was survival to hospital discharge, and secondary outcomes included return of circulation lasting more than 20 minutes and 24-hour survival.
Of 12 404 children (56.0% were male), 8731 (70.4%) experienced a return of circulation lasting more than 20 minutes, 7248 (58.4%) survived for 24 hours, and 4488 (36.2%) survived to hospital discharge. After adjusting for potential confounders, we found that the rate of survival to hospital discharge was lower during nights than during days/evenings (adjusted odds ratio, 0.88 95% CI, 0.80-0.97; P = .007) but was not different between weekends and weekdays (adjusted odds ratio, 0.92 95% CI, 0.84-1.01; P = .09).
The rate of survival to hospital discharge was lower for pediatric CPR events occurring at night than for CPR events occurring during daytime and evening hours, even after adjusting for many potentially confounding patient-, event-, and hospital-related factors.
To evaluate baseline hemoglobin (Hb) and radiographic progression over time in patients enrolled in the Brigham and Women's Rheumatoid Arthritis Sequential Study (BRASS) registry.
The BRASS is a ...prospective observational registry of patients with rheumatoid arthritis. BRASS Hb data and total sharp score data were matched with the main BRASS patients. Hb at baseline was categorized per the World Health Organization guidelines. Mean Hb, mean total sharp score, and mean changes over time from baseline to month 120 were summarized (overall, by low/normal Hb, and by current medication at baseline). All analyses were descriptive.
Out of the total (N = 1114) rheumatoid arthritis patients included in the analysis, patients with low Hb at baseline (n = 224 20%) had longer disease duration and higher disease activity and reported more pain compared with patients with normal Hb at baseline (n = 890 80%). Patients with low Hb at baseline continued to have lower Hb than patients with normal Hb throughout 10 years; although, on average, patients in the low Hb subgroup exhibited a steady increase in Hb levels. A larger increase in total sharp score over time was observed for patients with low Hb than for patients with normal Hb. No meaningful differences potentially attributable to medication at baseline were detected.
Patients with low Hb levels at baseline tended to have increased radiographic progression as measured by total sharp score compared with patients with rheumatoid arthritis having normal Hb levels. Patients with low Hb experienced sustained improvements in Hb levels over time, regardless of the class of medication used.
ClinicalTrials.gov NCT01793103.
Pediatric cardiopulmonary resuscitation (CPR) for >20 minutes has been considered futile after pediatric in-hospital cardiac arrests. This concept has recently been questioned, although the effect of ...CPR duration on outcomes has not recently been described. Our objective was to determine the relationship between CPR duration and outcomes after pediatric in-hospital cardiac arrests.
We examined the effect of CPR duration for pediatric in-hospital cardiac arrests from the Get With The Guidelines-Resuscitation prospective, multicenter registry of in-hospital cardiac arrests. We included 3419 children from 328 U.S. and Canadian Get With The Guidelines-Resuscitation sites with an in-hospital cardiac arrest between January 2000 and December 2009. Patients were stratified into 5 patient illness categories: surgical cardiac, medical cardiac, general medical, general surgical, and trauma. Survival to discharge was 27.9%, but only 19.0% of all cardiac arrest patients had favorable neurological outcomes. Between 1 and 15 minutes of CPR, survival decreased linearly by 2.1% per minute, and rates of favorable neurological outcome decreased by 1.2% per minute. Adjusted probability of survival was 41% for CPR duration of 1 to 15 minutes and 12% for >35 minutes. Among survivors, favorable neurological outcome occurred in 70% undergoing <15 minutes of CPR and 60% undergoing CPR >35 minutes. Compared with general medical patients, surgical cardiac patients had the highest adjusted odds ratios for survival and favorable neurological outcomes, 2.5 (95% confidence interval, 1.8-3.4) and 2.7 (95% confidence interval, 2.0-3.9), respectively.
CPR duration was independently associated with survival to hospital discharge and neurological outcome. Among survivors, neurological outcome was favorable for the majority of patients. Performing CPR for >20 minutes is not futile in some patient illness categories.
Occurrence of in-hospital cardiac arrest and survival patterns have not been characterized by time of day or day of week. Patient physiology and process of care for in-hospital cardiac arrest may be ...different at night and on weekends because of hospital factors unrelated to patient, event, or location variables.
To determine whether outcomes after in-hospital cardiac arrest differ during nights and weekends compared with days/evenings and weekdays.
We examined survival from cardiac arrest in hourly time segments, defining day/evening as 7:00 am to 10:59 pm, night as 11:00 pm to 6:59 am, and weekend as 11:00 pm on Friday to 6:59 am on Monday, in 86,748 adult, consecutive in-hospital cardiac arrest events in the National Registry of Cardiopulmonary Resuscitation obtained from 507 medical/surgical participating hospitals from January 1, 2000, through February 1, 2007.
The primary outcome of survival to discharge and secondary outcomes of survival of the event, 24-hour survival, and favorable neurological outcome were compared using odds ratios and multivariable logistic regression analysis. Point estimates of survival outcomes are reported as percentages with 95% confidence intervals (95% CIs).
A total of 58,593 cases of in-hospital cardiac arrest occurred during day/evening hours (including 43,483 on weekdays and 15,110 on weekends), and 28,155 cases occurred during night hours (including 20,365 on weekdays and 7790 on weekends). Rates of survival to discharge (14.7% 95% CI, 14.3%-15.1% vs 19.8% 95% CI, 19.5%-20.1%, return of spontaneous circulation for longer than 20 minutes (44.7% 95% CI, 44.1%-45.3% vs 51.1% 95% CI, 50.7%-51.5%), survival at 24 hours (28.9% 95% CI, 28.4%-29.4% vs 35.4% 95% CI, 35.0%-35.8%), and favorable neurological outcomes (11.0% 95% CI, 10.6%-11.4% vs 15.2% 95% CI, 14.9%-15.5%) were substantially lower during the night compared with day/evening (all P values < .001). The first documented rhythm at night was more frequently asystole (39.6% 95% CI, 39.0%-40.2% vs 33.5% 95% CI, 33.2%-33.9%, P < .001) and less frequently ventricular fibrillation (19.8% 95% CI, 19.3%-20.2% vs 22.9% 95% CI, 22.6%-23.2%, P < .001). Among in-hospital cardiac arrests occurring during day/evening hours, survival was higher on weekdays (20.6% 95% CI, 20.3%-21%) than on weekends (17.4% 95% CI, 16.8%-18%; odds ratio, 1.15 95% CI, 1.09-1.22), whereas among in-hospital cardiac arrests occurring during night hours, survival to discharge was similar on weekdays (14.6% 95% CI, 14.1%-15.2%) and on weekends (14.8% 95% CI, 14.1%-15.2%; odds ratio, 1.02 95% CI, 0.94-1.11).
Survival rates from in-hospital cardiac arrest are lower during nights and weekends, even when adjusted for potentially confounding patient, event, and hospital characteristics.
Anemia is common in patients with rheumatoid arthritis (RA). Higher hemoglobin (Hb) levels may be associated with better clinical outcomes and patient-reported outcomes (PROs). To assess this ...hypothesis, we conducted two post hoc analyses in three sarilumab phase III studies: TARGET, MOBILITY, and MONARCH.
Pooled data from combination therapy from placebo-controlled MOBILITY (sarilumab + methotrexate) and TARGET (sarilumab + conventional synthetic disease-modifying antirheumatic drugs csDMARDs) and monotherapy data from active-controlled MONARCH (sarilumab vs. adalimumab) studies were included. Associations between Hb levels and clinical measures and PROs were assessed over 24 weeks. The mean changes from baseline in clinical outcomes and PROs (to week 24) and radiographic outcomes (to week 52) were evaluated between low and normal Hb levels (based on the World Health Organization WHO criteria).
From TARGET, MOBILITY, and MONARCH, 546, 1197, and 369 patients, respectively, were stratified according to Hb levels (low vs. normal). Over 24 weeks, higher Hb levels were found to be consistently associated with better clinical outcomes and PROs in combination therapy and monotherapy groups and were more pronounced among the patients treated with sarilumab than those treated with placebo and adalimumab. The mean change from baseline to week 24 in clinical efficacy measures and PROs was similar in patients with low vs. normal Hb at baseline. Differences between sarilumab and/or adalimumab, for all outcomes, were larger for low Hb subgroups. In MOBILITY, by week 52, the inhibition of progression of structural damage (assessed via Modified Total Sharp Score mTSS) was 84% (sarilumab 200 mg) and 68% (sarilumab 150 mg) vs. placebo in patients with low Hb and 97% (sarilumab 200 mg) and 68% (sarilumab 150 mg) vs. placebo in patients with normal Hb. Similar results were observed for other radiographic outcomes.
In these post hoc analyses, a consistent relationship was observed between higher Hb levels and better clinical outcomes and PROs in patients with RA. Irrespective of the baseline Hb levels, sarilumab treatment was associated with improvements in clinical measures and PROs over 24 weeks (improvements were more pronounced than those with adalimumab treatment) and mitigation of joint damage progression over 52 weeks.
ClinTrials.gov NCT01061736, NCT01709578, and NCT02332590.
The aim of this study was to assess the effect of switching from adalimumab to sarilumab monotherapy in partial responders with rheumatoid arthritis from the MONARCH randomized trial and its ...open-label extension (OLE).
Partial response was defined as improvement in Clinical Disease Activity Index (CDAI) of 12 or 6 units (baseline score: >22 or >10 and ≤22, respectively). Proportions of adalimumab partial responders with meaningful worsening or improvement at OLE weeks 12 and 24 were evaluated using 2 CDAI thresholds (≥6 and ≥12 points), 28-joint Disease Activity Score using erythrocyte sedimentation rate (≥0.6 and ≥1.2 points), Health Assessment Questionnaire Disability Index (≥0.22 and ≥0.30 points), Simple Disease Activity Index (≥7 and ≥13 points), physician and patient global assessments (≥10 and ≥20), and 28-joint swollen and tender joint counts (≥1 and ≥2 joints). Outcomes were analyzed using mixed-effect models with repeated measures for observed cases. The p values were produced using Wilcoxon tests.
Of 369 enrolled patients, 320 (87%) entered the OLE and 155 switched from adalimumab to sarilumab; 59% (91/155) were partial responders. At week 24, 4%-17% and 2%-12% of partial responders experienced a worsening using the lower and higher thresholds, respectively, whereas 47%-78% and 27%-66% experienced improvement.
Partial responders to adalimumab who switched to sarilumab had a low likelihood of experiencing meaningful worsening, with most patients showing meaningful improvement or no change in disease activity. This may help alleviate patients' fears of worsening when considering switching to a treatment with a different mechanism of action.
Objectives The study aimed to assess the diagnostic properties of electrocardiographic (ECG) criteria for right ventricular hypertrophy (RVH) measured by cardiac magnetic resonance imaging (cMRI) in ...adults without clinical cardiovascular disease. Background Current ECG criteria for RVH were based on cadaveric dissection in small studies. Methods MESA (Multi-Ethnic Study of Atherosclerosis) performed cMRIs with complete right ventricle (RV) interpretation on 4,062 participants without clinical cardiovascular disease. Endocardial margins of the RV were manually contoured on diastolic and systolic images. The ECG screening criteria for RVH from the 2009 American Heart Association Recommendations for Standardization and Interpretation of the ECG were examined in participants with and without left ventricular (LV) hypertrophy or reduced ejection fraction. RVH was defined using sex-specific normative equations based on age, height, and weight. Results The study sample with normal LV morphology and function (n = 3,719) was age 61.3 ± 10.0 years, 53.5% female, 39.6% Caucasian, 25.5% African American, 21.9% Hispanic, and 13.0% Asian. The mean body mass index was 27.9 ± 5.0 kg/m2 . A total of 6% had RVH, which was generally mild. Traditional ECG criteria were specific (many >95%) but had low sensitivity for RVH by cMRI. The positive predictive values were not sufficiently high as to be clinically useful (maximum 12%). The results did not differ based on age, sex, race, or smoking status, or with the inclusion of participants with abnormal LV mass or function. Classification and regression tree analysis revealed that no combination of ECG variables was better than the criteria used singly. Conclusions The recommended ECG screening criteria for RVH are not sufficiently sensitive or specific for screening for mild RVH in adults without clinical cardiovascular disease.
Abstract Context HIV infection has become a manageable chronic disease. There are few studies of pain and symptoms in the current treatment era. Objectives Our primary objective was to determine the ...prevalence of and risk factors for pain and physical and psychological symptoms in a population of ambulatory HIV patients. Methods We performed a cross-sectional study using the Brief Pain Inventory and the Memorial Symptom Assessment Scale-Short Form (MSAS). Results We evaluated 156 individuals with a median age of 47.5 years (range 21–71), median time since HIV diagnosis of 11 years (range <1 to 25), and median CD4+ cell count of 502 cells/mm3 (interquartile range IQR 308–683). Most (125, 80.6%) of the patients had an undetectable viral load. Seventy-six (48.7%) patients reported pain, of whom 39 (51.3%) had moderate to severe pain, and 43 (57.3%) had pain that caused moderate to severe interference with their lives. The median number of symptoms was eight (IQR 5–14.5) of 32 queried. In multivariable analyses, patients with psychiatric illness were 39.8% more likely to have pain ( P < 0.001). Psychiatric illness was associated with 0.7 and 1.2 point higher MSAS subscale scores, and IV drug use was associated with 0.4 and 0.5 higher subscale scores (out of four). Conclusion Pain and other physical and psychological symptoms were common among ambulatory HIV patients. Pain and symptoms were strongly associated with psychiatric illness and IV drug use. Future investigation should evaluate interventions that include psychiatric and substance abuse components for HIV patients with pain.
Introduction
Atopic dermatitis (AD)—a chronic inflammatory skin disease characterized by intense itching—can have a detrimental impact on quality of life (QoL). We report results of a quantitative ...assessment of pediatric patient, caregiver, and physician perceptions of AD burden in children and adolescents.
Methods
Pediatric patients (aged 6–11 children or 12–17 adolescents years) with moderate-to-severe AD, their caregivers, and independent physicians were recruited in 13 countries. Caregivers and their children/adolescents completed an online survey about the impact of AD on 16 key items of patient QoL. Physicians completed surveys on their patients aged 6–11 and 12–17 years. Best–worst scaling was used to rank the importance of the QoL items.
Results
Overall, 1447 children/adolescents with moderate-to-severe AD (aged 6–11 years: 701; 12–17 years: 746), 1447 caregivers, and 1092 physicians participated. Patients and caregivers in both age groups ranked disturbed sleep as the most important QoL item, followed by feeling ashamed because of AD. Independent physicians ranked feeling ashamed because of AD as the most important QoL item for both age groups, followed by disturbed sleep for those aged 6–11 years and being singled out for those aged 12–17 years. The relative importance of the 16 QoL items to patients was strongly aligned between patients in both age groups and their caregivers, but somewhat less so between patients and physicians. Between-country differences were more apparent in physician- versus patient-/caregiver-reported results.
Conclusion
The most burdensome QoL items were impact of AD on sleep and feeling ashamed. Caregivers and physicians correctly identified the QoL items most burdensome to patients. However, patient and caregiver perceptions were generally more closely aligned than patient and physician perceptions. Between-country differences in perceptions (particularly for physicians) were observed, probably due to multifactorial reasons, necessitating further evaluation.
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Video Abstract (MP4 42,877 kb)
Infographic
The objective of this study was to assess whether pediatric inpatients who receive cardiopulmonary resuscitation (CPR) for bradycardia with poor perfusion are more likely to survive to hospital ...discharge than pediatric inpatients who receive CPR for pulseless arrest (asystole/pulseless electrical activity PEA), after controlling for confounding characteristics.
A prospective cohort from the National Registry of Cardiopulmonary Resuscitation was enrolled between January 4, 2000, and February 23, 2008. Patients who were younger than 18 years and had an in-hospital event that required chest compressions for >2 minutes were eligible. Patients were divided into 2 groups on the basis of initial rhythm and pulse state: bradycardia/poor perfusion and asystole/PEA. Patient characteristics, event characteristics, and clinical characteristics were analyzed as possible confounders. Univariate analysis between bradycardia and asystole/PEA patient groups was performed. Multivariable logistic regression was used to determine whether an initial state of bradycardia/poor perfusion was independently associated with survival to discharge.
A total of 6288 patients who were younger than 18 years were reported; 3342 met all inclusion criteria. A total of 1853 (55%) patients received chest compressions for bradycardia/poor perfusion compared with 1489 (45%) for asystole/PEA. Overall, 755 (40.7%) of 1353 patients with bradycardia survived to hospital discharge, compared with 365 (24.5%) of 1489 patients with asystole/PEA. After controlling for known confounders, CPR for bradycardia with poor perfusion was associated with increased survival to hospital discharge.
Pediatric inpatients with chest compressions initiated for bradycardia and poor perfusion before onset of pulselessness were more likely to survive to discharge than pediatric inpatients with chest compressions initiated for asystole or PEA.
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