Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality. Regional variations in reporting frameworks and survival mean the exact burden of OHCA to public health is unknown. ...Nevertheless, overall prognosis and neurological outcome are relatively poor following OHCA and have remained almost static for the past three decades. In this Series paper, we explore the aetiology of OHCA. Coronary artery disease remains the predominant cause, but there is a diverse range of other potential cardiac and non-cardiac causes to be aware of. Additionally, we describe how investigators and key stakeholders in resuscitation science have formulated specific Utstein data element domains in an attempt to standardise the definitions and outcomes reported in OHCA research so that management pathways can be improved. Finally, we identify the predictors of survival after OHCA and what primary and secondary prevention strategies can be instigated to mitigate the devastating sequelae of this growing public health issue.
Long-term care facilities are high-risk settings for severe outcomes from outbreaks of Covid-19, owing to both the advanced age and frequent chronic underlying health conditions of the residents and ...the movement of health care personnel among facilities in a region.
After identification on February 28, 2020, of a confirmed case of Covid-19 in a skilled nursing facility in King County, Washington, Public Health-Seattle and King County, aided by the Centers for Disease Control and Prevention, launched a case investigation, contact tracing, quarantine of exposed persons, isolation of confirmed and suspected cases, and on-site enhancement of infection prevention and control.
As of March 18, a total of 167 confirmed cases of Covid-19 affecting 101 residents, 50 health care personnel, and 16 visitors were found to be epidemiologically linked to the facility. Most cases among residents included respiratory illness consistent with Covid-19; however, in 7 residents no symptoms were documented. Hospitalization rates for facility residents, visitors, and staff were 54.5%, 50.0%, and 6.0%, respectively. The case fatality rate for residents was 33.7% (34 of 101). As of March 18, a total of 30 long-term care facilities with at least one confirmed case of Covid-19 had been identified in King County.
In the context of rapidly escalating Covid-19 outbreaks, proactive steps by long-term care facilities to identify and exclude potentially infected staff and visitors, actively monitor for potentially infected patients, and implement appropriate infection prevention and control measures are needed to prevent the introduction of Covid-19.
The Third International Consensus Definitions Task Force defined sepsis as "life-threatening organ dysfunction due to a dysregulated host response to infection." The performance of clinical criteria ...for this sepsis definition is unknown.
To evaluate the validity of clinical criteria to identify patients with suspected infection who are at risk of sepsis.
Among 1.3 million electronic health record encounters from January 1, 2010, to December 31, 2012, at 12 hospitals in southwestern Pennsylvania, we identified those with suspected infection in whom to compare criteria. Confirmatory analyses were performed in 4 data sets of 706,399 out-of-hospital and hospital encounters at 165 US and non-US hospitals ranging from January 1, 2008, until December 31, 2013.
Sequential Sepsis-related Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria, Logistic Organ Dysfunction System (LODS) score, and a new model derived using multivariable logistic regression in a split sample, the quick Sequential Sepsis-related Organ Failure Assessment (qSOFA) score (range, 0-3 points, with 1 point each for systolic hypotension ≤100 mm Hg, tachypnea ≥22/min, or altered mentation).
For construct validity, pairwise agreement was assessed. For predictive validity, the discrimination for outcomes (primary: in-hospital mortality; secondary: in-hospital mortality or intensive care unit ICU length of stay ≥3 days) more common in sepsis than uncomplicated infection was determined. Results were expressed as the fold change in outcome over deciles of baseline risk of death and area under the receiver operating characteristic curve (AUROC).
In the primary cohort, 148,907 encounters had suspected infection (n = 74,453 derivation; n = 74,454 validation), of whom 6347 (4%) died. Among ICU encounters in the validation cohort (n = 7932 with suspected infection, of whom 1289 16% died), the predictive validity for in-hospital mortality was lower for SIRS (AUROC = 0.64; 95% CI, 0.62-0.66) and qSOFA (AUROC = 0.66; 95% CI, 0.64-0.68) vs SOFA (AUROC = 0.74; 95% CI, 0.73-0.76; P < .001 for both) or LODS (AUROC = 0.75; 95% CI, 0.73-0.76; P < .001 for both). Among non-ICU encounters in the validation cohort (n = 66 522 with suspected infection, of whom 1886 3% died), qSOFA had predictive validity (AUROC = 0.81; 95% CI, 0.80-0.82) that was greater than SOFA (AUROC = 0.79; 95% CI, 0.78-0.80; P < .001) and SIRS (AUROC = 0.76; 95% CI, 0.75-0.77; P < .001). Relative to qSOFA scores lower than 2, encounters with qSOFA scores of 2 or higher had a 3- to 14-fold increase in hospital mortality across baseline risk deciles. Findings were similar in external data sets and for the secondary outcome.
Among ICU encounters with suspected infection, the predictive validity for in-hospital mortality of SOFA was not significantly different than the more complex LODS but was statistically greater than SIRS and qSOFA, supporting its use in clinical criteria for sepsis. Among encounters with suspected infection outside of the ICU, the predictive validity for in-hospital mortality of qSOFA was statistically greater than SOFA and SIRS, supporting its use as a prompt to consider possible sepsis.
Type I interferons (IFN-α and IFN-β) are important for protection against many viral infections, whereas type II interferon (IFN-γ) is essential for host defense against some bacterial and parasitic ...pathogens. Study of IFN responses in human leprosy revealed an inverse correlation between IFN-β and IFN-γ gene expression programs. IFN-γ and its downstream vitamin D—dependent antimicrobial genes were preferentially expressed in self-healing tuberculoid lesions and mediated antimicrobial activity against the pathogen Mycobacterium leprae in vitro. In contrast, IFN-β and its downstream genes, including interleukin-10 (IL-10), were induced in monocytes by M. leprae in vitro and preferentially expressed in disseminated and progressive lepromatous lesions. The IFN-γ—induced macrophage vitamin D—dependent antimicrobial peptide response was inhibited by IFN-β and by IL-10, suggesting that the differential production of IFNs contributes to protection versus pathogenesis in some human bacterial infections.
Abstract Background Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death and a 2010 meta-analysis concluded that outcomes have not improved over several decades. However, guidelines ...have changed to emphasize CPR quality, minimization of interruptions, and standardized post-resuscitation care. We sought to evaluate whether OHCA outcomes have improved over time among agencies participating in the Resuscitation Outcomes Consortium (ROC) cardiac arrest registry (Epistry) and randomized clinical trials (RCTs). Methods Observational cohort study of 47,148 EMS-treated OHCA cases in Epistry from 139 EMS agencies at 10 ROC sites that participated in at least one RCT between 1/1/2006 and 12/31/2010. We reviewed patient, scene, event characteristics, and outcomes of EMS-treated OHCA over time, including subgroups with initial rhythm of pulseless ventricular tachycardia or ventricular fibrillation (VT/VF). Results Mean response interval, median age and male proportion remained similar over time. Unadjusted survival to discharge increased between 2006 and 2010 for treated OHCA (from 8.2% to 10.4%), as well as for subgroups of VT/VF (21.4% to 29.3%) and bystander witnessed VT/VF (23.5% to 30.3%). Compared with 2006, adjusted survival to discharge was significantly higher in 2010 for treated cases (OR = 1.72; 95% CI 1.53, 1.94), VT/VF cases (OR = 1.69; 95% CI 1.45, 1.98) and bystander witnessed VT/VF cases (OR = 1.65; 95% CI 1.36, 2.00). Tests for trend in each subgroup were significant ( p < 0.001). Conclusions ROC-wide survival increased significantly between 2006 and 2010. Additional research efforts are warranted to identify specific factors associated with this improvement.
Although measures of functional status are often advocated when assessing short-term survival following cardiac arrest, little is known about how these measures predict long-term prognosis. We sought ...to determine whether the Cerebral Performance Category (CPC) was associated with long-term outcome following resuscitation from out-of-hospital cardiac arrest.
The study was a retrospective cohort investigation of adults who suffered out-of-hospital cardiac arrest in the study community between January 1, 2001 and December 31, 2009, and were successfully resuscitated and discharged alive from the hospital following the event. The CPC at the time of hospital discharge was ascertained through review of the hospital record. The primary outcome was survival following hospital discharge. Survival status was determined using state and national death indexes. We used Kaplan-Meier curves and Cox regression to evaluate the association between CPC and survival.
Among the 980 eligible subjects, 606 of 980 (62%) had a CPC of 1; 227 of 980 (23%) had a CPC of 2; 97 of 980 (10%) had a CPC of 3; and 50 of 980 (5%) had a CPC of 4. There were 336 deaths during 3,713 person-years of follow-up. Overall, 1-year survival was 82% and 5-year survival was 64%. Favorable CPC predicted better long-term prognosis. Compared with CPC 1, the relative risk of survival was 0.61 (0.47-0.80) for CPC 2, 0.43 (0.31-0.59) for CPC 3, and 0.10 (0.06-0.15) for CPC 4.
The CPC at hospital discharge is a useful surrogate measure of long-term survival and can be an informative tool for programmatic evaluation and research of resuscitation.
During cardiopulmonary resuscitation (CPR) in patients with out-of-hospital cardiac arrest, the interruption of manual chest compressions for rescue breathing reduces blood flow and possibly ...survival. We assessed whether outcomes after continuous compressions with positive-pressure ventilation differed from those after compressions that were interrupted for ventilations at a ratio of 30 compressions to two ventilations.
This cluster-randomized trial with crossover included 114 emergency medical service (EMS) agencies. Adults with non-trauma-related cardiac arrest who were treated by EMS providers received continuous chest compressions (intervention group) or interrupted chest compressions (control group). The primary outcome was the rate of survival to hospital discharge. Secondary outcomes included the modified Rankin scale score (on a scale from 0 to 6, with a score of ≤3 indicating favorable neurologic function). CPR process was measured to assess compliance.
Of 23,711 patients included in the primary analysis, 12,653 were assigned to the intervention group and 11,058 to the control group. A total of 1129 of 12,613 patients with available data (9.0%) in the intervention group and 1072 of 11,035 with available data (9.7%) in the control group survived until discharge (difference, -0.7 percentage points; 95% confidence interval CI, -1.5 to 0.1; P=0.07); 7.0% of the patients in the intervention group and 7.7% of those in the control group survived with favorable neurologic function at discharge (difference, -0.6 percentage points; 95% CI, -1.4 to 0.1, P=0.09). Hospital-free survival was significantly shorter in the intervention group than in the control group (mean difference, -0.2 days; 95% CI, -0.3 to -0.1; P=0.004).
In patients with out-of-hospital cardiac arrest, continuous chest compressions during CPR performed by EMS providers did not result in significantly higher rates of survival or favorable neurologic function than did interrupted chest compressions. (Funded by the National Heart, Lung, and Blood Institute and others; ROC CCC ClinicalTrials.gov number, NCT01372748.).
The aim of the study was to assess the influence of percutaneous coronary intervention (PCI) and therapeutic hypothermia (TH) on long-term prognosis.
Although hospital care consisting of TH and/or ...PCI in particular patients resuscitated following out-of-hospital cardiac arrest (OHCA) can improve survival to hospital discharge, there is little evidence regarding how these therapies may impact long-term prognosis.
We performed a cohort investigation of all persons >18 years of age who suffered nontraumatic OHCA and were resuscitated and discharged alive from the hospital between January 1, 2001, and December 31, 2009, in a metropolitan emergency medical service (EMS) system. We reviewed EMS and hospital records, state death certificates, and the national death index to determine clinical characteristics and vital status. Survival analyses were conducted using Kaplan-Meier estimates and multivariable Cox regression. Analyses of TH were restricted to those patients who were comatose at hospital admission.
Of the 5,958 persons who received EMS-attempted resuscitation, 1,001 (16.8%) were discharged alive from the hospital. PCI was performed in 384 of 1,001 (38.4%), whereas TH was performed in 241 of 941 (25.6%) persons comatose at hospital admission. Five-year survival was 78.7% among those treated with PCI compared with 54.4% among those not receiving PCI and 77.5% among those treated with TH compared with 60.4% among those not receiving TH (both p < 0.001). After adjustment for confounders, PCI was associated with a lower risk of death (hazard ratio HR: 0.46 95% confidence interval CI: 0.34 to 0.61; p < 0.001). Likewise, TH was associated with a lower risk of death (HR: 0.70 95% CI: 0.50 to 0.97; p = 0.04).
The findings suggested that effects of acute hospital interventions for post-resuscitation treatment extend beyond hospital survival and can positively influence prognosis following the arrest hospitalization.
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