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Background: Neurological outcomes after out-of-hospital cardiac arrest (OHCA) depend on multiple factors, including the patient's baseline condition and post-arrest management. The SLANT, developed specifically for OHCA survivors treated with targeted temperature management (TTM), requires further validation, particularly in Asian populations., Methods: This multicenter retrospective cohort study analyzed data from 2016 to 2023, examining demographics, pre-arrest conditions, resuscitation events, and laboratory biomarkers following TTM. The primary outcome was defined as a poor neurological outcome at hospital discharge. Model performance was assessed using the area under the receiver operating characteristic curve. Multivariate logistic regression analysis was used to analyze the included variables., Results: A total of 448 eligible adult patients were included, of whom 77.9% experienced poor neurological outcomes at discharge. The performance of the current cohort was comparable to that of the original SLANT cohort, achieving an area under the curve of 0.797 (95% confidence interval: 0.746-0.849). All five factors of the SLANT score remained statistically significant in predicting poor neurological outcomes. At a cutoff of ≥ 6.5, the SLANT score demonstrated a specificity of 53.5% and positive predictive value (PPV) of 86.9%. Increasing the cutoff value to 8.5 improved the specificity to 66.7% and the PPV to 89.6%., Conclusion: The SLANT showed high PPV for predicting poor neurological outcomes at discharge in patients with OHCA undergoing TTM across a multicenter Asian cohort. Combining the score with other neurological assessments is recommended for improved neuroprognostication., Competing Interests: Declarations. Ethics approval and consent to participate: The study was approved by the Institutional Review Board of NTUH (No. 202401013RINC). The requirement for informed consent was waived because of the retrospective nature of the study. Consent for publication: This manuscript does not contain any individual person’s data in any form (including any individual details, images or videos). Competing interests: The authors declare that they have no competing interests., (© 2025. The Author(s).)

Background: Despite the well-known importance of witnessed arrest and bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest outcomes, previous studies have shown significant statistical inconsistencies. We hypothesized an interaction effect and conducted stratified analyses to investigate whether witnessed arrest is more important than bystander CPR., Methods: This study enrolled patients with out-of-hospital cardiac arrest between January 2010 and December 2022 in 3 emergency medical service (systems in Taiwan). Data were extracted from emergency medical service dispatch reports, including patient characteristics, witnessed arrest, bystander CPR, time for each dispatch, and prehospital interventions. The outcome measure was prehospital return of spontaneous circulation (ROSC). Patients were categorized into 4 groups: witnessed and bystander CPR present (W+B+), witnessed present but bystander CPR absent (W+B-), witnessed absent but bystander CPR present (W-B+), and witnessed and bystander CPR absent (W-B-). Multiple logistic regression on prehospital ROSC were performed in the 4 subgroups separately., Results: A total of 14 737 patients with out-of-hospital cardiac arrest were identified, of whom 977 (6.6%) achieved prehospital ROSC. The W+B+ group exhibited the highest prehospital ROSC rate (14.0%). Stratification confirmed a statistically significant interaction between witnessed arrest and bystander CPR. Defibrillation, endotracheal intubation, and epinephrine administration were significantly associated with prehospital ROSC in all subgroups. Most explanatory variables significant in the witnessed arrest group were adjusted for in the nonwitnessed arrest group. Younger age was associated with prehospital ROSC only in the W+B+ group., Conclusions: Witnessed arrest and bystander CPR may interact to predict prehospital ROSC in out-of-hospital cardiac arrest, with witnessed arrest likely having more significant impact on outcomes.

Study Objective: Cardiopulmonary resuscitation (CPR) is critical for out-of-hospital cardiac arrest patients but is prone to rapid changes and errors. Effective teamwork and leadership are essential for high-quality CPR. We aimed to introduce the Airway-Circulation-Leadership-Support (A-C-L-S) teamwork model in the emergency department (ED) to address these challenges., Methods: The study comprised 2 phases. The development phase involved reviewing CPR videos, categorizing problems, and formulating strategies using the Systems Engineering Initiative for Patient Safety model. Resuscitation tasks were organized into A-C-L-S domains using hierarchical task analysis. Equipment and environmental deficits were optimized ergonomically with a pit-crew style arrangement. Mnemonics enhanced teamwork and leadership. The evaluation phase assessed postimplementation ED resuscitation team performance, focusing on adherence, timeliness, and quality of A-C-L-S tasks., Results: The development phase produced a structured teamwork model, assigning tasks, tools, mnemonics, and positions based on A-C-L-S domains. The A-team manages the airway and optimizes end-tidal CO 2 levels; the C-team focuses on high-quality chest compressions and defibrillation. Leadership coordinates resuscitation efforts using goal-directed mnemonics (DABCD 2 E 3 ), whereas the S-team handles medications, timekeeping, and recording. The evaluation phase showed improvements in adherence and timeliness of A-C-L-S tasks, with sustained increases in chest compression fraction before mechanical CPR, from 67.2% preimplementation to 83.0% postimplementation, 89.1% after 1 year, and 86.1% after 2 years. Overall, chest compression fraction also improved from 81.7% to 88.6%, peaking at 92.2% after 1 year and maintaining 90.8% after 2 years., Conclusion: The A-C-L-S teamwork model is feasible, applicable, and effective. Further research is needed to assess its influence on patient outcomes., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Introduction: This study aimed to investigate the patterns of healthcare system utilization before sudden cardiac death (SCD) in Taiwan, and compare the patterns between patients treated at medical centers and non-center hospitals., Methods: This descriptive multicenter retrospective cohort study recruited adult, nontraumatic SCD patients who were admitted to the National Taiwan University Hospital and its affiliated hospitals between January 2017 and December 2022. Healthcare utilization patterns, such as outpatient visits, emergency department (ED) visits, short-term ED returns, and hospitalizations, were analyzed during the weeks prior to SCD. The statistical analysis compared the above patterns between medical center and non-center cohorts to identify potential differences in patient behavior and healthcare use., Results: Analysis of 3,649 eligible patients revealed a significant increase in healthcare utilization before SCD. Outpatient visits began to rise sharply five weeks prior to SCD, peaking at 16.5% in the overall cohort. The number of ED visits showed a notable increase starting ten weeks prior, with a peak in the week immediately before the SCD, reaching 3.7%. Hospitalization rates exhibited a distinct pattern, peaking at 2.5% three weeks before SCD and then declining. The consistency between hospitalization diagnoses and the cause of SCD was approximately 40% within three weeks prior to SCD. The increases were consistent across both the medical center and non-center cohorts, although non-center patients generally exhibited higher utilization rates., Conclusions: Healthcare utilization significantly increased before SCD, including outpatient visits, ED visits, and hospitalization. This pattern was consistent among patients treated at medical centers and non-medical centers., Competing Interests: Declaration of conflict of interest No financial disclosures have been reported by the authors of this paper., (Copyright © 2025. Published by Elsevier Inc.)

Background: Dispatcher-assisted cardiopulmonary resuscitation (DACPR) significantly improves the survival of out-of-hospital cardiac arrest (OHCA) patients. However, the effectiveness of DACPR may vary depending on the location of the cardiac arrest. This study compares DACPR outcomes in private homes versus public places., Methods: This retrospective cohort study included all OHCA incidents with emergency medical service (EMS) activation in Taichung City, Taiwan, from May 1, 2021, to April 30, 2022. Trained dispatch reviewers analyzed audio recordings of the included cases to extract DACPR indicators. The primary outcome was the number of successful chest compressions performed. Secondary outcomes included the proportion of OHCA recognition, call-to-chest compression time, call-to-OHCA recognition time, reasons for failure to identify OHCA, and reasons for failure to perform chest compressions or complete instructions. A subgroup analysis examined the caller-patient relationship in both locations., Results: The study included 1,160 OHCA patients, with 1,009 cases occurring in private homes and 151 in public places. Patients in public places were younger (60 vs 75 years), more often male (81.5 % vs 59.9 %), and had a higher rate of witnessed collapse compared to those in private homes (40.4 % vs 26.7 %, p < 0.001). Chest compressions were less frequently administered in public places (41.1 % vs 65.5 %, adjusted odds ratio [aOR]: 0.48 [0.31 to 0.75]). Public place cases had a lower proportion of OHCA recognition (51.9 % vs 76.9 %) and longer call-to-OHCA recognition times (108 vs 79 s) than those in private homes. Callers in public places more often encountered hazardous environments or physical barriers (16.4 % vs 8.3 %) and refused to execute instructions (11.0 % vs 4.1 %), but faced fewer emotional or psychological obstacles (0 % vs 8.3 %). Family members in private homes had a higher proportion of chest compressions (67.1 % vs 53.8 %, aOR: 1.81 [1.15 to 2.83]) and shorter times to chest compression (160 s vs 171 s, adjusted beta: -30 s [-55.6 to -6.3]) compared to non-family members., Conclusion: This study demonstrated reduced DACPR effectiveness in public places compared to private homes, potentially influenced by caller factors, environmental conditions, and the caller-patient relationship. Developing location-specific strategies is essential to enhance DACPR effectiveness., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Aims: The PIVOT trial evaluates the clinical outcomes and ventilatory quality of an automatic pneumatic ventilation method compared to a bag-valve-mask ventilation method in patients who have experienced out-of-hospital cardiac arrest and have had an advanced airway placed., Methods: The PIVOT trial is a pragmatic, open-label, multicenter randomized controlled trial. It aims to recruit 514 patients in Hsinchu County, Taiwan. Adult, non-trauma patients who experience out-of-hospital cardiac arrest, are treated by emergency medical services, and have an advanced airway in place will be randomized. Biweekly cluster randomization will assign EMS teams to either the automatic pneumatic ventilation group or the bag-valve-mask group. Informed consent is waived. The primary outcome is the return of spontaneous circulation, either prehospital or in-hospital. Secondary outcomes include survival to discharge, neurological outcomes, prehospital ventilatory quality, and the content of prehospital resuscitation. Participants will be followed until they pass away or are discharged from the hospital., Conclusion: The PIVOT trial will provide new insight on the clinical effectiveness of automatic pneumatic ventilation in patients experienced out-of-hospital cardiac arrest. Trial number : NCT06067204 in clinicaltrial.gov ., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Objectives: The quality of prehospital resuscitation provided by emergency medical technicians (EMTs) is essential to ensure better outcomes following out-of-hospital cardiac arrests (OHCA). We assessed the quality of prehospital resuscitation by recording time to key prehospital interventions using EMT-worn video devices and investigated its association with outcomes of patients with OHCA., Methods: This retrospective, cross-sectional study included cases of non-traumatic OHCA in adults treated by emergency medical services (EMS) in Hsinchu City, Taiwan, during 2022 and 2023. We used data from high-resolution, chest-mounted wearable cameras to define and measure six quality indices (QIs) for prehospital resuscitation interventions (i.e., time spent recognizing OHCA). To evaluate the association between QI performance and sustained return of spontaneous circulation (ROSC), we used multivariable logistic regression., Results: Of 745 patients eligible for this study, 187 (25.1%) achieved sustained ROSC. Six core QIs were analyzed: recognition of OHCA (median time: 9.0 s), time from recognizing OHCA to initiating cardiopulmonary resuscitation (cardiopulmonary resuscitation [CPR]; 9.0 s), automated external defibrillator setup (34.0 s), time from recognizing OHCA to beginning ventilation (160.0 s), advanced airway management (300 s), and deploying a mechanical CPR device (50 s). The performance of the six QIs were not associated with sustained ROSC (Adjusted odds ratio [95% confidence interval]: 1.00 [0.99-1.00], 0.99 [0.98-1.00], 1.00 [1.00-1.01], 1.00 [1.00-1.00], 1.00 [1.00-1.00], and 0.99 [0.99-1.00], respectively)., Conclusions: This study describes the rate of sustained ROSC and time to key interventions captured by EMT-worn video devices in non-traumatic OHCA patients. Although we found no direct link between QI performance and improved OHCA outcomes, this study highlights the potential of video-assisted QIs to enhance the documentation and understanding of prehospital resuscitation processes. These findings suggest that further refinement and application of these QIs could support more effective resuscitation strategies and training programs.

Background and Aims: Adenoma detection rate (ADR) is a key quality metric in colonoscopy, reflecting the ability to detect adenomas. However, concerns remain regarding the robustness of ADR as a benchmark. In particular, the "one and done" phenomenon may exist in which physicians are less motivated to find additional adenomas after discovery of the first adenoma. To investigate this topic further, our goal was to understand the relationship between single and multiple adenoma detection., Methods: A retrospective cohort study was conducted by using data from 89,587 screening colonoscopies performed by 32 endoscopists within the Sutter Health-Palo Alto Medical Foundation between 2015 and 2020. ADR, single adenoma detection rate (ADR1), and multiple adenoma detection rate (ADR2+) were analyzed by using multivariate logistic regression and linear regression models. Endoscopists were then fit into 4 categories based on median ADR1 and ADR2+ (low ADR1, high ADR2+ ["all or none"], low ADR1, low ADR2+ ["none and done"], high ADR1, high ADR2+ ["all and done"], or high ADR1, low ADR2+ ["one and done"])., Results: The overall ADR was 45.4%. ADR, ADR1, and ADR2+ were significantly associated with similar factors, including older age, male sex, higher body mass index, smoking status, high-risk colonoscopies, Medicare insured, use of mucosal assist devices, longer withdrawal times, adequate preparation, and procedures performed by high-volume, female endoscopists with a longer duration in practice. The median ADR1 and ADR2+ were 23.95% and 21.29%, respectively. ADR1 and ADR2+ were positively correlated (Pearson correlation coefficient [r], .701; P < .001). Only 4 of 32 endoscopists fit our "one and done" category., Conclusions: These findings suggest that ADR1 correlates with ADR2+. Despite concerns, the "one and done" phenomenon is not commonly seen in clinical practice. ADR remains a good surrogate marker for multiple adenoma detection., Competing Interests: Disclosure All authors disclosed no financial relationships. This study was funded by a PAMF Innovation Grant., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Introduction: In comparison to other physical assessment methods, the inconsistency in respiratory evaluations continues to pose a major issue and challenge., Objectives: This study aims to evaluate the difference in the identification ability of different breath sound., Methods/description: In this prospective study, breath sounds from the Formosa Archive of Breath Sound were labeled by five physicians. Six artificial intelligence (AI) breath sound interpretation models were developed based on all labeled data and the labels from the five physicians, respectively. After labeling by AIs and physicians, labels with discrepancy were considered doubtful and relabeled by two additional physicians. The final labels were determined by a majority vote among the physicians. The capability of breath sound identification for humans and AI was evaluated using sensitivity, specificity and the area under the receiver-operating characteristic curve (AUROC)., Results/outcome: A total of 11,532 breath sound files were labeled, with 579 doubtful labels identified. After relabeling and exclusion, there were 305 labels with gold standard. For wheezing, both human physicians and the AI model demonstrated good sensitivities (89.5% vs. 86.0%) and good specificities (96.4% vs. 95.2%). For crackles, both human physicians and the AI model showed good sensitivities (93.9% vs. 80.3%) but poor specificities (56.6% vs. 65.9%). Lower AUROC values were noted in crackles identification for both physicians and the AI model compared to wheezing., Conclusion: Even with the assistance of artificial intelligence tools, accurately identifying crackles compared to wheezing remains challenging. Consequently, crackles are unreliable for medical decision-making, and further examination is warranted., (© 2024. The Author(s).)

Objectives: Few reports have indicated the secular trend in the sudden cardiac death (SCD) incidence and pre-arrest comorbidities. This study aimed to comprehensively analyze the trend of SCD incidence and its association with pre-arrest comorbidities., Methods: This population-based cohort study analyzed Taiwan's National Health Insurance (NHI) research database and identified SCD incidents by inspecting data from all emergency department visits from 2011 to 2018. The inclusion criteria were ICD-9:427.5 or 427.41, or ICD-10:I46.9, I46.8, or I46.2. Pre-existing comorbidities were confirmed based on medication use. Multivariable logistic regression was adopted with covariates age, sex, and pre-existing comorbidities., Results: This study reviewed a total of 184,164,969 person-year records, and identified 92,138 SCD incidents. From 2011 to 2018, the SCD incidence rate increased from 36.3 to 55.4 per 100,000 enrollees in Taiwan. The top five pre-arrest comorbidities were stable, while the prevalence of chronic kidney disease rose significantly. Compared to those aged 20-29, enrollees aged >65 years had significantly higher odds of SCD (aOR:27.30, 95% CI:26.05-28.61). Higher odds of SCD were noted in the enrollees who had a seizure (aOR:2.24, 95% CI:2.12-2.38), parkinsonism (aOR:1.81, 95% CI:1.73-1.89), psychological disorders (aOR:1.59, 95% CI:1.56-1.62), diabetes mellitus (aOR:1.44, 95% CI:1.41-1.46), heart diseases (aOR:1.41, 95% CI:1.38-1.44)., Conclusions: The incidence of SCD steadily increased in Taiwan from 2011 to 2018. Hypertension, diabetes mellitus, heart disease, psychological disorders, and arthritis were major pre-arrest comorbidities. Age is the most important risk factor for SCD. Further large-scaled population-based study that investigated in diverse ethnicities from countries in addition to Asians would be warranted., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Recurrent Clostridioides difficile infection (rCDI) often occurs after standard-of-care antibiotics. VOWST oral spores (VOS, previously SER-109), an FDA-approved orally administered microbiome therapeutic, is indicated to prevent rCDI following antibiotics for rCDI., Objective, Design, and Patients: To evaluate safety and efficacy of VOS from two phase 3 trials, (randomized, placebo-controlled [ECOSPOR III: NCT03183128] and open-label, single arm [ECOSPOR IV: NCT03183141]) of 349 adults with rCDI and prevalent comorbidities., Methods: VOS or placebo [ECOSPOR III only] (4 capsules once daily for 3 days). Integrated analysis of treatment-emergent adverse events (TEAEs) collected through week 8; serious TEAEs and TEAEs of special interest collected through week 24; and rates of rCDI (toxin-positive diarrhea requiring treatment) evaluated through weeks 8 and 24., Results: TEAEs were mostly mild or moderate and gastrointestinal. Most common treatment-related TEAEs were flatulence, abdominal pain and distension, fatigue, and diarrhea. There were 11 deaths (3.2%) and 48 patients (13.8%) with serious TEAEs, none treatment-related. The rCDI rate through week 8 was 9.5% (95% CI 6.6-13.0) and remained low through 24 weeks (15.2%; 95% CI 11.6-19.4). Safety and rCDI rates were consistent across subgroups including age, renal impairment/failure, diabetes, and immunocompromise/immunosuppression., Conclusions: VOS was well tolerated and rates of rCDI remained low through week 24 including in those with comorbidities. These data support the potential benefit of VOS following antibiotics to prevent recurrence in high-risk patients., Trial Registration: ClinicalTrials.gov identifier, NCT03183128 and NCT03183141., (© 2024. The Author(s).)

Background and Importance: Out-of-hospital cardiac arrest (OHCA) poses major public health issues. Pre-arrest heart function is a prognostic factor, but the specific contribution of pre-arrest echocardiographic evaluation in predicting OHCA outcome remains limited., Objective: The primary objective was to investigate the association between left ventricular ejection fraction (LVEF) measured in echocardiography prior to OHCA and survival to hospital discharge., Design, Settings, and Participants: This multicenter retrospective cohort study analyzed data from the National Taiwan University Hospital and its affiliated hospitals. We included adult nontraumatic OHCA patients who were treated by the emergency medical services (EMS) and underwent echocardiography within 6 months prior to the OHCA event from January 2016 to December 2022. Data included demographics, preexisting diseases, resuscitation events, and echocardiographic reports., Outcomes Measure and Analysis: The primary outcome was the survival to hospital discharge after post-arrest care. Statistical analysis involved multivariable logistic regression to modify potential confounders, reported as adjusted odds ratio (aOR) and 95% confidence interval (CI), and evaluate the association between echocardiographic findings and survival to hospital discharge., Main Results: This study analyzed 950 patients, with 33.6% surviving to discharge. A higher pre-arrest LVEF was independently associated with increased survival. Compared to patients with LVEF < 40%, those with LVEF between 40% and 60% had significantly higher odds of survival (aOR = 3.68, 95% CI = 2.14-6.35, P < 0.001), and those with LVEF > 60% had even greater odds of survival (aOR = 5.46, 95% CI = 3.09-9.66, P < 0.001). There was also an association between lower tricuspid regurgitation pressure gradient and survival (aOR = 0.98, 95% CI = 0.97-1.00, P = 0.015). Younger age, male gender, dyslipidemia, stroke, cancer, witnessed arrest, initial shockable rhythm, and shorter low-flow time are other significant predictors of survival., Conclusion: In adult, nontraumatic, EMS-treated OHCA patients, a higher LVEF 6 months prior to OHCA was associated with improved survival at hospital discharge., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Video-assisted thoracoscopic surgery (VATS) has been widely used for low invasiveness and shorter recovery time. However, patients receiving VATS still experienced moderate-to-severe pain even under both regional and systemic analgesia. Little is known on the effect of non-pharmaceutical method with physical stabilization for post-VATS pain control. The study aims to investigate the feasibility of physical stabilization as a surrogate method for pain control. The single-blinded, randomized-controlled trial recruited the patients into physical stabilization group and standard care group after VATS. The patients in the intervention group tied a thoracic belt for all day, while the control group did not. Both groups had intravenous patient-controlled analgesia (IVPCA) and on-demand oral analgesics. The primary outcome was the visual analogue scale for pain at the 6th, 24th and 48th hour post-VATS and at the hospital discharge. There were 18 patients assigned to the interventional group and 18 patients assigned to the control group. Four patients in the control group were dropped out from the study. Physical stabilization was found to enhance the analgesic effect post-operative 24-48 h compared to standard care (Difference of VAS: 1.11 ± 0.68 v.s. 0.5 ± 0.86, p = 0.031). It had no effect on the dose of IVPCA or the use of oral analgesic agents. No complications direct to the thoracic belt or adverse outcome from the surgery were found in the study. Physical stabilization with thoracic belt to patients receiving VATS benefits to pain control, especially between the 24th and 48th hour post-VATS. Clinical Trial Registry number: NCT04735614., (© 2024. Italian Society of Surgery (SIC).)

Background: The survival trend and factors influencing short- and mid-term mortality in Asian out-of-hospital cardiac arrest (OHCA) survivors should be elucidated. We performed survival analyses on days 3 and 30, hypothesizing decreased survival rates within the initial 3 days post-resuscitation. Additionally, variables linked to mortality at these two timepoints were examined., Methods: We performed a retrospective analysis on adult nontraumatic OHCA survivors admitted to the National Taiwan University Hospital and its branches between 2017 and 2021. We collected the following variables from the NTUH-Integrative Medical Database: basic characteristics, cardiopulmonary resuscitation events, inotrope administration, and post-resuscitation management. The outcomes included 3- and 30-day mortality. Subgroup analyses with the Kaplan-Meier method explored the survival probability of the OHCA survivors and assessed differences in cumulative survival among subgroups. Cox proportional hazards model was used to estimate adjusted hazard ratios with 95% confidence interval., Results: Of the 967 survivors, 273 (28.2%) and 604 (62.5%) died within 3 and 30 days, respectively. The 30-day survival curve after OHCA showed an uneven decline, with the most significant decrease within the first 3 days of admission. Various risk factors influence mortality at 3- and 30-day intervals. Although increased age, noncardiac etiology, and prolonged low-flow time increased mortality risks, bystander CPR, targeted temperature management, and continuous renal replacement therapy were associated with reduced mortality at 3- and 30-day timeframes., Conclusion: Survival declined in most OHCA survivors within 3 days post-resuscitation. The risk factors associated with mortality at 3- and 30-day intervals varied in this population., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Purpose: This study aimed to assess the prevalence and factors of physical, psychological, and social frailty among older adults in the emergency department, comparing these data with community population to understand emergency setting manifestations., Methods: Conducted at the Emergency Department of National Taiwan University BioMedical Park Hospital, this prospective observational cohort study enrolled older adult patients over a three-month period. Frailty assessments included the Study of Osteoporotic Fractures scale for physical frailty, the Tilburg Frailty Indicator for psychological frailty, and the Makizako Social Frailty Index for social frailty. Data analysis involved a multivariable logistic model to determine the risk factors associated with each frailty type., Results: Out of 991 older adult individuals seeking medical care, 207 participated in the study. The study found high prevalence rates of frailty: 46.38% for physical, 41.06% for psychological, and 48.79% for social frailty. Risk factors for frailty included older age and a history of falls. Interestingly, the prevalence of social frailty was notably higher than physical and psychological frailty. Gender and polypharmacy showed no significant association with any frailty type., Conclusion: This research reveals high physical, psychological, and social frailty among older ED patients, especially noting social frailty's prevalence. It highlights the importance for emergency care to adopt holistic care strategies that address older adults' multifaceted health challenges, suggesting a paradigm shift in current healthcare practices to better cater to the multifaceted needs of this vulnerable population., (© 2024. The Author(s), under exclusive licence to the Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Objective: To compare the effectiveness of intraosseous versus intravenous vascular access in the treatment of adult patients with out-of-hospital cardiac arrest., Design: Cluster randomised controlled trial., Setting: The VICTOR (Venous Injection Compared To intraOsseous injection during resuscitation of patients with out-of-hospital cardiac arrest) trial involved emergency medical service agencies with all four advanced life support ambulance teams in Taipei City, Taiwan. The enrolment period spanned 6 July 2020 to 30 June 2023 and was temporarily suspended between 20 May 2021 and 31 July 2021 owing to the covid-19 pandemic., Participants: Adult (age 20-80 years) patients with non-traumatic out-of-hospital cardiac arrest., Interventions: Biweekly randomised clusters of four participating advanced life support ambulance teams were assigned to insert either intravenous or intraosseous access., Main Outcome Measures: The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation, sustained return of spontaneous circulation (≥2 hours), and survival with favourable neurological outcomes (cerebral performance category score ≤2) at hospital discharge., Results: Among 1771 enrolled patients, 1732 (741 in the intraosseous group and 991 in the intravenous group) were included in the primary analysis (median age 65.0 years; 1234 (71.2%) men). In the intraosseous group, 79 (10.7%) patients were discharged alive, compared with 102 (10.3%) patients in the intravenous group (odds ratio 1.04, 95% confidence interval 0.76 to 1.42; P=0.81). The odds ratio of intraosseous versus intravenous access was 1.23 (0.89 to 1.69; P=0.21) for pre-hospital return of spontaneous circulation, 0.92 (0.75 to 1.13; P=0.44) for sustained return of spontaneous circulation, and 1.17 (0.82 to 1.66; P=0.39) for survival with favourable neurological outcomes., Conclusions: Among adults with non-traumatic out-of-hospital cardiac arrest, initial attempts to establish vascular access through the intraosseous route did not result in different outcomes compared with intravenous access in terms of the proportion of patients surviving to hospital discharge, pre-hospital return of spontaneous circulation, sustained return of spontaneous circulation, and favourable neurological outcomes., Trial Registration: NCT04135547ClinicalTrials.gov NCT04135547., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: this study was supported by the Taiwan Ministry of Science and Technology, National Science and Technology Council, and National Taiwan University Hospital, Yun-Lin Branch; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Peanut is an important food that can cause food allergies, often leading to moderate and severe allergic symptoms such as skin rashes, asthma, and even anaphylactic shock.Research indicates that Ara h 3 is one of the major peanut allergen. In order to establish a simple analytical method for detecting Ara h 3, we developed a sandwich enzyme-linked immunosorbent assay (ELISA) with antibodies that were induced from purified Ara h 3. The experimental results showed that the purified Ara h 3 had good purity, and we successfully prepared capture and detection antibodies. The method established in this study exhibited high specificity and did not cross-react with soybeans, cashew nuts, and sesame. For validation, including precision, recovery and sensitivity were in good condition. We also detected the Ara h 3 in peanut related foods. Overall, the ELISA developed in this study is a reliable method for Ara h 3 detection., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background and Importance: This study compared the on-scene Glasgow Coma Scale (GCS) and the GCS-motor (GCS-M) for predictive accuracy of mortality and severe disability using a large, multicenter population of trauma patients in Asian countries., Objective: To compare the ability of the prehospital GCS and GCS-M to predict 30-day mortality and severe disability in trauma patients., Design: We used the Pan-Asia Trauma Outcomes Study registry to enroll all trauma patients >18 years of age who presented to hospitals via emergency medical services from 1 January 2016 to November 30, 2018., Settings and Participants: A total of 16,218 patients were included in the analysis of 30-day mortality and 11 653 patients in the analysis of functional outcomes., Outcome Measures and Analysis: The primary outcome was 30-day mortality after injury, and the secondary outcome was severe disability at discharge defined as a Modified Rankin Scale (MRS) score ≥4. Areas under the receiver operating characteristic curve (AUROCs) were compared between GCS and GCS-M for these outcomes. Patients with and without traumatic brain injury (TBI) were analyzed separately. The predictive discrimination ability of logistic regression models for outcomes (30-day mortality and MRS) between GCS and GCS-M is illustrated using AUROCs., Main Results: The primary outcome for 30-day mortality was 1.04% and the AUROCs and 95% confidence intervals for prediction were GCS: 0.917 (0.887-0.946) vs. GCS-M:0.907 (0.875-0.938), P  = 0.155. The secondary outcome for poor functional outcome (MRS ≥ 4) was 12.4% and the AUROCs and 95% confidence intervals for prediction were GCS: 0.617 (0.597-0.637) vs. GCS-M: 0.613 (0.593-0.633), P  = 0.616. The subgroup analyses of patients with and without TBI demonstrated consistent discrimination ability between the GCS and GCS-M. The AUROC values of the GCS vs. GCS-M models for 30-day mortality and poor functional outcome were 0.92 (0.821-1.0) vs. 0.92 (0.824-1.0) ( P  = 0.64) and 0.75 (0.72-0.78) vs. 0.74 (0.717-0.758) ( P  = 0.21), respectively., Conclusion: In the prehospital setting, on-scene GCS-M was comparable to GCS in predicting 30-day mortality and poor functional outcomes among patients with trauma, whether or not there was a TBI., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Computed tomography (CT) is frequently performed in the patients who admitted to the emergency department (ED), discharged but returned to ED within 72 h. It is unknown whether the main complaints of patients assist physicians to use CT effectively. This study aimed to find the association between chief complaints and the CT results., Methods: This three-year retrospective cohort study was conducted in the ED of a tertiary medical center. Adult patients who returned to the ED after the index visit were included from 2019 to 2021. Demographics, pre-existing diseases, chief complaints, and CT region were recorded by independent ED physicians. A logistic regression model with an odds ratio (OR) and 95% confidence interval (CI) was used to determine the relationship between chief complaints and positive CT results., Results: In total, 7,699 patients revisited ED after the index visit; 1,202 (15.6%) received CT. The top chief complaints in patients who received CT were abdominal pain, dizziness, and muscle weakness. Patients with abdominal pain or gastrointestinal symptoms had a significantly higher rate of positive abdominopelvic CT than those without it (OR 2.83, 95% CI 1.98-4.05, p < 0.001), while the central nervous system and cardiopulmonary chief complaints were not associated (or negatively associated) with new positive CT findings., Conclusion: Chief complaints of patients on revisit to the ED are associated with different yields of new findings when CT scans of the chest, abdomen and head are performed. Physicians should consider these differential likelihoods of new positive findings based on these data., (© 2024. The Author(s).)

Background: High-risk emergency department (ED) revisit is considered an important quality indicator that may reflect an increase in complications and medical burden. However, because of its multidimensional and highly complex nature, this factor has not been comprehensively investigated. This study aimed to predict high-risk ED revisit with a machine-learning (ML) approach., Methods: This 3-year retrospective cohort study assessed adult patients between January 2019 and December 2021 from National Taiwan University Hospital Hsin-Chu Branch with high-risk ED revisit, defined as hospital or intensive care unit admission after ED return within 72 hours. A total of 150 features were preliminarily screened, and 79 were used in the prediction model. Deep learning, random forest, extreme gradient boosting (XGBoost) and stacked ensemble algorithm were used. The stacked ensemble model combined multiple ML models and performed model stacking as a meta-level algorithm. Confusion matrix, accuracy, sensitivity, specificity and area under the receiver operating characteristic curve (AUROC) were used to evaluate performance., Results: Analysis was performed for 6282 eligible adult patients: 5025 (80.0%) in the training set and 1257 (20.0%) in the testing set. High-risk ED revisit occurred for 971 (19.3%) of training set patients vs 252 (20.1%) in the testing set. Leading predictors of high-risk ED revisit were age, systolic blood pressure and heart rate. The stacked ensemble model showed more favourable prediction performance (AUROC 0.82) than the other models: deep learning (0.69), random forest (0.78) and XGBoost (0.79). Also, the stacked ensemble model achieved favourable accuracy and specificity., Conclusion: The stacked ensemble algorithm exhibited better prediction performance in which the predictions were generated from different ML algorithms to optimally maximise the final set of results. Patients with older age and abnormal systolic blood pressure and heart rate at the index ED visit were vulnerable to high-risk ED revisit. Further studies should be conducted to externally validate the model., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Gastric adenocarcinoma (GAC) is often diagnosed at advanced stages and portends a poor prognosis. We hypothesized that electronic health records (EHR) could be leveraged to identify individuals at highest risk for GAC from the population seeking routine care., Methods: This was a retrospective cohort study, with endpoint of GAC incidence as ascertained through linkage to an institutional tumor registry. We utilized 2010 to 2020 data from the Palo Alto Medical Foundation, a large multispecialty practice serving Northern California. The analytic cohort comprised individuals ages 40-75 receiving regular ambulatory care. Variables collected included demographic, medical, pharmaceutical, social, and familial data. Electronic phenotyping was based on rule-based methods., Results: The cohort comprised 316,044 individuals and approximately 2 million person-years (p-y) of observation. 157 incident GACs occurred (incidence 7.9 per 100,000 p-y), of which 102 were non-cardia GACs (incidence 5.1 per 100,000 p-y). In multivariable analysis, male sex [HR: 2.2, 95% confidence interval (CI): 1.6-3.1], older age, Asian race (HR: 2.5, 95% CI: 1.7-3.7), Hispanic ethnicity (HR: 1.9, 95% CI: 1.1-3.3), atrophic gastritis (HR: 4.6, 95% CI: 2.2-9.3), and anemia (HR: 1.9, 95% CI: 1.3-2.6) were associated with GAC risk; use of NSAID was inversely associated (HR: 0.3, 95% CI: 0.2-0.5). Older age, Asian race, Hispanic ethnicity, atrophic gastritis, and anemia were associated with non-cardia GAC., Conclusions: Routine EHR data can stratify the general population for GAC risk., Impact: Such methods may help triage populations for targeted screening efforts, such as upper endoscopy., (©2024 American Association for Cancer Research.)

Introduction: Adenoma detection rate (ADR) is an accepted benchmark for screening colonoscopy. Factors driving ADR and its relationship with sessile serrated lesions detection rate (SSLDR) over time remain unclear. We aim to explore patient, physician, and procedural influences on ADR and SSLDR trends., Methods: Using a large healthcare system in northern California from January 2010 to December 2020, a total of 146,818 screening colonoscopies performed by 33 endoscopists were included. ADR and SSLDR were calculated over time using natural language processing. Logistic regression was used to calculate the odd ratios of patient demographics, physician attributes, and procedural details over time., Results: Between 2010 and 2020, ADR rose from 19.4% to 44.4%, whereas SSLDR increased from 1.6% to 11.6%. ADR increased by 2.7% per year (95% confidence interval 1.9%-3.4%), and SSLDR increased by 1.0% per year (95% confidence interval 0.8%-1.2%). Higher ADR was associated with older age, male sex, higher body mass index, current smoker, higher comorbidities, and high-risk colonoscopy. By contrast, SSLDR was associated with younger age, female sex, white race, and fewer comorbidities. Patient and procedure characteristics did not significantly change over time ( P -interaction >0.05). Longer years in practice and male physician were associated with lower ADR and SSLDR in 2010, but significantly attenuated over time ( P -interaction <0.05)., Discussion: Both ADR and SSLDR have increased over time. Patient and procedure factors did not significantly change over time. Male endoscopist and longer years in practice had lower initial ADR and SSLDR, but significantly lessened over time., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

There remains a need to develop novel SARS-CoV-2 therapeutic options that improve upon existing therapies by an increased robustness of response, fewer safety liabilities, and global-ready accessibility. Functionally critical viral main protease (M pro , 3CL pro ) of SARS-CoV-2 is an attractive target due to its homology within the coronaviral family, and lack thereof toward human proteases. In this disclosure, we outline the advent of a novel SARS-CoV-2 3CL pro inhibitor, CMX990 , bearing an unprecedented trifluoromethoxymethyl ketone warhead. Compared with the marketed drug nirmatrelvir (combination with ritonavir = Paxlovid), CMX990 has distinctly differentiated potency (∼5× more potent in primary cells) and human in vitro clearance (>4× better microsomal clearance and >10× better hepatocyte clearance), with good in vitro -to- in vivo correlation. Based on its compelling preclinical profile and projected once or twice a day dosing supporting unboosted oral therapy in humans, CMX990 advanced to a Phase 1 clinical trial as an oral drug candidate for SARS-CoV-2.

Background: Studies have established that sex and age influence outcomes following out-of-hospital cardiac arrest (OHCA). However, a knowledge gap exists regarding their interaction. This study aimed to investigate the interaction of age and sex and how they cooperatively influence OHCA outcomes., Methods: This retrospective cohort study included adult, nontraumatic OHCA patients admitted to a university hospital and its affiliated hospitals in Taiwan from January 2017 to December 2021. Data including sex, age, body mass index, cardiac rhythm, and resuscitation information in the emergency department (ED) were collected from medical records. The study outcomes encompassed survival to intensive care unit (ICU) admission, survival to hospital discharge, and a favorable neurological outcome. Multivariable logistic regression was performed to estimate the influence of sex on study outcomes., Results: We analyzed a total of 2,826 eligible subjects categorized into three groups: young (18-44 years, 149 males and 57 females), middle-aged (45-64 years, 524 males and 188 females), and old (≥65 years, 1,049 males and 859 females). Analysis of the effects of sex according to age stratification showed that old males had higher odds for survival to ICU admission (OR: 1.49, 95% CI: 1.21-1.83) and favorable neurological outcomes (OR: 2.74, 95% CI: 1.58-4.76) than did old females. Analysis of the effects of age according to sex stratification revealed that old males had lower odds for survival to hospital discharge (OR: 0.33, 95% CI: 0.21-0.51) and favorable neurological outcomes (OR: 0.26, 95% CI: 0.16-0.43) than did young males. Old females also showed the same trend as males, with lower odds for survival to hospital discharge (OR: 0.37, 95% CI: 0.17-0.78) and favorable neurological outcomes (OR: 0.11, 95% CI: 0.05-0.25) than did young females., Conclusions: The interaction between sex and age in patients with OHCA results in diverse outcomes. Within the same sex, age demonstrated varying effects on distinct outcomes., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Objective: This study aims to describe out-of-hospital cardiac arrest (OHCA) characteristics and trends before and during the coronavirus disease-2019 (COVID-19) pandemic in Taiwan., Methods: We conducted a retrospective cohort study using a 5-year interrupted time series analysis. Eligible adults with non-traumatic OHCAs from January 2017 to December 2021 in 3 hospitals (university medical center, urban second-tier hospital, and rural second-tier hospital) were retrospectively enrolled. Variables were extracted from the emergency medical service reports and medical records. The years 2020 and 2021 were defined as the COVID-19 pandemic period. Outcomes included survival to admission after a sustained return of spontaneous circulation, survival to hospital discharge, and good neurological outcomes (cerebral performance category score 1 or 2)., Results: We analyzed 2819 OHCA, including 1227 from a university medical center, 617 from an urban second-tier hospital, and 975 from a rural second-tier hospital. The mean age was 71 years old, and 60% of patients were males. During the COVID-19 pandemic period, video-assisted endotracheal tube intubation replaced the traditional direct laryngoscopy intubation. The trends of outcomes in the pre-pandemic and pandemic periods varied among different hospitals. Compared with the pre-pandemic period, the outcomes at the university medical center during the COVID-19 pandemic were significantly poorer in several respects. The survival rate on admission dropped from 44.6% to 39.4% ( P  = 0.037), and the survival rate to hospital discharge fell from 17.5% to 14.9% ( P  = 0.042). Additionally, there was a notable decrease in patients' good neurological outcomes, declining from 13.2% to 9.7% ( P  = 0.048). In contrast, the outcomes in urban and rural second-tier hospitals during the COVID-19 pandemic did not significantly differ from those in the pre-pandemic period., Conclusions: COVID-19 may alter some resuscitation management in OHCAs. There were no overall significant differences in outcomes before and during COVID-19 pandemic, but there were significant differences in outcomes when stratified by hospital types., Competing Interests: The authors have no conflicts of interest to declare., (© 2023 The Authors. Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Shrimp allergy is a serious public health problem. Epidemiological studies indicated the main cause of food allergy is the ingestion of shrimp and crab. Consequently, reducing the risk of shrimp and crab allergy is a major research focus. Few studies have demonstrated the effect of enzyme hydrolysis on reduction of shrimp allergens in food. In this study, we used papain, a commonly used enzyme in the food industry, as an ingredient to decrease levels of allergen tropomyosin in shrimp. 0-50U of papain was used to treat the shrimp meat, and then heated to measure the levels of tropomyosin, and determined the change of the protein secondary structure. The results showed that 20U of papain decrease the tropomyosin levels up to 80 %, which was further enhanced when combined with 3 min of heating. Furthermore, the result of Fourier-transform infrared spectroscopy (FTIR) showed alteration of secondary protein structure after the processing. The processing developed in this study may be an effective method used to change the levels and structure of tropomyosin., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors.)

Background: Data about changes in the characteristics of ED return visits before and after the COVID-19 outbreak are limited. This study aimed to report the differences on utility in ED return visits after the COVID-19 outbreak., Methods: This retrospective cohort study was conducted from 2019 to 2020. Adult patients with ED return visits were included in the analysis. Variables including demographic characteristics, pre-comorbidities, triage levels, vital signs, chief complaints, management, and diagnosis were recorded and confirmed via a manual assessment., Results: The proportion of patients with ED visits decreased by 23%. Hence, that of patients with ED return visits also reduced from 2580 to 2020 patients (22%) after the COVID-19 outbreak. The average age (60-57.8 years) of patients with return visits was significantly younger, and the proportion of female patients decreased remarkably. Further, the proportion of patients with chronic pre-existing diseases at the return visit significantly differed after the COVID-19 outbreak. The proportion of patients with chief complaints including dizziness, dyspnea, cough, vomiting, diarrhea, and chills during the return visits significantly differed before and after the COVID-19 pandemic. In the multivariable logistic regression model, age, high triage level were significantly associated with unfavorable outcome return visit., Conclusion: The use of services in the ED has changed since the COVID-19 outbreak. Hence, the proportion of patients with unplanned return visits within 72 h decreased. After the COVID-19 outbreak, people are now cautious whether they should return to the ED, as in the pre-pandemic situation, or just treat conservatively at home., Competing Interests: Declaration of competing interest The authors declare no conflict of interests., (Copyright © 2023 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: Bacteremia is a severe complication of infectious disease. Patients with a high bacteremia risk in the emergency department (ED) but misidentified would lead to the unscheduled revisits. This study aimed to develop a simplified scoring model to predict bacteremia in patients with unscheduled ED revisits., Methods: Adult patients with unscheduled ED revisits within 72 h with a final diagnosis of infectious disease were retrospectively included. The development cohort included patients visiting the ED from January 1, 2019 to December 31, 2021. Internal validation was performed in patients visiting the ED from January 1, 2022 to March 31, 2022. Variables including demographics, pre-comorbidities, triage levels, vital signs, chief complaints, and laboratory data in the index visit were analyzed. Bacteremia was the primary outcome determined by blood culture in either index visits or revisits., Results: The SADFUL score for predicting bacteremia comprised the following predictors: "S"egmented neutrophil percentage (+3 points), "A"ge > 55 years (+1 point), "D"iabetes mellitus (+1 point), "F"ever (+2 points), "U"pper respiratory tract symptoms (-2 points), and "L"eukopenia (2 points). The area under receiver operating characteristic curve with 95% confidence interval in the development (1802 patients, 190 [11%] with bacteremia) and the validation cohort (134 patients, 17 [13%] with bacteremia) were 0.78 (0.74-0.81) and 0.79 (0.71-0.88), respectively., Conclusions: The SADFUL score is a simplified useful tool for predicting bacteremia in patients with unscheduled ED revisits. The scoring model could help ED physicians decrease misidentification of patients at a high risk for bacteremia and potential complications., Competing Interests: Declaration of competing interest The authors declared no conflict of interest., (Copyright © 2023. Published by Elsevier B.V.)

Aims: Acute cardiovascular (CV) emergencies are critical conditions that require urgent attention in the emergency department (ED). Failure to make a timely diagnosis may result in unscheduled ED revisits and severe outcomes. Therefore, this study aimed to investigate the risk factors associated with potentially missed acute CV emergencies., Methods and Results: This retrospective study enrolled adult patients who presented with chest pain and returned to the ED within 72 h. Demographic information, pre-existing medical conditions, chief complaints, triage level and vital signs, electrocardiography (ECG) reports, and laboratory data were collected from medical charts by independent physicians. The primary outcome was the diagnosis of acute CV diseases, including ACS, pulmonary embolism, unstable arrhythmia, acute decompensated heart failure, and aortic dissection. Multivariable logistic regression was used to analyze the association between variables and acute CV emergencies. A total of 453 eligible patients were included, with 60 (13.2%) patients diagnosed as acute CV emergencies at the ED revisit. Risk factors for acute CV emergencies included male gender (adjusted odds ratio [aOR] = 2.71, 95% confidence interval [CI] = 1.17-6.25), abnormal ECG rhythm (aOR = 10.33, 95% CI = 4.68-22.83), and abnormal changes in high sensitivity Troponin-T (hs-cTnT) during sequential follow-up (aOR = 6.52, 95% CI = 2.19-19.45)., Conclusions: Male gender, abnormal ECG rhythm, and a significant increase in sequential follow-up hs-cTnT levels were identified as significant risk factors for acute CV emergencies. ED physicians should recognize these high-risk patients with chest pain to prevent misdiagnosis and potential severe complications., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)

In-hospital cardiac arrest (IHCA) in the emergency department (ED) is not uncommon but often fatal. Using the machine learning (ML) approach, we sought to predict ED-based IHCA (EDCA) in patients presenting to the ED based on triage data. We retrieved 733,398 ED records from a tertiary teaching hospital over a 7 year period (Jan. 1, 2009-Dec. 31, 2015). We included only adult patients (≥ 18 y) and excluded cases presenting as out-of-hospital cardiac arrest. Primary outcome (EDCA) was identified via a resuscitation code. Patient demographics, triage data, and structured chief complaints (CCs), were extracted. Stratified split was used to divide the dataset into the training and testing cohort at a 3-to-1 ratio. Three supervised ML models were trained and performances were evaluated and compared to the National Early Warning Score 2 (NEWS2) and logistic regression (LR) model by the area under the receiver operating characteristic curve (AUC). We included 316,465 adult ED records for analysis. Of them, 636 (0.2%) developed EDCA. Of the constructed ML models, Random Forest outperformed the others with the best AUC result (0.931, 95% CI 0.911-0.949), followed by Gradient Boosting (0.930, 95% CI 0.909-0.948) and Extra Trees classifier (0.915, 95% CI 0.892-0.936). Although the differences between each of ML models and LR (AUC: 0.905, 95% CI 0.882-0.926) were not significant, all constructed ML models performed significantly better than using the NEWS2 scoring system (AUC 0.678, 95% CI 0.635-0.722). Our ML models showed excellent discriminatory performance to identify EDCA based only on the triage information. This ML approach has the potential to reduce unexpected resuscitation events if successfully implemented in the ED information system., (© 2022. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Importance: A safe and effective treatment for recurrent Clostridioides difficile infection (CDI) is urgently needed. Antibiotics kill toxin-producing bacteria but do not repair the disrupted microbiome, which promotes spore germination and infection recurrence., Objectives: To evaluate the safety and rate of CDI recurrence after administration of investigational microbiome therapeutic SER-109 through 24 weeks., Design, Setting, and Participants: This phase 3, single-arm, open-label trial (ECOSPOR IV) was conducted at 72 US and Canadian outpatient sites from October 2017 to April 2022. Adults aged 18 years or older with recurrent CDI were enrolled in 2 cohorts: (1) rollover patients from the ECOSPOR III trial who had CDI recurrence diagnosed by toxin enzyme immunoassay (EIA) and (2) patients with at least 1 CDI recurrence (diagnosed by polymerase chain reaction [PCR] or toxin EIA), inclusive of their acute infection at study entry., Interventions: SER-109 given orally as 4 capsules daily for 3 days following symptom resolution after antibiotic treatment for CDI., Main Outcomes and Measures: The main outcomes were safety, measured as the rate of treatment-emergent adverse events (TEAEs) in all patients receiving any amount of SER-109, and cumulative rates of recurrent CDI (toxin-positive diarrhea requiring treatment) through week 24 in the intent-to-treat population., Results: Of 351 patients screened, 263 were enrolled (180 [68.4%] female; mean [SD] age, 64.0 [15.7] years); 29 were in cohort 1 and 234 in cohort 2. Seventy-seven patients (29.3%) were enrolled with their first CDI recurrence. Overall, 141 patients (53.6%) had TEAEs, which were mostly mild to moderate and gastrointestinal. There were 8 deaths (3.0%) and 33 patients (12.5%) with serious TEAEs; none were considered treatment related by the investigators. Overall, 23 patients (8.7%; 95% CI, 5.6%-12.8%) had recurrent CDI at week 8 (4 of 29 [13.8%; 95% CI, 3.9%-31.7%] in cohort 1 and 19 of 234 [8.1%; 95% CI, 5.0%-12.4%] in cohort 2), and recurrent CDI rates remained low through 24 weeks (36 patients [13.7%; 95% CI, 9.8%-18.4%]). At week 8, recurrent CDI rates in patients with a first recurrence were similarly low (5 of 77 [6.5%; 95% CI, 2.1%-14.5%]) as in patients with 2 or more recurrences (18 of 186 [9.7%; 95% CI, 5.8%-14.9%]). Analyses by select baseline characteristics showed consistently low recurrent CDI rates in patients younger than 65 years vs 65 years or older (5 of 126 [4.0%; 95% CI, 1.3%-9.0%] vs 18 of 137 [13.1%; 95% CI, 8.0%-20.0%]) and patients enrolled based on positive PCR results (3 of 69 [4.3%; 95% CI, 0.9%-12.2%]) vs those with positive toxin EIA results (20 of 192 [10.4%; 95% CI, 6.5%-15.6%])., Conclusions and Relevance: In this trial, oral SER-109 was well tolerated in a patient population with recurrent CDI and prevalent comorbidities. The rate of recurrent CDI was low regardless of the number of prior recurrences, demographics, or diagnostic approach, supporting the beneficial impact of SER-109 for patients with CDI., Trial Registration: ClinicalTrials.gov identifier: NCT03183141.

Objective: Injury is a major cause of morbidity and mortality in children. However, the epidemiology and prehospital care for pediatric unintentional injuries in Asia are still unclear., Methods: A total of 9,737 pediatric patients aged <18 years with unintentional injuries cared for at participating centers of the Pan-Asian Trauma Outcome Study (PATOS) from October 2015 to December 2020 were reviewed retrospectively. Patients were divided into two groups: those <8 and those ≥8 years of age. Variables such as patient demographics, injury epidemiology, Injury Severity Score (ISS), and prehospital care were collected. Injury severity and administered prehospital care stratified by gross national income were also analyzed., Results: Pediatric unintentional injuries accounted for 9.4% of EMS-transported trauma cases in the participating Asian centers, and the mortality rate was 0.88%. The leading cause of injury was traffic injuries in older children aged ≥8 years (56.5%), while falls at home were common among young children aged <8 years (43.9%). Compared with younger children, older children with similar ISS tended to receive more prehospital interventions. Uneven disease severity was found in that older children in lower-middle and upper-middle-income countries had higher ISS compared with those in high-income countries. The performance of prehospital interventions also differed among countries with different gross national incomes. Immobilizations were the most performed prehospital intervention followed by oxygen administration, airway management, and pain control; only one patient received prehospital thoracentesis. Procedures were performed more frequently in high-income countries than in upper-middle-income and lower-middle-income countries., Conclusions: The major cause of injury was road traffic injuries in older children, while falls at home were common among young children. Prehospital care in pediatric unintentional injuries in Asian countries was not standardized and might be insufficient, and the economic status of countries may affect the implementation of prehospital care.

Background: This study aimed to investigate the association between the carotid ultrasound results and 1-yr mortality of patients with neurological deficits in the emergency department (ED)., Methods: This study included patients with neurological symptoms who presented to the ED between January 1, 2009 and December 31, 2018, and underwent sonographic imaging of the bilateral carotid bulb, common carotid artery (CCA), internal carotid artery (ICA), and external carotid arteries. A stenosis degree of >50% was defined as significant carotid stenosis. Carotid plaque score (CPS) was calculated by adding the score of stenosis severity of all segments. The association between carotid ultrasound results and 1-yr mortality was investigated using the Cox regression model., Results: The analysis included 7,961 patients (median age: 69 yr; men: 58.7%). Among them, 247 (3.1%) passed away from cardiovascular (CV)-related causes, and 746 (9.4%) died within a year. The mortality group presented with more significant carotid stenosis of the carotid bulb, CCA, or ICA and had a higher median CPS. A higher CPS was associated with a greater 1-yr all-cause mortality (adjusted hazard ratio [aHR] = 1.08; 95% confidence interval [CI] = 1.03-1.13; p = 0.001; log-rank p < 0.001) and CV-related mortality (aHR = 1.13; 95% CI = 1.04-1.22; p = 0.002, log-rank p < 0.001). Significant stenosis of either carotid artery segment did not result in a higher risk of 1-yr mortality., Conclusions: We comprehensively investigated the utility of carotid ultrasound parameters on predicting mortality in this 10-yr population-based cohort, which included over 7,000 patients with acute neurological deficits presented to the ED. The result showed that CPS could be used as risk stratification tools for 1-yr all-cause and CV mortality., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Chen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Termination-of-resuscitation rules (TORRs) in out-of-hospital cardiac arrest (OHCA) patients have been applied in western countries; in Asia, two TORRs were developed and have not been externally validated widely. We aimed to externally validate the TORRs using the registry of Pan-Asian Resuscitation Outcomes Study (PAROS)., Methods: PAROS enrolled 66,780 OHCA patients in seven Asian countries from 1 January 2009 to 31 December 2012. The American Heart Association-Basic Life Support and AHA-ALS (AHA-BLS), AHA-Advanced Life Support (AHA-ALS), Goto, and Shibahashi TORRs were selected. The diagnostic test characteristics and area under the receiver operating characteristic curve (AUC) were calculated. We further determined the most suitable TORR in Asia and analysed the variable differences between subgroups., Results: We included 55,064 patients in the final analysis. The sensitivity, specificity, negative predictive value, positive predictive value, and AUC, respectively, for AHA-BLS, AHA-ALS, Goto, Shibashi TORRs were 79.0%, 80.0%, 19.6%, 98.5%, and 0.80; 48.6%, 88.3%, 9.8%, 98.5%, and 0.60; 53.8%, 91.4%, 11.2%, 99.0%, and 0.73; and 35.0%, 94.2%, 8.4%, 99.0%, and 0.65. In countries using the Goto TORR with PPV<99%, OHCA patients were younger, had more males, a higher rate of shockable rhythm, witnessed collapse, pre-hospital defibrillation, and survival to discharge, compared with countries using the Goto TORR with PPV ≥99%., Conclusions: There was no single TORR fit for all Asian countries. The Goto TORR can be considered the most suitable; however, a high predictive performance with PPV ≥99% was not achieved in three countries using it (Korea, Malaysia, and Taiwan)., Competing Interests: The authors have declared that no competing interests exist.

Background/purpose: During pandemics like SARS-CoV-2, healthcare providers' well-being and morale are in particular at stake. Burnout may substantially hinder the well-being and morale of healthcare providers, challenging our efforts at disease containment. This study investigated the relationship between perceived COVID-19 stigma and burnout symptoms among physicians and nurses. We further aimed to identify potential factors that may moderate this relationship, including profession, clinical contact with COVID-19 patients, and prior experience with 2003 SARS-CoV-1., Methods: We used a web-based, structured survey from March 12th to 29th, 2020 to collect cross-sectional, self-reported data. Participants were provided with a link to the survey which took them on average 5-8 minutes. Survey consisted of demographic characteristics, clinical experiences, perceived COVID-19 related stigma, and burnout symptoms. Linear regression with bootstrapping techniques was adopted to test the relations between stigma and burnout, as well as other potential moderators, while adjusting for demographic and clinical factors., Results: Of the 1421 consented respondents, 357 identified as physicians while 1064 identified as nurses. Participants reported some levels of stigma, and noticeable burnout symptoms. Burnout symptoms were positively correlated with COVID-19 stigma, profession, and currently care for confirmed/suspected COVID-19 patients. The interaction between stigma and profession (Stigma × Nurses) but no other interaction terms reached the significance level, suggesting that the slope for nurses was flatter than the slope for physicians., Conclusion: The study results suggest that COVID-19 stigma may contribute to burnout among physicians and nurses, and this relation may not vary across clinical roles and experiences but profession., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article., (Copyright © 2021. Published by Elsevier B.V.)

Purpose This work aims to conduct a geospatial analysis of recent ultrasound access and usage within the United States, with a particular focus on disparities between rural and urban areas. Methods/Materials Multiple public datasets were merged on a county level, including US Department of Agriculture economic metrics and Centers for Medicare Services data using the most recent years available (2015-2019). From these databases, 39 total variables encompassing the socioeconomic, health, and ultrasound characteristics of each county were obtained. Current Procedural Terminology (CPT) codes incorporated included ultrasound-guided procedures and diagnostic exams. Three thousand eleven counties were included. The combined dataset was then exported to GeoDa for network-based analysis and to produce map visualizations. To identify statistically significant (p < 0.05) hotspots and coldspots in point-of-care ultrasound (POCUS) prevalence, Moran's I was used. Choropleth maps were created for visualization. ANOVA was run across the four Moran's I groups for each of 39 variables of interest. Results A total of 30,135,085 ultrasound-related CPT codes were billed to Medicare over 2015-2019, with 26.55% of codes being ultrasound-guided procedures and 73.45% being diagnostic exams. 38.84% of rural counties had access to POC ultrasound compared to 88.56% of metropolitan counties and 74.19% of counties overall. Hotspots of POCUS were in Southern California and the Eastern US (average of 1,441 per 10,000 Medicare members per year). Coldspot areas were seen in the Great Plains and Midwest (average of 7.43 per 10k Medicare members per year). Hotspot clusters, when compared to coldspot clusters, were significantly (p < 0.001) more dense (703.6 to 14.9 people per square mile), more urbanized (3.5 to 7.1 Rural-Urban Continuum (RUC)), more college-educated (25.1% to 20.0%), more likely to have an Emergency Department (ED) visit (725.8 to 616.9 visits per 1,000 Medicare members), more likely to be obese (19.0% to 12.9%), less likely to be uninsured (10.1% to 13.0%), had more Black representation (8.5% to 3.4%), and less Hispanic representation (2.6% to 5.5%). Conclusions Ultrasound access and usage demonstrate significant geospatial trends across the United States. Hotspot and coldspot counties differ on several key sociodemographic and economic variables., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Peterman et al.)

Background: The association between out-of-hospital cardiac arrest patient survival and advanced life support response time remained controversial. We aimed to test the hypothesis that for adult, non-traumatic, out-of-hospital cardiac arrest patients, a shorter advanced life support response time is associated with a better chance of survival. We analyzed Utstein-based registry data on adult, non-traumatic, out-of-hospital cardiac arrest patients in Taipei from 2011 to 2015., Methods: Patients without complete data, witnessed by emergency medical technicians, or with response times of ≥ 15 minutes, were excluded. We used logistic regression with an exposure of advanced life support response time. Primary and secondary outcomes were survival to hospital discharge and favorable neurological outcomes (cerebral performance category ≤ 2), respectively. Subgroup analyses were based on presenting rhythms of out-of-hospital cardiac arrest, bystander cardiopulmonary resuscitation, and witness status., Results: A total of 4,278 cases were included in the final analysis. The median advanced life support response time was 9 minutes. For every minute delayed in advanced life support response time, the chance of survival to hospital discharge would reduce by 7% and chance of favorable neurological outcome by 9%. Subgroup analysis showed that a longer advanced life support response time was negatively associated with the chance of survival to hospital discharge among out-of-hospital cardiac arrest patients with shockable rhythm and pulse electrical activity groups., Conclusions: In non-traumatic, adult, out-of-hospital cardiac arrest patients in Taipei, a longer advanced life support response time was associated with declining odds of survival to hospital discharge and favorable neurologic outcomes, especially in patients presenting with shockable rhythm and pulse electrical activity., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Although infection was the most common symptom in patients returning to the ED, whether intravenous antibiotic administration at the index visit could serve as an indicator of patients with infectious diseases at high risk for hospital admission after returning to the ED within a short period of time remains unclear. The study aimed to investigate the potential risk factors for hospital admission in patients returning to the ED within 72 hours with a final diagnosis of infectious diseases., Material and Methods: This retrospective cohort study analyzed return visits to the ED from January to December 2019. Adult patients aged >20 years who had a return visit to the ED within 72 hours with an infectious disease were included herein. In total, 715 eligible patients were classified into the intravenous antibiotics and non-intravenous antibiotics group (reference group). The outcome studied was hospital admission to general ward and intensive care unit (ICU) at the return visits., Results: Patients receiving intravenous antibiotics at index visits had significantly higher risk-approximately two times-for hospital admission at the return visits than those did not (adjusted odds ratio = 2.47, 95% CI = 1.34-4.57, p = 0.004). For every 10 years increase in age, the likelihood for hospital admission increased by 38%. Other factors included abnormal respiratory rate and high C-reactive protein levels., Conclusions: Intravenous antibiotic administration at the index visit was an independent risk factor for hospital admission at return visits in patients with an infection disease. Physicians should consider carefully before discharging patients receiving intravenous antibiotics., Competing Interests: The authors have declared that no competing interests exist.

Evidence regarding the recurrence of diverticulitis is limited in Asian patients. This study aims to investigate recurrence rates and identify predictive factors for the recurrence of diverticulitis following successful nonoperative treatment in Asian patients. A multicenter, retrospective cohort study was conducted between 2012 and 2018. Adult patients with computed tomography (CT)-proven colonic diverticulitis were included. The primary outcome was the recurrence of diverticulitis, which was defined as another episode of occurrence of the infection after index hospital stay. Cumulative recurrence rates were calculated using the Kaplan-Meier method. Cox regression models were employed to identify parameters that significantly and independently predicted recurrence. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. A total of 929 patients were included. Diverticulitis in the cecum/ascending occurred in 675 (72.6%) patients. The average follow-up period was 651 days. Recurrence was observed in 115 (12.4%) patients and most significantly observed in patients with sigmoid diverticulitis (HR, 2.24; 95% CIs 1.59-3.97), followed by those with descending colon diverticulitis (HR, 1.92; 95% CIs 1.17-3.25). Although most of the Asian patients had right-sided colonic diverticulitis, those with sigmoid diverticulitis had the highest risk of recurrence., (© 2022. The Author(s).)