International variation in survival after out-of-hospital cardiac arrest : A validation study of the Utstein template

Introduction: Out-of-hospital cardiac arrest (OHCA) survival varies greatly between communities. The Utstein template was developed and promulgated to improve the comparability of OHCA outcome reports, but it has undergone limited empiric validation. We sought to assess how much of the variation in OHCA survival between emergency medical services (EMS) across the globe is explained by differences in the Utstein factors. We also assessed how accurately the Utstein factors predict OHCA survival. Methods: We performed a retrospective analysis of patient-level prospectively collected data from 12 OHCA registries from 12 countries for the period 1 Jan 2006 through 31 Dec 2011. We used generalized linear mixed models to examine the variation in survival between EMS agencies (n = 232). Results: Twelve registries contributed 86,759 cases. Patient arrest characteristics, EMS treatment and patient outcomes varied across registries. Overall survival to hospital discharge was 10% (range, 6% to 22%). Overall survival with Cerebral Performance Category of 1 or 2 (available for 8/12 registries) was 8%(range, 2% to 20%). The area-under-the-curve for the Utstein model was 0.85 (Wald CI: 0.85-0.85). The Utstein factors explained 51% of the EMS agency variation in OHCA survival. Conclusions: The Utstein factors explained 51%. of the variation in survival to hospital discharge among multiple large geographically separate EMS agencies. This suggests that quality improvement and public health efforts should continue to target modifiable Utstein factors to improve OHCA survival. Further study is required to identify the reasons for the variation that is incompletely understood.Peer reviewe

Regions of High Out-Of-Hospital Cardiac Arrest Incidence and Low Bystander CPR Rates in Victoria, Australia

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a major public health issue and research has shown that large regional variation in outcomes exists. Of the interventions associated with survival, the provision of bystander CPR is one of the most important modifiable factors. The aim of this study is to identify census areas with high incidence of OHCA and low rates of bystander CPR in Victoria, Australia. METHODS: We conducted an observational study using prospectively collected population-based OHCA data from the state of Victoria in Australia. Using ArcGIS (ArcMap 10.0), we linked the location of the arrest using the dispatch coordinates (longitude and latitude) to Victorian Local Government Areas (LGAs). We used Bayesian hierarchical models with random effects on each LGA to provide shrunken estimates of the rates of bystander CPR and the incidence rates. RESULTS: Over the study period there were 31,019 adult OHCA attended, of which 21,436 (69.1%) cases were of presumed cardiac etiology. Significant variation in the incidence of OHCA among LGAs was observed. There was a 3 fold difference in the incidence rate between the lowest and highest LGAs, ranging from 38.5 to 115.1 cases per 100,000 person-years. The overall rate of bystander CPR for bystander witnessed OHCAs was 62.4%, with the rate increasing from 56.4% in 2008-2010 to 68.6% in 2010-2013. There was a 25.1% absolute difference in bystander CPR rates between the highest and lowest LGAs. CONCLUSION: Significant regional variation in OHCA incidence and bystander CPR rates exists throughout Victoria. Regions with high incidence and low bystander CPR participation can be identified and would make suitable targets for interventions to improve CPR participation rates

An extended genotyping framework for Salmonella enterica serovar Typhi, the cause of human typhoid.

The population of Salmonella enterica serovar Typhi (S. Typhi), the causative agent of typhoid fever, exhibits limited DNA sequence variation, which complicates efforts to rationally discriminate individual isolates. Here we utilize data from whole-genome sequences (WGS) of nearly 2,000 isolates sourced from over 60 countries to generate a robust genotyping scheme that is phylogenetically informative and compatible with a range of assays. These data show that, with the exception of the rapidly disseminating H58 subclade (now designated genotype 4.3.1), the global S. Typhi population is highly structured and includes dozens of subclades that display geographical restriction. The genotyping approach presented here can be used to interrogate local S. Typhi populations and help identify recent introductions of S. Typhi into new or previously endemic locations, providing information on their likely geographical source. This approach can be used to classify clinical isolates and provides a universal framework for further experimental investigations

Paramedic exposure to cardiac arrest and patient survival: does practice make perfect?

Background: Out-of-hospital cardiac arrest (OHCA) is a common cause of premature death and the rate of survival is low. Early defibrillation and high quality chest compressions are known to influence OHCA survival and it is likely that paramedics who are frequently exposed to OHCA cases will perform more competently these vital components of resuscitation. Given that resuscitation skills decline over time and paramedic treatment of OHCA often falls short of the recommended standard, the number of OHCAs that paramedics are exposed to may be contributing to low and varied OHCA survival rates. Therefore, the broad aim of this thesis was to examine the association between paramedic exposure to OHCA and patient survival.<br> <br> Methods: Firstly, I performed a systematic review of the literature which identified that the association between paramedic exposure to OHCA and patient survival was a clear knowledge gap. To address this knowledge gap, I undertook a survey of emergency medical services (EMS) and conducted three epidemiological studies. The survey investigated the methods that EMS in Australia and New Zealand use to develop and maintain paramedic competency in resuscitation. The epidemiological studies were conducted in the setting of a large, statewide, two-tiered EMS agency, Ambulance Victoria (AV), and high quality data were sourced from the Victorian Ambulance Cardiac Arrest Registry as well as routinely collected data from AV. I measured typical paramedic exposure to OHCA. Then, using multivariable regression analysis, adjusting for internationally accepted covariates, I analysed the association between paramedic exposure to OHCA and patient survival. To determine whether increasing paramedic exposure is associated with better performance – the potential intermediary factor between exposure and outcomes, the association between paramedic exposure to endotracheal intubation (ETI) and performance (as measured by successful endotracheal tube [ETT] placement) was examined. I chose to investigate performance in ETI because it is one of the most technical individual skills carried out by paramedics during OHCA resuscitation.<br> <br> Results: The survey found that EMS agencies provided paramedics with minimal refresher training and rarely used other evidence-based methods of maintaining resuscitation competency. Paramedics were typically exposed to 1.4 (interquartile range [IQR]: 0.0-3.0) OHCAs per year and OHCA exposure declined over time. It would take paramedics an average of 163 days to be exposed to an OHCA and up to a decade for paediatric and traumatic OHCAs, which occur relatively rarely. OHCA exposure was lower in paramedics who were employed part-time, in rural areas, and with lower qualifications. Compared to patients treated by paramedics with a median of ≤6 exposures during the previous three years (7% survival), the odds of survival were higher for patients treated by paramedics with >6-11 (12%, adjusted odds ratio [AOR] :1.26, 95% confidence interval [CI] :1.04-1.54), >11-17 (14%, AOR:1.29, 95% CI:1.04-1.59) and >17 exposures (17%, AOR:1.50, 95% CI:1.22-1.86). I found that paramedic exposure to an individual component of OHCA resuscitation, namely ETI, was associated with better performance (AOR for successful ETT placement: 1.04, 95%CI: 1.03-1.05) but not OHCA patient survival. Intensive care paramedics typically performed 3 (IQR: 1-6) ETIs per year, the majority of which were performed on OHCAs (66%).<br> <br> Conclusions: Individual paramedics are rarely exposed to OHCA and increasing exposure is associated with improved patient survival. In addition, paramedic exposure to a single complex component of resuscitation, ETI, was associated with improved performance but not OHCA survival. The poor performance and patient outcomes commonly reported for OHCA may in part be the consequence of inadequate opportunities for paramedics to practise their resuscitation skills. These findings suggest that paramedic exposure to OHCA and resuscitation procedures need to be monitored and strategies to supplement low exposure, such as simulation training, should be explored

Associations between COVID-19 and hospitalisation with respiratory and non-respiratory conditions: a record linkage study.

OBJECTIVES: To assess associations between SARS-CoV-2 infection and the incidence of hospitalisation with selected respiratory and non-respiratory conditions in a largely SARS-CoV-2 vaccine-naïve population . DESIGN, SETTING, PARTICIPANTS: Self-control case series; analysis of population-wide surveillance and administrative data for all laboratory-confirmed COVID-19 cases notified to the Victorian Department of Health (onset, 23 January 2020 - 31 May 2021; ie, prior to widespread vaccination rollout) and linked hospital admissions data (admission dates to 30 September 2021). MAIN OUTCOME MEASURES: Hospitalisation of people with acute COVID-19; incidence rate ratios (IRRs) comparing incidence of hospitalisations with defined conditions (including cardiac, cerebrovascular, venous thrombo-embolic, coagulative, and renal disorders) from three days before to within 89 days of onset of COVID-19 with incidence during baseline period (60-365 days prior to COVID-19 onset). RESULTS: A total of 20 594 COVID-19 cases were notified; 2992 people (14.5%) were hospitalised with COVID-19. The incidence of hospitalisation within 89 days of onset of COVID-19 was higher than during the baseline period for several conditions, including myocarditis and pericarditis (IRR, 14.8; 95% CI, 3.2-68.3), thrombocytopenia (IRR, 7.4; 95% CI, 4.4-12.5), pulmonary embolism (IRR, 6.4; 95% CI, 3.6-11.4), acute myocardial infarction (IRR, 3.9; 95% CI, 2.6-5.8), and cerebral infarction (IRR, 2.3; 95% CI, 1.4-3.9). CONCLUSION: SARS-CoV-2 infection is associated with higher incidence of hospitalisation with several respiratory and non-respiratory conditions. Our findings reinforce the value of COVID-19 mitigation measures such as vaccination, and awareness of these associations should assist the clinical management of people with histories of SARS-CoV-2 infection

Anion Exchange‐Induced Crystal Engineering via Hot‐Pressing Sublimation Affording Highly Efficient and Stable Perovskite Solar Cells

Crystalline, dense, and uniform perovskite thin films are crucial for achieving high-power conversion efficiency solar cells. Herein, a universal method of fabricating highly crystalline and large-grain perovskite films via crystal engineering is demonstrated. Anion exchange of Cl− and I−, and annealing perovskite films, in an ultraconfined and uniform temperature enclosed space with saturated MAI (or FAI) vapor using hot-pressing sublimation technology are conducted. This process ensures a rapid crystal growth rate due to fast exchange between the gas phase and the crystalline film to reduce vertically oriented grain boundaries. The generation of the commonly observed PbI2 phase is also suppressed due to the chemical equilibrium state during the thermal annealing process. Using this approach, pinhole-free perovskite films with preferred crystal orientation and micrometer-scale grains are obtained, leading to a high steady-state efficiency of 22.15% based on mixed-cation perovskite composition. In addition, devices based on different perovskite compositions all exhibit enhanced photovoltaic performance based on the crystal engineering method. The device (without encapsulation) has an efficiency loss of about only 4% after 2520 h of aging in ambient conditions and retains 87% of its initial efficiency after 1000 h of continuous 1 Sun light soaking, thus demonstrating considerably improved stability.The work was supported by the National Program for Support of Topnotch Young Professionals and the Australian Government through the Australian Renewable Energy Agency, and the Swiss National Science Foundation, Switzerland

Incidence and outcomes of out-of-hospital cardiac arrest in singapore and Victoria : a collaborative study

Background: Incidence and outcomes of out-of-hospital cardiac arrest (OHCA) vary between communities. We aimed to examine differences in patient characteristics, prehospital care, and outcomes in Singapore and Victoria. Methods and Results: Using the prospective Singapore Pan-Asian Resuscitation Outcomes Study and Victorian Ambulance Cardiac Arrest Registry, we identified 11 061 and 32 003 emergency medical services-attended adult OHCAs between 2011 and 2016 respectively. Incidence and survival rates were directly age adjusted using the World Health Organization population. Survival was analyzed with logistic regression, with model selection via backward elimination. Of the 11 061 and 14 834 emergency medical services-treated OHCAs (overall mean age±SD 65.5±17.2; 67.4% males) in Singapore and Victoria respectively, 11 054 (99.9%) and 5595 (37.7%) were transported, and 440 (4.0%) and 2009 (13.6%) survived. Compared with Victoria, people with OHCA in Singapore were older (66.7±16.5 versus 64.6±17.7), had less shockable rhythms (17.7% versus 30.3%), and received less bystander cardiopulmonary resuscitation (45.7% versus 58.5%) and defibrillation (1.3% versus 2.5%) (all P<0.001). Age-adjusted OHCA incidence and survival rates increased in Singapore between 2011 and 2016 (P<0.01 for trend), but remained stable, though higher, in Victoria. Likelihood of survival increased significantly (P<0.001) with arrest in public locations (adjusted odds ratio [aOR] 1.81), witnessed arrest (aOR 2.14), bystander cardiopulmonary resuscitation (aOR 1.72), initial shockable rhythm (aOR 9.82), and bystander defibrillation (aOR 2.04) but decreased with increasing age (aOR 0.98) and emergency medical services response time (aOR 0.91). Conclusions: Singapore reported increasing OHCA incidence and survival rates between 2011 and 2016, compared with stable, albeit higher, rates in Victoria. Survival differences might be related to different emergency medical services practices including patient selection for resuscitation and transport.Ministry of Health (MOH)National Medical Research Council (NMRC)Published versionPAROS is supported by grants from the National Medical Research Council (Singapore), Ministry of Health, Singapore. VACAR receives funding from Victorian Government Department of Health

Bystander witnessed OHCA cases by Victorian Local Government Area with the Observed Prevalence and shrunken estimate of Bystander CPR among witnessed arrests, 2008–2013.

<p>Bystander witnessed OHCA cases by Victorian Local Government Area with the Observed Prevalence and shrunken estimate of Bystander CPR among witnessed arrests, 2008–2013.</p

Incidence and Outcomes of Out-of-Hospital Cardiac Arrest in Singapore and Victoria: A Collaborative Study

10.1161/JAHA.119.015981JOURNAL OF THE AMERICAN HEART ASSOCIATION92