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Objective: The objective was to investigate whether early advanced airway management during the entire resuscitation period is associated with favorable neurological outcomes and survival in patients with out-of-hospital cardiac arrest (OHCA)., Methods: We performed a retrospective cohort study of patients with OHCA aged ≥18 years enrolled in OHCA registry in Japan who received advanced airway management during cardiac arrest between June 2014 and December 2020. To address resuscitation time bias, we performed risk set matching analyses in which patients who did and did not receive advanced airway management were matched at the same time point (min) using the time-dependent propensity score; further, we compared early (≤10 min) and late (>10 min) advanced airway management. The primary and secondary outcome measures were favorable neurological outcomes using Cerebral Performance Category scores and survival at 1 month after cardiac arrest., Results: Of the 41,101 eligible patients, 21,446 patients received early advanced airway management. Thus, risk set matching was performed with a total of 42,866 patients. In the main analysis, early advanced airway management was significantly associated with favorable neurological outcomes (risk ratio [RR] 0.997, 95% confidence interval [CI] 0.995-0.999) and survival (RR 0.990, 95% CI 0.986-0.994) at 1 month after cardiac arrest. In the sensitivity analysis with early advanced airway management defined as ≤5 min and ≤20 min, the results were comparable., Conclusions: Although early advanced airway management was statistically significant for improved neurological outcomes and survival at 1 month after cardiac arrest, the RR was very close to 1, indicating that the timing of advanced airway management has minimal impact on clinical outcomes, and decisions should be made based on the individual needs of the patient., (© 2024 Society for Academic Emergency Medicine.)

Refining out-of-hospital cardiopulmonary arrest (OHCA) resuscitation protocols for local emergency practices is vital. The lack of comprehensive evaluation methods for individualized protocols impedes targeted improvements. Thus, we employed machine learning to assess emergency medical service (EMS) records for examining regional disparities in time reduction strategies. In this retrospective study, we examined Japanese EMS records and neurological outcomes from 2015 to 2020 using nationwide data. We included patients aged ≥ 18 years with cardiogenic OHCA and visualized EMS activity time variations across prefectures. A five-layer neural network generated a neurological outcome predictive model that was trained on 80% of the data and tested on the remaining 20%. We evaluated interventions associated with changes in prognosis by simulating these changes after adjusting for time factors, including EMS contact to hospital arrival and initial defibrillation or drug administration. The study encompassed 460,540 patients, with the model's area under the curve and accuracy being 0.96 and 0.95, respectively. Reducing transport time and defibrillation improved outcomes universally, while combining transport time and drug administration showed varied efficacy. In conclusion, the association of emergency activity time with neurological outcomes varied across Japanese prefectures, suggesting the need to set targets for reducing activity time in localized emergency protocols., (© 2023. Springer Nature Limited.)

Objectives: To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out-of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome., Design: Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE)., Setting: Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older., Participants: A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics., Results and Measurements: The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the "appropriate" subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the "uncertain" subgroup, and 2 of 107 (1.9%) in the "inappropriate" subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate., Conclusion: Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39-45, 2019., (© 2019 The American Geriatrics Society.)

Aim: The association between out-of-hospital cardiac arrest (OHCA) and the appropriate provision of public access defibrillation (PAD) remains unclear. This study aimed to evaluate the factors associated with whether or not PAD was provided., Methods: This retrospective cohort study utilized the All-Japan Utstein and Emergency Transport Registries in 2021. We included OHCA patients who were applied to automated external defibrillators (AEDs) by bystanders and were deemed eligible for defibrillation by an AED. We defined PAD provided or no PAD provided based on bystander defibrillation. Multivariable logistic regression analysis with the Firth bias adjustment method was employed to estimate the adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the exploratory evaluation of factors associated with PAD provided., Results: 1949 patients were eligible for analysis (PAD provided, n = 1696 [87.0%]; no PAD provided, n = 253 [13.0%]). Factors positively associated with PAD provided were male (AOR [95% CI], 1.61 [1.17-2.21]; vs. female), other public place incidence (AOR [95% CI], 10.65 [1.40-1367.54]; vs. public place), non-family member witnessed (AOR [95% CI], 2.51 [1.86-3.42]; vs. unwitnessed) and conventional cardiopulmonary resuscitation (CPR), (AOR [95% CI], 1.75 [1.17-2.67]; vs. hands-only CPR). Conversely, factors negatively associated with no PAD provided were over 65 years old (AOR [95% CI], 0.48 [0.28-0.80]; vs. 19-64 yr), night-time onset (AOR [95% CI], 0.61 [0.45-0.83]; vs. daytime), non-cardiogenic (AOR [95% CI], 0.43 [0.31-0.61]; vs. cardiogenic), home setting (AOR [95% CI], 0.33 [0.14-0.83]; vs. public place), healthcare facility setting (AOR [95% CI], 0.40 [0.23-0.66]; vs. public place), no bystander CPR (AOR [95% CI], 0.31 [0.14-0.71]; vs. hands-only CPR), and dispatcher-assistance (AOR [95% CI], 0.72 [0.53-0.97]; vs. no dispatcher-assistance)., Conclusion: Male patients, other public place onset, witnessed by non-family and conventional CPR were associated with PAD provide. Therefore, training skilled first responders to use AEDs appropriately is necessary., 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.)

Background: Effective bystander cardiopulmonary resuscitation (CPR) improves outcomes in out-of-hospital cardiac arrest (OHCA) patients. However, the effect of CPR training on the rate of return of spontaneous circulation (ROSC) among laypersons has yet to be thoroughly evaluated., Methods: This prospective, multicenter observational study was conducted across 42 centers in Japan. We assessed OHCA patients who received bystander CPR from a layperson, excluding those performed by healthcare staff. The primary outcome was the ROSC rate. Secondary outcomes included pre-hospital ROSC, ROSC after hospital arrival, favorable neurological outcomes, and 30-day survival. Propensity score with inverse probability treatment weighting (IPTW) was used to adjust for confounders, including age, sex, presence or absence of witnesses, and past medical history., Results: A total of 969 OHCA patients were included, divided into CPR-trained (n = 322) and control (n = 647). Before adjustment, the ROSC rate was higher in the trained group than the control (40.1% vs. 30.1%, P < 0.01). After IPTW adjustment, the trained group showed a significantly higher ROSC rate (36.7% vs. 30.6%; P = 0.02). All secondary outcomes in the trained group were significantly improved before adjustment. After IPTW adjustment, the trained group showed improved rates of pre-hospital ROSC and ROSC after hospital arrival (30.7% vs. 24.0%; P < 0.01, 23.9% vs. 20.7%; P = 0.04). There were no differences in neurological outcomes and 30-day survival., Conclusion: This study demonstrated that CPR training for laypersons was associated with increased ROSC rates in OHCA patients, indicating potential advantages of CPR training for non-healthcare professionals., 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.)

Aim: To develop a new scoring model for patients with cardiogenic out-of-hospital cardiac arrest (OHCA) to facilitate neurological prognosis prediction upon hospital arrival by using prehospital resuscitation features alone., Methods: Between 2005 and 2019, we enrolled 942,891 adult patients with OHCA of presumed cardiac aetiology from the All-Japan Utstein Registry. Scoring models applied prehospital resuscitation features a priori from the variables the American College of Cardiology algorithm including age, duration to return of spontaneous circulation (ROSC) or hospital arrival, no bystander cardiopulmonary resuscitation (CPR), unwitnessed arrest, and nonshockable rhythm (R-EDByUS score) to predict unfavorable neurological outcomes defined as Cerebral Performance Category 3, 4, or 5 at 1 month. We created nomograms as a "Regression-based model," and created a "Simplified model" in which points were assigned by category for predicting unfavorable neurological outcomes for both the prehospital ROSC cohort (67,064 patients) and the ongoing CPR cohort (875,827 patients). For internal validation, bootstrap optimism-corrected estimates of predictive performance were calculated., Results: A total of 46,971 (70.0%) and 870,991 (99.4%) patients in the prehospital ROSC and ongoing CPR cohorts, respectively, had unfavorable neurological outcomes. In the prehospital ROSC cohort, the C-statistics of the Regression-based and Simplified models were 0.851 and 0.842, and the bootstrap-validated C-statistics were 0.852 and 0.841, respectively. In the ongoing CPR cohort, the C-statistics of the Regression-based and Simplified models were 0.872 and 0.865, and the bootstrap-validated C-statistics were 0.852 and 0.841, respectively., Conclusions: The R-EDByUS score accurately predicted the neurological prognosis of cardiogenic OHCA upon hospital arrival., 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 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The impact of a national initiative to provide cardiopulmonary resuscitation (CPR) education to the public on the rates of citizen-initiated CPR and survival following out-of-hospital cardiac arrest (OHCA) remains uncertain., Methods: We examined 358,025 cases of citizen-witnessed OHCA with presumed cardiac origin, recorded in the Japanese nationwide registry from 2005 to 2020. We assessed the relationship between the number of individuals certified in CPR courses, citizen interventions, and neurologically favorable survival at one month., Results: The cumulative number of certified citizens has linearly increased from 9,930,327 in 2005 to 34,938,322 in 2020 (incidence rate ratio for annual number = 1.03, p < 0.001), encompassing 32.3% of the Japanese population aged 15 and above. Similarly, the prevalence of citizen-initiated CPR has consistently increased from 40.6% in 2005 to 56.8% in 2020 (P for trend < 0.001). Greater citizen CPR engagement was significantly associated with better outcome in initial shockable rhythm patients [chest compression only: odds ratio (OR) 1.24; 95% confidence interval (CI) 1.02-1.51; P = 0.029; chest compression with rescue breathing: OR 1.33; 95% CI 1.08-1.62; P = 0.006; defibrillation with chest compression: OR 2.27; 95% CI 1.83-2.83; P < 0.001; defibrillation with chest compression and rescue breathing: OR 2.15; 95% CI 1.70-2.73; P < 0.001 vs. no citizen CPR]., Conclusions: The incidence of citizen-initiated CPR across Japan has consistently and proportionately increased with the rising number of individuals certified in CPR courses. Greater citizen CPR involvement has been linked to neurologically favorable survival, particularly in cases with an initial shockable rhythm., 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.)

Aim: Out-of-hospital cardiac arrest (OHCA) has a poor prognosis in children; however, the annual patterns of prognosis and treatment have not been fully investigated., Methods: From the Japanese Association for Acute Medicine OHCA registry, a multicenter prospective observational registry in Japan, we identified pediatric patients (zero to 17 years old) between June 2014 and December 2019. The primary outcome was one-month survival. We investigated the annual patterns in patient characteristics, treatment, and one-month prognosis., Results: During the study period, 1188 patients were eligible for analysis. For all years, the zero-year-old group accounted for a large percentage of the total population (between 30% and 40%). There were significant increases in the rates of bystander-initiated cardiopulmonary resuscitation (CPR; from 50.6% to 62.3%, p = 0.003), dispatcher instructions (from 44.7% to 65.7%, p = 0.001), and adrenaline administration (from 2.4% to 6.9%, p = 0.014) over time, whereas the rate of advanced airway management decreased significantly (from 17.7% to 8.8%, p = 0.003). The odds ratios for one-month survival adjusted for potential resuscitation factors also did not change significantly (from 7.1% to 10.3%, adjusted odds ratio for one-year increment = 0.98, confidence interval: 0.86-1.11)., Conclusion: Despite an increase in the rate of bystander-initiated CPR and pre-hospital adrenaline administration, there was no significant change in one-month survival., 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 © 2023 Elsevier B.V. All rights reserved.)

Background: Targeted temperature management (TTM) can potentially improve the prognosis of patients with out-of-hospital cardiac arrest (OHCA). However, the effectiveness of TTM in older adults remains unknown. Therefore, this study aimed to assess the outcomes of older adult patients with OHCA who underwent TTM., Methods: This study was a multicenter, retrospective, nationwide observational analysis of the Japanese Association for Acute Medicine out-of-hospital cardiac arrest (JAAM-OHCA) registry. We included patients aged ≥18 years who had experienced OHCA and underwent TTM from June 1, 2014, to December 31, 2017, in Japan. The primary outcome was a 1-month neurological favorable outcome, and the secondary outcome was 1-month survival., Results: A total of 1847 patients were included in the analysis. 79 of 389 patients aged ≥75 years (20.3%) had a 1-month neurological favorable outcome compared with 369 of 959 patients aged 18-64 years (38.5%) (adjusted odds ratios, 0.31; 95% confidence interval [CI], 0.21-0.45; P for trend <0.001). With increasing age, 1-month mortality showed an increasing trend; however, there was no significant difference., Conclusion: In this retrospective nationwide observational study in Japan, neurological outcomes worsened as age increased in patients with OHCA who underwent TTM., 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 © 2023 Elsevier Inc. All rights reserved.)

Aim: To elucidate the effectiveness of extracorporeal membrane oxygenation (ECMO) in accidental hypothermia (AH) patients with and without cardiac arrest (CA), including details of complications., Methods: This study was a multicentre, prospective, observational study of AH in Japan. All adult (aged ≥18 years) AH patients with body temperature ≤32 °C who presented to the emergency department between December 2019 and March 2022 were included. Among the patients, those with CA or circulatory instability, defined as severe AH, were selected and divided into the ECMO and non-ECMO groups. We compared 28-day survival and favourable neurological outcomes at discharge between the ECMO and non-ECMO groups by adjusting for the patients' background characteristics using multivariable logistic regression analysis., Results: Among the 499 patients in this study, 242 patients with severe AH were included in the analysis: 41 in the ECMO group and 201 in the non-ECMO group. Multivariable analysis showed that the ECMO group was significantly associated with better 28-day survival and favourable neurological outcomes at discharge in patients with CA compared to the non-ECMO group (odds ratio [OR] 0.17, 95% confidence interval [CI]: 0.05-0.58, and OR 0.22, 95%CI: 0.06-0.81). However, in patients without CA, ECMO not only did not improve 28-day survival and neurological outcomes, but also decreased the number of event-free days (ICU-, ventilator-, and catecholamine administration-free days) and increased the frequency of bleeding complications., Conclusions: ECMO improved survival and neurological outcomes in AH patients with CA, but not in AH patients without CA., 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 © 2022 Elsevier B.V. All rights reserved.)

Aim: Temporal changes in cerebral regional oxygen saturation (crSO 2 ) are useful for predicting return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients. However, little is known regarding the usefulness of peripheral regional oxygen saturation (prSO 2 ) associated with OHCA patient outcomes. This study evaluated the association between temporal changes in prSO 2 and ROSC in patients with OHCA., Methods: This was a prospective study at two tertiary emergency centres in Japan. We evaluated the relationship between ROSC and temporal changes in crSO 2 and prSO 2 . The rSO 2 sensor was attached to the patient's forehead and upper arm, and rSO 2 was continuously measured until resuscitative efforts were terminated or until the patient with sustained ROSC (>20 min) arrived at the emergency department., Results: We included 145 patients with OHCA, of whom 35 achieved ROSC. Witness status (odds ratio [95% confidence interval]: 11.6 [3.13-58.1]) and ΔprSO 2 (1.13 [1.06-1.24]) were significantly associated with ROSC in multiple logistic analysis. In the ROSC group, ΔprSO 2 increased earlier than ΔcrSO 2 during cardiopulmonary resuscitation. In the non-ROSC group, there was no significant difference between ΔcrSO 2 and ΔprSO 2 , and neither increased before termination of resuscitation (TOR)., Conclusion: We demonstrated for the first time that prSO 2 is associated with ROSC in OHCA patients and showed that temporal changes in prSO 2 could predict ROSC earlier than those in crSO 2 . Our findings could provide time to prepare early interventions after ROSC and assist in determining the TOR for OHCA patients in Japan. Further studies are needed to validate these findings., 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 © 2022 Elsevier B.V. All rights reserved.)

Background: Cardiac arrest, particularly in children, often has a poor outcome and international guidelines highlight significant gaps in the evidence base for effective resuscitation. Whilst randomised controlled trials for some interventions can be justified, they are not appropriate for many aspects of resuscitation. Therefore, guidelines must use other sources of data such as epidemiological evidence from cardiac arrest registries, to improve the efficacy of resuscitation. The aim of our study was to identify existing national cardiac arrest registries and document key information about the registries, including whether they contain data on paediatric arrests., Methods: Key bibliographic databases were searched for papers about or using data from cardiac arrest registries. Two reviewers independently screened the search results for relevant papers. A list of registers named in the papers was compiled and information obtained from the papers and the websites of registers where possible., Results: Twenty three active national or large regional cardiac arrest registries were identified. These included five international collaborations and 10 registries that cover a population of at least 10 million people. Twelve registries are based in Europe, five in North America, four in Asia and two in Australasia. The registries vary in their organisation, but the majority (20) defer to the Utstein reporting guidelines for cardiac arrest. Registries covered populations between 0.4 and 174.5 million and contained between 100 and 605,505 records. Sixteen collected data on out-of-hospital arrests only; three in-hospital arrests only; and four included both. For ten registers the number of paediatric arrests was available and ranged from 56 to 3900., Conclusions: To our knowledge this report contains the most complete list of active national and large regional cardiac arrest registries. Register data support current guidelines on effective resuscitation however, even the largest registries include relatively small numbers, particularly of paediatric events. A less fragmented approach has the potential to improve the utility of registration data for the benefit of patients., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Although patients who underwent night-time resuscitation for out-of-hospital cardiac arrest (OHCA) had worse clinical outcomes than those who underwent day-time resuscitation, the differences between the outcomes of patients with OHCA who underwent extracorporeal cardiopulmonary resuscitation (ECPR) in the day-time and night-time remain unclear. We analyzed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan. Patients were categorized according to whether they received treatment during the day-time or night-time. The primary outcomes were survival to hospital discharge and favorable neurological outcome at discharge, and the secondary outcomes were estimated low-flow time, implementation time of ECPR, and complications due to ECPR. A multivariate logistic regression model adjusted for confounders was used for comparison. Among the 1644 patients, the night-time patients had a significantly longer ECMO implementation time and estimated low-flow time than the day-time patients, along with a significantly higher number of complications than the day-time patients. However, the survival and neurologically favorable survival rates did not differ significantly between the groups. Thus, although patients who underwent ECPR at night had an increased risk of longer implementation time and complications, their clinical outcomes did not differ from those who underwent day-time ECPR. [ABSTRACT FROM AUTHOR]

Recently, patients with out-of-hospital cardiac arrest (OHCA) refractory to conventional resuscitation have started undergoing extracorporeal cardiopulmonary resuscitation (ECPR). However, the mortality rate of these patients remains high. This study aimed to clarify whether a center ECPR volume was associated with the survival rates of adult patients with OHCA resuscitated using ECPR. This was a secondary analysis of a retrospective multicenter registry study, the SAVE-J II study, involving 36 participating institutions in Japan. Centers were divided into three groups according to the tertiles of the annual average number of patients undergoing ECPR: high-volume (≥ 21 sessions per year), medium-volume (11–20 sessions per year), or low-volume (< 11 sessions per year). The primary outcome was survival rate at the time of discharge. Patient characteristics and outcomes were compared among the three groups. Moreover, a multivariable-adjusted logistic regression model was applied to study the impact of center ECPR volume. A total of 1740 patients were included in this study. The center ECPR volume was strongly associated with survival rate at the time of discharge; furthermore, survival rate was best in high-volume compared with medium- and low-volume centers (33.4%, 24.1%, and 26.8%, respectively; P = 0.001). After adjusting for patient characteristics, undergoing ECPR at high-volume centers was associated with an increased likelihood of survival compared to middle- (adjusted odds ratio 0.657; P = 0.003) and low-volume centers (adjusted odds ratio 0.983; P = 0.006). The annual number of ECPR sessions was associated with favorable survival rates and lower complication rates of the ECPR procedure. Clinical trial registration: https://center6.umin.ac.jp/cgi-open-bin/ctr%5fe/ctr%5fview.cgi?recptno=R000041577 (unique identifier: UMIN000036490). [ABSTRACT FROM AUTHOR]

Background: Objective structured clinical examination: OSCE is now widely used in educational scene in medical schools before medical students start their clinical training. However, the utility of OSCE on BLS education has not been confirmed yet. The effect of OSCE on BLS education was examined using questionnaires., Methods: Questionnaires on knowledge of resuscitation were distributed to 166 medical school students (100 students in 1999 semester without OSCE, 66 in 2004 semester with OSCE). The questionnaire included 13 questions based on the 1992 or 2000 guidelines for cardiopulmonary resuscitation. Six out of 12 questions were defined as "skill related questions" and the student who correctly answered all these "skill related questions" were thought to be competent for providing adequate BLS., Results: Competent student ratio was significantly higher in students with OSCE (48%, vs 20% without OSCE, P < 0.001). Thus OSCE was useful for medical student to establish BLS knowledge when compared with students without OSCE. However, this result also revealed that the acquired knowledge through OSCE did not last long. Although 98% of students actually passed OSCE, only half of them were competent on paper test during clinical training., Conclusions: OSCE improved medical students' knowledge of BLS, but did not contribute to prevent forgetting for a long time. Thus, reeducation in BLS is still necessary for students after passing OSCE.

Background: The effectiveness of IABP for shockable out-of-hospital cardiac arrest (OHCA) has not been extensively investigated. This study aimed to investigate whether the use of an intra-aortic balloon pump (IABP) for non-traumatic shockable OHCA patients was associated with favorable neurological outcomes. Methods: From the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a nationwide multicenter prospective registry, we enrolled adult patients with non-traumatic and shockable OHCA for whom resuscitation was attempted, and who were transported to participating hospitals between 2014 and 2019. The primary outcome was 1-month survival with favorable neurological outcomes after OHCA. After adopting the propensity score (PS) inverse probability of weighting (IPW), we evaluated the association between IABP and favorable neurological outcomes. Results: Of 57,754 patients in the database, we included a total of 2738 adult non-traumatic shockable patients. In the original cohort, the primary outcome was lower in the IABP group (OR with 95% confidence intervals (CIs)), 0.57 (0.48–0.68), whereas, in the IPW cohort, it was not different between patients with and without IABP (OR, 1.18; 95% CI, 0.91–1.53). Conclusion: In adult patients with non-traumatic shockable OHCA, IABP use was not associated with 1-month survival with favorable neurological outcomes. [ABSTRACT FROM AUTHOR]

Objective To investigate the 1-year functional outcomes after cardiopulmonary resuscitation (CPR) in adults aged ≥65 years with pre-existing long-term care needs. Methods This population-based cohort study was conducted in Tochigi Prefecture, one of 47 prefectures in Japan. We used medical and long-term care administrative databases, which included data on functional and cognitive impairment that were assessed with the nationally standardised care-needs certification system. Among individuals aged ≥65 years registered between June 2014 and February 2018, patients who underwent CPR were identified. The primary outcome was mortality and care needs at 1 year after CPR. The outcome was stratified by pre-existing care needs before CPR based on the total daily estimated care minutes: no care needs, support levels 1 and 2 and care-needs level 1 (estimated care time 25–49 min), care-needs levels 2 and 3 (50–89 min) and care-needs levels 4 and 5 (≥90 min). Results Among 594,092 eligible individuals, 5,086 (0.9%) underwent CPR. The 1-year mortalities after CPR in patients with no care needs, support levels 1 and 2 and care-needs level 1, care-needs levels 2 and 3 and care-needs levels 4 and 5 were 94.6% (n  = 2,207/2,332), 96.1% (n  = 736/766), 94.5% (n  = 930/984) and 95.9% (n  = 963/1,004), respectively. Among survivors, most patients had no change in care needs before and at 1 year after CPR. There was no significant association between pre-existing functional and cognitive impairment and 1-year mortality and care needs after adjusting for potential confounders. Conclusion Healthcare providers need to discuss poor survival outcomes after CPR with all older adults and their families in shared decision making. [ABSTRACT FROM AUTHOR]

Introduction: Japan went through five surges of coronavirus disease 2019 (COVID-19) or "waves". However, their impacts on the do not attempt cardiopulmonary resuscitation (DNACPR) of the patients are not known. Methods: A retrospective single-center cohort study was conducted for all hospitalized patients with COVID-19 from March 1, 2020, to September 30, 2021. Their code status was retrieved, and its association with the waves and other parameters, such as in-hospital mortality, was investigated. The relationship between DNACPR status and each wave was examined, as well as the effect on in-hospital mortality. Results: A total of 1153 patients were hospitalized with the diagnosis of COVID-19 during the study period. On admission, 117 patients (10.1%) had DNACPR orders, 373 patients (32.4%) were on full code, 45 patients (3.9%) stated that they cannot decide code status. DNACPR rate appeared to increase at the summit of each wave. Subsequently, 160 patients (13.9%) became DNACPR status, 385 patients (33.4%) became full code, and 12 patients (1.0%) stated that they remained unable to decide code status. There was no association between DNACPR status and each wave, and DNACPR status was not associated with higher mortality (P = 0.87), both by logistic regression analysis. Conclusion: DNACPR status among hospitalized COVID-19 patients appeared to have changed over multiple waves in Japan, but it is more likely due to the change of the patients' demographics, particularly their age. DNACPR was common among the elderly, but it was not independently associated with higher mortality. [ABSTRACT FROM AUTHOR]

Background: Although numerous studies have investigated out-of-hospital cardiac arrest, few studies have been conducted on in-hospital cardiac arrest (IHCA). Knowledge of the nationwide epidemiology of IHCA in Japan, with its super-aging society, is important to understand the current situation of IHCA and to establish evidenced-based medicine in the future. The present study aimed to determine the incidence and outcomes of IHCA and their trends in Japan. Methods: This observational cohort study was performed using a national administrative inpatient database for more than 1600 acute-care hospitals covering about 50% of all acute-care hospital beds in Japan from April 2011 to March 2018. We defined cardiac arrest patients who received cardiopulmonary resuscitation (chest compression) during hospitalization as IHCA. We excluded out-of-hospital cardiac arrest patients from the source population. The incidence of IHCA per 1000 hospital admissions and survival to discharge rate was reported with trend analyses by calendar year 2011–2017. Results: Among 53,871,101 hospitalized patients without out-of-hospital cardiac arrest patients in 1626 hospitals, 2,136,038 (4.0%) had cardiac arrest. Of them, 274,664 (12.9%) received cardiopulmonary resuscitation at least once during hospitalization and were identified as IHCA, and 1,861,374 (87.1%) did not receive cardiopulmonary resuscitation. The incidence of IHCA per 1000 hospital admissions was 5.1, with a significant decreasing trend from 6.1 in 2011 to 4.6 in 2017 (P for trend = 0.033). Our estimated incidence can be translated to approximately 87,000 IHCA cases in Japan each year. The percentage of IHCA patients among cardiac arrest patients was 12.9%, with a significant decreasing trend from 14.0% in 2011 to 12.2% in 2017 (P for trend = 0.006). The overall rate of survival to discharge was 12.7%, with a significant increasing trend from 10.5% in 2011 to 14.0% in 2017 (P for trend < 0.001). Conclusions: We found substantial associations between mortality and loss of health and IHCA in Japan. The incidence of IHCA showed a decreasing trend over time, the percentage of treated cardiac arrest patients also had a decreasing trend, and the overall survival to discharge rate improved over time. [ABSTRACT FROM AUTHOR]

Background: Patient participation is a key foundation of advance care planning (ACP). However, a patient himself/herself may be left out from sensitive conversations such as end-of-life (EOL) care discussions. The objectives of this study were to investigate patients' participation rate in the discussion of Cardiopulmonary Resuscitation (CPR) / Do-Not-Attempt-Resuscitation (DNAR) order, and in the discussion that the patient is at his/her EOL stage (EOL disclosure), and to explore their associated factors. Methods: This is a retrospective chart review study. The participants were all the patients who were hospitalized and died in a university-affiliated teaching hospital (tertiary medical facility) in central Tokyo, Japan during the period from April 2018 to March 2019. The following patients were excluded: (1) cardiopulmonary arrest on arrival; (2) stillbirth; (3) under 18 years old at the time of death; and (4) refusal by their bereaved family. Presence or absence of CPR/DNAR discussion and EOL disclosure, patients' involvement in those discussions, and their associated factors were investigated. Results: CPR/DNAR discussions were observed in 336 out of the 358 patients (93.9%). However, 224 of these discussions were carried out without a patient (patient participation rate 33.3%). Male gender (odds ratio (OR) = 2.37 [95% confidence interval (CI) 1.32–4.25]), living alone (OR = 2.51 [1.34–4.71]), and 1 year or more from the date of diagnosis (OR = 1.78 [1.03–3.10]) were associated with higher patient's participation in CPR/DNAR discussions. The EOL disclosure was observed in 341 out of the 358 patients (95.3%). However, 170 of the discussions were carried out without the patient (patient participation rate 50.1%). Patients who died of cancer (OR = 2.41[1.45–4.03]) and patients without mental illness (OR=2.41 [1.11–5.25]) were more likely to participate in EOL disclosure. Conclusions: In this clinical sample, only up to half of the patients participated in CPR/DNAR discussions and EOL disclosure. Female, living with family, a shorter period from the diagnosis, non-cancer, and mental illness presence are risk factors for lack of patients' participation in CPR/DNAR or EOL discussions. Further attempts to facilitate patients' participation, based on their preference, are warranted. [ABSTRACT FROM AUTHOR]

Background: A better understanding of differences between the preferences of the general public and the recommendations of healthcare providers with regard to end-of-life (EOL) care may facilitate EOL discussion. Methods: The aim of this study was to clarify differences between preferences of the general public and recommendations of healthcare providers with regard to treatment, EOL care, and life-sustaining treatment (LST) based on a hypothetical scenario involving a patient with advanced cancer. This study comprised exploratory post-hoc analyses of "The Survey of Public Attitude Towards Medical Care at the End of life", which was a population based, cross-sectional anonymous survey in Japan to investigate public attitudes toward medical care at the end of life. Persons living in Japan over 20 years old were randomly selected nationwide. Physicians, nurses, and care staff were recruited at randomly selected facilities throughout Japan. The general public data from the original study was combined to the data of healthcare providers in order to conduct exploratory post-hoc analyses. The preferences of the general public and recommendations of healthcare providers with regard to EOL care and LST was assessed based on the hypothetical scenario of an advanced cancer patient. Results: All returned questionnaires were analyzed: 973 from the general public, 1039 from physicians, 1854 from nurses, and 752 from care staff (response rates of 16.2, 23.1, 30.9, and 37.6%, respectively). The proportion of the general public who wanted "chemotherapy or radiation", "ventilation", and "cardiopulmonary resuscitation" was significantly higher than the frequency of these options being recommended by physicians, nurses, and care staff, but the general public preference for "cardiopulmonary resuscitation" was significantly lower than the frequency of its recommendation by care staff. Conclusion: Regarding a hypothetical scenario for advanced cancer, the general public preferred more aggressive treatment and more frequent LST than that recommended by healthcare providers. [ABSTRACT FROM AUTHOR]

Objective: We evaluated the association between prehospital epinephrine administration by emergency medical services (EMS) and the long-term outcomes of out-of-hospital cardiac arrest (OHCA) with initial pulseless electrical activity (PEA) or asystole.Methods: We conducted a controlled, propensity-matched, retrospective cohort study by using Japan's nationwide OHCA registry database. We studied 110,239 bystander-witnessed OHCA patients aged 15–94 years with initial non-shockable rhythms registered between January 2008 and December 2012. We created 1–1 matched pairs of patients with or without epinephrine by using sequential risk set matching based on time-dependent propensity scores to balance the patients' severity and characteristics. We compared overall and neurologically intact survival 1 month after OHCA between cases and controls using conditional logistic regression models by category of the initial rhythm.Results: Propensity matching created 7,431 pairs in patients with PEA and 8,906 pairs in those with asystole. Epinephrine administration was associated with higher overall survival (4.49% vs. 2.96%; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.30–1.85) but not with neurologically intact survival (0.98% vs. 0.78%; OR, 1.26; 95% CI, 0.89–1.78) in patients with PEA, and with higher overall survival (2.38% vs. 1.04%; OR, 2.34; 95% CI, 1.82–3.00) and neurologically intact survival (0.48% vs. 0.22%; OR, 2.28; 95% CI, 1.31–3.96) in those with asystole.Conclusions: Prehospital epinephrine administration by EMS is favorably associated with long-term neurological outcomes in patients with initial asystole and with long-term survival outcomes in those with PEA. [ABSTRACT FROM PUBLISHER]

Aim: To demonstrate that unrecognised situation awareness failures events (UNSAFE) transfers are associated with poorer outcomes in the intensive care unit (ICU) at a Japanese children's hospital lacking a rapid response system.Methods: This retrospective cohort study was conducted between January 2013 and February 2016. UNSAFE transfers were defined as unplanned in-hospital ward-to-ICU transfers requiring tracheal intubation, vasoactive medications or ≥3 fluid boluses before arrival or in the first 60 min of ICU care. We compared ICU stay duration and mortality between UNSAFE and non-UNSAFE transfers.Results: There were 2126 admissions to the paediatric ICU during the study period, and 244 cases met the definition of an unscheduled in-hospital transfer (11.5%). Of these, the number of patients transferred following cardiopulmonary resuscitation, in the UNSAFE group and in the non-UNSAFE group were 9 (3.7%), 68 (28%) and 167 (68%), respectively. In the UNSAFE group, the number of patients who required tracheal intubation, initiation of vasoactive medications or ≥ 3 fluid boluses in the first 60 min of ICU care or before arrival in the ICU was 61 (90%), 38 (56%) and 9 (13%), respectively. ICU stay duration and mortality were significantly poorer in the UNSAFE group than in the non-UNSAFE group (9 vs. 4 days, P < 0.0001; 13 vs. 4.2%, odds ratio = 3.5, 95% confidence interval = 1.2-9.8, P = 0.020, respectively).Conclusions: Patients who experienced UNSAFE transfers had longer ICU stays and higher mortality, and it may be used as a metric of evaluation of effects of rapid response system implementation. [ABSTRACT FROM AUTHOR]

Objective: Survival after out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical service (EMS) personnel has been insufficiently understood. The aim of this study was to evaluate temporal trends in survival after EMS-witnessed OHCAs in Japan. Methods: A nationwide, population-based, observational cohort study of consecutive adult OHCA patients with emergency responder resuscitation attempts from January 2005 to December 2012 in Japan. We assessed the trends in annual incidence, characteristics, and outcomes of OHCA patients witnessed by EMS personnel. Multiple logistic regression analysis was used to assess factors that were potentially associated with neurologically favorable outcome defined as cerebral performance category scale 1or 2. Results: During the study period, a total of 66,760 EMS-witnessed OHCAs were documented. The annual incidence rates per 100,000 persons of EMS-witnessed OHCA patients increased from 4.6 (n = 7219) in 2005 to 4.9 (n = 9256) in 2012 (p for trend = 0.035). The proportion of one-month survival with neurologically favorable outcome improved from 5.9% in 2005 to 8.6% in 2012 (p for trend < 0.001), and the proportion increased from 22.1% in 2005 to 30.2% in 2012 in cases with shockable rhythm (p for trend < 0.001). In a multivariate analysis, adults, male gender, shockable rhythm, presumed cardiac origin, and year were associated with a better neurological outcome. Conclusions: In this population, the proportion of one-month survival with neurologically favorable outcome among OHCA patients witnessed by EMS personnel significantly improved during the study period. [ABSTRACT FROM AUTHOR]

Background: The families of people with late-stage dementia need to be informed about the course of the dementia and the comfort/palliative care option. A booklet was written for that purpose and can be provided to family members by physicians and nurses. Methods: The acceptability of the booklet for nurses was tested in Canada (French and English version), France (French Canadian version) and Japan (translated and adapted version). Results: Overall, 188 nurses completed a survey questionnaire. The booklet was accepted best in Canada and less so in France and Japan. Despite regional variation, the majority of the nurses perceived the booklet as useful for families. The French and Japanese nurses also reported a greater need for palliative care education in advanced dementia. Conclusion: The booklet may help nurses educate families about end-of-life issues in dementia palliative care, but local adaptation of the booklet content and physician engagement are necessary. [ABSTRACT FROM AUTHOR]

We aimed to investigate how the types of bystander-initiated cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) among students have changed recently. We also determined the association between two types of bystander-CPRs (i.e., chest compression-only CPR [CCCPR] and conventional CPR with rescue breathing [CCRB]) and survival after OHCA. From a nationwide registry of pediatric OHCAs occurring in school settings in Japan, the data of 253 non-traumatic OHCA patients (elementary, junior high, and high school/technical college students) receiving bystander-CPR between April 2008 and December 2017 were analyzed. Multivariable logistic regression analysis was conducted to assess the impact of different types of bystander-CPR on 30-day survival with favorable neurological outcomes. The proportion of patients receiving CCCPR increased from 25.0% during 2008–2009 to 55.3% during 2016–2017 (p for trend < 0.001). Overall, 53.2% (50/94) of patients receiving CCCPR and 46.5% (74/159) of those receiving CCRB survived for 30 days with favorable neurological outcomes. Multivariable analysis showed no significant difference in outcomes between the two groups (adjusted odds ratio: 1.23, 95% confidence interval: 0.67–2.28). In this setting, CCCPR is a common type of bystander-CPR for OHCA in students, and the effectiveness of CCCPR and CCRB on survival outcomes seems comparable. [ABSTRACT FROM AUTHOR]