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Introduction: Simplifying the learning of cardiopulmonary resuscitation (CPR) is advocated to improve skill acquisition and retention. A simplified CPR training programme focusing on continuous chest compression, with a simple landmark tracing technique, was introduced to laypeople. The study aimed to examine the effectiveness of the simplified CPR training in improving lay rescuers' CPR performance as compared to standard CPR., Methods: A total of 85 laypeople (aged 21-60 years) were recruited and randomly assigned to undertake either a two-hour simplified or standard CPR training session. They were tested two months after the training on a simulated cardiac arrest scenario. Participants' performance on the sequence of CPR steps was observed and evaluated using a validated CPR algorithm checklist. The quality of chest compression and ventilation was assessed from the recording manikins., Results: The simplified CPR group performed significantly better on the CPR algorithm when compared to the standard CPR group (p < 0.01). No significant difference was found between the groups in time taken to initiate CPR. However, a significantly higher number of compressions and proportion of adequate compressions was demonstrated by the simplified group than the standard group (p < 0.01). Hands-off time was significantly shorter in the simplified CPR group than in the standard CPR group (p < 0.001)., Conclusion: Simplifying the learning of CPR by focusing on continuous chest compressions, with simple hand placement for chest compression, could lead to better acquisition and retention of CPR algorithms, and better quality of chest compressions than standard CPR., (Copyright: © Singapore Medical Association.)

Aims: To explore predictors of bystander CPR (i.e. any CPR performed prior to EMS arrival) in Ireland over the period 2012–2020. To examine the relationship between bystander CPR and key health system developments during this period. Methods: National level out-of-hospital cardiac arrest (OHCA) registry data relating to unwitnessed, and bystander witnessed OHCA were interrogated. Logistic regression models were built, then refined by fitting predictors, performing stepwise variable selection and by adding pairwise interactions that improved fit. Missing data sensitivity analyses were conducted using multiple imputation. Results: The data included 18,177 OHCA resuscitation attempts of whom 77% had bystander CPR. The final model included ten variables. Four variables (aetiology, incident location, time of day, and who witnessed collapse) were involved in interactions. The COVID-19 period was associated with reduced adjusted odds of bystander CPR (OR 0.77, 95% CI 0.65, 0.92), as were increasing age in years (OR 0.992, 95% CI 0.989, 0.994) and urban location (OR 0.52, 95% CI 0.47, 0.57). Increasing year over time (OR 1.23, 95% CI 1.16, 1.29), and an increased call response interval in minutes (OR 1.017, 95% CI 1.012, 1.022) were associated with increased adjusted odds of bystander CPR. Conclusions: Bystander CPR increased over the study period, and it is likely that health system developments contributed to the yearly increases observed. However, COVID-19 appeared to disrupt this positive trend. Urban OHCA location was associated with markedly decreased odds of bystander CPR compared to rural location. Given its importance bystander CPR in urban areas should be an immediate target for intervention.

Background: Cardiac arrest constitutes a critical medical emergency necessitating swift intervention to reinstate normal heart rhythm and prevent harm to vital organs. The pivotal role of bystander cardiopulmonary resuscitation (CPR) in influencing survival rates is well recognized. With older adults being the most common group to witness such events, it's curcial to understand their attitudes and knowledge about performing CPR. Additionally, understanding if health status has an influence can help in tailoring education for specific seniors needs. Methods: A cross-sectional survey was sent to University of the Third Age (UTA) students. The survey comprised sections focusing on demographic data, CPR knowledge, automated external defibrillator (AED) knowledge, first aid training, and readiness to perform CPR and use AEDs. Participants' health conditions were also assessed through multiple-choice options. Results: We received 456 responses. Significant awareness of emergency numbers and cardiac arrest recognition was revealed. However, knowledge gaps persisted, particularly in compression rates. Most participants comprehended AED usage, yet training primarily relied on theoretical approaches. Health conditions notably affected CPR readiness, with associations between specific chronic diseases and willingness to perform CPR. Conclusions: Addressing knowledge gaps and tailoring education for elderly needs are crucial for improving survival rates. Future research should explore barriers to bystander CPR during out-of-hospital cardiac arrests to further enhance survival prospects. [ABSTRACT FROM AUTHOR]

Background: Fever after cardiac arrest may impact outcome. We aimed to assess the incidence of fever in post‐cardiac arrest patients, factors predicting fever and its association with functional outcome in patients treated without targeted temperature management (TTM). Methods: The FINNRESUSCI observational cohort study in 2010–2011 included intensive care unit (ICU)‐treated out‐of‐hospital cardiac arrest (OHCA) patients from all five Finnish university hospitals and 14 of 15 central hospitals. This post hoc analysis included those FINNRESUSCI study patients who were not treated with TH. We defined fever as at least one temperature measurement of ≥37.8°C within 72 h of ICU admission. The primary outcome was favourable functional outcome at 12 months, defined as cerebral performance category (CPC) of 1 or 2. Binary logistic regression models including witnessed arrest, bystander cardiopulmonary resuscitation (CPR), initial rhythm and delay of return of spontaneous circulation were used to compare the functional outcomes of the groups. Results: There were 67,428 temperature measurements from 192 patients, of whom 89 (46%) experienced fever. Twelve‐month CPC was missing in 7 patients, and 51 (28%) patients had favourable functional outcome at 12 months. The patients with shockable initial rhythms had a lower incidence of fever within 72 h of ICU admission (28% vs. 72%, p <.01), and the patients who experienced fever had a longer median return of spontaneous circulation (ROSC) delay (20 [IQR 10–30] vs. 14 [IQR 9–22] min, p <.01). Only initial non‐shockable rhythm (OR 2.99, 95% CI 1.51–5.94) was associated with increased risk of fever within the first 72 h of ICU admission. Neither time in minutes nor area (minutes × degree celsius over threshold) over 37°C, 37.5°C, 38°C, 38.5°C, 39°C, 39.5°C or 40°C were significantly different in those with favourable functional outcome compared to those with unfavourable functional outcome within the first 24, 48 or 72 h from ICU admission. Fever was not associated with favourable functional outcome at 12 months (OR 0.90, 95% CI 0.44–1.84). Conclusions: Half of OHCA patients not treated with TTM developed fever. We found no association between fever and outcome. [ABSTRACT FROM AUTHOR]

While various supraglottic airway devices are available for use during out-of-hospital cardiac arrest (OHCA) resuscitation, comparisons of patient outcomes by device are limited. In this study, we aimed to compare outcomes of OHCA patients who had airway management by emergency medical services (EMS) with the iGel or King-LT. We used the 2018-2021 ESO Data Collaborative public use research datasets for this retrospective study. All patients with non-traumatic OHCA who had iGels or King-LTs inserted by EMS were included. Our primary outcome was survival to discharge to home, and secondary outcomes included first-pass success, return of spontaneous circulation (ROSC), and prehospital rearrest. We examined the association between airway device and each outcome using two-level mixed effects logistic regression with EMS agency as the random effect, adjusted for standard Utstein variables and failed intubation prior to supraglottic airway insertion. Average treatment effects were calculated through propensity score matching. A total of 286,192 OHCA patients were screened, resulting in 93,866 patients eligible for inclusion in this analysis. A total of 9,456 transported patients (59.8% iGel) had associated hospital disposition data. Use of the iGel was associated with greater survival to discharge to home (aOR:1.36 [1.06, 1.76]; ATE: 2.2%[+0.5, +3.8]; n = 7,576), first pass airway success (aOR:1.94 [1.79, 2.09]; n = 73,658), and ROSC (aOR:1.19 [1.13, 1.26]; n = 73,207) in comparison to airway management with the King-LT. iGel use was associated with lower odds of experiencing a rearrest (aOR:0.73 [0.67, 0.79]; n = 20,776). Among patients who received a supraglottic device as a primary airway, use of the iGel was not associated with significantly greater survival to discharge to home (aOR:1.26 [0.95, 1.68]). Among patients who received a supraglottic device as a rescue airway following failed intubation, use of the iGel was associated with greater odds of survival to discharge to home (aOR:2.16 [1.15, 4.04]). In this dataset, use of the iGel during adult OHCA resuscitation was associated overall with better outcomes compared to use of the King-LT. Subgroup analyses suggested that use of the iGel was associated with greater odds of achieving the primary outcome than the King-LT when used as a rescue device but not when used as the primary airway management device. [ABSTRACT FROM AUTHOR]

Every 10 years, the American Heart Association (AHA) Emergency Cardiovascular Care Committee establishes goals to improve survival from cardiac arrest. These goals align with broader AHA Impact Goals and support the AHA's advocacy efforts and strategic investments in research, education, clinical care, and quality improvement programs. This scientific statement focuses on 2030 AHA emergency cardiovascular care priorities, with a specific focus on bystander cardiopulmonary resuscitation, early defibrillation, and neurologically intact survival. This scientific statement also includes aspirational goals, such as establishing cardiac arrest as a reportable disease and mandating reporting of standardized outcomes from different sources; advancing recognition of and knowledge about cardiac arrest; improving dispatch system response, availability, and access to resuscitation training in multiple settings and at multiple time points; improving availability, access, and affordability of defibrillators; providing a focus on early defibrillation, in-hospital programs, and establishing champions for debriefing and review of cardiac arrest events; and expanding measures to track outcomes beyond survival. The ability to track and report data from these broader aspirational targets will potentially require expansion of existing data sets, development of new data sets, and enhanced integration of technology to collect process and outcome data, as well as partnerships of the AHA with national, state, and local organizations. The COVID-19 (coronavirus disease 2019) pandemic, disparities in COVID-19 outcomes for historically excluded racial and ethnic groups, and the longstanding disparities in cardiac arrest treatment and outcomes for Black and Hispanic or Latino populations also contributed to an explicit focus and target on equity for the AHA Emergency Cardiovascular Care 2030 Impact Goals. [ABSTRACT FROM AUTHOR]

Background. Devices for mechanical cardiopulmonary resuscitation (CPR) are recommended when high quality CPR cannot be provided. Different devices are available, but the literature is poor in direct comparison studies. Our aim was to assess whether the type of mechanical chest compressor could affect the probability of return of spontaneous circulation (ROSC) and 30-day survival in Out-of-Hospital Cardiac Arrest (OHCA) patients as compared to manual standard CPR. Methods. We considered all OHCAs that occurred from 1 January 2015 to 31 December 2022 in seven provinces of the Lombardy region equipped with three different types of mechanical compressor: Autopulse®(ZOLL Medical, MA), LUCAS® (Stryker, MI), and Easy Pulse® (Schiller, Switzerland). Results. Two groups, 2146 patients each (manual and mechanical CPR), were identified by propensity-score-based random matching. The rates of ROSC (15% vs. 23%, p < 0.001) and 30-day survival (6% vs. 14%, p < 0.001) were lower in the mechanical CPR group. After correction for confounders, Autopulse® [OR 2.1, 95%CI (1.6–2.8), p < 0.001] and LUCAS® [OR 2.5, 95%CI (1.7–3.6), p < 0.001] significantly increased the probability of ROSC, and Autopulse® significantly increased the probability of 30-day survival compared to manual CPR [HR 0.9, 95%CI (0.8–0.9), p = 0.005]. Conclusion. Mechanical chest compressors could increase the rate of ROSC, especially in case of prolonged resuscitation. The devices were dissimilar, and their different performances could significantly influence patient outcomes. The load-distributing-band device was the only mechanical chest able to favorably affect 30-day survival. [ABSTRACT FROM AUTHOR]

Background: Basic life support education for schoolchildren has become a key initiative to increase bystander cardiopulmonary resuscitation rates. Our objective was to review the existing literature on teaching schoolchildren basic life support to identify the best practices to provide basic life support training in schoolchildren. Methods: After topics and subgroups were defined, a comprehensive literature search was conducted. Systematic reviews and controlled and uncontrolled prospective and retrospective studies containing data on students <20 years of age were included. Results: Schoolchildren are highly motivated to learn basic life support. The CHECK-CALL-COMPRESS algorithm is recommended for all schoolchildren. Regular training in basic life support regardless of age consolidates long-term skills. Young children from 4 years of age are able to assess the first links in the chain of survival. By 10 to 12 years of age, effective chest compression depths and ventilation volumes can be achieved on training manikins. A combination of theoretical and practical training is recommended. Schoolteachers serve as effective basic life support instructors. Schoolchildren also serve as multipliers by passing on basic life support skills to others. The use of age-appropriate social media tools for teaching is a promising approach for schoolchildren of all ages. Conclusions: Schoolchildren basic life support training has the potential to educate whole generations to respond to cardiac arrest and to increase survival after out-of-hospital cardiac arrest. Comprehensive legislation, curricula, and scientific assessment are crucial to further develop the education of schoolchildren in basic life support. [ABSTRACT FROM AUTHOR]

Objectives: To improve public awareness and the rate of bystander cardiopulmonary resuscitation )CPR(, a novel and exciting approach called fit-CPR that incorporates mass CPR with high-intensity physical activity into the beat of locally favoured music was proposed. This study was conducted to measure the effectiveness of fit-CPR compared to the standard classroom method )CCM(. Methods: Between 30th August to 29th November 2018, 129 participants from Syiah Kuala University, Banda Aceh, Indonesia, were randomized to learn CPR, either through fit-CPR or CCM protocol. All participants underwent pre, post, and 6-month retention tests. Each test had a 10-item Original Article questionnaire with CPR performance on a manikin that was assessed using a validated checklist. Results: Sixty-one )47.3%( participants completed the fit-CPR while 68 )52.7%( completed the CCM. There was a significant improvement in knowledge, performance, and quality of CPR from pre, post, and 6-month retention tests )p<0.01( in both groups. On high-quality CPR, the fit-CPR and CCM groups obtained an increased score of 285.0% and 151%, respectively, p=0.014 between pre and immediate post-test. Knowledge scores between fit- CPR and CCM groups showed an increase of 79.5% and 111.2%, respectively, p=0.002. Fit-CPR was completed between 52.5-57.5 minutes, while CCM took 75 minutes. Conclusion: The fit-CPR demonstrated a comparable outcome to standard CPR when teaching to the mass public with less time spent. [ABSTRACT FROM AUTHOR]

Out-of-hospital cardiac arrest (OHCA) remains a health problem worldwide, carrying a high mortality rate. Comparison of emergency department (ED) return of spontaneous circulation (ROSC) after OHCA in relation to emergency medical services (EMS) and non-EMS modes of transportation to the hospital was conducted to assess the impact points of the EMS system in Thailand. This retrospective observational study enrolled all OHCA patients who visited the ED of Ramathibodi Hospital, a tertiary university hospital in Bangkok, between January 1, 2008, and May 31, 2020. Patients were differentiated into EMS and non-EMS groups according to mode of transportation to the ED. Patients' characteristics and comorbidities, witnessed arrests, bystander chest compression, initial rhythm, and resuscitation treatment were documented. ED-sustained ROSC, ED survival, 30-day survival, and 30-day survival with good cerebral performance category (CPC) scores were monitored and recorded. Multivariate logistic analyses were performed to assess factors influencing clinical outcomes. A total of 339 patients were enrolled, 117 (34.51%) of whom were in the EMS transport group. There were no differences between the EMS and non-EMS groups in ED-sustained ROSC (adjusted odds ratio [aOR], 0.99; 95% confidence interval [CI], 0.58–1.70; P = 0.98), or ED survival (aOR, 0.99; 95% CI, 0.57–1.71; P = 0.97). There were also no differences in 30-day survival or 30-day survival with good CPC score between the two groups. In our cohort data of OHCA, ED-sustained ROSC and ED survival outcomes were not superior in the EMS transportation group. Evidence to show that EMS transportation affected 30-day survival and 30-day good CPC score was also lacking. Thus, public promotion of Thailand's EMS system is advocated with a simultaneous improvement of EMS response to enhance OHCA outcomes. [ABSTRACT FROM AUTHOR]

Objective: To determine if patients presenting to our toxicology unit following self‐reported heroin use had positive urine immunoassay testing for fentanyl or its analogues. Methods: Urine samples from consenting patients were tested at the bedside for the presence of opiates or fentanyl and its analogues. Results: Over a 30‐month period, 58 patients were recruited. All samples tested positive for opiates, but none tested positive for fentanyl or its analogues. Conclusion: In patients presenting to our toxicology unit in Brisbane, we did not find any cases where the urine of patients self‐reporting heroin exposure tested positive for fentanyl or its analogues. [ABSTRACT FROM AUTHOR]

Introduction: Poor outcome is still a challenging concern in patients with out-of-hospital cardiac arrest (OHCA) world-wide and there are large differences between European countries regarding not only incidence rates, but survival rates as well. In 2014, Serbian Resuscitation Council initiated regular data collection on epidemiology of OHCA, according to the European Registry of Cardiac Arrest (EuReCa) study protocol. Study Objective: The aim of this study is to analyze the results of the first five-year period after initiation of EuReCa study protocol elements implementation in OHCA epidemiological data collection in Serbia. Methods: The observed period in this study is about the data on OHCA, collected within the observed area of 16 municipalities covering 1,604,015 citizens, during the period from October 1, 2014 – December 31, 2019. The study included data on all-cause OHCA in both adult and pediatric patients, according to the EuReCa One study protocol, of which all segments were observed. Results: Within the study period, 5,196 OHCA patients were observed with annual incidence of 83.60/100,000. Of all registered events, 43.9% were witnessed. The most common collapse location was patient's residence (88.7%). Within the group of initiated cardiopulmonary resuscitation (CPR), cardiac etiology was observed in 80.5% of cases and shockable rhythm in 21.7%. Return of spontaneous circulation (ROSC) prior to hospital admission was significantly more frequently achieved and maintained on admission in witnessed cases, cases occurring out of patient's residence, and in cases with shockable initial rhythm (P <.01). Conclusion: The OHCA incidence in Serbia is comparable with the incidence in the majority of European countries, and survival rates are now significantly higher in Utstein events compared to previous results from Serbia. Enrolment of witnessing bystanders in initiating CPR measures remains a concern requiring effort towards understanding of CPR initiation importance and education of general population in administering CPR measures. [ABSTRACT FROM AUTHOR]

Immediate resuscitation is crucial for the survival of a patient with cardiac arrest. Research has suggested that self-led bystander cardiopulmonary resuscitation (CPR) is significantly associated with favourable neurological outcomes for patients. Furthermore, medical students play an important role in providing public CPR training to the community. This study aims to evaluate the effects of a CPR training programmes and a public training event on the knowledge, attitudes, and perceived competency towards CPR among medical students. The quasi-experimental study was conducted among the medical students in clinical years studying at a private medical institution in Malaysia. The intervention group received CPR training for two sessions and participated as trainers in a community-training event; the control group was excluded from these activities. A total of 106 students (intervention group, n = 51; control group, n = 55) participated in this study. The total knowledge score (5.24 ± 1.67 vs 3.75 ± 1.22, P < 0.001), attitude score (22.38 ± 3.67 vs 20.82 ± 2.33, P = 0.011), and perceived competencies to perform CPR and automated external defibrillator (AED) (7.22 ± 2.33 vs 4.93 ± 2.40, P < 0.001) were significantly higher among the participants in the intervention group compared to those in the control group after the intervention. Meanwhile, concerns regarding initiating CPR was significantly higher in the intervention group compared to the control group (12.44 ± 5.15 vs 9.55 ± 3.96, P = 0.002). The results suggested that CPR training is beneficial for students and should be organised regularly. In addition to providing physical skills training, such sessions should explain legal implications of initiating CPR and should encourage and assure students to do so in case of an emergency. [ABSTRACT FROM AUTHOR]

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Aims Trends in characteristics, management, and survival in out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) were studied in the Swedish Cardiopulmonary Resuscitation Registry (SCRR). Methods and results The SCRR was used to study 106 296 cases of OHCA (1990–2020) and 30 032 cases of IHCA (2004–20) in whom resuscitation was attempted. In OHCA, survival increased from 5.7% in 1990 to 10.1% in 2011 and remained unchanged thereafter. Odds ratios [ORs, 95% confidence interval (CI)] for survival in 2017–20 vs. 1990–93 were 2.17 (1.93–2.43) overall, 2.36 (2.07–2.71) for men, and 1.67 (1.34–2.10) for women. Survival increased for all aetiologies, except trauma, suffocation, and drowning. OR for cardiac aetiology in 2017–20 vs. 1990–93 was 0.45 (0.42–0.48). Bystander cardiopulmonary resuscitation increased from 30.9% to 82.2%. Shockable rhythm decreased from 39.5% in 1990 to 17.4% in 2020. Use of targeted temperature management decreased from 42.1% (2010) to 18.2% (2020). In IHCA, OR for survival in 2017–20 vs. 2004–07 was 1.18 (1.06–1.31), showing a non-linear trend with probability of survival increasing by 46.6% during 2011–20. Myocardial ischaemia or infarction as aetiology decreased during 2004–20 from 67.4% to 28.3% [OR 0.30 (0.27–0.34)]. Shockable rhythm decreased from 37.4% to 23.0% [OR 0.57 (0.51–0.64)]. Approximately 90% of survivors (IHCA and OHCA) had no or mild neurological sequelae. Conclusion Survival increased 2.2-fold in OHCA during 1990–2020 but without any improvement in the final decade, and 1.2-fold in IHCA during 2004–20, with rapid improvement the last decade. Cardiac aetiology and shockable rhythms were halved. Neurological outcome has not improved. [ABSTRACT FROM AUTHOR]

Objective: To determine whether young rural Australians have higher rates or different underlying causes of out‐of‐hospital cardiac arrest (OHCA). Design: A case–control design identified patients experiencing an OHCA, then compared annual OHCA rates and underlying causes in rural versus metropolitan Victoria. OHCA causes were defined as either cardiac or non‐cardiac, with specific aetiologies including coronary disease, cardiomyopathy, unascertained cause of arrest, drug toxicity, respiratory event, neurological event and other cardiac and non‐cardiac. For OHCAs with confirmed cardiac aetiology, cardiovascular risk profiles were compared. Setting: A state‐wide prospective OHCA registry (combining ambulance, hospital and forensic data) in the state of Victoria, Australia (population 6.5 million). Participants: Victorians aged 1–50 years old experienced an OHCA between April 2019 and April 2020. Main outcome measures: Rates and underlying causes of OHCA in young rural and metropolitan Victorians. Results: Rates of young OHCA were higher in rural areas (OHCA 22.5 per 100 000 rural residents vs. 13.4 per 100 000 metropolitan residents, standardised incidence ratio 168 (95% CI 101–235); confirmed cardiac cause of arrest 12.1 per 100 000 rural residents versus 7.5 per 100 000 metropolitan residents, standardised incidence ratio 161 (95% CI 71–251). The underlying causation of the OHCA and cardiovascular risk factor burden did not differ between rural and metropolitan areas. Conclusion: Higher rates of OHCA occur in young rural patients, with standardised incidence ratio of 168 compared to young metropolitan residents. Rural status did not influence causes of cardiac arrest or known cardiovascular risk factor burden in young patients experiencing OHCA. [ABSTRACT FROM AUTHOR]

Objective: The COVID-19 pandemic changed the time-dependent cardiac arrest network. This study aims to understand whether the rescue standards of CPR and out-of-hospital cardiac arrest (OHCA) were handled differently during pandemic compared to the previous year.Methods: Data for the years 2019 and 2020 were provided by the records of the Lombardy office of the Regional Agency for Emergency and Urgency (AREU). We analysed where the cardiac arrest occurred, when CPR started and whether the bystanders used PAD.Results: During 2020, there was a reduction in CPRs performed by bystanders (OR = 0.936 [CI95% 0.882-0.993], P = 0.029) and in the return of spontaneous circulation (ROSC) (OR = 0.621 [CI95% 0.563- 0.685], P < 0.0001), while there was no significant reduction in the use of PAD. Analysing only March, the period of the first wave in Lombardy, the comparison shows a reduction in bystanders CPRs (OR = 0.727 [CI95% 0.602- 0.877], P = 0.0008), use of PAD (OR = 0.441 [CI95% 0.272-0.716], P = 0.0009) and in ROSC (OR = 0.179 [CI95% 0.124-0.257], P < 0.0001). These phenomena could be influenced by the different setting in which the OHCAs occurred; in fact, those that occurred in public places with a mandatory PAD were strongly reduced (OR = 0.49 [CI95% , 0.44-0.55], P < 0.0001).Conclusions: COVID-19 had a profound impact on the time-dependant OHCA network. During the first pandemic wave, CPR and PAD used by bystanders decreased. The different context in which OHCAs occurred may partially explain these differences. [ABSTRACT FROM AUTHOR]

Background: Out-of-hospital cardiac arrest (OHCA) due to trauma is rare, and survival in this group is infrequent. Over the last decades, several new procedures have been implemented to increase survival, and a "Special circumstances chapter" was included in the European Resuscitation Council (ERC) guidelines in 2015. This article analysed outcomes after traumatic cardiac arrest in Germany using data from the German Resuscitation Registry (GRR) and the TraumaRegister DGU® (TR-DGU) of the German Trauma Society.  METHODS: In this study, data from patients with OHCA between 01.01.2014 and 31.12.2019 secondary to major trauma and where cardiopulmonary resuscitation (CPR) was started were eligible for inclusion. Endpoints were return of spontaneous circulation (ROSC), hospital admission with ROSC and survival to hospital discharge.Results: 1.049 patients were eligible for inclusion. ROSC was achieved in 28.7% of the patients, 240 patients (22.9%) were admitted to hospital with ROSC and 147 (14.0%) with ongoing CPR. 643 (67.8%) patients were declared dead on scene. Of all patients resuscitated after traumatic OHCA, 27.3% (259) died in hospital. The overall mortality was 95.0% and 5.0% survived to hospital discharge (47). In a multivariate logistic regression analysis; age, sex, injury severity score (ISS), head injury, found in cardiac arrest, shock on admission, blood transfusion, CPR in emergency room (ER), emergency surgery and initial electrocardiogram (ECG), were independent predictors of mortality.Conclusion: Traumatic cardiac arrest was an infrequent event with low overall survival. The mortality has remained unchanged over the last decades in Germany. Additional efforts are necessary to identify reversible cardiac arrest causes and provide targeted trauma resuscitation on scene.Trial Registration: DRKS, DRKS-ID DRKS00027944. Retrospectively registered 03/02/2022. [ABSTRACT FROM AUTHOR]

Foreign body airway obstruction (FBAO) is a life-threatening condition. We aimed to quantify the impact of bystander FBAO interventions on survival and neurological outcomes. We conducted a Japan-wide prospective, multi-center, observational study including all FBAO patients who presented to the Emergency Department from April 2020 to March 2023. Information on bystander FBAO interventions was collected through interviews with emergency medical services personnel. Primary outcomes included 1-month survival and favorable neurologic outcome defined as Cerebral Performance Category 1 or 2. We performed a multivariable logistic regression and a Cox proportional hazards modeling to adjust for confounders. We analyzed a total of 407 patients in the registry who had the median age of 82 years old (IQR 73–88). The FBAO incidents were often witnessed (86.5%, n = 352/407) and the witnesses intervened in just over half of the cases (54.5%, n = 192/352). The incidents frequently occurred at home (54.3%, n = 221/407) and nursing home (21.6%, n = 88/407). Common first interventions included suction (24.8%, n = 101/407) and back blow (20.9%, n = 85/407). The overall success rate of bystander interventions was 48.4% (n = 93/192). About half (48.2%, n = 196/407) survived to 1-month and 23.8% patients (n = 97/407) had a favorable neurological outcome. Adjusting for pre-specified confounders, bystander interventions were independently associated with survival (hazard ratio, 0.55; 95% CI, 0.39–0.77) and a favorable neurological outcome (adjusted OR, 2.18; 95% CI, 1.23–3.95). Bystander interventions were independently associated with survival and favorable neurological outcome, however, they were performed only in the half of patients. [ABSTRACT FROM AUTHOR]

Background: A victim's gender is a known factor that influences the willingness of adult bystanders to perform cardiopulmonary resuscitation (CPR) if an out-of-hospital cardiac arrest (OHCA) occurs. This study aims to identify whether gender characteristics of OHCA victims are also relevant to schoolchildren, who are the key target group of CPR trainings worldwide. Methods: A prospective, educative intervention study was performed in schoolchildren (5th–7th grade). Schoolchildren's willingness to perform CPR was assessed by means of questionnaires before (t0) and after (t1) standardized CPR training. Participants were asked how determined they were to perform CPR in male and female OHCA victims on a 5-point Likert scale (not being determined to being very determined). A data analysis was performed according to the gender characteristics of schoolchildren. Results: Overall, 342 schoolchildren aged 10–15 years were included, and 166 male (MG) and 176 female (FG) schoolchildren served as a comparison group. Before (t0) and after (t1) the intervention, females showed a significantly higher general willingness to perform CPR than males (t0: 97.1% vs. 89.0%; p < 0.003 and t1: 95.7% vs. 98.9%; p = 0.038). The general willingness to perform CPR after training had a stronger increase in males (8.0% vs. 2.3%; p = 0.017). In the case that the OHCA victim was female, male schoolchildren were less willing to perform CPR than females at baseline (MG: n = 101;60.8% vs. FG: n = 147;84.5%; p < 0.001) and after training (MG: n = 97;58.4% vs. FG: n = 138;79.3%; p < 0.001). At t1, CPR willingness for female victims was improved in males (MG: n = 36;21.7% vs. FG: n = 19;10.9%; p = 0.006). Conclusions: The gender characteristics of OHCA victims, as well as schoolchildren themselves, have a relevant impact on the willingness to perform CPR. Training concepts should effectively motivate male schoolchildren to reduce preexisting inhibitions, especially towards female OHCA patients. Trial registration: This study was registered at the German Clinical Trials Register (Registration number: DRKS00017707) on 2 August 2019. [ABSTRACT FROM AUTHOR]

Background: Regular exercise is known to prevent cardiovascular disorders, but it may also trigger acute cardiac events. This study examined the incidence, prognosis, and outcomes of out-of-hospital cardiac arrest (OHCA) related to exercise in the general population of Denmark.Methods: This retrospective cohort study examined all the OHCAs in the Danish Cardiac Arrest Registry from 2016 to 2019. OHCA related to exercise was identified in a nationwide electronic database and coupled to the patient register. Descriptive statistics were used in combination with a multivariate logistic regression model to assess predefined factors.Results: A total of 20,470 OHCAs were identified, of which 459 (2.2%) were related to exercise. Most were male (75.3%), with a median age of 61 years. Further, 95% of exercise-related OHCA received bystander cardiopulmonary resuscitation, compared to 77.4% in non-exercise-related OHCA (p < 0.001), and 38.3% received defibrillation by bystanders versus 7.5% in the non-exercise group (p < 0.001). Exercise-related OHCAs had a 30-day survival rate of 57.7% compared to 12.6% in the non-exercise group, yielding an adjusted odds ratio of 5.56. The 30-day survival rate of exercise-related subjects aged 15-35 years was 80.0%, compared to 25.0% in the non-exercise group. When comparing sports categories, team sports were associated with the greatest chance of survival (odds ratio of 18.5 versus a non-exercise odds ratio of 0.09).Conclusion: Exercise-related OHCA has a low incidence and is related to a significantly better prognosis when compared to non-exercise OHCA. Furthermore, many patients experiencing exercise-related OHCA received defibrillation and cardiopulmonary resuscitation by bystanders. These findings could help plan and execute campaigns and education. [ABSTRACT FROM AUTHOR]

Introduction: The Australasian Resuscitation Outcomes Consortium (Aus-ROC) out-of-hospital cardiac arrest (OHCA) Epistry (Epidemiological Registry) now covers 100% of Australia and New Zealand (NZ). This study reports and compares the Utstein demographics, arrest characteristics and outcomes of OHCA patients across our region.Methods: We included all OHCA cases throughout 2019 as submitted to the Epistry by the eight Australian and two NZ emergency medical services (EMS). We calculated crude and age-standardised incidence rates and performed a national and EMS regional comparison.Results: We obtained data for 31,778 OHCA cases for 2019: 26,637 in Australia and 5,141 in NZ. Crude incidence was 107.9 per 100,000 person-years in Australia and 103.2/100,000 in NZ. Overall, the majority of OHCAs occurred in adults (96%), males (66%), private residences (76%), were unwitnessed (63%), of presumed medical aetiology (83%), and had an initial monitored rhythm of asystole (64%). In non-EMS-witnessed cases, 38% received bystander CPR and 2% received public defibrillation. Wide variation was seen between EMS regions for all OHCA demographics, arrest characteristics and outcomes. In patients who received an EMS-attempted resuscitation (13,664/31,778): 28% (range across EMS = 13.1% to 36.7%) had return of spontaneous circulation (ROSC) at hospital arrival and 13% (range across EMS = 9.9% to 20.7%) survived to hospital discharge/30-days. Survival in the Utstein comparator group (bystander-witnessed in shockable rhythm) varied across the EMS regions between 27.4% to 42.0%.Conclusion: OHCA across Australia and NZ has varied incidence, characteristics and survival. Understanding the variation in survival and modifiable predictors is key to informing strategies to improve outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Out-of-hospital cardiac arrest (OHCA) is a major cause of death and disability in the United States. Cardiac arrest centers (CAC) are necessary for the management of these critically ill and complex post arrest patients due to their specialized services and provider expertise. We report the case of a patient with OHCA and the systems of care involved in his resuscitation and recovery. Case Report: Emergency medical services attended a 39-year-old male with ongoing bystander cardiopulmonary resuscitation (CPR) after a witnessed collapse. Despite receiving appropriate advanced cardiac life support, including three defibrillations, he remained in refractory ventricular fibrillation. A prehospital physician identified him as an extracorporeal cardiopulmonary resuscitation (ECPR) candidate due to his age, witnessed arrest, refractory rhythm, and functional status. He was expedited to a CAC but no longer qualified for ECPR due to the time limit. He was resuscitated by the multiple teams activated prior to his arrival. He eventually had sustained return of circulation, was taken to the catheterization lab for emergent percutaneous coronary intervention, and recovered with a good neurologic outcome. Conclusion: Cardiac arrest centers may be capable of advanced interventions including ECPR. However, the systems of care offered by these centers is itself a lifesaving intervention. As this case highlights, despite not receiving the specified intervention (ECPR) the systems of care required to offer such a resource led to this favorable outcome. [ABSTRACT FROM AUTHOR]

Background: To investigate and understand the determinants of decisions not to attempt resuscitation following out-of-hospital cardiac arrest, to contribute to establishing rules that are appropriate to China.Methods: We recruited participants through directors of emergency medical services across China. A 28-question web survey was available between February 5 and March 6, 2021 that targeted demographic information and views on emergency work and cardiopulmonary resuscitation. Each question was assigned a value between 1 and 7 based on the level of importance from low to high. T-tests, one-way analysis of variance, and Kruskal-Wallis H-tests were used to compare continuous variables. Binary logistic regression analysis was used to identify factors influencing when people considered it suitable to initiate cardiopulmonary resuscitation.Results: The study involved 4289 participants from 31 provinces, autonomous regions and municipalities in mainland China, of whom 52.8% were male. The top three reasons for not attempting cardiopulmonary resuscitation were decomposition/hypostasis/rigor mortis (6.39 ± 1.44 points), massive injury (4.57 ± 2.08 points) and family members' preference (4.35 ± 1.98 points). In total, 2761 (64.4%) thought emergency services should not attempt cardiopulmonary resuscitation when cardiac arrest had happened more than 30 min before, and there had been no bystander cardiopulmonary resuscitation. Gender (OR 1.233, p = 0.002), religion (OR 1.147, p = 0.046), level (OR 0.903, p = 0.028) or classification of city (OR 0.920, p = 0.049), years of work experience (OR 0.884, p = 0.004), and major (OR 1.032, p = 0.044) all influenced how long after cardiac arrest was considered suitable for initiating cardiopulmonary resuscitation.Conclusions: Chinese emergency physicians have different perceptions of when not to attempt resuscitation to those practicing elsewhere. The existing guidelines for resuscitation are not suitable for China, and China-specific guidelines need to be established. [ABSTRACT FROM AUTHOR]

Aim: There have been no direct comparisons of cardiopulmonary resuscitation (CPR)-related injuries between those who die during CPR and those who survive to intensive care unit (ICU) admission. This study aimed to compare the incidence, severity, and impact on survival rate of these injuries and potential influencing factors.Method: This retrospective multicenter study analyzed autopsy reports of patients who experienced out-of-hospital cardiac arrest (OHCA) and were not admitted to hospital. CPR-related injuries were compared to OHCA patients with clinical suspicion of CPR-related injury confirmed on imaging when admitted to the ICU.Results: A total of 859 out-of-hospital cardiac arrests (OHCA) were divided into 2 groups: those who died during CPR and underwent autopsy (DEAD [n = 628]); and those who experienced return of spontaneous circulation and admitted to the ICU (ICU [n = 231]). Multivariable analyses revealed that independent factors of 30-day mortality included no bystander arrest, cardiac etiology, no shockable rhythm, and CPR-related injury. Trauma was independently associated with older age, bystander CPR, cardiac etiology, duration of CPR, and no defibrillation. CPR-related injury occurred in 30 (13%) patients in the ICU group and 547 (87%) in the DEAD group (p < 0.0001). Comparison of injuries revealed that those in the DEAD group experienced more thoracic injuries, rib(s) and sternal fractures, and fewer liver injuries compared to those in the ICU group, without differences in injury severity.Conclusion: CPR-related injuries were observed more frequently in those who died compared with those who survived to ICU admission. Injury was an independent factor of 30-day mortality. [ABSTRACT FROM AUTHOR]

Background: Dispatcher-assisted CPR (DA-CPR) has the potential to deliver early bystander CPR (BCPR) and improve out-of-hospital cardiac arrest (OHCA) survival. This study in the Asia-Pacific evaluated the impact of a DA-CPR program on BCPR rates and survival.Methods: This was a three-arm, prospective, multi-national, population-based, community-level, implementation trial. Cases between January 2009 and June 2018 from the Pan-Asian Resuscitation Outcomes Study were included. Sites either implemented a comprehensive (with quality improvement tool) or a basic DA-CPR package, or served as controls. Primary outcome was survival-to-discharge/30th day post-arrest. Secondary outcomes were BCPR and favorable neurological outcome. A before-after comparison was made within each country; this before-after change was then compared across the three groups using logistic regression.Results: 170,687 cases were analyzed. Before-after comparison showed that survival to discharge was higher in the 'implementation' period in all three groups: comprehensive odds ratio (OR) 1.09, 95% confidence interval (CI; [1.0-1.19]); basic OR 1.14, 95% CI (1.08-1.2); and control OR 1.25, 95% CI (1.02-1.53). Comparing between groups, the comprehensive group had significantly higher change in BCPR (comprehensive vs control ratio of OR 1.86, 95% CI [1.66-2.09]; basic vs control ratio of OR 0.94, 95% CI [0.85-1.05]; and comprehensive vs basic ratio of OR 1.97, 95% CI [1.87-2.08]) and survival with favorable neurological outcome (comprehensive vs basic ratio of OR 1.2, 95% CI [1.04-1.39]).Conclusion: We evaluated the impact of a DA-CPR program across heterogeneous EMS systems and demonstrated that a comprehensive DA-CPR program had the most impact on BCPR and favorable neurological outcome. [ABSTRACT FROM AUTHOR]

Objective: Minority student-athletes have a lower survival rate from sudden cardiac arrest (SCA) than non-minority student-athletes. This study examined the relationship between high school indicators of socioeconomic status (SES) and survival in student-athletes with exercise-related SCA.Methods: High school student-athletes in the USA with exercise-related SCA on school campuses were prospectively identified from 1 July 2014 to 30 June 2018 by the National Center for Catastrophic Sports Injury Research. High school indicators of SES included the following: median household and family income, proportion of students on free/reduced lunch and percent minority students. Resuscitation details included witnessed arrest, presence of an athletic trainer, bystander cardiopulmonary resuscitation and use of an on-site automated external defibrillator (AED). The primary outcome was survival to hospital discharge. Differences in survival were analysed using risk ratios (RR) and univariate general log-binomial regression models.Results: Of 111 cases identified (mean age 15.8 years, 88% male, 49% white non-Hispanic), 75 (68%) survived. Minority student-athletes had a lower survival rate compared with white non-Hispanic student-athletes (51.1% vs 75.9%; RR 0.67, 95% CI 0.49 to 0.92). A non-significant monotonic increase in survival was observed with increasing median household or family income and with decreasing percent minority students or proportion on free/reduced lunch. The survival rate was 83% if an athletic trainer was on-site at the time of SCA and 85% if an on-site AED was used.Conclusions: Minority student-athletes with exercise-related SCA on high school campuses have lower survival rates than white non-Hispanic athletes, but this difference is not fully explained by SES markers of the school. [ABSTRACT FROM AUTHOR]

Background: Major efforts have been made to reduce the burden of sports-related sudden cardiac arrest (SrSCA). The extent to which the incidence, management, and outcomes changed over time has not been investigated.Objectives: The purpose of this study was to assess temporal trends in SrSCA incidence, management, and survival.Methods: Using data from the French National Institute of Health and Medical Research, we evaluated the evolution of incidence, prehospital management, and survival at hospital discharge of SrSCA among subjects aged 18 to 75 years, over 6 successive 2-year periods between 2005 and 2018.Results: Among the 377 SrSCA, 20 occurred in young competitive athletes (5.3%), whereas 94.7% occurred in middle-aged recreational sports participants. Comparing the last 2-year to the first 2-year period, SrSCA incidence remained stable (6.24 vs 7.00 per million inhabitants/y; P = 0.51), with no significant differences in patients' mean age (46.6 ± 13.8 years vs 51.0 ± 16.4 years; P = 0.42), sex (men 94.7% vs 95.2%; P = 0.99), and history of heart disease (12.5% vs 15.9%; P = 0.85). However, frequency of bystander cardiopulmonary resuscitation and public automated external defibrillator use increased significantly (34.9% vs 94.7%; P < 0.001 and 1.6% vs 28.8%; P = 0.006, respectively). Survival to hospital discharge improved steadily, reaching 66.7% in the last study period compared with 23.8% in the first (P < 0.001).Conclusions: Incidence of SrSCA remained relatively stable over time, suggesting a need for improvement in screening strategies. However, major improvements in on-field resuscitation led to a 3-fold increase in survival, underlining the value of public education in basic life support that should serve as an example for SCA in general. [ABSTRACT FROM AUTHOR]

Background: Current Advanced Life Support Termination of Resuscitation (TOR) guidelines suggest when to cease cardiopulmonary resuscitation (CPR). With the significant increase of Dispatch-Assisted CPR (DA-CPR) programs, the impact of DA-CPR on the TOR criteria performance is not clear.Methods: We conducted a secondary analysis of a prospectively collected registry, the Pan-Asian Resuscitation Outcomes Study. We included patients >15 years old with out-of-hospital cardiac arrest between 2014 and 2017 (after implementation of Singapore's DA-CPR program). We excluded patients with non-cardiac etiology, known do-not-resuscitate status, and healthcare provider bystanders. All cases were collected in accordance to Utstein standards. We evaluated the addition of DA-CPR to the diagnostic performance of TOR criteria using logistic regression modeling. The primary outcome was performance for predicting non-survival at 30 days. Sensitivity, specificity, and positive and negative predictive values were calculated.Results: Of the 6009 cases, 319 (5.3%) were still alive at 30 days. Patients had a mean age of 67.9 (standard deviation 15.7) years and were mostly male and Chinese. Almost half of patients had no bystander CPR. The TOR criteria differentiating DA-CPR from unassisted bystander CPR has a specificity of 94% and predictive value of death of 99%, which was not significantly different from undifferentiated CPR criteria. There were differences in adjusted association with survival between unassisted and DA-CPR.Conclusion: Advanced life support TOR criteria retain high specificity and predictive value of death in the context of DA-CPR. Further research should explore the differences between unassisted CPR and DA-CPR to understand differential survival outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Bystander cardiopulmonary resuscitation (BCPR) is strongly advocated by resuscitation councils for paediatric out-of-hospital cardiac arrests (OHCAs). However, there are limited reports on rates of BCPR in children and its relationship with return of spontaneous circulation (ROSC) or survival outcomes.Objective: We describe the rate of BCPR and its association with any ROSC and survival- to- hospital-discharge.Methods: We conducted retrospective analysis of prospectively collected paediatric (<18 years of age) OHCA cases in England; we included specialist registry patients treated by emergency medical services (EMS) with known BCPR status and outcome between January 2014 and November 2018. Data included patient demographics, aetiology, witness status, initial rhythm, EMS, season, time of day and bystander status. Associations between BCPR, and any ROSC and survival-to-hospital-discharge outcomes were explored using multivariable logistic regression.Results: There were 2363 paediatric OHCAs treated across 11 EMS regions. BCPR was performed in 69.6% (1646/2363) of the cases overall (range 57.7% (206/367) to 83.7% (139/166) across EMS regions). Only 34.9% (550/1572) of BCPR cases were witnessed. Overall, any ROSC was achieved in 22.8% (523/2289) and survival to hospital discharge in 10.8% (225/2066). Adjusted odds ratio (aOR) for any ROSC was significantly improved following BCPR compared to no BCPR (aOR 1.37, 95% CI 1.03-1.81), but adjusted odds ratio for survival-to-hospital-discharge were similar (aOR 1.01, 95% CI 0.66-1.55).Conclusions: BCPR was associated with improved rates of any ROSC but not survival-to-hospital-discharge. Variations in EMS BCPR rates may indicate opportunities for regional targeted increase in public BCPR education. [ABSTRACT FROM AUTHOR]

Background: In out-of-hospital cardiac arrest (OHCA), bystander initiated cardiopulmonary resuscitation (CPR) increases the chance of return of spontaneous circulation and survival with a favourable neurological status. Socioeconomic disparities have been highlighted in OHCA field. In areas with the lowest average socioeconomic status, OHCA incidence increased, and bystander CPR decreased. Evaluations were performed on restricted geographical area, and European evaluation is lacking. We aimed to analyse, at a national level, the impact of area-level social deprivation on the initiation of CPR in case of a witnessed OHCA.Methods: We included all witnessed OHCA cases with age over 18 years from July 2011 to July 2018 form the OHCA French national registry. We excluded OHCA occurred in front of rescue teams or in nursing home, and patients with incomplete address or partial geocoding. We collected data from context, bystander and patient. The area-level social deprivation was estimated by the French version of the European Deprivation Index (in quintile) associated with the place where OHCA occurred. We assessed the associations between Utstein variables and social deprivation level using a mixed-effect logit model with bystander-initiated CPR.Results: We included 23,979 witnessed OHCA of which 12,299 (51%) had a bystander-initiated CPR. More than one third of the OHCA (8,326 (35%)) occurred in an area from the highest quintile of social deprivation. The higher the area-level deprivation, the less the proportion of bystander-initiated CPR (56% in Quintile 1 versus 48% in Quintile 5). The In the multivariable analysis, bystander less often began CPR in areas with the highest deprivation level, compared to those with the lowest deprivation level (OR=0.69, IC95%: 0.63-0.75).Conclusions: The level of social deprivation of the area where OHCA occurred was associated with bystander-initiated CPR. It decreased in the more deprived areas although these areas also concentrate more younger patients. [ABSTRACT FROM AUTHOR]

We validated the NUE rule, using three criteria (Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older) to predict futile resuscitation of patients with out-of-hospital cardiac arrest (OHCA). We performed a retrospective cohort analysis of all recorded OHCA in Marion County, Indiana, from January 1, 2014 to December 31, 2019. We described patient, arrest, and emergency medical services (EMS) response characteristics, and assessed the performance of the NUE rule in identifying patients unlikely to survive to hospital discharge. From 2014 to 2019, EMS responded to 4370 patients who sustained OHCA. We excluded 329 (7.5%) patients with incomplete data. Median patient age was 62 years (IQR 49 − 73), 1599 (39.6%) patients were female, and 1728 (42.8%) arrests were witnessed. The NUE rule identified 290 (7.2%) arrests, of whom none survived to hospital discharge. In external validation, the NUE rule (Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older) correctly identified 7.2% of OHCA patients unlikely to survive to hospital discharge. The NUE rule could be used in EMS protocols and policies to identify OHCA patients very unlikely to benefit from aggressive resuscitation. [ABSTRACT FROM AUTHOR]

Background The mechanism by which bystander cardiopulmonary resuscitation (CPR) improves survival following out‐of‐hospital cardiac arrest is unclear. We hypothesized that ventricular fibrillation (VF) waveform measures, as surrogates of myocardial physiology, mediate the relationship between bystander CPR and survival. Methods and Results We performed a retrospective cohort study of adult, bystander‐witnessed patients with out‐of‐hospital cardiac arrest with an initial rhythm of VF who were treated by a metropolitan emergency medical services system from 2005 to 2018. Patient, resuscitation, and outcome variables were extracted from emergency medical services and hospital records. A total of 3 VF waveform measures (amplitude spectrum area, peak frequency, and median peak amplitude) were computed from a 3‐second ECG segment before the initial shock. Multivariable logistic regression estimated the association between bystander CPR and survival to hospital discharge adjusted for Utstein elements. Causal mediation analysis quantified the proportion of survival benefit that was mediated by each VF waveform measure. Of 1069 patients, survival to hospital discharge was significantly higher among the 814 patients who received bystander CPR than those who did not (0.52 versus 0.43, respectively; P