Search

Rhodopsin is a G protein-coupled receptor essential for vision and rod photoreceptor viability. Disease-associated rhodopsin mutations, such as P23H rhodopsin, cause rhodopsin protein misfolding and trigger endoplasmic reticulum (ER) stress, activating the unfolded protein response (UPR). The pathophysiologic effects of ER stress and UPR activation on photoreceptors are unclear. Here, by examining P23H rhodopsin knock-in mice, we found that the UPR inositol-requiring enzyme 1 (IRE1) signaling pathway is strongly activated in misfolded rhodopsin-expressing photoreceptors. IRE1 significantly upregulated ER-associated protein degradation (ERAD), triggering pronounced P23H rhodopsin degradation. Rhodopsin protein loss occurred as soon as photoreceptors developed, preceding photoreceptor cell death. By contrast, IRE1 activation did not affect JNK signaling or rhodopsin mRNA levels. Interestingly, pro-apoptotic signaling from the PERK UPR pathway was also not induced. Our findings reveal that an early and significant pathophysiologic effect of ER stress in photoreceptors is the highly efficient elimination of misfolded rhodopsin protein. We propose that early disruption of rhodopsin protein homeostasis in photoreceptors could contribute to retinal degeneration.

PURPOSE: The aim of this study was to assess the performance of 3 different influenza-like illness (ILI) case definitions, adopted by the European (European-CDC), USA (USA-CDC), and Taiwan Centers for Disease Prevention and Control (Taiwan-CDC), as screening tools for influenza during the 2009 H1N1 pandemic. METHODS: From August 15 to 30, 2009, all emergency department patients with clinical symptoms or at epidemiologic risk for influenza were enrolled in an observational cohort study. Influenza diagnosis was established by positive rapid influenza diagnostic test or virus isolation. Sensitivity, specificity, positive predictive value, and negative predictive value of the European-, USA, and Taiwan-CDC ILI case definitions for screening were determined. RESULTS: A total of 870 patients were screened during the study period. Rapid influenza diagnostic test was positive in 315 patients, 273 (85.6%) of whom had fever duration less than 72 hours. Virus isolation identified 4 more patients with influenza A initially negative by rapid influenza diagnostic test. The mean (SD) age of these 319 patients was 24.3 (18.1) years. Of the 870 screened patients, 670 (77.0%), 476 (54.7%), and 325 (37.4%) met the European-, USA-, and Taiwan-CDC ILI case definition, respectively. Screening sensitivity was 95%, 77.7%, and 57.7% and specificity was 33.4%, 58.6%, and 74.4%, respectively. Differences in sensitivity and specificity between any 2 of the 3 groups were statistically significant (P < .05). CONCLUSION: First-line physicians should recognize the advantage and limitation of different ILI case definitions in influenza screening, especially confronted by pandemic or highly pathogenic avian influenza in the future. [ABSTRACT FROM AUTHOR]

BACKGROUND: Pentoxifylline potently inhibits cell proliferation, inflammation, and extracellular matrix accumulation. Human studies have proved its antiproteinuric effect in patients with glomerular diseases. Its benefit in addition to angiotensin receptor blockade in patients with chronic kidney disease is not clear. STUDY DESIGN: Randomized controlled study. SETTING & PARTICIPANTS: 85 patients with estimated glomerular filtration rate (eGFR) of 10 to 60 mL/min/1.73 m(2) and proteinuria with protein greater than 500 mg/g of creatinine on treatment with losartan, 100 mg/d, for longer than 6 months were screened in National Taiwan University Hospital. INTERVENTION: In the first stage (12 months), group 1 served as control and group 2 was administered pentoxifylline. In the second stage (6 months), both groups were administered pentoxifylline. The pentoxifylline dose was 400 mg twice daily for patients with eGFR of 30 to 60 mL/min/1.73 m(2) or once daily for patients with eGFR of 10 to 29 mL/min/1.73 m(2). OUTCOMES: Proteinuria and eGFR. MEASUREMENTS: Proteinuria was assessed as total protein-creatinine ratio, eGFR was computed by using the Modification of Diet in Renal Disease Study equation. RESULTS: 27 and 29 patients were randomly assigned to groups 1 and 2, respectively. In the first stage, pentoxifylline decreased median proteinuria from 1,140 to 800 mg/g (median change, -23.9%) compared with 1,410 to 1,810 mg/g (median change, 13.8%) in the control group. The difference between groups was 38.7% (95% confidence interval, 25.7 to 51.6; P < 0.001). The change in proteinuria was related to the change in urinary tumor necrosis factor alpha and monocyte chemoattractant protein 1 excretion (R = 0.64 and R = 0.55, respectively; P < 0.001 for both). In the second stage, pentoxifylline reproduced the change in proteinuria in group 1. LIMITATIONS: Small sample size, disease of late stages, open-labeled study. CONCLUSIONS: Pentoxifylline added to losartan therapy for 1 year decreased proteinuria in patients with CKD stages 3 to 5. A large-scale clinical trial is necessary to confirm this result. [ABSTRACT FROM AUTHOR]

Objective: Healthcare workers in the emergency department are particularly vulnerable to communicable disease. This study aimed to evaluate compliance with standard precautions by analysis of the incidence and systems sources of such contaminations and by quantifying the use of personal protective equipment.Method: A prospective observational study from 1 November 2005 to 30 April 2006, using analysis of video segments. Videotapes were recorded in two rooms designed for cardiopulmonary resuscitation of out-of-hospital cardiac arrests, and compliance with basic infection control measures by all emergency department crews was monitored.Results: A total of 44 consecutive performances of cardiopulmonary resuscitation were recorded for time-motion analysis. The percentages of staff wearing personal protective equipment were 90%, 50%, 20% and 75% for masks, eye protection, gowns and gloves, respectively. Compliance ranking scored doctors as high, trainees as moderate and nursing staff as low. Overall contamination rate was 16.9x10(-2) events/person-min. The two leading systems sources for contamination were lack of specific task assignments among rescuers (44%) and inadequate preparation for procedures (42%).Conclusions: Among healthcare workers in the emergency setting, the study disclosed suboptimal compliance with basic infection control measures, including use of personal protective equipment and avoiding contamination. By further time-motion analysis of resuscitation sessions, major systems sources and strategies for improvement could be identified. [ABSTRACT FROM AUTHOR]

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

The mRNA 5'-cap structure removal by the decapping enzyme DCP2 is a critical step in gene regulation. While DCP2 is the catalytic subunit in the decapping complex, its activity is strongly enhanced by multiple factors, particularly DCP1, which is the major activator in yeast. However, the precise role of DCP1 in metazoans has yet to be fully elucidated. Moreover, in humans, the specific biological functions of the two DCP1 paralogs, DCP1a and DCP1b, remain largely unknown. To investigate the role of human DCP1, we generated cell lines that were deficient in DCP1a, DCP1b, or both to evaluate the importance of DCP1 in the decapping machinery. Our results highlight the importance of human DCP1 in decapping process and show that the EVH1 domain of DCP1 enhances the mRNA-binding affinity of DCP2. Transcriptome and metabolome analyses outline the distinct functions of DCP1a and DCP1b in human cells, regulating specific endogenous mRNA targets and biological processes. Overall, our findings provide insights into the molecular mechanism of human DCP1 in mRNA decapping and shed light on the distinct functions of its paralogs., Competing Interests: TC, HL, MN, JS, YC, WC, YL, CC No competing interests declared, (© 2024, Chen, Liao et al.)

Background: Chest compression at a rate of 100-120 compressions per minute (cpm) during cardiopulmonary resuscitation (CPR) is associated with the highest survival rates. Performing compressions at a faster rate may exhaust the rescuers., Objectives: To compare a new cue of 'two compressions per second' to the traditional cue of '100-120 compressions per minute' on compression rate in CPR training., Methods: In this cluster-randomized study, students from two senior high schools were assigned into two groups. For the experimental group, the cue for the compression rate was 'two compressions per second'. For the control group, the cue was '100-120 cpm'. Except the different cues, all participants underwent the same standardized CPR training program. Verbal compression rate-related feedback was not obtained during practice. Quality indicators of chest compressions were recorded by a sensorized manikin. The primary outcome measure was mean compression rate at course conclusion. The secondary outcome measures were individual compression quality indicators at course conclusion and 3 months after training., Results: We included 164 participants (85 participants, experimental group; 79 participants, control group). Both groups had similar characteristics. The experimental group had a significantly lower mean compression rate at course conclusion (144.3 ± 16.17 vs. 152.7 ± 18.38 cpm, p = 0.003) and at 3 months after training (p = 0.09). The two groups had similar mean percentage of adequate compression rate (≥ 100 cpm), mean compression depth, and mean percentage of complete recoil at course conclusion and 3 months after training., Conclusion: The new cue of 'two compressions per second' resulted in participants having a lower compression rate, although it still exceeded 120 cpm., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Ambulance-based telestroke may be a promising solution to improving stroke care. We assessed the technical feasibility and reliability of prehospital evaluations using commercial mobile phones with fifth-generation wireless communication technology., Methods: Six standardized patients portrayed scripted stroke scenarios during ambulance transport in an urban city and were remotely evaluated by independent raters using tablets (three neurologists and three emergency physicians) in a hospital, assisted by paramedics (trained in National Institute of Health Stroke Scale [NIHSS] assessment) in the ambulance; commercial cellular networks were utilized for videoconferencing transmission. The primary outcomes were mean difference (MD) and correlation of NIHSS scores between the face-to-face and remote assessments. We also examined the Bland-Altman plot for itemized NIHSS components, and Kaplan-Meier curves were used to compare the differences in the duration of the two evaluations between neurologists and emergency physicians., Results: We conducted 32 ambulance runs and successfully completed all NIHSS examinations. No significant difference was found between the face-to-face and remote evaluations (MD, 0.782; 95% confidence interval [CI], -0.520-0.395). The correlation of NIHSS scores between the two methods was 0.994 (95% CI, 0.945-1.026), and three items exhibited the highest frequency of runs, with score differences between the two methods. There were no significant differences between neurologists and emergency physicians in the mean evaluation duration and NIHSS scores for the two methods., Conclusion: Prehospital evaluation using commercial mobile phones with fifth-generation wireless communication technology is feasible and reliable during ambulance transport in urban areas. Emergency physicians and neurologists performed similarly in stroke evaluations., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

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

To assess a quality improvement project using alternating pressure air mattresses' impact on reducing full-thickness pressure injuries by enhancing setting accuracy and device utilization. We retrospectively evaluated adult acute care unit patients with inclusion criteria (Braden scores ≤12 or existing full-thickness pressure injuries) between May 2020 and August 2023. A wound team attempted to enhance the accuracy, utilization and effectiveness of alternating pressure air mattress implementation. The implementation outcomes were setting accuracy and accurate utilization rates. The clinical outcome was the full-thickness pressure injury proportion. Utilization and allocation gaps were also calculated. The setting accuracy and accurate utilization rates increased (0.59 to 0.88 and 0.15 to 0.37, respectively). The full-thickness pressure injury proportion decreased (0.17 to 0.06), with a strong negative correlation coefficient (-0.789) (p < 0.001) with accurate utilization rates. The full-thickness pressure injury proportion declined faster during the project's complete phase than the partial phase (-0.0046 vs. -0.0016; p < 0.05). The utilization gap narrowed (99 to 60); however, the allocation gap increased (1 to 13), suggesting increased alternating pressure air mattress usage among ineligible patients. Targeting high-risk patients for alternating pressure air mattress utilization and ensuring correct settings, both performed by a dedicated team, substantially reduces the full-thickness pressure injury incidence., (© 2024 The Author(s). International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

The optimal prehospital blood pressure in patients following traumatic brain injury (TBI) remains controversial. We aimed to assess the association between the systolic blood pressure (SBP) at emergency department triage and patient outcomes following isolated moderate-to-severe TBI. We conducted a cross-national multicenter retrospective cohort study using the Pan-Asia Trauma Outcomes Study database from January 1, 2016, to November 30, 2018. The enrollees were adult patients with isolated moderate-to-severe TBI defined by the International Classification of Diseases code, a Glasgow Coma Scale (GCS) <13 at triage, and a nonhead Abbreviated Injury Scale ≤3. The studied variables were SBPs at triage categorized into different ranges. The primary outcome was 30-day mortality, and the secondary outcome was poor functional status at hospital discharge defined by the modified Rankin Scale ≥4. Multivariable logistic regression was applied to adjust for confounders including country, sex, age, mechanism of injury, prehospital vascular access, respiratory rate, GCS, oxygen saturation, intubation, Injury Severity Score, head surgery, intensive care unit admission, and length of hospital stay. Subgroup analyses were performed on different severity of TBI. A total of 785 patients (median age, 42 years; male patients 77.5%; mean SBP at triage, 136.3 ± 33.1 mmHg) were included in the primary analysis. The lowest 30-day mortality rate existed in patients with SBP of 100-119 mmHg. Taking it as baseline, the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of SBP <100 mmHg, 120-139 mmHg, 140-159 mmHg, and ≥160 mmHg were 7.05 (2.51-19.78), 3.14 (1.14-8.65), 2.91 (1.04-8.17), and 3.28 (1.14-9.42). As for the secondary outcome, the aORs and 95% CIs were 1.36 (0.68-2.68) of <100 mmHg, 0.99 (0.57-1.70) of 120-139 mmHg, 1.23 (0.67-2.25) of 140-159 mmHg, and 1.52 (0.78-2.95) of ≥160 mmHg. Subgroup analyses revealed trends of the best outcomes in both moderate and severe TBI patients with SBP 100-119 mmHg, whereas statistical significance appeared only in patients with severe TBI. SBP of 110-119 mmHg at triage is associated with the lowest 30-day mortality in patients following isolated moderate-to-severe TBI and possibly related to a better functional outcome.

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

Objectives: Following current cardiopulmonary resuscitation (CPR) guidelines, which recommend chest compressions at "the center of the chest," ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression, obstructing blood flow. We used resuscitative transesophageal echocardiography (TEE) to elucidate the impact of uncompressed vs. compressed AV on outcomes of adult patients experiencing OHCA., Design: Prospective observational cohort study., Setting: Single center., Patients: This study included adult OHCA patients undergoing resuscitative TEE in the emergency department. Patients were categorized into AV uncompressed or AV compressed groups based on TEE findings., Interventions: None., Measurements and Main Results: The primary outcome was sustained return of spontaneous circulation (ROSC). The secondary outcomes included end-tidal co2 (Et co2 ) during CPR, any ROSC, survival to ICU and hospital discharge, post-resuscitation withdrawal, and favorable neurologic outcomes at discharge. Additional analyses on intra-arrest arterial blood pressure (ABP) were also conducted. The sample size was pre-estimated at 37 patients/group. From October 2020 to January 2023, 76 patients were enrolled, 39 and 37 in the AV uncompressed and AV compressed groups, respectively. Intergroup baseline characteristics were similar. Compared with the AV compressed group, the AV uncompressed group had a higher probability of sustained ROSC (53.8% vs. 24.3%; adjusted odds ratio [aOR], 4.72; p = 0.010), any ROSC (56.4% vs. 32.4%; aOR, 3.30; p = 0.033), and survival to ICU (33.3% vs. 8.1%; aOR, 6.74; p = 0.010), and recorded higher initial diastolic ABP (33.4 vs. 11.5 mm Hg; p = 0.002) and a larger proportion achieving diastolic ABP greater than 20 mm Hg during CPR (93.8% vs. 33.3%; p < 0.001). The Et co2 , post-resuscitation withdrawal, and survival to discharge revealed no significant intergroup differences. No patients were discharged with favorable neurologic outcomes. Uncompressed AV seemed critical for sustained ROSC across all subgroups., Conclusions: Absence of AV compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. However, its effect on long-term outcomes remains unclear., Competing Interests: Drs. Cheng and Tsai disclosed work for hire. Dr. Sun received funding from the Far Eastern Memorial Hospital (PI20200001). The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

This study aimed to enhance the evaluation of facial symmetry crucial for planning and assessing outcomes of orthognathic surgery (OGS). An innovative approach combining three-dimensional (3D) facial contour lines with hyperdimensional (HD) computing was developed for this purpose. Data were collected using 3D cone beam computed tomography (CBCT) at Chang Gung Memorial Hospital from 2016 to 2021. A comprehensive dataset was compiled, including images from 150 normal individuals and 2500 patients, totaling 5150 preoperative and postoperative facial images. A machine learning model was trained to analyze these images, and 3D contour data were used to create a facial symmetry quantification system with HD computing. Additionally, 3D CBCT data from 200 patients before and after OGS were retrospectively reviewed for clinical application. The developed facial symmetry algorithm demonstrated an overall accuracy of 84.1 %. Postoperative facial symmetry scores improved significantly, with a mean score increase of 53 %, from 2.40 to 3.63. The study culminated in the creation of a web-based system that leverages HD computing and 3D contour mapping to automate facial symmetry assessment. This system offers a user-friendly interface for rapid and accurate evaluations, facilitating better communication between clinicians and patients., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

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

Background: There has been limited data regarding the incidence of anaphylaxis in Asia. We aim to describe patterns in patient characteristics, triggers and clinical presentation of childhood anaphylaxis in Singapore., Methods: This was a retrospective review of emergency electronic medical records of children with anaphylaxis. Patients with the allergy-related diagnoses of anaphylaxis, angioedema, allergy and urticaria based on ICD-9 codes were screened. Cases fulfilling the World Allergy Organization criteria for anaphylaxis were included., Results: A total of 1188 cases of anaphylaxis were identified with a median age of 6.3 years. Extrapolating data from the study sites, from 2015 to 2022, the incidence rate of childhood anaphylaxis emergency visits in Singapore doubled from 18.9 to 38.8 per 100,000 person-years, with an incidence rate ratio (IRR) of 2.06 (95% confidence interval [CI] 1.70-2.49). In 2022, the incidence rate of food anaphylaxis was 30.1 per 100,000 person-years, IRR 2.39 (95% CI 1.90-3.01) and drug anaphylaxis was 4.6 per 100,000 person-years, IRR 1.89 (95% CI 1.11-3.25). The incidence rate in children aged 0-4 years quadrupled during the study period. Common triggers were egg (10.4%), peanut (9.3%), tree nut (8.8%), milk (8%), shellfish (7.8%) and non-steroidal anti-inflammatory drug (4.4%). The majority (88.6%) of patients were treated with intramuscular adrenaline. Total number of allergy-related visits did not increase over time between 2015 and 2019. Rates of severe anaphylaxis, namely anaphylactic shock and admission to high-dependency and intensive care, did not increase over time, with a mean incidence of 1.6, IRR 0.85 (95% CI 0.40-1.83) and 0.7, IRR 1.77 (95% CI 0.54-5.76) per 100,000 person-years, respectively., Conclusion: While the number of emergency visits due to childhood anaphylaxis has increased, the number of cases of allergy-related visits, anaphylactic shock and anaphylaxis requiring high-dependency and intensive care did not rise., (© 2024 John Wiley & Sons Ltd.)

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

Background: Prehospital electrocardiogram (PHECG) shortens door-to-balloon time in patients with ST-elevation myocardial infarction. However, it may increase the prehospital service time, thus offsetting the benefits gained. The performance of PHECG could be influenced by the proficiency of the emergency medical technicians (EMTs)., Objectives: To investigate whether there are differences in the performance of PHECG between EMT-II and EMT-paramedics (EMT-P)., Methods: This prospectively designed, retrospectively analyzed study of PHECG was conducted in Taipei from February 2019 to April 2021. Comparisons were made between EMT-II and EMT-P teams. The primary outcomes were the acceptance of PHECG suggestions and prehospital service time. The secondary outcomes were gender disparities in the primary outcomes., Results: A total of 2,991 patients were included, of whom 2,617 received PHECG. For the primary outcomes, the acceptance of PHECG was higher in those approached by EMT-P (99.6% vs. 71.5%, p < 0.001). The scene time and scene-to-hospital time showed no significant differences. For gender disparities, the acceptance of PHECG in female patients was significantly lower in those approached by EMT-II (59.3% vs. 99.2%, p < 0.001). The scene time and scene-to-hospital time were generally longer in the female patients, especially in the younger and middle age groups. Compared to EMT-P, both were significantly longer in the female patients approached by EMT-II., Conclusions: The acceptance of PHECG was lower in those approached by EMT-II, especially in females. Although there were generally no significant differences between EMT-II and EMT-P, the scene time and scene-to-hospital time were significantly longer in female patients, especially in those aged < 75 years approached by EMT-II., Competing Interests: All the authors declare no conflict of interest.

Vertebrate photoreceptors are highly specialized retinal neurons that have cilium-derived membrane organelles called outer segments, which function as platforms for phototransduction. Male germ cell-associated kinase (MAK) is a cilium-associated serine/threonine kinase, and its genetic mutation causes photoreceptor degeneration in mice and retinitis pigmentosa in humans. However, the role of MAK in photoreceptors is not fully understood. Here, we report that zebrafish mak mutants show rapid photoreceptor degeneration during embryonic development. In mak mutants, both cone and rod photoreceptors completely lacked outer segments and underwent apoptosis. Interestingly, zebrafish mak mutants failed to generate axonemes during photoreceptor ciliogenesis, whereas basal bodies were specified. These data suggest that Mak contributes to axoneme development in zebrafish, in contrast to mouse Mak mutants, which have elongated photoreceptor axonemes. Furthermore, the kinase activity of Mak was found to be critical in ciliary axoneme development and photoreceptor survival. Thus, Mak is required for ciliogenesis and outer segment formation in zebrafish photoreceptors to ensure intracellular protein transport and photoreceptor survival., Competing Interests: Competing interests The authors declare no competing or financial interests., (© 2024. Published by The Company of Biologists Ltd.)

Background: Diabetic autonomic neuropathy is a common complication of type 2 diabetes mellitus (T2DM), especially in patients with long-term, poorly controlled diabetes. This study investigates the effects of exercise on autonomic nervous system activity in T2DM patients over time., Methods: A literature review using MEDLINE, Embase, Cochrane Library, Scopus, and PubMed identified studies assessed via heart rate variability. Papers were categorized into three groups: immediate effects (within 60 min), short-term effects (2-3 months), and long-term effects (over 4 months)., Results: Nine articles with 161 T2DM patients were included in the meta-analysis. RMSSD changes after exercise were -4.3 ( p = 0.227), 8.14 ( p < 0.001), and 4.17 ( p = 0.002) for the immediate, short-term, and long-term groups, respectively. LF/HF ratio changes were 0.21 ( p = 0.264), -3.04 ( p = 0.102), and -0.05 ( p = 0.006) for the respective groups. Meta-regression indicated age, male gender, and exercise duration were associated with increased RMSSD, with coefficients of 2.36 ( p = 0.001), 13.76 ( p = 0.008), and 1.50 ( p = 0.007), respectively. Age positively correlated with the LF/HF ratio, with a coefficient of 0.049 ( p = 0.048)., Conclusions: Regular exercise (≥3 times per week) for over 2 months increases parasympathetic activity in T2DM patients, while sympathetic activity decreases significantly after 4 months. Further study is needed to validate these findings.

Background/purpose: Blended learning offers the advantages of both instructor-led and self-instruction methods in basic life support (BLS). Our study aims to compare the effects of blended learning with those of traditional instructor-led methods on the performance of laypersons taking BLS courses., Methods: A total of 108 participants were randomly assigned to three groups: traditional instruction (group A, n = 36), blended learning with two rounds of practice (group B, n = 36), and blended learning with three rounds of practice (group C, n = 36). Group A received a 90-min lecture and a 30-min hands-on practice session using a manikin and a metronome. Participants in groups B and C received 18-min standardized online video lessons and performed hands-on practice twice and thrice, respectively. The primary outcome was chest compression at a correct speed (100-120 compressions per min) after the training course. Secondary outcomes included knowledge test scores, attitudes and confidence, and individual skill performance after training., Results: Patient characteristics were similar between the groups. Blended learning with practicing thrice resulted in the highest compressions at a correct speed (group A vs. B vs. C, 68.09 vs 80.03 vs 89.42, p = 0.015) and the shortest average hands-off time (group A vs. B vs. C, 1.12 vs 0.86 vs 0.17 s, p = 0.015). Both blended groups performed better in confirming environmental safety (p < 0.001). No differences in scores of the knowledge test, attitude, or confidence were noted among the three groups., Conclusion: Blended learning with three rounds of hands-on practice may be considered an alternative teaching method., Competing Interests: Declarations of interest None., (Copyright © 2023 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

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

Background: Deep learning-based segmentation algorithms usually required large or multi-institute data sets to improve the performance and ability of generalization. However, protecting patient privacy is a key concern in the multi-institutional studies when conventional centralized learning (CL) is used., Purpose: To explores the feasibility of a proposed lesion delineation for stereotactic radiosurgery (SRS) scheme for federated learning (FL), which can solve decentralization and privacy protection concerns., Study Type: Retrospective., Subjects: 506 and 118 vestibular schwannoma patients aged 15-88 and 22-85 from two institutes, respectively; 1069 and 256 meningioma patients aged 12-91 and 23-85, respectively; 574 and 705 brain metastasis patients aged 26-92 and 28-89, respectively., Field Strength/sequence: 1.5T, spin-echo, and gradient-echo [Correction added after first online publication on 21 August 2023. Field Strength has been changed to "1.5T" from "5T" in this sentence.]., Assessment: The proposed lesion delineation method was integrated into an FL framework, and CL models were established as the baseline. The effect of image standardization strategies was also explored. The dice coefficient was used to evaluate the segmentation between the predicted delineation and the ground truth, which was manual delineated by neurosurgeons and a neuroradiologist., Statistical Tests: The paired t-test was applied to compare the mean for the evaluated dice scores (p < 0.05)., Results: FL performed the comparable mean dice coefficient to CL for the testing set of Taipei Veterans General Hospital regardless of standardization and parameter; for the Taichung Veterans General Hospital data, CL significantly (p < 0.05) outperformed FL while using bi-parameter, but comparable results while using single-parameter. For the non-SRS data, FL achieved the comparable applicability to CL with mean dice 0.78 versus 0.78 (without standardization), and outperformed to the baseline models of two institutes., Data Conclusion: The proposed lesion delineation successfully implemented into an FL framework. The FL models were applicable on SRS data of each participating institute, and the FL exhibited comparable mean dice coefficient to CL on non-SRS dataset. Standardization strategies would be recommended when FL is used., Level of Evidence: 4 TECHNICAL EFFICACY: Stage 1., (© 2023 International Society for Magnetic Resonance in Medicine.)

Introduction: The optimal vascular access for patients with out-of-hospital cardiac arrest (OHCA) remains controversial. Increasing evidence supports intraosseous (IO) access due to faster medication administration and higher first-attempt success rates compared to intravenous (IV) access. However, the impact on patient outcomes has been inconclusive., Methods: This retrospective cohort study in Taoyuan City, Taiwan, from January 1, 2019, to December 31, 2022, included patients aged ≥18 years with non-traumatic OHCA resuscitated by emergency medical technician paramedics (EMT-Ps) with either IVs or IOs for final vascular access. The exclusion criteria were cardiac arrest en route to the hospital and resuscitation during the coronavirus pandemic (from May 1, 2022, to October 31, 2022). The primary and secondary outcomes were sustained ROSC (≥2 h) and cerebral performance category (CPC) 1-2, respectively. Univariate logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CI) for the primary analysis. Multivariable logistic regression was employed, with variables selected based on a p-value of <0.05 in the univariate analysis. The survival benefits of different insertion sites and subgroups like general ambulance teams (with a composition that includes fewer EMT-Ps and limited experience in using IO access) were also analyzed., Results: A total of 2003 patients were enrolled; 1602 received IV access and 401 IO access. The median patient age was 70 years, and most were male (66.6%). Compared to patients receiving IV access, the adjusted odds ratios (aORs) for primary and secondary outcomes in patients with IOs were 0.83 (95% confidence interval [CI], 0.61-1.11; p = 0.20) and 0.96 (95% CI, 0.39-2.40; p = 0.93), respectively. Different insertion sites showed no outcome differences. In the subgroups of females and patients resuscitated by general ambulance teams, the aORs for sustained ROSC were 0.55 (95% CI, 0.33-0.92; p = 0.02) and 0.62 (95% CI, 0.41-0.94; p = 0.02), respectively., Conclusions: For patients with OHCA resuscitated by EMT-Ps, IO access was comparable to IV access regarding patient outcomes. However, in females and patients resuscitated by general ambulance teams, IV access might be favorable., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 Elsevier Inc. All rights reserved.)