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Background: As part of efforts to revitalize regional medical care, we implemented training in physical assessment for nurses and school nurses. We conducted a questionnaire survey using a realist approach to evaluate the training for school nurses that has been ongoing for 12 years., Materials and Methods: The summer training held by the Toyama Prefecture School Nurse Association includes education on severity assessment (evaluation of consciousness and vital signs), auscultation (heart, respiratory, and bowel sounds), the Heimlich maneuver, a review of Basic Life Support, and case studies. Following the training, we conducted an online questionnaire survey with participating school nurses to assess the outcome of the program., Results: A total of 122 people responded (response rate: 35.6%) with 109 (89%) indicating that the results of the training session met or exceeded their expectations. The most common outcome of the training was improvement in their own response capabilities, followed by increased trust in students/guardians and school staff members. The training also fostered a sense of responsibility among the participants, motivating them toward further self-improvement. Furthermore, within the school, it led to collaboration with other staff members, a review of the emergency system, and improvement of equipment, which was beyond our expectations. The findings suggest that continuous repetition of basic physical assessment education will form a community of practice and bring about collaboration and revitalization within the organization as well as the acquisition of knowledge and skills., Conclusions: Continuous training improved their ability to respond, earned the trust of students/parents and school staff, and motivated them to continue improving themselves. Furthermore, a community of practice was formed within the organization by continuing the training sessions., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Ethics Committee of Toyama University Hospital issued approval R2023167/November/2023. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Yamashiro et al.)

Background: Collecting blood cultures from indwelling arterial catheters is an attractive option in critically ill adult patients when peripheral venipuncture is difficult. However, whether the contamination proportion of blood cultures from arterial catheters is acceptable compared with that from venipuncture is inconclusive., Research Question: Is contamination of blood cultures from arterial catheters noninferior to that from venipuncture in critically ill adult patients with suspected bloodstream infection?, Study Design and Methods: In this multicenter prospective diagnostic study conducted at five hospitals, we enrolled episodes of paired blood culture collection, each set consisting of blood drawn from an arterial catheter and another by venipuncture, were obtained from critically ill adult patients with cilinical indication. The primary measure was the proportion of contamination, defined as the number of false-positive results relative to the total number of procedures done. The reference standard for true bloodstream infection was blinded assessment by infectious disease specialists. We examined the noninferiority hypothesis that the contamination proportion of blood cultures from arterial catheters did not exceed that from venipuncture by 2.0%., Results: Of 1,655 episodes of blood culture from December 2018 to July 2021, 590 paired blood culture episodes were enrolled, and 41 of the 590 episodes (6.9%) produced a true bloodstream infection. In blood cultures from arterial catheters, 33 of 590 (6.0%) were positive, and two of 590 (0.3%) were contaminated; in venipuncture, 36 of 590 (6.1%) were positive, and four of 590 (0.7%) were contaminated. The estimated difference in contamination proportion (arterial catheter - venipuncture) was -0.3% (upper limit of one-sided 95% CI, +0.3%). The upper limit of the 95% CI did not exceed the predefined margin of +2.0%, establishing noninferiority (P for noninferiority < .001)., Interpretation: Obtaining blood cultures from arterial catheters is an acceptable alternative to venipuncture in critically ill patients., Clinical Trial Registration: University Hospital Medical Information Network Center (UMIN-CTR); No.: UMIN000035392; URL: https://center6.umin.ac.jp/., (Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

The purpose of the study was to investigate the accuracy of mainstream EtCO 2 measurements on the Y-piece (filtered) side of the heat and moisture exchanger filter (HMEF) in adult critically ill patients, compared to that on the patient (unfiltered) side of HMEF. We conducted a prospective observational method comparison study between July 2019 and December 2019. Critically ill adult patients receiving mechanical ventilation with HMEF were included. We performed a noninferiority comparison of the accuracy of EtCO 2 measurements on the two sides of HMEF. The accuracy was measured by the absolute difference between PaCO 2 and EtCO 2 . We set the non-inferiority margin at + 1 mmHg in accuracy difference between the two sides of HMEF. We also assessed the agreement between PaCO 2 and EtCO 2 using Bland-Altman analysis. Among thirty-seven patients, the accuracy difference was - 0.14 mmHg (two-sided 90% CI - 0.58 to 0.29), and the upper limit of the CI did not exceed the predefined margin of + 1 mmHg, establishing non-inferiority of EtCO 2 on the Y-piece side of HMEF (P for non-inferiority < 0.001). In the Bland-Altman analyses, 95% limits of agreement between PaCO 2 and EtCO 2 were similar on both sides of HMEF (Y-piece side, - 8.67 to  + 10.65 mmHg; patient side, - 8.93 to  + 10.67 mmHg). The accuracy of mainstream EtCO 2 measurements on the Y-piece side of HMEF was noninferior to that on the patient side in critically ill adults. Mechanically ventilated adult patients could be accurately monitored with mainstream EtCO 2 on the Y-piece side of the HMEF unless their tidal volume was extremely low., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Aims: Little is known about the effect of prehospital epinephrine administration in out-of-hospital cardiac arrest (OHCA) patients with refractory shockable rhythm, for whom initial defibrillation was unsuccessful., Methods and Results: This study using Japanese nationwide population-based registry included all adult OHCA patients aged ≥18 years with refractory shockable rhythm between January 2014 and December 2017. Patients with or without epinephrine during cardiac arrest were sequentially matched using a risk set matching based on the time-dependent propensity scores within the same minute. The primary outcome was 1-month survival. The secondary outcomes included 1-month survival with favourable neurological outcome (cerebral performance category scale: 1 or 2) and prehospital return of spontaneous circulation (ROSC). Of the 499 944 patients registered in the database during the study period, 22 877 were included. Among them, 8467 (37.0%) received epinephrine. After time-dependent propensity score-sequential matching, 16 798 patients were included in the matched cohort. In the matched cohort, positive associations were observed between epinephrine and 1-month survival [epinephrine: 17.3% (1454/8399) vs. no epinephrine: 14.6% (1224/8399); RR 1.22 (95% confidence interval, CI: 1.13-1.32)] and prehospital ROSC [epinephrine: 22.2% (1868/8399) vs. no epinephrine: 10.7% (900/8399); RR 2.07 (95% CI: 1.91-2.25)]. No significant positive association was observed between epinephrine and favourable neurological outcome [epinephrine: 7.8% (654/8399) vs. no epinephrine: 7.1% (611/8399); RR 1.13 (95% CI 0.998-1.27)]., Conclusion: Using the nationwide population-based registry with time-dependent propensity score-sequential matching analysis, prehospital epinephrine administration in adult OHCA patients with refractory shockable rhythm was positively associated with 1-month survival and prehospital ROSC., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021.)

Background The timing of advanced airway management (AAM) on patient outcomes after out-of-hospital cardiac arrest has not been fully investigated. We evaluated the association between the timing of prehospital AAM and 1-month survival. Methods and Results We conducted a secondary analysis of a prospective, nationwide, population-based out-of-hospital cardiac arrest registry in Japan. We included emergency medical services-treated adult (≥18 years) out-of-hospital cardiac arrests from 2014 through 2017, stratified into initial shockable or nonshockable rhythms. Patients who received AAM at any minute after emergency medical services-initiated cardiopulmonary resuscitation underwent risk-set matching with patients who were at risk of receiving AAM within the same minute using time-dependent propensity scores. Eleven thousand three hundred six patients with AAM in shockable and 163 796 with AAM in nonshockable cohorts, respectively, underwent risk-set matching. For shockable rhythms, the risk ratios (95% CIs) of AAM on 1-month survival were 1.01 (0.89-1.15) between 0 and 5 minutes, 1.06 (0.98-1.15) between 5 and 10 minutes, 0.99 (0.87-1.12) between 10 and 15 minutes, 0.74 (0.59-0.92) between 15 and 20 minutes, 0.61 (0.37-1.00) between 20 and 25 minutes, and 0.73 (0.26-2.07) between 25 and 30 minutes after emergency medical services-initiated cardiopulmonary resuscitation. For nonshockable rhythms, the risk ratios of AAM were 1.12 (1.00-1.27) between 0 and 5 minutes, 1.34 (1.25-1.44) between 5 and 10 minutes, 1.39 (1.26-1.54) between 10 and 15 minutes, 1.20 (0.99-1.45) between 15 and 20 minutes, 1.18 (0.80-1.73) between 20 and 25 minutes, 0.63 (0.29-1.38) between 25 and 30 minutes, and 0.44 (0.11-1.69) after 30 minutes. Conclusions In this observational study, the timing of AAM was not statistically associated with improved 1-month survival for shockable rhythms, but AAM within 15 minutes after emergency medical services-initiated cardiopulmonary resuscitation was associated with improved 1-month survival for nonshockable rhythms.

Objective: The possible effects of Assisted Reproductive Technology (ART) on sex ratio at birth are extremely significant. This study aimed to determine whether ART affects the sex ratio of infants born through in vitro fertilization and embryo transfer (IVF-ET)., Materials and Methods: We ran this retrospective study on 290 singleton infants born following IVF-ET from February 2014 to August 2018 at a single institution. We compared the sex ratios of these infants with respect to insemination versus intracytoplasmic sperm injection (ICSI), early-cleavage embryo versus blastocyst transfer, fresh versus frozen-thawed embryo transfer and normal sperm versus asthenospermia., Results: There were no significant differences in the sex ratio with respect to the fertilization method, transfer time, fresh embryo or frozen-thawed embryo transfer. In addition, the multiple logistic regression analysis revealed that these factors did not significantly affect the sex ratio., Conclusions: Our study indicated that the differences in the fertilization method transfer time and sperm motility rate did not affect the sex ratio of IVF live births. However, with increasing numbers of ICSI and blastocyst transfer cycles, factors possibly affecting the sex ratio need to be further investigated.

Background: The optimal timing for transporting pediatric patients with out-of-hospital cardiac arrest (OHCA) who do not achieve return of spontaneous circulation (ROSC) is unclear. Therefore, we assessed the association between resuscitation time on the scene and 1-month survival. Methods and Results: Data from the All-Japan Utstein Registry from 2013 through 2015 for 3,756 pediatric OHCA patients (age <18 years) who did not achieve ROSC prior to departing the scene were analyzed. Overall, the proportion of 1-month survival for on-scene resuscitation time <5, 5-9, 10-14, and ≥15 min was 13.6% (104/767), 10.2% (170/1,666), 8.6% (75/870), and 4.0% (18/453), respectively. Among specific age groups, the proportion of 1-month survival for on-scene resuscitation time of <5, 5-9, 10-14, and ≥15 min was 12.6% (54/429), 8.7% (59/680), 8.6% (23/267), and 6.8% (8/118), respectively, for patients aged 0 years; 16.4% (38/232), 11.0% (52/473), 11.9% (23/194), and 7.1% (6/85), respectively, for those aged 1-7 years; and 11.3% (12/106), 11.5% (59/513), 7.1% (29/409), and 1.6% (4/250), respectively, for those aged 8-17 years. Conclusions: Longer on-scene resuscitation was associated with decreased chance of 1-month survival among pediatric OHCA patients without ROSC. For patients aged <8 years, earlier departure from the scene, within 5 min, may increase the chances of 1-month survival. Conversely, for patients aged ≥8 years, continuing on-scene resuscitation for up to 10 min would be reasonable., Competing Interests: All authors have no conflicts of interest to declare., (Copyright © 2021, THE JAPANESE CIRCULATION SOCIETY.)

Purpose: To investigate impact of the one-carbon metabolism (OCM) on oocyte maturity and embryo development., Methods: This prospective study analyzed 18 women who agreed to participate. We measured the OCM biomarkers' concentrations including Vitamin B12 (VB12), folic acid (FA), and homocysteine (Hcy) in serum and follicular fluid (FF), and assessed their correlation. We also evaluated the influence of such OCM biomarker concentrations in mono-FF on oocyte maturation, fertilization, embryo quality, and consequent pregnancy after embryo transfers., Results: All biomarkers showed a high concentration variability in different follicles of each woman, but their mean levels correlated with the serum levels. Among the 106 collected oocytes, 92 were mature, 59 were fertilized, and 16 yielded good-quality embryos. We performed 26 single embryo transfers, and 7 patients achieved clinical pregnancies. VB12 concentration (FF) was significantly lower in fertilized than unfertilized oocytes by univariate analysis. In multivariate logistic analysis, a significant correlation was found between FA concentration (FF) <14.25 ng/mL and good-quality embryos and between Hcy concentration (FF) <4.9 nmol/mL and clinical pregnancy., Conclusion: OCM in FF may affect fertilization, embryo quality, and clinical pregnancy., Competing Interests: Conflicts of Interest: Kozue Akamine, Keiko Mekaru, Keiya Gibo, Chinatsu Nagata, Rie Nakamura, Sugiko Oishi, Maho Miyagi, Chiaki Heshiki, and Yoichi Aoki declare that they have no conflict of interest. Human rights statements and informed consent: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and its later amendments. Informed consent was obtained from all patients for being included in the study. This article does not contain any studies with animal subjects performed by the any of the authors. Approval by Ethics Committee: This retrospective study was approved by the Institutional Review Board of the University of the Ryukyus Hospital (February 21, 2013; No. 498)., (© 2020 The Authors. Reproductive Medicine and Biology published by John Wiley & Sons Australia, Ltd on behalf of Japan Society for Reproductive Medicine.)

Background: There is little evidence about pre-hospital advanced life support including epinephrine administration for pediatric out-of-hospital cardiac arrests (OHCAs)., Objectives: This study aimed to assess the effect of pre-hospital epinephrine administration by emergency-medical-service (EMS) personnel for pediatric OHCA., Methods: This nationwide population-based observational study in Japan enrolled pediatric patients age 8 to 17 years with OHCA between January 2007 and December 2016. Patients were sequentially matched with or without epinephrine during cardiac arrest using a risk-set matching based on time-dependent propensity score (probability of receiving epinephrine) calculated at each minute after initiation of cardiopulmonary resuscitation by EMS personnel. The primary endpoint was 1-month survival. Secondary endpoints were 1-month survival with favorable neurological outcome, defined as the cerebral performance category scale of 1 or 2, and pre-hospital return of spontaneous circulation (ROSC)., Results: During the study period, a total of 1,214,658 OHCA patients were registered, and 3,961 pediatric OHCAs were eligible for analyses. Of these, 306 (7.7%) patients received epinephrine and 3,655 (92.3%) did not receive epinephrine. After time-dependent propensity score-sequential matching, 608 patients were included in the matched cohort. In the matched cohort, there were no significant differences between the epinephrine and no epinephrine groups in 1-month survival (epinephrine: 10.2% [31 of 304] vs. no epinephrine: 7.9% [24 of 304]; risk ratio [RR]: 1.13 [95% confidence interval (CI): 0.67 to 1.93]) and favorable neurological outcome (epinephrine: 3.6% [11 of 304] vs. no epinephrine: 2.6% [8 of 304]; RR: 1.56 [95% CI: 0.61 to 3.96]), whereas the epinephrine group had a higher likelihood of achieving pre-hospital ROSC (epinephrine: 11.2% [34 of 304] vs. no epinephrine: 3.3% [10 of 304]; RR: 3.17 [95% CI: 1.54 to 6.54])., Conclusions: In this study, pre-hospital epinephrine administration was associated with ROSC, whereas there were no significant differences in 1-month survival and favorable neurological outcome between those with and without epinephrine., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Although prehospital advanced airway management (AAM) (i.e., endotracheal intubation [ETI] and insertion of supraglottic airways [SGA]) has been performed for paediatric out-of-hospital cardiac arrest (OHCA), the effect of AAM has not been fully studied. We evaluated the association between prehospital AAM for paediatric OHCA and patient outcomes., Methods: We conducted an observational cohort study, using the All-Japan Utstein Registry between 2014 and 2016. We included paediatric patients (age <18 years) with OHCA. We calculated time-dependent propensity score at each minute after initiation of cardiopulmonary resuscitation by EMS providers, using a Fine-Gray regression model. We sequentially matched patients who received AAM during cardiac arrest to patients at risk of receiving AAM within the same minute (risk-set matching). The primary outcome was 1-month survival. Secondary outcome was 1-month survival with favourable functional status, defined as Cerebral Performance Category score of 1 or 2., Results: We analysed 3801 paediatric patients with OHCA. 481 patients (12.7%) received AAM and 3320 (87.3%) did not. Among the 3801 analysed patients, 912 patients underwent risk-set matching. In the matched cohort, AAM was not associated with 1-month survival (AAM: 52/456 [11.4%] vs. no AAM: 44/456 [9.6%]; risk ratio [RR], 1.15 [95% CI, 0.76-1.73]; risk difference [RD], 1.5% [-3.0 to 6.1%]) or favourable functional status (AAM: 9/456 [2.0%] vs. no AAM: 10/456 [2.2%]; RR, 0.69 [95% CI, 0.26-1.79]; RD, -0.8% [-2.9 to 1.3%])., Conclusion: Among paediatric patients with OHCA, we found that prehospital AAM was not associated with 1-month survival or favourable functional status., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: Patient outcomes after out-of-hospital cardiac arrest (OHCA) varies at multilevel (geographical regions, emergency medical service agencies and receiving hospitals) in the USA. However, it remains unclear whether there is a variation in patient outcomes after OHCA between relevant units of the healthcare system such as receiving hospitals in Japan. Therefore, we aimed to quantify the variation in patient outcomes after OHCA between receiving hospitals in Japan., Design: Secondary analysis of the prospective multicentre OHCA registry., Setting: The Japan Association for Acute Medicine OHCA Registry, a prospective multicentre OHCA registry, including 73 medical institutions in Japan., Participants: 9303 adults (≥18 years old) with OHCA of medical origin, treated at 67 hospitals from June 2014 to December 2015., Primary and Secondary Outcome Measures: The primary outcome was 1-month survival after OHCA. The secondary outcome was favourable functional status at 1 month, defined as cerebral performance category scale 1 or 2. We constructed a series of multivariable hierarchical logistic regression models predicting outcomes, accounting for patient-level variables and clustering of patients within hospitals. We evaluated the adjusted 1-month survival and functional outcome for each hospital, ranked hospitals for each outcome and calculated median ORs (MORs) to quantify the between-hospital variation in outcomes., Results: The prevalence of 1-month survival after OHCA was 7.1% (663/9303) and that of favourable functional outcome was 3.6% (331/9303). After adjustment for patient-level factors, we observed variations in 1-month survival (range, 1.6%-13.8%; adjusted MOR 1.34; 95% CI 1.16 to 1.67) and favourable functional outcome (range, 0.7%-7.3%; adjusted MOR 1.53; 95% CI 1.10 to 2.24) between hospitals., Conclusions: We found substantial variations in patient outcomes after OHCA within a large group of hospitals in Japan, despite adjustment for patient factors that are known to be associated with different outcomes., Competing Interests: Competing interests: None declared., (© 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.)

Until now, we routinely administered oxygen to trauma patients in prehospital settings irrespective of whether oxygen delivery affected the prognosis. To determine the necessity of prehospital oxygen administration (POA) to trauma patients, we aimed to assess whether POA contributed to in-hospital mortality.This was a multicenter propensity-matched cohort study involving 172 major emergency hospitals in Japan. During 2004 to 2010, 70,683 patients with trauma aged ≥15 years were eligible for enrolment. The main outcome measures were survival until hospital discharge after POA, and propensity score analyses were used to adjust for patient factors and hospital site.Of 32,225 trauma patients, 19,985 (62.0%) were administered oxygen by the emergency medical services in prehospital settings and 12,240 (38.0%) did not receive oxygen. Overall, 29,555 patients (90.7%) survived till hospital discharge. In the multivariable unconditional logistic regression, POA had an odds ratio (OR) of 0.33 (95% confidence interval [CI], 0.30-0.37; P <.001) for favorable in-hospital mortality. Furthermore, there were significant differences in all the important variables between the POA and no POA groups (P <.001); therefore, we used propensity score matching analysis. After adjustment for the covariates of selected variables, we found that POA was not associated with a higher rate of survival after hospitalization (adjusted OR, 1.02; 95% CI, 0.99-1.04; P = .27). Even after adjustment for all covariates, POA did not improve in-hospital mortality (adjusted OR, 1.01; 95% CI, 0.99-1.03; P = .08).In this study, POA did not improve in-hospital mortality in trauma patients. However, further studies are needed to validate our results.

Background: The quick sequential organ failure assessment (qSOFA) score has recently been introduced to the emergency department (ED) and wards, and it predicted a higher number of deaths among patients with sepsis compared with baseline risk. However, studies about the application of the qSOFA score are limited in prehospital settings. Thus, this study aimed to assess the performance of prehospital qSOFA score in predicting the risk of mortality among patients with infection., Methods: This single center, retrospective cohort study was conducted in a Japanese tertiary care teaching hospital between April 2016 and March 2017. We enrolled all consecutive adult patients transported to the hospital by ambulance and admitted to the ED due to a suspected infection. We calculated the prehospital qSOFA score using the first vital sign obtained at the scene by emergency medical service (EMS) providers. The primary outcome was in-hospital mortality. The Cox proportional hazards model was used to assess the association between prehospital qSOFA positivity and in-hospital mortality., Results: Among the 925 patients admitted to the ED due to a suspected infection, 51.1% (473/925) were prehospital qSOFA-positive and 48.9% (452/925) were prehospital qSOFA-negative. The in-hospital mortality rates were 14.0% (66/473) in prehospital qSOFA-positive patients and 6.0% (27/452) in prehospital qSOFA-negative patients. The Cox proportional hazard regression model revealed a strong association between prehospital qSOFA score and in-hospital mortality (adjusted hazard ratio: 2.41, 95% confidence interval: 1.51-3.98; p <0.01)., Conclusions: Among the patients with suspected infection who were admitted at the ED, a strong association was observed between the prehospital qSOFA score and in-hospital mortality. In order to use this score in clinical practice, future study is necessary to evaluate how infection is suspected in the prehospital arena., Competing Interests: The authors have declared that no competing interests exist.

Objective: To assess whether sex-based disparities occur by location of arrest in out-of-hospital cardiac arrest (OHCA) victims receiving bystander cardiopulmonary resuscitation (BCPR)., Patients and Methods: This secondary analysis of the All-Japan Utstein Registry included patients 18 years and older with OHCA of medical origin in public or residential locations, witnessed by bystanders, from January 1, 2013, through December 31, 2015. We assessed the likelihood of receiving BCPR based on sex differences and by arrest location. Sex-based disparities in receiving BCPR stratified by age and location were assessed via multivariable logistic regression analyses., Results: During the study period, 373,359 OHCAs were registered, and 84,734 were eligible for analysis. Overall, 54.2% of women (3123 of 5766) and 57.0% of men (8672 of 15,213) received BCPR in public locations (P<.001), and 46.5% of women (11,263 of 24,216) and 44.0% of men (17,390 of 39,539) received BCPR in residential locations (P<.001). In the multivariable logistic regression analyses, there was no significant difference between the sexes in terms of who received BCPR in public locations (adjusted odds ratio [AOR], 0.99; 95% CI, 0.92-1.06), and women had a higher likelihood of receiving BCPR in residential locations (AOR, 1.08; 95% CI, 1.04-1.13). In public locations, women aged 18 to 64 years were less likely to receive BCPR (AOR, 0.86; 95% CI, 0.74-0.99), and when witnessed by a non-family member, women were less likely to receive BCPR regardless of age group., Conclusion: The reasons for this sex-based disparity should be better understood to facilitate public health interventions., (Copyright © 2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Aim: Methylxanthines are no longer recommended for emergency department (ED) patients with acute asthma according to international guidelines. We aimed to describe the current methylxanthine use for acute asthma and to determine factors related to its use in the ED., Methods: We undertook a multicenter retrospective study in 23 EDs across Japan. From each participating hospital, we randomly identified 60 ED patients aged 18-54 years with acute asthma from 2009 through 2011. We examined the associations of ED and patient characteristics with methylxanthine use by constructing a multivariable logistic regression model adjusting for a predefined set of ED- and patient-level factors., Results: Among 1,380 patients, methylxanthines were used for 79 patients (5.7%, 95% confidence interval [CI], 4.6-7.0%). The proportion of methylxanthine treatment varied substantially among EDs, ranging from 0% to 26.1%. In the multivariable analysis, the number of annual ED patients with acute asthma (odds ratio [OR] per 100 increase in annual asthma patients, 0.12; 95% CI, 0.04-0.34; P  < 0.001) and having a protocol for asthma treatment (OR 2.91; 95% CI, 1.06-8.00; P  = 0.04) at the ED level, and systemic corticosteroid use (OR 6.39; 95% CI, 3.34-12.22; P  < 0.001) at the patient level were associated with likelihood of methylxanthine use., Conclusions: In this multicenter study, approximately 6% of ED patients with acute asthma were treated with methylxanthines, with a wide variation across EDs. The number of annual ED patients with acute asthma was significantly associated with a lower likelihood of methylxanthine use, whereas having an ED asthma treatment protocol and systemic corticosteroid use in the ED were associated with a higher likelihood of methylxanthine treatment.

Aims: Studies have suggested relationships between obesity and cardiovascular disease (CVD) morbidity. However, little is known about whether substantial weight reduction affects the risk of CVD-related acute care use in obese patients with CVD. The objective of this study was to determine whether bariatric surgery is associated with decreased risk of CVD-related acute care use., Methods and Results: We performed a self-controlled case series study of obese adults with CVD who underwent bariatric surgery, using population-based emergency department (ED), and inpatient samples in California, Florida, and Nebraska from 2005 to 2011. The primary outcome was ED visit or unplanned hospitalization for CVD. We used conditional logistic regression to compare the risk during sequential 12-month periods, using pre-surgery months 13-24 as the reference period. We identified 11 106 obese adults with CVD who underwent bariatric surgery. During the reference period, 20.6% [95% confidence interval (CI), 19.8-21.3%] of patients had an ED visit or unplanned hospitalization for CVD. The risk did not significantly change in the subsequent 12-month pre-surgery period [adjusted odds ratio (aOR) 0.98; 95% CI, 0.93-1.04; P = 0.42]. By contrast, in the first 12-month period after bariatric surgery, the risk significantly decreased (aOR 0.91; 95% CI, 0.86-0.96; P = 0.002). The risk remained reduced in the subsequent 13-24 months post-bariatric surgery (aOR 0.84; 95% CI, 0.79-0.89; P < 0.001). There was no reduction in the risk in separate obese populations that underwent non-bariatric surgery (i.e. cholecystectomy, hysterectomy). By CVD category, the risk of acute care use for coronary artery disease (CAD), heart failure (HF), and hypertension decreased after bariatric surgery, whereas that of dysrhythmia and venous thromboembolism transiently increased (Bonferroni corrected P < 0.05 for all comparisons)., Conclusion: Bariatric surgery is associated with a lower risk of overall CVD-related ED visit or unplanned hospitalization. The decline was mainly driven by reduced risk of acute care use for CAD, HF, and hypertension after bariatric surgery., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.)

Background Layperson cardiopulmonary resuscitation ( CPR ) is a crucial intervention for patients with out-of-hospital cardiac arrest ( OHCA ). Although a sex disparity in receiving layperson CPR (ie, female patients were less likely to receive layperson CPR ) has been reported in adults, there are few data in the pediatric population, and we therefore investigated sex differences in receiving layperson CPR in pediatric patients with OHCA . Methods and Results From the All-Japan Utstein Registry, a prospective, nationwide, population-based OHCA database, we included pediatric patients (≤17 years) with layperson-witnessed OHCA from 2005 through 2015. The primary outcome was receiving layperson CPR . Patient sex was the main exposure. We fitted multivariable logistic regression models to examine associations between patient sex and receiving layperson CPR . We included a total of 4525 pediatric patients with layperson-witnessed OHCA in this study, 1669 (36.9%) of whom were female. Female patients received layperson CPR more often than male patients (831/1669 [49.8%] versus 1336/2856 [46.8%], P=0.05). After adjustment for age, time of day of arrest, year, witnesses persons, and dispatcher CPR instruction, the sex difference in receiving layperson CPR was not significant (adjusted odds ratio for female subjects 1.14, 95% CI, 0.996-1.31). Conclusions In a pediatric population, female patients with layperson-witnessed OHCA received layperson CPR more often than male patients. After adjustment for covariates, there was no significant association between patient sex and receiving layperson CPR .

Background: Early prehospital advanced airway management (AAM) by emergency medical services (EMS) personnel has been intended to improve patient outcomes from out-of-hospital cardiac arrest (OHCA). However, few studies examine the effectiveness of early prehospital AAM. We investigated whether early prehospital AAM was associated with functionally favourable survival after adult OHCA., Methods: We conducted a population-based cohort study of OHCA in Osaka, Japan, between 2005 and 2012. We included all consecutive, non-traumatic adult OHCA in which EMS personnel performed cardiopulmonary resuscitation (CPR) and AAM. Main exposure was time from CPR to AAM. Primary outcome was functionally favourable survival at one-month. As the primary analysis, we estimated adjusted odds ratio (OR) of time from CPR to AAM using multivariable logistic regression in the original cohort. In the secondary analysis, we divided the time from CPR to AAM into early (0-4 min) and late (5-29 min). We calculated propensity scores (PS) for early AAM and performed PS-matching., Results: We included 27,471 patients who received prehospital AAM by EMS personnel. In this original cohort, time from CPR to AAM was inversely associated with functionally favourable survival (adjusted OR 0.90 for one-increment of minute, 95% confidence interval [CI] 0.87-0.94). In the PS-matched cohort of 17,022 patients, early AAM, compared to late AAM, was associated with functionally favourable survival: 2.2% vs 1.4%; adjusted OR 1.58 (95% CI 1.24-2.02)., Conclusions: Earlier prehospital AAM by EMS personnel was associated with functionally better survival among adult patients who received AAM., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Study Objective: We seek to determine the effect of intraosseous over intravenous vascular access on outcomes after out-of-hospital cardiac arrest., Methods: This secondary analysis of the Resuscitation Outcomes Consortium Prehospital Resuscitation Using an Impedance Valve and Early Versus Delayed (PRIMED) study included adult patients with nontraumatic out-of-hospital cardiac arrests treated during 2007 to 2009, excluding those with any unsuccessful attempt or more than one access site. The primary exposure was intraosseous versus intravenous vascular access. The primary outcome was favorable neurologic outcome on hospital discharge (modified Rankin Scale score ≤3). We determined the association between vascular access route and out-of-hospital cardiac arrest outcome with multivariable logistic regression, adjusting for age, sex, initial emergency medical services-recorded rhythm (shockable or nonshockable), witness status, bystander cardiopulmonary resuscitation, use of public automated external defibrillator, episode location (public or not), and time from call to paramedic scene arrival. We confirmed the results with multiple imputation, propensity score matching, and generalized estimating equations, with study enrolling region as a clustering variable., Results: Of 13,155 included out-of-hospital cardiac arrests, 660 (5.0%) received intraosseous vascular access. In the intraosseous group, 10 of 660 patients (1.5%) had favorable neurologic outcome compared with 945 of 12,495 (7.6%) in the intravenous group. On multivariable regression, intraosseous access was associated with poorer out-of-hospital cardiac arrest survival (adjusted odds ratio 0.24; 95% confidence interval 0.12 to 0.46). Sensitivity analyses revealed similar results., Conclusion: In adult out-of-hospital cardiac arrest patients, intraosseous vascular access was associated with poorer neurologic outcomes than intravenous access., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Although prior work reported regional variation in survival after out-of-hospital cardiac arrest (OHCA), mechanisms of the variation have not been fully investigated. We sought to evaluate regional variation in favourable functional outcome after OHCA across 47 prefectures in Japan as our primary aim. We also evaluated the associations between favourable functional outcome and the numbers of basic life support (BLS) providers and public access automated external defibrillators (AEDs) within each prefecture as our secondary aim., Methods: Using the All-Japan Utstein Registry, a nationwide prospective, population-based OHCA database, we identified 97,408 patients with OHCA of medical origin across 47 prefectures in 2014. Primary outcome was 1-month survival with favourable functional outcome, defined as Cerebral Performance Category (CPC) scale 1 or 2. We fitted multivariable hierarchical logistic regression models (patients nested within prefectures) to adjust for potential confounding factors at patient- and prefecture-level and clustering of patients within prefectures. We calculated median odds ratios (ORs) from the hierarchical models to quantify the outcome variation at prefecture-level. We also evaluated the associations between OHCA outcome and the numbers of BLS providers and public access AEDs within each prefecture, using the hierarchical models., Results: A total of 2246 patients (2.3%) had 1-month survival with favourable functional outcome. The unadjusted rates of 1-month survival with favourable functional outcome in each prefecture ranged from 1.1% to 4.1% (median OR = 1.29; 95% credible interval, 1.20-1.40) and the adjusted rates varied from 0.9% to 3.5% (median OR = 1.34; 95% credible interval, 1.24-1.48). We observed no associations between 1-month survival with favourable functional outcome and the numbers of BLS providers (correlation coefficient = -0.25; 95% confidence interval [CI], -0.50 to 0.04; p = 0.09) and public access AEDs (correlation coefficient = -0.27; 95% CI, -0.51 to 0.02; p = 0.07) within prefectures., Conclusions: We found substantial regional variation in favourable functional outcome after OHCA of medical origin that was not explained by the numbers of BLS providers and public access AEDs within each prefecture., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: To evaluate the effect of embryo quality on pregnancy outcomes., Methods: This retrospective analysis included 80 live singleton births, resulting from morphologically good-quality embryo transfers, and 25 live singleton births that resulted from morphologically poor-quality embryo transfers between January, 2008 and December, 2014. Cleavage embryos that were graded as ≥2, according to the Veeck classification system, and blastocysts that were graded as ≥3BB, according to the Gardner classification system, were defined as good quality. The obstetric and neonatal outcomes were compared between the poor- and good-quality embryo transfer groups., Results: The mean maternal age between the groups was similar. The blastocyst transfer rate was higher in the good-quality, than in the poor-quality, embryo transfer group. Other characteristics, including parity, infertility duration, the intracytoplasmic sperm injection rate, frozen-thawed embryo transfer rate, endometrial thickness, and hormone values before the embryo transfer, were similar between the groups. The obstetric and neonatal outcomes of live births between the two groups were not different in terms of preterm delivery, birthweight, small or large size for gestational age, malformation, umbilical artery cord pH of <7.20, hypertensive disorders of pregnancy, gestational diabetes mellitus, chorioamnionitis, placenta previa, and placental abruption., Conclusion: The obstetric and neonatal outcomes of live births between the poor- and good-quality embryo transfers were equivalent.

Background: Although rapid sequence intubation (RSI) is the method of choice in emergency department (ED) airway management, data to support the use of RSI remain scarce. We sought to compare the effectiveness of airway management between RSI and non-RSI (intubation with sedative agents only or without medications) in the ED., Methods: Secondary analysis of the data from a multicenter prospective observational registry at 13 Japanese EDs. All non-cardiac-arrest patients who underwent intubation with RSI or non-RSI were included for the analysis. Outcomes of interest were the success rate of intubation and intubation-related complications., Results: Of 2365 eligible patients, 761 (32%) underwent intubations with RSI and 1,604 (68%) with non-RSI. Intubations with RSI had a higher success rate on the first attempt compared to those with non-RSI (73 vs. 63%; P < 0.0001). By contrast, the complication rates did not differ significantly between RSI and non-RSI groups (12 vs. 13%; P = 0.59). After adjusting for age, sex, estimated weight, principal indication, device, specialties and training level of the intubator, and clustering of patients within EDs, intubation with RSI was associated with a significantly higher success rate on the first attempt (OR, 2.3; 95% CI, 1.8-2.9; P < 0.0001) while that with RSI was not associated with the risk of complications (OR, 0.9; 95% CI, 0.6-1.2; P = 0.31)., Conclusions: In this large multicenter study of ED airway management, we found that intubation with RSI was independently associated with a higher success rate on the first attempt but not with the risk of complications.

Background: Sodium bicarbonate (SB) is widely used for resuscitation in out-of- hospital cardiac arrest (OHCA); however, its effect on long term outcomes is unclear., Methods: From 2005-2016, we prospectively conducted a province-wide population-based observational study including adult non-traumatic OHCA patients managed by paramedics. SB was administered by paramedics based on their clinical assessments. To examine the association of SB administration and survival and favorable neurological outcome to hospital discharge, defined as modified Rankin scale of 3 or less, we performed a multivariable logistic regression analysis: (1) within propensity score matched comparison groups, and; (2) within the full cohort with missing variables addressed by multiple imputation techniques., Results: Of 15 601 OHCA patients, 13,865 were included in this study with 5165 (37.3%) managed with SB. In the SB treated group, 118 (2.3%) patients survived and 62 (1.2%) had favorable neurological outcomes to hospital discharge, compared to 1699 (19.8%) and 831 (10.6%) in the non-SB treated group, respectively. In the 1:1 propensity matched cohort including 5638 OHCA patients, SB was associated with decreased probability of outcomes (adjusted OR for survival: 0.64, 95% CI 0.45-0.91, and adjusted OR for favorable neurological outcome: 0.59, 95% CI 0.39-0.88, respectively). The association remained consistent in the multiply imputed cohort (adjusted OR 0.48, 95 CI 0.36-0.64, and adjusted OR 0.54, 95% CI 0.38-0.76, respectively)., Conclusions: In OHCA patients, prehospital SB administration was associated with worse survival rate and neurological outcomes to hospital discharge., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Reduction of 30-day readmissions in patients hospitalized for chronic obstructive pulmonary disease (COPD) is a national objective. However, there is a dearth of research on sex and racial/ethnic differences in the reason for 30-day readmission., Methods: We conducted a retrospective cohort study using 2006-2012 data from the State Inpatient Database of eight geographically-diverse US states (Arkansas, California, Florida, Iowa, Nebraska, New York, Utah, and Washington). After identifying all hospitalizations for COPD made by patients aged ≥40 years, we investigated the primary diagnostic code for all-cause readmissions within 30 days after the original COPD hospitalization, among the overall group and by sex and race/ethnicity strata., Results: Between 2006 and 2012, there was a total of 845,465 COPD hospitalizations at risk for 30-day readmissions in the eight states. COPD was the leading diagnostic for 30-day readmission after COPD hospitalization, both overall (28%) and across all sex and race/ethnicity strata. The proportion of respiratory diseases (COPD, pneumonia, respiratory failure, and asthma) as the readmission diagnosis was higher in non-Hispanic black (55%), compared to non-Hispanic white (52%) and Hispanics (51%) (p < 0.001). The proportion of asthma as the readmission diagnosis differed significantly by sex (6% in men and 9% in women; p < 0.001). Similarly, the proportion of asthma also differed significantly by race/ethnicity (5% in non-Hispanic white, 16% in non-Hispanic black, 15% in Hispanics, 13% in others; p < 0.001)., Conclusions: In this analysis of all-payer population-based data, we found sex and racial/ethnic differences in the reason for 30-day readmission in patients hospitalized for COPD., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Recently, the number of ambulance dispatches has been increasing in Japan, and it is therefore difficult for hospitals to accept emergency patients smoothly and appropriately because of the limited hospital capacity. To facilitate the process of requesting patient transport and hospital acceptance, an emergency information system using information technology (IT) has been built and introduced in various communities. However, its effectiveness has not been thoroughly revealed. We introduced a smartphone app system in 2013 that enables emergency medical service (EMS) personnel to share information among themselves regarding on-scene ambulances and the hospital situation., Objective: The aim of this study was to assess the effects of introducing this smartphone app on the EMS system in Osaka City, Japan., Methods: This retrospective study analyzed the population-based ambulance records of Osaka Municipal Fire Department. The study period was 6 years, from January 1, 2010 to December 31, 2015. We enrolled emergency patients for whom on-scene EMS personnel conducted hospital selection. The main endpoint was the difficulty experienced in gaining hospital acceptance at the scene. The definition of difficulty was making ≥5 phone calls by EMS personnel at the scene to hospitals until a decision to transport was determined. The smartphone app was introduced in January 2013, and we compared the patients treated from 2010 to 2012 (control group) with those treated from 2013 to 2015 (smartphone app group) using an interrupted time-series analysis to assess the effects of introducing this smartphone app., Results: A total of 600,526 emergency patients for whom EMS personnel selected hospitals were eligible for our analysis. There were 300,131 emergency patients in the control group (50.00%, 300,313/600,526) from 2010 to 2012 and 300,395 emergency patients in the smartphone app group (50.00%, 300,395/600,526) from 2013 to 2015. The rate of difficulty in hospital acceptance was 14.19% (42,585/300,131) in the control group and 10.93% (32,819/300,395) in the smartphone app group. No change over time in the number of difficulties in hospital acceptance was found before the introduction of the smartphone app (regression coefficient: -2.43, 95% CI -5.49 to 0.64), but after its introduction, the number of difficulties in hospital acceptance gradually decreased by month (regression coefficient: -11.61, 95% CI -14.57 to -8.65)., Conclusions: Sharing information between an ambulance and a hospital by using the smartphone app at the scene was associated with decreased difficulty in obtaining hospital acceptance. Our app and findings may be worth considering in other areas of the world where emergency medical information systems with IT are needed., (©Yusuke Katayama, Tetsuhisa Kitamura, Kosuke Kiyohara, Taku Iwami, Takashi Kawamura, Junichi Izawa, Koichiro Gibo, Sho Komukai, Sumito Hayashida, Takeyuki Kiguchi, Mitsuo Ohnishi, Hiroshi Ogura, Takeshi Shimazu. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 11.09.2017.)

Objectives: Out-of-hospital cardiac arrest (OHCA) remains a major public health burden. Aggregate OHCA survival to hospital discharge has reportedly remained unchanged at 7.6% for almost 30 years from 1970 to 2008. We examined the trends in adult OHCA survival over a 16-year period from 1998 to 2013 within a single EMS agency., Methods: Observational cohort study of adult OHCA patients treated by Tualatin Valley Fire & Rescue (TVF&R) from 1998 to 2013. This is an ALS first response fire agency that maintains an active Utstein style cardiac arrest registry and serves a population of approximately 450,000 in 9 incorporated cities in Oregon. Primary outcomes were survival to hospital discharge in all patients and in the subgroup with witnessed ventricular fibrillation/pulseless ventricular tachycardia (VF/VT). The impact of key covariates on survival was assessed using univariate logistic regression. These included patient factors (age and sex), event factors (location of arrest, witnessed status, and first recorded cardiac arrest rhythm), and EMS system factors (response time interval, bystander CPR, and non-EMS AED shock). We used multivariate logistic regression to examine the impact of year increment on survival after multiple imputation for missing data. Sensitivity analysis was performed with complete cases., Results: During the study period, 2,528 adult OHCA had attempted field resuscitation. The survival rate for treated cases increased from 6.7% to 18.2%, with witnessed VF/VT cases increasing from 14.3% to 31.4% from 1998 to 2013. Univariate analysis showed that younger age, male sex, public location of arrest, bystander or EMS witnessed event, initial rhythm of pulseless electrical activity (PEA) or VF/VT, bystander CPR, non-EMS AED shock, and a shorter EMS response time were independently associated with survival. After adjustment for covariates, the odds of survival increased by 9% (OR 1.09, 95%CI: 1.05-1.12) per year in all treated cases, and by 6% (OR 1.06, 95% 1.01-1.10) per year in witnessed VF/VT subgroups. Findings remained consistent on sensitivity analysis., Conclusions: Overall survival from treated OHCA has increased over the last 16 years in this community. These survival increases demonstrate that OHCA is a treatable condition that warrants further investigation and investment of resources.

Background: Reduction in 30-day readmission rate after chronic obstructive pulmonary disease (COPD)-related hospitalization is a national objective. However, little is known about trends in readmission rates in recent years, particularly in priority populations defined by the Agency for Healthcare Research and Quality (AHRQ)(e.g., the elderly, women, racial/ethnic minorities, low-income and rural populations, and populations with chronic illnesses)., Methods: We conducted a retrospective cohort study using data from the State Inpatient Database of eight geographically-dispersed US states (Arkansas, California, Florida, Iowa, Nebraska, New York, Utah, and Washington) from 2006 through 2012. We identified all COPD-related hospitalizations by patients ?40 years old. The primary outcome was any-cause readmission within 30 days of discharge from the index hospitalization for COPD., Results: From 2006 to 2012, a total of 845,465 hospitalizations at risk for 30-day readmissions were identified. Overall, 30-day readmission rate for COPD-related hospitalization decreased modestly from 20.0% in 2006 to 19.2% in 2012, an 0.8% absolute decrease (OR 0.991, 95%CI 0.989-0.995, P trend <0.001). This modest decline remained statistically significant after adjusting for patient demographics and comorbidities (adjusted OR 0.981, 95%CI 0.977-0.984, P trend <0.001). Similar to the overall population, the readmission rate over the 7-year period remained persistently high in most of AHRQ-defined priority populations., Conclusions: Our observations provide a benchmark for future investigation of the impact of Hospital Readmissions Reduction Program on readmissions after COPD hospitalization. Our findings encourage researchers and policymakers to develop effective strategies aimed at reducing readmissions among patients with COPD in an already-stressed healthcare system., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: H1-antihistamines (H1a) can be used to treat emergency department (ED) patients with allergic reactions; however, this is inconsistently done, likely because there is no evidence that this therapy has an impact on serious outcomes. Among ED patients initially presenting with allergic reactions, we investigated whether H1a were associated with lower rates of progression to anaphylaxis., Methods: This was a retrospective cohort study conducted at two urban Canadian EDs from April 1, 2007, to March 31, 2012. We included consecutive adult patients with allergic reactions while excluding those presenting with anaphylaxis, according to prespecified criteria. The primary outcome was the proportion of patients who subsequently developed anaphylaxis during medical care, either by emergency medical services (EMS) or in the ED. A prespecified subgroup analysis excluded patients who received H1a prior to EMS or ED contact. We compared those who received H1a and those who did not and used multivariable regression and propensity score adjustment techniques to compare outcomes., Results: Of 2,376 overall patients included, 1,880 (79.1%) were managed with H1a. Of the latter group, 36 of 1,880 (1.9%) developed anaphylaxis, compared to 17 of 496 (3.4%) in the non-H1a-treated group (adjusted odds ratio [AOR] = 0.34, 95% confidence interval [CI] = 0.17-0.70; number needed to treat [NNT] to benefit = 44.74, 95% CI = 35.36-99.67). In the subgroup analysis of 1,717 patients who did not receive H1a prior to EMS or ED contact, a similar association was observed (AOR = 0.26, 95% CI = 0.10-0.50; NNT to benefit 38.20, 95% CI = 32.58-55.24)., Conclusions: Among ED patient with allergic reactions, H1a administration was associated with a lower likelihood of progression to anaphylaxis. These data indicate that early H1a treatment in the ED or prehospital setting may decrease progression to anaphylaxis., (© 2016 by the Society for Academic Emergency Medicine.)

Background: Reducing hospital readmissions has attracted attention from many stakeholders. However, the characteristics of 30-day readmissions after asthma-related hospital admissions in adults are not known. It is also unclear whether older adults are at higher risk of 30-day readmission., Objectives: To investigate the rate, timing, and principal diagnosis of 30-day readmissions in adults with asthma and to determine age-related differences., Methods: Retrospective cohort study of adults hospitalized for asthma exacerbation using the population-based inpatient samples of three states (California, Florida, and Nebraska) from 2005 through 2011. Patients were categorized into three age groups: younger (18-39 years), middle aged (40-64 years), and older (≥ 65 years) adults. Outcomes were 30-day all-cause readmission rate, timing, and principal diagnosis of readmission., Results: Of 301,164 asthma-related admissions at risk for 30-day readmission, readmission rate was 14.5%. Compared with younger adults, older adults had significantly higher readmission rates (10.1% vs 16.5%; OR, 2.15 [95% CI, 2.07-2.23]; P < .001). The higher rate attenuated with adjustment (OR, 1.19 [95% CI, 1.13-1.26]; P < .001), indicating that most of the age-related difference is explained by sociodemographics and comorbidities. For all age groups, readmission rate was highest in the first week after discharge and declined thereafter. Overall, only 47.1% of readmissions were assigned respiratory diagnoses (asthma, COPD, pneumonia, and respiratory failure). Older adults were more likely to present with nonrespiratory diagnoses (41.7% vs 53.8%; P < .001)., Conclusions: After asthma-related admission, 14.5% of patients had 30-day readmission with wide range of principal diagnoses. Compared with younger adults, older adults had higher 30-day readmission rates and proportions of nonrespiratory diagnoses., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: (1) To develop a clinical prediction rule to identify patients with bacteremia, using only information that is readily available in the emergency room (ER) of community hospitals, and (2) to test the validity of that rule with a separate, independent set of data., Design: Multicenter retrospective cohort study., Setting: To derive the clinical prediction rule we used data from 3 community hospitals in Japan (derivation). We tested the rule using data from one other community hospital (validation), which was not among the three "derivation" hospitals., Participants: Adults (age ≥ 16 years old) who had undergone blood-culture testing while in the ER between April 2011 and March 2012. For the derivation data, n = 1515 (randomly sampled from 7026 patients), and for the validation data n = 467 (from 823 patients)., Analysis: We analyzed 28 candidate predictors of bacteremia, including demographic data, signs and symptoms, comorbid conditions, and basic laboratory data. Chi-square tests and multiple logistic regression were used to derive an integer risk score (the "ID-BactER" score). Sensitivity, specificity, likelihood ratios, and the area under the receiver operating characteristic curve (i.e., the AUC) were computed., Results: There were 241 cases of bacteremia in the derivation data. Eleven candidate predictors were used in the ID-BactER score: age, chills, vomiting, mental status, temperature, systolic blood pressure, abdominal sign, white blood-cell count, platelets, blood urea nitrogen, and C-reactive protein. The AUCs was 0.80 (derivation) and 0.74 (validation). For ID-BactER scores ≥ 2, the sensitivities for derivation and validation data were 98% and 97%, and specificities were 20% and 14%, respectively., Conclusions: The ID-BactER score can be computed from information that is readily available in the ERs of community hospitals. Future studies should focus on developing a score with a higher specificity while maintaining the desired sensitivity.

Introduction: The objective of this study was to investigate the factors associated with first-pass success in pediatric intubation in the emergency department (ED)., Methods: We analyzed the data from two multicenter prospective studies of ED intubation in 17 EDs between April 2010 and September 2014. The studies prospectively measured patient's age, sex, principal indication for intubation, methods (e.g., rapid sequence intubation [RSI]), devices, and intubator's level of training and specialty. To evaluate independent predictors of first-pass success, we fit logistic regression model with generalized estimating equations. In the sensitivity analysis, we repeated the analysis in children <10 years., Results: A total of 293 children aged ≤18 years who underwent ED intubation were eligible for the analysis. The overall first-pass success rate was 60% (95%CI [54%-66%]). In the multivariable model, age ≥10 years (adjusted odds ratio [aOR], 2.45; 95% CI [1.23-4.87]), use of RSI (aOR, 2.17; 95% CI [1.31-3.57]), and intubation attempt by an emergency physician (aOR, 3.21; 95% CI [1.78-5.83]) were significantly associated with a higher chance of first-pass success. Likewise, in the sensitivity analysis, the use of RSI (aOR, 3.05; 95% CI [1.63-5.70]), and intubation attempt by an emergency physician (aOR, 4.08; 95% CI [1.92-8.63]) were significantly associated with a higher chance of first-pass success., Conclusion: Based on two large multicenter prospective studies of ED airway management, we found that older age, use of RSI, and intubation by emergency physicians were the independent predictors of a higher chance of first-pass success in children. Our findings should facilitate investigations to develop optimal airway management strategies in critically-ill children in the ED.

Background: Although the international guidelines emphasize early and systematic use of rescue intubation techniques, there is little evidence to support this notion. We aimed to test the hypothesis that preceding multiple failed intubation attempts are associated with a decreased success rate on the first rescue intubation in emergency departments (EDs)., Methods: We analysed data from two multicentre prospective registries designed to characterize current ED airway management in Japan between April 2010 and June 2013. All patients who underwent a rescue intubation after a failed attempt or a series of failed attempts were included for the analysis. Multiple failed intubation attempts were defined as ≥2 consecutive failed intubation attempts before a rescue intubation. Primary outcome measure was success rate on the first rescue intubation attempt., Results: Of 6,273 consecutive patients, 1,151 underwent a rescue intubation. The success rate on the first rescue intubation attempt declined as the number of preceding failed intubation attempts increased (81% [95% CI, 79%-84%] after one failed attempt; 71% [95% CI, 66%-76%] after two failed attempts; 67% [95% CI, 55%-78%] after three or more failed attempts; P(trend) <0.001). In the multivariable analysis adjusting for age, sex, principal indication, change in methods, devices, and intubator specialty, and clustering of patients within EDs, success rate on the first rescue intubation after two failed attempts was significantly lower (OR, 0.56; 95% CI, 0.41-0.77) compared to that after one failed attempt. Similarly, success rate on the first rescue intubation attempt after three or more failed attempts was significantly lower (OR, 0.49; 95% CI, 0.25-0.94) compared to that after one failed attempt., Conclusion: Preceding multiple failed intubation attempts was independently associated with a decreased success rate on the first rescue intubation in the ED.

A functional analysis, including Rowe score and measurements of isokinetic peak torque and range of motion of the shoulder, and a subjective assessment were performed in 26 consecutive patients (23 males and 3 females) with unoperated anterior shoulder instability. Patients experienced the initial dislocation at an average age of 23 +/- 8 years and 58% occurred during sports activity. No patient had gone through any controlled rehabilitation program. In this study, an average of 7 years (range, 1 to 28) had passed since the initial dislocation. Fifty-nine percent of the patients complained of markedly reduced ability to perform in sports because of instability, impaired strength, decreased range of motion, and pain induced by activity. The majority (65%) of the patients reported instability only during physical activity. The average Rowe score was 68 +/- 14 on a scale of 100. In comparison with the healthy side, the injured shoulder had a significantly lower isokinetic peak torque during abduction and internal rotation, as well as a reduced range of motion in extension, abduction, and external rotation, but not in flexion. The severity of impairment (Rowe score, deficit in range of motion, and peak torque) was not related to the number of dislocations sustained or to the duration of instability.