Acute Medicine Research Articles

A prospective study of risk factors associated with seroprevalence of SARS-CoV-2 antibodies in healthcare workers at a large UK teaching hospital

ObjectivesTo describe the risk factors for SARS-CoV-2 infection in UK healthcare workers (HCWs). MethodsWe conducted a prospective sero-epidemiological study of HCWs at a major UK teaching hospital using a SARS-CoV-2 immunoassay. Risk factors for seropositivity were analysed using multivariate logistic regression. Results410/5,698 (7·2%) staff tested positive for SARS-CoV-2 antibodies. Seroprevalence was higher in those working in designated COVID-19 areas compared with other areas (9·47% versus 6·16%) Healthcare assistants (aOR 2·06 [95%CI 1·14-3·71]; p=0·016) and domestic and portering staff (aOR 3·45 [95% CI 1·07-11·42]; p=0·039) had significantly higher seroprevalence than other staff groups after adjusting for age, sex, ethnicity and COVID-19 working location. Staff working in acute medicine and medical sub-specialities were also at higher risk (aOR 2·07 [95% CI 1·31-3·25]; p<0·002). Staff from Black, Asian and minority ethnic (BAME) backgrounds had an aOR of 1·65 (95% CI 1·32 – 2·07; p<0·001) compared to white staff; this increased risk was independent of COVID-19 area working. The only symptoms significantly associated with seropositivity in a multivariable model were loss of sense of taste or smell, fever, and myalgia; 31% of staff testing positive reported no prior symptoms. ConclusionsRisk of SARS-CoV-2 infection amongst HCWs is highly heterogeneous and influenced by COVID-19 working location, role, age and ethnicity. Increased risk amongst BAME staff cannot be accounted for solely by occupational factors.

Extracurricular work experience and its association with training and confidence in emergency medicine procedures among medical students: a cross-sectional study from a Norwegian medical school

ObjectiveProficiency in basic emergency procedures is important for junior doctors, but the amount of practical exposure may vary. We studied the association between students’ extracurricular healthcare-related (ECHR) work experience and...

Contemporary management of atrial fibrillation in primary and secondary care in the UK: the prospective long-term AF-GEN-UK Registry.

This study established a prospective registry of contemporary management of UK patients with atrial fibrillation (AF) by cardiologists, general practitioners, and stroke, acute, and emergency medicine physicians at baseline and 1-year follow-up. Data on patients with recently diagnosed AF (≤12 months) were collected from medical records from 101 UK sites to permit comparison of patient characteristics and treatments between specialities. The impact of guideline-adherent oral anticoagulation (OAC) use on outcomes was assessed using Cox regression analysis. One thousand five hundred and ninety-five AF patients [mean (standard deviation) age 70.5 (11.2) years; 60.1% male; 97.4% white] were recruited in June 2017-June 2018 and followed up for 1 year. Overall OAC prescription rates were 84.2% at baseline and 87.1% at 1 year, with non-vitamin K antagonist oral anticoagulants (NOACs) predominating (74.9 and 79.2% at baseline and 1 year, respectively). Vitamin K antagonist prescription was significantly higher in primary care, with NOAC prescription higher among stroke physicians. Guideline-adherent OAC (CHA2DS2-VASc ≥2) at baseline significantly reduced risk of death and stroke at 1 year [adjusted hazard ratio (95% confidence interval): 0.48 (0.27-0.84) and 0.11 (0.02-0.48), respectively]. Rhythm control is evident in ∼25%; only 1.6% received catheter ablation. High OAC use (>80%, mainly NOACs) rates varied by speciality, with VKA prescription higher in primary care. Guideline-adherent OAC therapy at baseline was associated with significant reduction in death and stroke at 1 year, regardless of speciality. Rhythm-control management is evident in only one-quarter despite AF symptoms reported in 56.6%. This registry extends the knowledge of contemporary AF management outside cardiology and demonstrates good implementation of clinical guidelines for the management of AF, particularly for stroke prevention.

Exploring the process of care for people who inject drugs in hospital settings

In recent years, hospitals have experienced alarming increases in admissions of people who inject drugs (PWID), which present unique challenges to the care process. Untangling the complexity of care can be difficult due to interactions that occur between human and non-human elements including hospital systems, policy, technology, time, and space. The purpose of this study was to explore relations between social and material elements within the acute care environment, to better understand how care is enacted and to identify novel approaches for improvement. Data collection and analysis utilized a practice-based approach informed by constructivist grounded theory and sociomaterial perspectives, which emphasized relationships between human and non-human elements. Data included observational field notes, interviews, and artifacts from 154 hours spent on acute medicine units of two hospitals in an urban setting in Ontario, Canada. Findings revealed that differing expectations, strained conversations, and various policies assembled to produce misalignments in care. Such misalignments included mistrust, suboptimal pain and withdrawal management, and frequent patient absences and/or discharge against medical advice. Care misaligned in ways that reflected both social and material elements, demonstrating a need for hospital staff and systems to challenge existing care models built around individual control and abstinence-informed practices.

Hyperoxemia is Associated With Poor Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Rescued by Extracorporeal Cardiopulmonary Resuscitation: Insight From the Nationwide Multicenter Observational JAAM-OHCA (Japan Association for Acute Medicine) Registry

BackgroundPrevious studies have shown an association between hyperoxemia and mortality in patients with out-of-hospital cardiac arrest (OHCA) after cardiopulmonary resuscitation (CPR); however, evidence is lacking in the extracorporeal CPR (ECPR) setting. ObjectiveThe aim of this study was to test the hypothesis that hyperoxemia is associated with poor neurological outcomes in patients treated by ECPR. MethodsThe Japanese Association for Acute Medicine OHCA Registry is a multicenter, prospective, observational registry of patients from 2014 to 2017. Adult (18 years or older) patients who had undergone ECPR after OHCA were included. Eligible patients were divided into two groups based on the partial pressure of oxygen in arterial blood (PaO2) levels at 24 h after ECPR: the high-PaO2 group (n = 242) defined as PaO2 ≥ 157 mm Hg (median) and the low-PaO2 group (n = 211) defined as PaO2 60 to < 157 mm Hg. The primary outcome was the favorable neurological outcome, defined as a Cerebral Performance Categories Scale score of 1 to 2 at 30 days after OHCA. ResultsOf 34,754 patients with OHCA, 453 patients were included. The neurological outcome was significantly lower in the high-PaO2 group than in the low-PaO2 group (15.9 vs. 33.5%; p < 0.001). After adjusting for potential confounders, high PaO2 was negatively associated with favorable neurological outcomes (adjusted odds ratio [aOR] 0.48; 95% confidence interval [CI] 0.24–0.97; p = 0.040). In a multivariate analysis with multiple imputation, high PaO2 was also negatively associated with favorable neurological outcomes (aOR 0.63; 95% CI 0.49–0.81; p < 0.001). ConclusionsHyperoxemia was associated with worse neurological outcomes in OHCA patients with ECPR.

Audit of General Intensive Care Unit of Sir Salimullah Medical College, Mitford, Dhaka

Background: Intensive care units provide care to patients with severe or life-threatening illnesses and injuries, which require constant support, close supervision from life support equipment and medication in order to ensure normal bodily functions. It is staffed by highly trained physicians, nurses and respiratory therapists who specialize in caring for critically ill patients. ICUs are also different from general hospital wards by a higher staff-to-patient ratio and access to advanced medical resources and equipment that is not routinely available somewhere else. Common conditions include acute respiratory distress syndrome, septic shock, and other life-threatening conditions that are treated within ICUs. Aim of the study: The aim of the study was to assess the operational power, existing facilities, bed requirement, patients source and follow up and to determine and analyze the mortality in the ICU of this institution. Methods: It was a retrospective study conducted in the General Intensive Care Unit of Sir Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh from January 2019 to December 2019. A total of 607 patients who had been taken admission in General ICU unit of the hospital was recruited as study population. According to the criteria of analysis already informed, data were collected from admission register and mortality record books. We divided the total number of patients into 4 age groups, 10-30 years, 31-45 years, 46-65 years and above 65 years. We calculated patients’ mortality and male female ratio. We also considered patients coming from different specialties those who were referred to the ICU. We observed the relationship of mortality with number of organ failure too. We categorized the patients as single, double or more organs involvement and its relationship with mortality. Duration of stay in the ICU was defined as the number of days between the admission in ICU and discharge with a minimum stay of one day and also more. Relationship with mortality and number of staying days was noticed. All data were collected within data collection sheets. Result: Hospital ICU mortality in an average was 45%. Patients with long ICU stay have higher mortality than shorter stay. Nonsurvivors were older than survivors. Patients from outside have a higher mortality (85%) than those from ward, postoperative and emergency (35%).25% of patients were in the intensive care unit for more than 3 days and shared 80% of bed occupancy. Much mortality was due to inappropriate early discharge, lack of meticulous attention before admission and inadequate care after discharge. Conclusion: So strengthening of facilities may be provided by appropriate transport system and acute medicine service at emergency and also by step down units or high dependency unit in ICU surroundings. Resources and study should be directed towards the low probable mortalities to improve the ICU outcome and to decrease the mortality percentage. Continuous advice and follow up should be provided to the patients after transferring to the ward, cabin or home.

Early computed tomography coronary angiography in adults presenting with suspected acute coronary syndrome: the RAPID-CTCA RCT.

Acute coronary syndrome is a common medical emergency. The optimal strategy to investigate patients who are at intermediate risk of acute coronary syndrome has not been fully determined. To investigate the role of early computed tomography coronary angiography in the investigation and treatment of adults presenting with suspected acute coronary syndrome. A prospective, multicentre, open, parallel-group randomised controlled trial with blinded end-point adjudication. Thirty-seven hospitals in the UK. Adults (aged ≥ 18 years) presenting to the emergency department, acute medicine services or cardiology department with suspected or provisionally diagnosed acute coronary syndrome and at least one of the following: (1) a prior history of coronary artery disease, (2) a cardiac troponin level > 99th centile and (3) an abnormal 12-lead electrocardiogram. Early computed tomography coronary angiography in addition to standard care was compared with standard care alone. Participants were followed up for 1 year. One-year all-cause death or subsequent type 1 (spontaneous) or type 4b (stent thrombosis) myocardial infarction, measured as the time to such event adjudicated by two cardiologists blinded to the computerised tomography coronary angiography ( CTCA ) arm. Cost-effectiveness was estimated as the lifetime incremental cost per quality-adjusted life-year gained. Between 23 March 2015 and 27 June 2019, 1748 participants [mean age 62 years (standard deviation 13 years), 64% male, mean Global Registry Of Acute Coronary Events score 115 (standard deviation 35)] were randomised to receive early computed tomography coronary angiography (n = 877) or standard care alone (n = 871). The primary end point occurred in 51 (5.8%) participants randomised to receive computed tomography coronary angiography and 53 (6.1%) participants randomised to receive standard care (adjusted hazard ratio 0.91, 95% confidence interval 0.62 to 1.35; p = 0.65). Computed tomography coronary angiography was associated with a reduced use of invasive coronary angiography (adjusted hazard ratio 0.81, 95% confidence interval 0.72 to 0.92; p = 0.001) but no change in coronary revascularisation (adjusted hazard ratio 1.03, 95% confidence interval 0.87 to 1.21; p = 0.76), acute coronary syndrome therapies (adjusted odds ratio 1.06, 95% confidence interval 0.85 to 1.32; p = 0.63) or preventative therapies on discharge (adjusted odds ratio 1.07, 95% confidence interval 0.87 to 1.32; p = 0.52). Early computed tomography coronary angiography was associated with longer hospitalisations (median increase 0.21 days, 95% confidence interval 0.05 to 0.40 days) and higher mean total health-care costs over 1 year (£561 more per patient) than standard care. The principal limitation of the trial was the slower than anticipated recruitment, leading to a revised sample size, and the requirement to compromise and accept a larger relative effect size estimate for the trial intervention. The potential role of computed tomography coronary angiography in selected patients with a low probability of obstructive coronary artery disease (intermediate or mildly elevated level of troponin) or who have limited access to invasive cardiac catheterisation facilities needs further prospective evaluation. In patients with suspected or provisionally diagnosed acute coronary syndrome, computed tomography coronary angiography did not alter overall coronary therapeutic interventions or 1-year clinical outcomes, but it did increase the length of hospital stay and health-care costs. These findings do not support the routine use of early computed tomography coronary angiography in intermediate-risk patients with acute chest pain. This trial is registered as ISRCTN19102565 and Clinical Trials NCT02284191. This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 37. See the NIHR Journals Library website for further project information.

Improving patient understanding on discharge from the short stay unit: an integrated human factors and quality improvement approach

This intervention used a systems approach to improve patient understanding on discharge from the adult acute medicine short stay unit (SSU). Patient understanding was assessed across five domains: diagnosis, medication...

Development of entrustable professional activities for regional anesthesia and pain medicine fellowship training

IntroductionThe Accreditation Council for Graduate Medical Education (ACGME) offers descriptions of competencies and milestones but does not provide standardized assessments to track trainee competency. Entrustable professional activities (EPAs) and special...

Sleep insecurity as a health disparity.

Sleep insecurity as a health disparity.

Development of the Interdisciplinary and Interprofessional Course Concept "Advanced Critical Illness Life Support".

The Advanced Critical Illness Life Support (ACiLS) course was developed on behalf of the German Society for Interdisciplinary Emergency and Acute Medicine (DGINA). The goal of the ACiLS course is to provide a nationally recognized and certified life support course that teaches medical professionals the key principles of initial care of critically ill patients in the emergency department, including the (PR_E-)AUD2IT-algorithm. It is designed for interdisciplinary and multi-professional staff in the resuscitation room to optimize patient safety and outcome. ACiLS includes a new blended learning concept with a theoretical part as comprehensive e-learning and a two-day practical part with strong focus on team training in scenarios and workshops. The course format was conceived to balance best teaching practices within the limited instructional time and resources available. This article describes the development of the ACiLS course and provides an overview of its future implementation.

Implementing the HEART score in an NHS emergency department: can identity leadership combined with quality improvement promote racial equality?

PurposeThe purpose of this paper is to report on the dynamics of “identity leadership” with a quality improvement project undertaken by an International Medical Graduate (IMG) from Sri Lanka, on a two year Medical Training Initiative (MTI) placement in the National Health Service (NHS) [Academy of Medical Royal Colleges (AoMRC), 2017]. A combined MTI rotation with an integrated Fellowship in Quality Improvement (Subedi et al., 2019) provided the driver to implement the HEART score (HS) in an NHS Emergency Department (ED) in the UK. The project was undertaken across ED, Acute Medicine and Cardiology at the hospital, with stakeholders emphasizing different and conflicting priorities to improve the pathway for chest pain patients.Design/methodology/approachA social identity approach to leadership provided a framework to understand the insider/outsider approach to leadership which helped RH to negotiate and navigate the conflicting priorities from each departments’ perspective. A staff survey tool was undertaken to identify reasons for the lack of implementation of a clinical protocol for chest pain patients, specifically with reference to the use of the HS. A consensus was reached to develop and implement the pathway for multi-disciplinary use of the HS and a quality improvement methodology (with the use of plan do study act (PDSA) cycles) was used over a period of nine months.FindingsThe results demonstrated significant improvements in the reduction (60%) of waiting time by chronic chest pain patients in the ED. The use of the HS as a stratified risk assessment tool resulted in a more efficient and safe way to manage patients. There are specific leadership challenges faced by an MTI doctor when they arrive in the NHS, as the MTI doctor is considered an outsider to the NHS, with reduced influence. Drawing upon the Social Identity Theory of Leadership, NHS Trusts can introduce inclusion strategies to enable greater alignment in social identity with doctors from overseas.Research limitations/implicationsMore than one third of doctors (40%) in the English NHS are IMGs and identify as black and minority ethnic (GMC, 2019a) a trend that sees no sign of abating as the NHS continues its international medical workforce recruitment strategy for its survival (NHS England, 2019; Beech et al., 2019). IMGs can provide significant value to improving the NHS using skills developed from their own health-care system. This paper recommends a need for reciprocal learning from low to medium income countries by UK doctors to encourage the development of an inclusive global medical social identity.Originality/valueThis quality improvement research combined with identity leadership provides new insights into how overseas doctors can successfully lead sustainable improvement across different departments within one hospital in the NHS.

Position of trauma surgery in emergency medicine

The decision of the Federal Joint Committee has resulted in the further development of in-hospital emergency medicine through the establishment of central emergency departments and staged emergency care. In addition, the additional training in clinical acute and emergency medicine was established. The aim of this work is on the one hand to make trauma surgeons aware of these structural changes. On the other hand, we would like to evaluate an opinion and discuss the position of trauma surgery in emergency medicine. Aweb-based online survey was conducted at the Trauma Network and Trauma Registry Congress to collect participants' opinions on the position of trauma surgery in emergency medicine. Of 143 congress participants, 98 (67%) responded to the survey. The majority of participants were male (n = 78, 80%), over 40years of age (n = 62, 63%), and in aprofessional position with staff responsibility (n = 73, 75%). Emergency medicine (mean: 84.8; SD: 18.7) and intensive care medicine (mean: 78.3; SD: 20.4) training appears important. On the other hand, subsequent work in these areas appears less important (prehospital emergency medicine: mean: 65.1; SD: 28.0; ICU: mean: 53.7, SD: 30.3); however, activity in an emergency department is rated higher (MW: 87.0; SD: 18.7). There is high agreement that the trauma leader should be atrauma surgeon (mean 87.9; SD: 19.7). Ahigh volume of emergency trauma surgery patients and the care of severely injured patients in designated trauma centers show that trauma surgery expertise is mandatory in acentral emergency department. Senior positions should also be sought to ensure high quality standards.

Hospital mortality and length of stay differences in emergency medical admissions related to ‘on-call’ specialty

BackgroundThe outcomes of acute medical admissions have been shown to be influenced by a variety of factors including system, patient, societal, and physician-specific differences.AimTo evaluate the influence of on-call specialty on outcomes in acute medical admissions.MethodsAll acute medical admissions to our institution from 2015 to 2020 were evaluated. Admissions were grouped based on admitting specialty. Thirty-day in-hospital mortality and length of stay (LOS) were evaluated. Data was analysed using multivariable logistic regression and truncated Poisson regression modelling.ResultsThere were 50,347 admissions in 30,228 patients. The majority of admissions were under Acute Medicine (47.0%), and major medical subspecialties (36.1%); Elderly Care admitted 12.1%. Acute Medicine admissions were older at 72.9 years (IQR 57.0, 82.9) vs. 67.2 years (IQR 50.1, 80.2), had higher Acute Illness Severity (grades 4–6: 85.9% vs. 81.3%; p < 0.001), Charlson Index (> group 0; 61.5% vs. 54.6%; p < 0.001), and Comorbidity Score (40.7% vs. 36.7%; p < 0.001). Over time, there was a small (+ 8%) but significant increase in 30-day in-hospital mortality. Mortality rates for Acute Medicine, major medical specialties, and Elderly Care were not different at 5.1% (95% CI: 4.7, 5.5), 4.7% (95% CI: 4.3, 5.1), and 4.7% (95% CI: 3.9, 5.4), respectively. Elderly Care admissions had shorter LOS (7.8 days (95% CI: 7.6, 8.0)) compared with either Acute Medicine (8.7 days (95% CI: 8.6, 8.8)) or major medical specialties (8.7 days (95% CI: 8.6, 8.9)).ConclusionNo difference in mortality and minor differences in LOS were observed. The prior pattern of improved outcomes year on year for emergency medical admissions appears ended.

Effect of annual hospital admissions of out-of-hospital cardiac arrest patients on prognosis following cardiac arrest

BackgroundAlthough the prognosis of patients treated at specialized facilities has improved, the relationship between the number of patients treated at hospitals and prognosis is controversial and lacks constancy in those with out-of-hospital cardiac arrest (OHCA). This study aimed to clarify the effect of annual hospital admissions on the prognosis of adult patients with OHCA by analyzing a large cohort.MethodsThe effect of annual hospital admissions on patient prognosis was analyzed retrospectively using data from the Japanese Association for Acute Medicine OHCA registry, a nationwide multihospital prospective database. This study analyzed 3632 of 35,754 patients hospitalized for OHCA of cardiac origin at 86 hospitals. The hospitals were divided into tertiles based on the volume of annual admissions. The effect of hospital volume on prognosis was analyzed using logistic regression analysis with multiple imputation. Furthermore, three subgroup analyses were performed for patients with return of spontaneous circulation (ROSC) before arrival at the emergency department, patients admitted to critical care medical centers, and patients admitted to extracorporeal membrane oxygenation-capable hospitals.ResultsFavorable neurological outcomes 30 days after OHCA for patients overall showed no advantage for medium- and high-volume centers over low-volume centers; Odds ratio (OR) 0.989, (95% Confidence interval [CI] 0.562-1.741), OR 1.504 (95% CI 0.919-2.463), respectively. However, the frequency of favorable neurological outcomes in OHCA patients with ROSC before arrival at the emergency department at high-volume centers was higher than those at low-volume centers (OR 1.955, 95% CI 1.033-3.851).ConclusionHospital volume did not significantly affect the prognosis of adult patients with OHCA. However, transport to a high-volume hospital may improve the neurological prognosis in OHCA patients with ROSC before arrival at the emergency department.

Structure and Organization of an Emergency Department

The more diverse the German hospital landscape, the more important it is to define tasks and processes in order to ensure a uniform standard of care at the highest level for the population. With the introduction of additional training in clinical acute and emergency medicine and specifications for inpatient emergency care, important foundations for the necessary structure of emergency rooms have been given.

重症急性膵炎に対する予防的抗菌薬使用の現況 第49回日本救急医学会総会・学術集会より(Current status of prophylactic antimicrobial use for severe acute pancreatitis: in the 49th Annual Meeting of the Japanese Association for Acute Medicine)

要旨【背景】急性膵炎診療における予防的抗菌薬投与に関して，世界のガイドラインでは投与は非推奨となりつつあるが，日本の多くの施設では重症度に関わらず予防的抗菌薬は投与されている。施設ごとの診療パターンや，投与を支持するかしないかの背景にある根拠や臨床的動機は不明であり，第49回日本救急医学会総会学術集会で本命題に関するセッションが開催された。【目的】各演者の発表・討論内容，会場の投票結果を提示し，予防的抗菌薬投与の是非を検討する。【方法】発表要旨と質疑，投票結果の推移を記述した。【結果】Pros：抗菌薬の予防的投与と治療的投与を明確に区別するのは難しく，胆石性膵炎疑い例，医療暴露（耐性菌）（高感染リスク）例には，厳選して短期間（3日間）使用するべき。Cons：感染の証拠が明確でなければ使用するべきではない。投票結果推移：（軽症膵炎）非投与派が80%から90%に増加。（重症膵炎）投与派が77%から42%に減少。【考察】ガイドライン遵守率の低さと予防的抗菌薬投与の臨床的動機が判明した。世界のエビデンスやガイドライン推奨を正しく提示することで，行動変容が可能であることが示唆された。今後のガイドラインには，無菌性急性膵炎と胆管炎・敗血症併発の鑑別に関する指針や，その遵守率の定期的調査が求められる。【結論】予防的抗菌薬投与が推奨されなくなった事実を理解し，日本の最新版ガイドラインの遵守に努めるべきである。

Instructor Development Workshops for Advanced Life Support Training Courses Held in a Fully Virtual Space: Observational Study.

BackgroundVarious face-to-face training opportunities have been lost due to the COVID-19 pandemic. Instructor development workshops for advanced resuscitation (ie, advanced life support) training courses are no exception. Virtual reality (VR) is an attractive strategy for remote training. However, to our knowledge, there are no reports of resuscitation instructor training programs being held in a virtual space.ObjectiveThis study aimed to investigate the learning effects of an instructor development workshop that was conducted in a virtual space.MethodsIn this observational study, we created a virtual workshop space by using NEUTRANS (Synamon Inc)—a commercial VR collaboration service. The instructor development workshop for the advanced life support training course was held in a virtual space (ie, termed the VR course) as a certified workshop by the Japanese Association of Acute Medicine. We asked 13 instructor candidates (students) who participated in the VR course to provide a workshop report (VR group). Reports from a previously held face-to-face workshop (ie, the face-to-face course and group) were likewise prepared for comparison. A total of 5 certified instructor trainers viewed and scored the reports on a 5-point Likert scale.ResultsAll students completed the VR course without any problems and received certificates of completion. The scores for the VR group and the face-to-face group did not differ at the level of statistical significance (median 3.8, IQR 3.8-4.0 and median 4.2, IQR 3.9-4.2, respectively; P=.41).ConclusionsWe successfully conducted an instructor development workshop in a virtual space. The degree of learning in the virtual workshop was the same as that in the face-to-face workshop.

Incidence, Outcome, and Risk Factors of Cardiovascular Surgery-Associated Disseminated Intravascular Coagulation: A Single-Center Retrospective Study.

Cardiovascular surgery is highly invasive, with a risk of postoperative coagulopathy due to various factors such as bleeding. Coagulopathy can progress to disseminated intravascular coagulation (DIC), which complicates various clinical conditions. However, no study to date has reported on DIC associated with cardiovascular surgery. Therefore, we investigated retrospectively the incidence, outcome, and risk factors of cardiovascular surgery-associated DIC in our institute. All patients who underwent cardiovascular surgery and were admitted to our intensive care unit between January 2016 and December 2017 were included in this study. The Japanese Association for Acute Medicine (JAAM) DIC score was calculated using our institute’s database at the following time points: preoperatively, postoperative day 1 (POD1), POD3, and POD7. Data regarding surgery, 90-day mortality, and risk factors of DIC were also collected and analyzed by multiple regression. In total, 553 patients were considered eligible for analysis. Median age of eligible patients was 72 years, with a 90-day mortality rate of 1.4%. Patients with DIC at POD7 had higher Sequential Organ Failure Assessment (SOFA) score, preoperative JAAM DIC scores, and a longer anesthesia time than those without DIC. Female sex, preoperative DIC score, and anesthesia time were found to be risk factors for DIC.

Extracorporeal cardiopulmonary resuscitation with temperature management could improve the neurological outcomes of out-of-hospital cardiac arrest: a retrospective analysis of a nationwide multicenter observational study in Japan

BackgroundTarget temperature management (TTM) is an effective component of treating out-of-hospital cardiac arrest (OHCA) after return of spontaneous circulation in conventional cardiopulmonary resuscitation. However, therapeutic hypothermia (32–34 °C TTM) is not recommended based on the results of recent studies. Extracorporeal cardiopulmonary resuscitation (ECPR) with veno-arterial extracorporeal membrane oxygenation is another promising therapy for OHCA, but few studies have examined the effectiveness of ECPR with TTM. Therefore, we hypothesized that ECPR with TTM could have the effectiveness to improve the neurological outcomes for adults following witnessed OHCA, in comparison to ECPR without TTM.MethodsWe performed retrospective subanalyses of the Japanese Association for Acute Medicine OHCA registry. We focused on adults who underwent ECPR for witnessed OHCA. We performed univariate (the Mann–Whitney U test and Fisher’s exact test), multivariable (logistic regression analyses), and propensity score analyses (the inverse probability of the treatment-weighting method) with to compare the neurological outcomes between patients with or without TTM, among all eligible patients, patients with a cardiogenic cause, and patients divided into subgroups according to the interval from collapse to pump start (ICPS) (> 30, > 45, or > 60 min).ResultsWe analyzed data for 977 patients. Among 471 patients treated with TTM, the target temperature was therapeutic hypothermia in 70%, and the median interval from collapse to target temperature was 249 min. Propensity score analysis showed a positive association between TTM and favorable neurological outcomes in all patients (odds ratio 1.546 [95% confidence interval 1.046–2.286], P = 0.029), and in patients with ICPS of > 30 or > 45 min, but not in those with ICPS of > 60 min. The propensity score analysis also showed a positive association between TTM and favorable neurological outcomes in patients with a cardiogenic cause (odds ratio 1.655 [95% confidence interval 1.096–2.500], P = 0.017), including in all ICPS subgroups (> 30, > 45, and > 60 min).ConclusionWithin patients who underwent ECPR following OHCA, ECPR with TTM could show the potential of improvement in the neurological outcomes, compared to ECPR without TTM.