Increased Odds Of Survival Research Articles

The Learning Curve in Digital Replant Surgery: 46 Prospectively Collected Cases From a Single Surgeon Over a 10-Year Period.

Digital replantation is a technically difficult microsurgery requiring significant surgical skill.The aim of this study was to investigate postoperative outcomes associated with the surgical learning curve for microvascular digital replantation. A prospectively maintained surgical database of consecutive patients who underwentdigital replantation from 2002 to 2012 was reviewed.All cases were performed by a single surgeon and began immediately after the surgeon's fellowship.A total of 46 patients were identified.Outcomes of digital replantation were tested for association with time since fellowship, total microvascular operative experience, and location and type of injury. Overall, 38/46 (82.6%) of patients underwent a successful digital replantation.There was a significant difference between survival percentages over the years (p=0.04), with improvement seen over time.Total microvascular experience was significantly associated with successful outcomes (p<0.001).After 100 hours of microvascular experience, there was a significant increase in the survival odds ratio (OR 8.5, 95% CI 1.5-47.9).Crush and thumb injuries were more likely to have detrimental outcomes. There was marked improvement in replant survival over time, with a significant increase in odds of survival after 100 hours of microvascular experience.One hundred operating hours under the microscope occurred around 2 years in practice for this high-volume surgeon.There is strong evidence that a steep learning curve occurs in microvascular digit replantation surgery.

Prognostic Factors of Survival in Veno-Arterial ECMO Patients: A Multivariable Logistic Regression Analysis

Background: Several models exist to predict mortality in patients on Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO). Whether expanded demographic data points have prognostic implications is less understood. This study assessed the prognostic value of demographics in patients on VA-ECMO. Methods: This retrospective cohort study investigated 410 patients who received VA-ECMO. Survival to hospital discharge, survival to intensive care unit discharge and survival to ECMO explantation were examined. A multivariable logistic regression was performed incorporating 11 demographic variables. Results: 44% (181/410) of patients survived to ECMO explant, 37% (152/410) of patients survived to ICU discharge, and 36% (146/410) of patients survived to hospital discharge. There was an increase in odds of survival to hospital discharge in patients who were less than 55 years old (Odds Ratio (OR) = 3.91 [95% Confidence Interval (CI) 2.35-6.49]). There was a decrease in odds of survival to hospital discharge in patients who had a prior cardiac arrest (OR = 0.35 [95% CI 0.20-0.63]). Patients who survived to hospital discharge less frequently had a history of smoking (51% vs 65%, respectively; p=0.008), and were younger compared to those who did not survive (51.4+/- 14.03 vs 57.3+/- 16.54). Conclusion: Age less than 55 years old was a prognostic indicator of survival to hospital discharge following VA-ECMO, while history of smoking, history of dialysis, and history of cardiac arrest were associated with mortality. Sex, BMI, atrial fibrillation, hypertension, DM, and COPD were not significant indicators. These data may help guide optimal patient selection for VA-ECMO support.

Direct Trauma Center Access by Helicopter Emergency Medical Services is Associated With Improved Survival After Severe Injury.

Evaluate the association of survival with helicopter transport directly to a trauma center compared with ground transport to a non-trauma center (NTC) and subsequent transfer. Helicopter transport improves survival after injury. One potential mechanism is direct transport to a trauma center when the patient would otherwise be transported to an NTC for subsequent transfer. Scene patients 16 years and above with positive physiological or anatomic triage criteria within PTOS 2000-2017 were included. Patients transported directly to level I/II trauma centers by helicopter were compared with patients initially transported to an NTC by ground with a subsequent helicopter transfer to a level I/II trauma center. Propensity score matching was used to evaluate the association between direct helicopter transport and survival. Individual triage criteria were evaluated to identify patients most likely to benefit from direct helicopter transport. In all, 36,830 patients were included. Direct helicopter transport was associated with a nearly 2-fold increase in odds of survival compared with NTC ground transport and subsequent transfer by helicopter (aOR 2.78; 95% CI 2.24-3.44, P <0.01). Triage criteria identifying patients with a survival benefit from direct helicopter transport included GCS≤13 (1.71; 1.22-2.41, P <0.01), hypotension (2.56; 1.39-4.71, P <0.01), abnormal respiratory rate (2.30; 1.36-3.89, P <0.01), paralysis (8.01; 2.03-31.69, P <0.01), hemothorax/pneumothorax (2.34; 1.36-4.05, P <0.01), and multisystem trauma (2.29; 1.08-4.84, P =0.03). Direct trauma center access is a mechanism driving the survival benefit of helicopter transport. First responders should consider helicopter transport for patients meeting these criteria who would otherwise be transported to an NTC.

Clinical outcomes following out-of-hospital cardiac arrest: The minute-by-minute impact of bystander cardiopulmonary resuscitation

AimsThe time-dependent prognostic role of bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients has not been described with great precision, especially for neurologic outcomes. Our objective was to assess the association between bystander CPR, emergency medical service (EMS) response time, and OHCA patients’ outcomes. MethodsThis cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registries. Bystander-witnessed adult OHCA treated by EMS were included. The primary outcome was survival to hospital discharge and secondary outcome was survival with a good neurologic outcome (modified Rankin scale 0–2). Multivariable logistic regression models were used to assess the associations and interactions between bystander CPR, EMS response time and clinical outcomes. ResultsOut of 229,637 patients, 41,012 were included (18,867 [46.0%] without bystander CPR and 22,145 [54.0%] with bystander CPR). Bystander CPR was independently associated with higher survival (adjusted odds ratio [AOR] = 1.70 [95%CI 1.61–1.80]) and survival with a good neurologic outcome (AOR = 1.87 [95%CI 1.70–2.06]), while longer EMS response times were independently associated with lower survival to hospital discharge (each additional minute of EMS response time: AOR = 0.92 [95%CI 0.91–0.93], p < 0.001) and lower survival with a good neurologic outcome (AOR = 0.88 [95%CI 0.86–0.89], p < 0.001). There was no interaction between bystander CPR and EMS response time’s association with survival (p = 0.12) and neurologic outcomes (p = 0.65). ConclusionsAlthough bystander CPR is associated with an immediate increase in odds of survival and of good neurologic outcome for OHCA patients, it does not influence the negative association between longer EMS response time and survival and good neurologic outcome.

Gender-specific differences in return-to-spontaneous circulation and outcome after out-of-hospital cardiac arrest: Results of sixteen-year-state-wide initiatives

AimSeveral studies reported a lower proportion of laypeople cardio-pulmonary resuscitation (CPR) in female victims of out-of-hospital cardiac arrest (OHCA). We aimed to verify how sixteen-years of state-wide initiatives impacted on gender-differences in OHCA treatment and survival. MethodsAll the 2481 consecutive OHCAs of presumed cardiac origin occurred between 2002 and 2018 in the Swiss Ticino Canton and in which a resuscitation was attempted, were included. Emergency medical system (EMS)-witnessed OHCAs were excluded. ResultsTime from call to CPR decreased from 9-min in 2002–2006 to 5-min in 2015–2018 (p<0.01) and until 2014, it was longer in women. Survival to discharge increased overall from 11% in 2002–2006 to 23% in 2015–2018 (p<0.001) related to telephone-assisted CPR development (period 2011–2014) and first responder and layperson recruitment via a mobile application (period 2015–2018). In males, survival increased from 12% to 25% (p=0.001) with a statistically significant increase in odds of survival in 2007–2010 (OR 1.6 95%CI 1.1–2.3; p=0.001), in 2011–2014 (OR 2 95%CI 1.4–2.8; p=0.001), and in 2015–2018 (2.4 95%CI 1.7–3.3; p=0.001) compared to 2002–2006. On the other hand, in females, survival increased from 7% to 18% (p<0.001), with a corresponding increase in the odds of survival of almost 3 times from 2002–2006 to 2015–2018 time period (OR 2.9 95%CI 1.5–5.8, p=0.001). No difference in survival probability was observed according to gender when adjusted for age, presenting rhythm, year-groups, OHCA location, EMS arrival time, witnessed status and laypeople-CPR. ConclusionsState-wide initiatives can significantly increase the chances of survival in both male and female victims of OHCAs, by increasing the probability to receive CPR in a shorter time span.

Association of Interfacility Helicopter versus Ground Ambulance Transport and in-Hospital Mortality among Trauma Patients

Background Relatively few studies have compared outcomes between helicopter transport (HT) and ground transport (GT) for the inter-facility transfer of trauma patients to tertiary trauma centers (TTC). Mixed results have been reported from these studies ranging from a slight increase in odds of survival for the severely injured to no evident benefit for HT patients. We hypothesized there was no adjusted difference in mortality between patients transported interfacility by HT or GT taking into account distance from TTC. Methods Data from an inclusive statewide trauma registry was used to conduct a retrospective cohort study of adult (18+ years old) trauma patients who initially presented to a non-tertiary trauma center (NTC) before subsequent transfer by HT or GT to a TTC. Records from the NTC and TTC were linked (N = 9880). We used propensity adjusted, multivariable Cox proportional hazards models to assess the association of HT on mortality at 72-hour and within the first 2 weeks of arrival at a TTC; these multivariable analyses were stratified by distance (miles) between NTC and TTC: 21-90, and greater than 90. Results Mean distance between NTC and TTC was greater for HT patients, 96.7 miles versus 69.9 miles for GT. A higher proportion of patients among the HT group had an ISS of 16 or higher (24.6% vs 10.9%), an initial SBP < 90 mmHg (7.3% vs 2.8%), and GCS < 10 (12.5% vs 3.7%) than the GT group. HT was associated with significantly decreased 72-hour mortality (HR 0.65, 95%CI 0.48-0.90) for patients transferred from a NTC <90 miles from the TTC. No association was seen for patients transferred more than 90 miles to the TTC. No significant association of HT and 2-week mortality was seen at any distance from the TTC. Conclusions Only for patients transferred from an NTC <90 miles from the receiving TTC was HT associated with a significantly decreased hazard of mortality in the first 72 hours. Many HT patients, especially from the most distant NTCs, had minor injuries and normal vital signs at both the NTC and TTC suggesting the decision to use HT for these patients was resource-driven rather than clinical.

Improved Survival for Rural Trauma Patients Transported by Helicopter to a Verified Trauma Center: A Propensity Score Analysis.

ObjectivesRecent studies using advanced statistical methods to control for confounders have demonstrated an association between helicopter transport (HT) versus ground ambulance transport (GT) in terms of improved survival for adult trauma patients. The aim of this study was to apply a methodologically vigorous approach to determine if HT is associated with a survival benefit for when trauma patients are transported to a verified trauma center in a rural setting.MethodsThe ascertainment of trauma patients age ≥ 15 years (n = 469 cases) by HT and (n = 580 cases) by GT between 1999 and 2012 was restricted to the scene of injury in a rural area of 10 to 35 miles from the trauma center. The propensity score (PS) was determined using data including demographics, prehospital physiology, intubation, total prehospital time, and injury severity. The PS matching was performed with different calipers to select a higher percentage of matches of HT compared to GT patients. The outcome of interest was survival to discharge from hospital. Identical logistic regression analysis was done taking into account for each matched design to select an appropriate effect estimate and confidence interval (CI) controlling for initial vital signs in the emergency department, the need for urgent surgery, intensive care unit admission, and mechanical ventilation.ResultsUnadjusted mortalities for HT compared to GT were 7.7 and 5.3%, respectively (p > 0.05). The adjusted rates were 4.0% for HT and 7.6% for GT (p < 0.05). In a PS well‐matched data set, HT was associated with a 2.69‐fold increase in odds of survival compared to GT patients (adjusted odds ratio = 2.69; 95% CI = 1.21–5.97).ConclusionsIn a rural setting, we demonstrated improved survival associated with HT compared to GT for scene transportation of adult trauma patients to a verified Level II trauma center using an advanced methodologic approach, which included adjustment for transport distance. The implication of survival benefit to rural population is discussed. We recommend larger studies with multiple trauma systems need to be repeated using similar study methodology to substantiate our findings.

Association Between Partial Pressure of Arterial Carbon Dioxide and Survival to Hospital Discharge Among Patients Diagnosed With Sepsis in the Emergency Department.

The objective of this study was to test the association between the partial pressure of arterial carbon dioxide and survival to hospital discharge among mechanically ventilated patients diagnosed with sepsis in the emergency department. Retrospective cohort study of a single center trial registry. Academic medical center. Mechanically ventilated emergency department patients. age 18 years and older, diagnosed with sepsis in the emergency department, and mechanical ventilation initiated in the emergency department. Arterial blood gases obtained after initiation of mechanical ventilation were analyzed. The primary outcome was survival to hospital discharge. We tested the association between partial pressure of arterial carbon dioxide and survival using multivariable logistic regression adjusting for potential confounders. Sensitivity analyses, including propensity score matching were also performed. Six hundred subjects were included, and 429 (72%) survived to hospital discharge. The median (interquartile range) partial pressure of arterial carbon dioxide was 42 (34-53) mm Hg for the entire cohort and 44 (35-57) and 39 (31-45) mm Hg among survivors and nonsurvivors, respectively (p < 0.0001 Wilcox rank-sum test). On multivariable analysis, a 1 mm Hg rise in partial pressure of arterial carbon dioxide was associated with a 3% increase in odds of survival (adjusted odds ratio, 1.03; 95% CI, 1.01-1.04) after adjusting for tidal volume and other potential confounders. These results remained significant on all sensitivity analyses. In this sample of mechanically ventilated sepsis patients, we found an association between increasing levels of partial pressure of arterial carbon dioxide and survival to hospital discharge. These findings justify future studies to determine the optimal target partial pressure of arterial carbon dioxide range for mechanically ventilated sepsis patients.

65 Out-of-hospital cardiac arrests in the older population in ireland

Background Out of hospital cardiac arrest (OHCA) is associated with a poor survival. Age influences survival but it is unclear to what extent. Patient selection is crucial in deciding who should receive attempted resuscitation to optimise outcomes and minimise inappropriate end-of-life management. Aim To describe the demographics, characteristics and outcomes following resuscitation attempts in OHCA patients aged 70 years and older in the Republic of Ireland. Methods Data was extracted from the national Out of Hospital Cardiac Arrest Register (OHCAR) for patients aged 70 years and older. Patient and event characteristics were compared across three age categories (70–79; 80–89; 90 years and older). Logistic regression was used to determine the predictors of the primary outcome in the overall cohort (discharge from hospital alive). Results A total of 2,443 OHCAs in patients aged 70 years and older were attended by emergency medical services and had resuscitation attempted between 2012 and 2014 in the Republic of Ireland. For the entire cohort, survival to hospital discharge was 3.4%. Asystole was the first rhythm identified in 52.6% of all cases. A shockable initial rhythm persisted as a predictor of survival as age progressed; overall 14.6% of those aged over 70 years survived if the presenting rhythm was shockable, 0.1% of OHCAs survived if asystole was the initial rhythm analysed. Of those suffering an OHCA in a residential institution, 2.2% survived to hospital discharge. Logistic regression analysis showed that an initial shockable initial rhythm and having a witnessed cardiac arrest were independent predictors associated with increased odds of survival to discharge. Conclusion Resuscitation is a purposeful exercise in those with advancing age when favourable prognostic markers are present. Data on age related survival can inform those discussing end of life decisions.

Helicopters and injured kids: Improved survival with scene air medical transport in the pediatric trauma population.

Helicopter emergency medical services (HEMS) are frequently used to transport injured children, despite unclear evidence of benefit. The study objective was to evaluate the association of HEMS compared with ground emergency medical services (GEMS) transport with outcomes in a national sample of pediatric trauma patients. Patients 15 years or younger undergoing scene transport by HEMS or GEMS in the National Trauma Data Bank from 2007 to 2012 were included. Propensity score matching was used to match HEMS and GEMS patients for likelihood of HEMS transport based on demographics, prehospital physiology and time, injury severity, and geographic region. Absolute standardized differences of less than 0.1 indicated adequate covariate balance between groups after matching. The primary outcome was in-hospital survival, while the secondary outcome was discharge disposition in survivors. Conditional logistic regression determined the association between HEMS versus GEMS transport with outcomes while controlling for demographics, admission physiology, injury severity, nonaccidental trauma, and in-hospital complications not accounted for in the propensity score. Subgroup analysis was performed in patients with a transport time of greater than 15 minutes to capture patients with the potential for HEMS transport. A total of 25,700 HEMS/GEMS pairs were matched from 166,594 patients. Groups were well matched, with all propensity score variables having absolute standardized differences of less than 0.1. In matched patients, HEMS was associated with a 72% increase in odds of survival compared with GEMS (adjusted odds ratio, 1.72; 95% confidence interval, 1.26-2.36; p < 0.01). Transport mode was not associated with discharge disposition (p = 0.47). Subgroup analysis included 17,657 HEMS/GEMS pairs. HEMS was again associated with a significant increase in odds of survival (adjusted odds ratio, 1.81; 95% confidence interval, 1.24-2.65; p < 0.01), while transport mode was not associated with discharge disposition (p = 0.58). Scene transport by HEMS was associated with improved odds of survival compared with GEMS in pediatric trauma patients. Further study is warranted to understand the underlying mechanisms and develop specific triage criteria for HEMS transport in this population. Therapeutic study, level III.

Helicopter transport improves survival following injury in the absence of a time-saving advantage

Although survival benefits have been shown at the population level, it remains unclear what drives the outcome benefits for helicopter emergency medical services (HEMS) in trauma. Although speed is often cited as the vital factor of HEMS, we hypothesized a survival benefit would exist in the absence of a time savings over ground emergency medical services (GEMS). The objective was to examine the association of survival with HEMS compared with GEMS transport across similar prehospital transport times. We used a retrospective cohort of scene HEMS and GEMS transports in the National Trauma Databank (2007-2012). Propensity score matching was used to match HEMS and GEMS subjects on the likelihood of HEMS transport. Subjects were stratified by prehospital transport times in 5-minute increments. Conditional logistic regression determined the association of HEMS with survival across prehospital transport times strata controlling for confounders. Transport distance was estimated from prehospital transport times and average HEMS/GEMS transport speeds. There were 155,691 HEMS/GEMS pairs matched. HEMS had a survival benefit over GEMS for prehospital transport times between 6 and 30 minutes. This benefit ranged from a 46% increase in odds of survival between 26 and 30 minutes (adjusted odds ratio [AOR], 1.46; 95% CI, 1.11-1.93; P < .01) to an 80% increase in odds of survival between 16 and 20 minutes (AOR, 1.80; 95% CI, 1.51-2.14; P < .01). This prehospital transport times window corresponds to estimated transport distance between 14.3 and 71.3 miles for HEMS and 3.3 and 16.6 miles for GEMS. When stratified by prehospital transport times, HEMS had a survival benefit concentrated in a window between 6 and 30 minutes. Because there was no time-savings advantage for HEMS, these findings may reflect care delivered by HEMS providers.

CORAL REEFS. Genomic determinants of coral heat tolerance across latitudes.

As global warming continues, reef-building corals could avoid local population declines through "genetic rescue" involving exchange of heat-tolerant genotypes across latitudes, but only if latitudinal variation in thermal tolerance is heritable. Here, we show an up-to-10-fold increase in odds of survival of coral larvae under heat stress when their parents come from a warmer lower-latitude location. Elevated thermal tolerance was associated with heritable differences in expression of oxidative, extracellular, transport, and mitochondrial functions that indicated a lack of prior stress. Moreover, two genomic regions strongly responded to selection for thermal tolerance in interlatitudinal crosses. These results demonstrate that variation in coral thermal tolerance across latitudes has a strong genetic basis and could serve as raw material for natural selection.

Quantitative anti-F1 and anti-V IgG ELISAs as serological correlates of protection against plague in female Swiss Webster mice

A recombinant fusion protein composed of Yersinia pestis fraction 1 capsule (F1) and virulence-associated V antigen (V) (F1–V) has been developed as the next-generation vaccine against plague. In this study, female Swiss Webster mice received a single intramuscular vaccination with one of eight doses of the F1–V vaccine and exposed 4 weeks later to either Y. pestis CO92 or C12 organisms by the subcutaneous or aerosol routes of infection. Quantitative anti-F1 and anti-V immunoglobulin G (IgG) ELISAs were used to examine the relationship between survival outcome and antibody titers to F1 and V. Results suggested that each 1log10 increase in week 4 quantitative anti-F1 and anti-V IgG ELISA titers were associated with a 1.7-fold (p=0.0051) and 2.5-fold (p=0.0054) increase in odds of survival, respectively, against either bubonic or pneumonic plague and may serve as serological correlates of protection.

An in vivo passive protection assay for the evaluation of immunity in AVA-vaccinated individuals

Samples of human plasma from anthrax vaccine adsorbed (AVA, BioThrax™)-vaccinated individuals were used to demonstrate passive protection of A/J mice from a lethal challenge with the Sterne strain of anthrax bacteria. The maximum concentration of human anti-protective antigen IgG in mouse sera 24 h after injection of 260 μg of anti-PA IgG was 134 μg/ml, declining to 91 μg/ml at 72 h (half-life = 101.7 h). Mice showed significant survival ( p ≤ 0.001) after injection of serial dilutions up to 1:4 of the standard plasma and challenged with 100 LD 50. Similarly, mice injected with the standard anti-AVA plasma and challenged up to 5 days post-treatment also survived ( p ≤ 0.001). Using a cohort of human plasma to measure passive protection, the best correlation between passive protection and an in vitro assay was found to be with the quantitative toxin neutralization assay (minimum fold increase in odds of survival: 2.71, p = 0.0062). These results demonstrate a reliable in vivo neutralization method that correlates with standard in vitro measures of neutralizing antibody levels in plasma from individuals vaccinated with the standard anthrax vaccine. This analytical method may provide additional opportunities to compare the efficacy of improved anthrax vaccines with the licensed vaccine.