Abstract 12956: Racial and Ethnic Disparities in Post-Arrest Care

Introduction: Post-arrest care is essential to the chain of survival after out-of-hospital cardiac arrest (OHCA). While racial/ethnic disparities in prehospital care are well studied, there is sparse literature evaluating these disparities in post-arrest care. We sought to measure post-arrest care disparities in a statewide OHCA registry. Methods: We evaluated 2014-2020 data in Texas from the Cardiac Arrest Registry to Enhance Survival (CARES) and included all adult OHCAs surviving to hospital admission. We stratified subjects by race and ethnicity. We defined outcomes as targeted temperature management (TTM), percutaneous intervention (PCI), and early prognostication (made DNR and died <72 hours of arrest), survival to discharge, and survival with CPC of 1-2 (good CPC). We used a mixed effects model logistic regression to evaluate the association between strata and outcomes, modeling receiving hospital as the random intercept. We adjusted for age, household income, sex, witnessed arrest, bystander CPR (B-CPR), and initial shockable rhythm. For early prognostication, we performed a multivariable logistic regression adjusted for bystander witnessed arrest and B-CPR. Results: Of 37,055 adult OHCAs, 9,346 (25.2%) survived to admission; median age was 62, 60.7% were male, 3,036 (32.5%) received TTM, 533 (5.7%) received PCI, 93 (1.0%) had early prognostication, 34.9% survived to discharge, and 22.0% survived with good CPC. Blacks were less likely than whites to receive PCI (2.7% v 7.9%, aOR 0.6, 95% CI 0.4-0.8), less likely to receive early prognostication (0.3% v 1.0%, aOR 0.3, 95% CI 0.1-0.6), and less likely to have good CPC (17.3% v 26.0%, aOR 0.8, 0.7-0.9). Despite a lower percentage receiving TTM, blacks had a higher odds of TTM (30.7% v 34.5%, aOR 1.2, 95% CI 1.03-1.4). Blacks had a similar survival (1.0, 95% CI 0.9-1.2). Compared to whites, Latinos had higher early prognostication (1.7%, aOR 1.7, 95% CI 1.1-2.7), worse survival (30.3%, v 37.1%, aOR 0.9, 95% CI 0.8-0.99), lower good CPC (17.8%, aOR 0.8, 95% CI 0.7-0.96). Latinos had a similar rate of TTM (aOR 1.0, 95%CI 0.8-1.2) and PCI (aOR 1.0, 95% CI 0.8-1.4). Conclusions: Black and Latino OHCA victims experienced disparities in post arrest care and outcomes, even when adjusted for receiving hospital.

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Effects of Targeted Temperature Management in Patients with Post-Cardiac Arrest Syndrome after an Out-Of-Hospital Cardiac Arrest Caused by Hanging: A Prospective Observational Cohort Study in Japan

10.21203/rs.3.rs-1120328/v1 ◽

2021 ◽

Author(s):

Ryuichiro Kakizaki ◽

Naofumi Bunya ◽

Shuji Uemura ◽

Takehiko Kasai ◽

Keigo Sawamoto ◽

...

Keyword(s):

Logistic Regression ◽

Cardiac Arrest ◽

Propensity Score ◽

Multivariate Logistic Regression Analysis ◽

Targeted Temperature Management ◽

Temperature Management ◽

Matched Cohort ◽

Neurological Outcomes ◽

Post Cardiac Arrest Syndrome ◽

Hospital Cardiac Arrest

Abstract Background: Targeted temperature management (TTM) is recommended for unconscious patients after a cardiac arrest. However, its effectiveness in patients with post-cardiac arrest syndrome (PCAS) by hanging remains unclear. Therefore, this study aimed to investigate the relationship between TTM and favorable neurological outcomes in patients with PCAS by hanging.Methods: This study was a retrospective analysis of the Japanese Association for Acute Medicine out-of-hospital cardiac arrest (OHCA) registry between June 2014 and December 2017 among patients with PCAS admitted to the hospitals after an OHCA caused by hanging. A multivariate logistic regression analysis was performed to estimate the propensity score and to predict whether patients with PCAS by hanging receive TTM. We compared patients with PCAS by hanging who received TTM (TTM group) and those who did not (non-TTM group) using propensity score analysis.Results: A total of 199 patients with PCAS by hanging were enrolled in this study. Among them, 43 were assigned to the TTM group and 156 to the non-TTM group. Logistic regression model adjusted for propensity score revealed that TTM was not associated with favorable neurological outcome at 1-month (adjusted odds ratio [OR]: 1.38, 95% confidence interval [CI]: 0.27–6.96). Moreover, no difference was observed in the propensity score-matched cohort (adjusted OR: 0, 73, 95% CI: 0.10–4.71) and in the inverse probability of treatment weighting-matched cohort (adjusted OR: 0.63, 95% CI: 0.15–2.69).Conclusions: TTM was not associated with increased favorable neurological outcomes at 1-month in patients with PCAS after OHCA by hanging.

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Impact of cooling method on the outcome of initial shockable or non-shockable out of hospital cardiac arrest patients receiving target temperature management: a nationwide multicentre cohort study

Annals of Intensive Care ◽

10.1186/s13613-021-00953-y ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Makoto Watanabe ◽

Tasuku Matsuyama ◽

Hikaru Oe ◽

Makoto Sasaki ◽

Yuki Nakamura ◽

...

Keyword(s):

Cardiac Arrest ◽

Propensity Score Analysis ◽

Temperature Management ◽

Target Temperature Management ◽

Multivariable Logistic Regression Analysis ◽

Neurological Outcomes ◽

Shockable Rhythm ◽

Score Analysis ◽

Hospital Cardiac Arrest ◽

Cooling Methods

Abstract Background Little is known about the effectiveness of surface cooling (SC) and endovascular cooling (EC) on the outcome of out-of-hospital cardiac arrest (OHCA) patients receiving target temperature management (TTM) according to their initial rhythm. Methods We retrospectively analysed data from the Japanese Association for Acute Medicine Out‐of‐Hospital Cardiac Arrest registry, a multicentre, prospective nationwide database in Japan. For our analysis, OHCA patients aged ≥ 18 years who were treated with TTM between June 2014 and December 2017 were included. The primary outcome was 30-day survival with favourable neurological outcome defined as a Glasgow–Pittsburgh cerebral performance category score of 1 or 2. Cooling methods were divided into the following groups: SC (ice packs, fans, air blankets, and surface gel pads) and EC (endovascular catheters and any dialysis technique). We investigated the efficacy of the two categories of cooling methods in two different patient groups divided according to their initially documented rhythm at the scene (shockable or non-shockable) using multivariable logistic regression analysis and propensity score analysis with inverse probability weighting (IPW). Results In the final analysis, 1082 patients were included. Of these, 513 (47.4%) had an initial shockable rhythm and 569 (52.6%) had an initial non-shockable rhythm. The proportion of patients with favourable neurological outcomes in SC and EC was 59.9% vs. 58.3% (264/441 vs. 42/72), and 11.8% (58/490) vs. 21.5% (17/79) in the initial shockable patients and the initial non-shockable patients, respectively. In the multivariable logistic regression analysis, differences between the two cooling methods were not observed among the initial shockable patients (adjusted odd ratio [AOR] 1.51, 95% CI 0.76–3.03), while EC was associated with better neurological outcome among the initial non-shockable patients (AOR 2.21, 95% CI 1.19–4.11). This association was constant in propensity score analysis with IPW (OR 1.40, 95% CI 0.83–2.36; OR 1.87, 95% CI 1.01–3.47 among the initial shockable and non-shockable patients, respectively). Conclusion We suggested that the use of EC was associated with better neurological outcomes in OHCA patients with initial non-shockable rhythm, but not in those with initial shockable rhythm. A TTM implementation strategy based on initial rhythm may be important.

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Abstract 338: Relationship Between Post-arrest Care Cardiac Index and Clinical Outcomes in Comatose Survivors of Out-of-hospital Cardiac Arrest: Insights From the CAPITAL-RETURN Trial

Circulation ◽

10.1161/circ.142.suppl_4.338 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Juan J Russo ◽

Paul Boland ◽

Simon Parlow ◽

Rudy Unni ◽

Pietro Di Santo ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiac Index ◽

Clinical Outcomes ◽

Primary Outcome ◽

Temperature Management ◽

Neurologic Dysfunction ◽

Icu Admission ◽

Shockable Rhythm ◽

Hospital Cardiac Arrest ◽

Capital Return

Introduction: Comatose survivors of out-of-hospital cardiac arrest (OHCA) have decreased cardiac index (CI) following return of spontaneous circulation. Although reversible, a reduced CI can contribute to cerebral hypoperfusion and impaired neurologic outcomes. We sought to examine the relationship between CI and clinical outcomes following OHCA. Methods: CAPITAL-RETURN was a prospective study examining hemodynamics in comatose survivors of OHCA undergoing targeted temperature management. Between August 2016 and December 2017, comatose survivors of OHCA with an initial shockable rhythm underwent continuous, blinded monitoring of CI using bioimpedance (Cheetah Medical, Portland, OR, USA) for 96 hours after intensive care unit (ICU) admission. In the present study, we examined the association between CI and the composite of death or severe neurologic dysfunction at 6 months (primary outcome) using logistic regression. Severe neurologic dysfunction was defined as a modified Rankin Scale score ≥4. We excluded patients who died or had withdrawal of advanced life support within 72 hours of ICU admission. Results: In 53 patients in this analysis (mean age 59±13 years, downtime 24±13 minutes, STEMI 35%), the rate of the primary outcome was 25%. The mean CI was lower in patients with (3.0±0.5 L/min/m 2 ) versus without (3.3±0.5 L/min/m 2 ) the primary outcome (p=0.018). A higher mean CI during the first 96 hours of ICU admission was associated with lower rates of the primary outcome (OR 0.85 per 0.1L/min/m 2 increase in CI; p=0.025). This association persisted after adjusting for age and downtime (OR 0.78 per 0.1L/min/m2 increase in CI; p=0.014). Cardiac index was similar in patients with versus without the primary outcome at the end of the 96-hour monitoring period (Figure). Conclusion: In comatose survivors of OHCA with an initial shockable rhythm, a higher CI during the first 96 hours of ICU admission is associated with lower rates of death or severe neurologic dysfunction.

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Abstract 236: Gender Disparities in Bystander CPR and Defibrillation Persist in Black and Hispanic Neighborhoods in the US

Circulation ◽

10.1161/circ.142.suppl_4.236 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Audrey L Blewer ◽

Monique A Starks ◽

Carolina Malta Hansen ◽

Marcus E Ong ◽

Anthony J Viera ◽

...

Keyword(s):

Cardiac Arrest ◽

Race And Ethnicity ◽

Gender Disparities ◽

Ethnic Composition ◽

Minority Population ◽

Black Neighborhoods ◽

The Us ◽

Bystander Cpr ◽

To Receive ◽

Racial Ethnic

Introduction: Bystander CPR (B-CPR) and defibrillation for sudden cardiac arrest (SCA) vary by gender with females being less likely to receive these interventions. Despite known differences by race and ethnicity, it is unknown whether gender disparities in B-CPR and defibrillation persist by neighborhood race and ethnicity. Objectives: We examined the likelihood of receiving B-CPR and defibrillation by gender stratified by public location and neighborhood racial/ethnic composition. We hypothesized that in public locations within Black neighborhoods, females will have a lower likelihood of receiving B-CPR compared to males. Methods: We conducted a retrospective cohort study using data from the US Cardiac Arrest Registry to Enhance Survival (CARES) registry. Neighborhoods were classified by census tract based on percent of Black or Hispanic residents using the threshold in the definition of “White flight” where Whites leave a neighborhood when it exceeds >30% of a minority population. We independently modeled the likelihood of receipt of B-CPR and defibrillation by gender stratified by public location and neighborhood racial/ethnic composition controlling for confounding variables. Results: From 2013-2018, CARES collected 350,722 US arrests; after excluding pediatric arrests, those witnessed by EMS, or those that occurred in a healthcare facility, 214,464 were included. Mean age was 64±16 and 65% were male; 39% received B-CPR, 9% received bystander defibrillation prior to 9-1-1 responders arrival, and 18% occurred in the public. In Black neighborhoods, females who had SCA in public locations were 22% less likely to receive B-CPR (OR: 0.78 (0.64-0.95), p=0.01) and 42% less likely to receive defibrillation (OR: 0.58 (0.45-0.74), p<0.01) compared to males. In Hispanic neighborhoods, females who had SCA in public locations were also less likely to receive B-CPR (OR: 0.72 (0.59-0.87), p<0.01) and less likely to receive defibrillation (OR: 0.62 (0.48-0.80), p<0.01) compared to males. Conclusion: Females with public SCA have a decreased likelihood of receiving B-CPR and defibrillation, and these findings persist in Black and Hispanic neighborhoods. This has implications for strategies to reduce disparities around bystander response to SCA.

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Abstract 349: Target Temperature Management After Return of Spontaneous Circulation Did Not Ameliorate Mid-term (30 to 90-day) Neurological Improvement in Out-of-hospital Cardiac Arrest Patients

Circulation ◽

10.1161/circ.142.suppl_4.349 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Hiromichi Naito ◽

Takashi Yorifuji ◽

Tetsuya Yumoto ◽

Tsuyoshi Nojima ◽

Noritomo Fujisaki ◽

...

Keyword(s):

Logistic Regression ◽

Cardiac Arrest ◽

Regression Analysis ◽

Spontaneous Circulation ◽

Temperature Management ◽

Multivariable Logistic Regression Analysis ◽

Return Of Spontaneous Circulation ◽

Neurological Improvement ◽

Hospital Cardiac Arrest

Introduction: Mid/long-term outcomes of out-of-hospital cardiac arrest (OHCA) survivors have not been extensively studied. Targeted temperature management (TTM) after return of spontaneous circulation is one known therapeutic approach to ameliorate short-term neurological improvement of OHCA patients; however, the prognostic significance of TTM in the mid/long-term clinical setting have not been defined. Hypothesis: TTM would confer additional improvement of OHCA patients’ mid-term neurological outcomes. Methods: Retrospective study using the Japanese Association for Acute Medicine OHCA Registry (Jun 2014 - Dec 2017): a nationwide multicenter registry. Patients who did not survive 30 days after OHCA, those with missing 30-day Cerebral Performance Category (CPC) scores, and those < 18 years old were excluded. Primary endpoint was alteration of neurological function evaluated with 30-day and 90-day CPC. Association between application of TTM (33-36°C) and mid-term CPC alteration was evaluated. Multivariable logistic regression analysis was used for the primary outcome; results are expressed with odds ratio (OR) and 95% confidence interval (CI). Results: We included 2,905 in the analysis. Patient characteristics were: age: 67 [57 - 78] years old, male gender: 70.8%, witnessed collapse: 81.4%, dispatcher instruction for CPR: 51.6%, initial shockable rhythm: 67.0%, and estimated cardiac origin: 76.5%. TTM was applied to 1,352/2,905 (46.5%) patients. Thirty-day CPC values in surviving patients were: CPC 1: 1,155/2,905 (39.8%), CPC 2: 321/2,905 (11.1%), CPC 3: 497/2,905 (17.1%), and CPC 4: 932/2,905 (32.1%), respectively. Ninety-day CPC values were: CPC 1: 866/1,868 (46.4%), CPC 2: 154/1,868 (8.2%), CPC 3: 224/1,868 (12.0%), CPC 4: 392/1,868 (20.1%), and CPC 5: 232/1,868 (12.4%), respectively. Of 1,636 patients with 90-day survival, 28 (1.7%) demonstrated improved CPC at 90 days, whereas, 133 (8.1%) showed worsened CPC at 90 days compared with 30-day CPC, respectively. Multivariable logistic regression analysis revealed TTM did not result in favorable mid-term neurological changes (adjusted OR: 1.44, 95% CI: 0.48 - 4.31). Conclusions: TTM may not contribute to the beneficial effect on OHCA patients’ mid-term neurological changes.

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Prehospital cardiopulmonary resuscitation duration and neurological outcome after adult out-of-hospital cardiac arrest by location of arrest

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872620921598 ◽

2020 ◽

Vol 9 (4_suppl) ◽

pp. S90-S99

Author(s):

Takefumi Kishimori ◽

Tasuku Matsuyama ◽

Kosuke Kiyohara ◽

Tetsuhisa Kitamura ◽

Haruka Shida ◽

...

Keyword(s):

Logistic Regression ◽

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Emergency Medical Service ◽

Neurological Outcome ◽

Medical Service ◽

Regression Analyses ◽

Neurological Outcomes ◽

Shockable Rhythm ◽

Hospital Cardiac Arrest

Background Little is known about the association between prehospital cardiopulmonary resuscitation duration for adults with out-of-hospital cardiac arrest and outcome by the location of arrests. This study aimed to investigate the association between prehospital cardiopulmonary resuscitation duration and one-month survival with favourable neurological outcome. Methods We analysed 276,391 adults aged 18 years and older with out-of-hospital cardiac arrest of medical origin before emergency medical service arrival. Prehospital cardiopulmonary resuscitation duration was defined as the time from emergency medical service-initiated cardiopulmonary resuscitation to prehospital return of spontaneous circulation or to hospital arrival. The primary outcome was one-month survival with favourable neurological outcome (cerebral performance category 1 or 2). The association between prehospital cardiopulmonary resuscitation duration and favourable neurological outcome was assessed using univariable and multivariable logistic regression analyses. Results The proportion of favourable neurological outcomes was 2.3% in total, 7.6% in public locations, 1.5% in residential locations and 0.7% in nursing homes ( P < 0.001). In univariable and multivariable logistic regression analyses, longer prehospital cardiopulmonary resuscitation duration was associated with poor neurological outcome, regardless of arrest location ( P for trend < 0.001). Patients with shockable rhythm in both public and residential locations had better neurological outcome than those in nursing homes at any time point, and residential and public locations had a similar neurological outcome tendency among patients with shockable rhythm. Conclusions Longer prehospital cardiopulmonary resuscitation duration was independently associated with a lower proportion of patients with favourable neurological outcomes. Moreover, the association between prehospital cardiopulmonary resuscitation duration and neurological outcome differed according to the location of arrest and the first documented rhythm.

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An Examination of the Impacts of Gender, Race, and Ethnicity on the Judicial Processing of Offenders in Family Violence Cases

Crime & Delinquency ◽

10.1177/0011128717743780 ◽

2017 ◽

Vol 64 (13) ◽

pp. 1663-1697 ◽

Cited By ~ 2

Author(s):

Tina L. Freiburger ◽

Danielle Romain

Keyword(s):

Family Violence ◽

Race And Ethnicity ◽

Ethnic Disparities ◽

Sentence Length ◽

Pretrial Release ◽

Focal Concerns ◽

White Offenders ◽

Black Defendants ◽

Focal Concerns Perspective ◽

To Receive

Using the focal concerns perspective, the present study examined possible gender, race, and ethnic disparities on judges’ pretrial release, incarceration, and sentence length decisions in family violence cases. The results indicate that males were more likely to receive an order of bail (as opposed to release on own recognizance), received higher bail amounts, were less likely to make bail, were more likely to receive prison opposed to jail, and were incarcerated for significantly longer periods of time than women. Hispanic defendants were more likely than White defendants to receive higher bail amounts and were more likely to be detained until sentencing. Black defendants, on the other hand, were more likely to receive prison as opposed to jail than White offenders.

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Age-related differences in the prehospital management of 2,500 patients with sudden cardiac arrest

Archives of Medical Science ◽

10.5114/aoms/134614 ◽

2021 ◽

Author(s):

Janusz Sielski ◽

Karol Kaziród-Wolski ◽

Marta Solnica ◽

Mirosław Data ◽

Dominika Kukla ◽

...

Keyword(s):

Cardiac Arrest ◽

Urban Area ◽

Older Patients ◽

Prehospital Care ◽

Age Groups ◽

Sudden Cardiac Arrest ◽

Risk Of Death ◽

Shockable Rhythm ◽

Age Related ◽

Prehospital Management

IntroductionPrehospital care affects outcomes after out-of-hospital cardiac arrest (OHCA). The aim of the study is to analyze age-related differences in prehospital care and survival after OHCA and to define variables affecting the efficacy of cardiopulmonary resuscitation (CPR).Material and methodsAnalysis of differences in patient characteristics influencing the efficacy of CPR. Analysis of survival in four age groups: < 65, 65 - 74, 75 - 84, and ≥85. This retrospective registry-based study aimed to compare prehospital care in OHCA patients across age groups.ResultsCPR was performed in 2,500 patients, return of spontaneous circulation (ROSC) occurred in 1061 subjects. Of them, 339 had incomplete medical records, 201 survived at least 24 hours, 115 up to 30 days and 78 were alive at 365 days after discharge. The occurrence of shockable rhythms and the ROSC rate decreased with age. Overall mortality increased with age. Such factors as age, gender, urban area, home location, time to arrival, and witnessed OHCA were predictors of the initial shockable rhythm. Gender, urban area, OHCA witnessed by family member, time to arrival, cardiac cause and shockable rhythm were predictors of ROSC. The risk of death increased with each age group by about 56% (HR = 1.56, P < 0.0001).ConclusionsShockable initial rhythm and urban location were the strongest predictors of ROSC. Survival at 30 and 365 days after OHCA decreased in older patients. Survival among older patients with OHCA is worse as compared to younger subjects which results from lower efficacy of resuscitation and more frequent death declared upon arrival.

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Cerebral autoregulation in anoxic brain injury patients treated with targeted temperature management

Journal of Intensive Care ◽

10.1186/s40560-021-00579-z ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Ilaria Alice Crippa ◽

Jean-Louis Vincent ◽

Federica Zama Cavicchi ◽

Selene Pozzebon ◽

Filippo Annoni ◽

...

Keyword(s):

Cardiac Arrest ◽

Brain Injury ◽

Body Temperature ◽

Hospital Discharge ◽

Core Body Temperature ◽

Targeted Temperature Management ◽

Temperature Management ◽

Anoxic Brain Injury ◽

Shockable Rhythm ◽

Core Body

Abstract Background Little is known about the prevalence of altered CAR in anoxic brain injury and the association with patients’ outcome. We aimed at investigating CAR in cardiac arrest survivors treated by targeted temperature management and its association to outcome. Methods Retrospective analysis of prospectively collected data. Inclusion criteria: adult cardiac arrest survivors treated by targeted temperature management (TTM). Exclusion criteria: trauma; sepsis, intoxication; acute intra-cranial disease; history of supra-aortic vascular disease; severe hemodynamic instability; cardiac output mechanical support; arterial carbon dioxide partial pressure (PaCO2) > 60 mmHg; arrhythmias; lack of acoustic window. Middle cerebral artery flow velocitiy (FV) was assessed by transcranial Doppler (TCD) once during hypothermia (HT) and once during normothermia (NT). FV and blood pressure (BP) were recorded simultaneously and Mxa calculated (MATLAB). Mxa is the Pearson correlation coefficient between FV and BP. Mxa > 0.3 defined altered CAR. Survival was assessed at hospital discharge. Cerebral Performance Category (CPC) 3–5 assessed 3 months after CA defined unfavorable neurological outcome (UO). Results We included 50 patients (Jan 2015–Dec 2018). All patients had out-of-hospital cardiac arrest, 24 (48%) had initial shockable rhythm. Time to return of spontaneous circulation was 20 [10–35] min. HT (core body temperature 33.7 [33.2–34] °C) lasted for 24 [23–28] h, followed by rewarming and NT (core body temperature: 36.9 [36.6–37.4] °C). Thirty-one (62%) patients did not survive at hospital discharge and 36 (72%) had UO. Mxa was lower during HT than during NT (0.33 [0.11–0.58] vs. 0.58 [0.30–0.83]; p = 0.03). During HT, Mxa did not differ between outcome groups. During NT, Mxa was higher in patients with UO than others (0.63 [0.43–0.83] vs. 0.31 [− 0.01–0.67]; p = 0.03). Mxa differed among CPC values at NT (p = 0.03). Specifically, CPC 2 group had lower Mxa than CPC 3 and 5 groups. At multivariate analysis, initial non-shockable rhythm, high Mxa during NT and highly malignant electroencephalography pattern (HMp) were associated with in-hospital mortality; high Mxa during NT and HMp were associated with UO. Conclusions CAR is frequently altered in cardiac arrest survivors treated by TTM. Altered CAR during normothermia was independently associated with poor outcome.

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