Impact of dual dispatch system implementation on response times and survival outcomes in out-of-hospital cardiac arrest in rural areas

Objectives: Dual dispatch early defibrillation in out-of-hospital cardiac arrest (OHCA) victims provided by firefighters in addition to Emergency medical services (EMS) has proven to increase rate of return of spontaneous circulation (ROSC) and thus survival in the metropolitan or suburban areas whereas the data in rural areas are scarce. Methods: This was a retrospective observational cohort study of EMS resuscitated OHCA victims in regions with dual dispatch of volunteer firefighters as first responders (intervention group). Historical group was based on all OHCAs occurring in these regions before the implementation of first responders (EMS response only). Multivariate logistic regression with following variables: intervention, age, gender, witnessed status, bystander cardiopulmonary resuscitation (CPR), first rhythm and etiology were used to control for confounding factors affecting ROSC. Results: A total of 312 OHCAs were included in the study (historical group, n = 115 and intervention group, n = 197). Median time to arrival of first help shortened significantly for all patients, patients with ROSC and patients with Cerebral Performance Category 1/2 (CPC 1/2) in intervention vs historical group (8 vs 12 min, p < 0.001; 7.5 vs 11 min, p = 0.002; 7 vs 10 min, p = 0.011; respectively). The proportion of patients with ROSC, 30-day survival and CPC 1/2 at hospital discharge remained unchanged in intervention vs historical group (21% vs 23%, p = 0.808; 7% vs 6%, p = 0.914; 6% vs 3%, p = 0.442; respectively). The logistic regression model of adjustment confirms the absence of improvement in the ROSC rate after the implementation of first responders. Conclusions: Introduction of a dual dispatch of local first responders in addition to EMS in cases of OHCA significantly shortened response times. However, reduced response times were not associated with better survival outcomes.

Hyperbaric Oxygen Therapy with Iloprost Improves Digit Salvage in Severe Frostbite Compared to Iloprost Alone

Background and Objectives: Frostbite is a freezing injury that can lead to amputation. Current treatments include tissue rewarming followed by thrombolytic or vasodilators. Hyperbaric oxygen (HBO) therapy might decrease the rate of amputation by increasing cellular oxygen availability to the damaged tissues. The SOS-Frostbite study was implemented in a cross-border program among the hyperbaric centers of Geneva, Lyon, and the Mont-Blanc hospitals. The objective was to assess the efficacy of HBO + iloprost among patients with severe frostbite. Materials and Methods: We conducted a multicenter prospective single-arm study from 2013 to 2019. All patients received early HBO in addition to standard care with iloprost. Outcomes were compared to a historical cohort in which all patients received iloprost alone between 2000 and 2012. Inclusion criteria were stage 3 or 4 frostbite and initiation of medical care <72 h from frostbite injury. Outcomes were the number of preserved segments and the rate of amputated segments. Results: Thirty patients from the historical cohort were eligible and satisfied the inclusion criteria, and 28 patients were prospectively included. The number of preserved segments per patient was significantly higher in the prospective cohort (mean 13 ± SD, 10) compared to the historical group (6 ± 5, p = 0.006); the odds ratio was significantly higher by 45-fold (95%CI: 6-335, p < 0.001) in the prospective cohort compared to the historical cohort after adjustment for age and delay between signs of freezing and treatment start. Conclusions: This study demonstrates that the combination of HBO and iloprost was associated with higher benefit in patients with severe frostbite. The number of preserved segments was two-fold higher in the prospective cohort compared to the historical group (mean of 13 preserved segments vs. 6), and the reduction of amputation was greater in patients treated by HBO + iloprost compared with the iloprost only.

Letermovir Prophylaxis Versus Pre-Emptive Therapy for Cytomegalovirus after Hematopoietic Stem-Cell Transplantation

Introduction Cytomegalovirus (CMV) infection is one of the most common complication after allogeneic hematopoietic stem-cell transplantation (HSCT) still associated with significant morbidity and mortality. Although pre-emptive therapy (PET) are routinely used in treatment of CMV after SCT, their prophylactic use is limited by clinically unacceptable myelosuppression and nephrotoxicity. Letermovir, available since 2019 in Italy, is the first antiviral agent approved by FDA and EMA which is indicated for the prophylaxis of CMV infection in CMV seropositive (R+) patients undergoing SCT. Presently, cost and drug interactions are the main disadvantages of Letermovir use. We performed a single-center observational retrospective study to evaluate the efficacy of primary Letermovir prophylaxis for CMV infection among high-risk patients (R+) receiving HSCT from serological negative donor (D-). Methods We evaluated a cohort of R+/D- patients transplanted from January 2017 to December 2020 (86/235 transplanted patients): among those eligible for Letermovir prophylaxis (N=70), 29 patients (transplanted after 2019) received Letermovir until day +100, whereas 41 patients (the historical control group transplanted before 2019) received CMV PET only in case of increased viral load (CMV reactivation). Patients unable to take oral therapy at day +7 from HSCT or assuming drugs for concomitant clinical conditions bringing about major pharmacokinetic interaction were excluded (N=16). We compared day +100 and day +200 cumulative incidence of clinically significant CMV infection (CS-CMVi), defined according to drug registration trial: Letermovir discontinuation before day +100, CMV reactivation (CMV-DNAemia leading to PET), CMV tissue invasive disease, disease relapse and death from any causes. Survival functions between groups were estimated by the Kaplan-Meier method and compared using log-rank test. Moreover, the overall survival (OS), disease free survival (DFS), non-relapse mortality (NRM) and cumulative incidence of II-IV grade acute graft-versus-host disease (aGVHD) was compared in the two cohorts. Finally, we analyzed the number of accesses in day hospital from initial discharge to day +180, as an indirect cost-effectiveness evaluation of letermovir prophylaxis. Results No severe adverse events related to the therapy were observed in the letermovir group. Letermovir prophylaxis started at a median of 11 days (range, 5-27) after HSCT. The median duration of Letermovir administration was 89 days (range, 40-113). The only early stop was due to patient death, not related to CMV or drug toxicity. CS-CMVi at day +100 occurred in 13.8% vs 61.0% in letermovir and historical group, respectively (p &lt;0.001). Of note, none of the events in letermovir group was related to CMV reactivation whereas 24/25 in the historical group were. A trend toward lower CS-CMVi in the letermovir group was observed also at day +180 (44,8% vs 65,9%, p =0.080), with 6 late reactivations in patients who received prophylaxis. Moreover, at follow-up one patient in the experimental group and 3 in the control group developed CMV disease. Of note, in vivo T-cell depletion was used in 86% of patients in letermovir and 83% in historical group, and most of the CMV reactivations occurred after development of aGVHD: in 83% and 54% of patients, respectively. No differences in OS and DFS were observed between the two cohorts. Finally, a trend toward lower number of day hospital admissions was shown in patients who received letermovir prophylaxis (median 2 admissions, IQR 0-8, vs median 4.5, IQR 0-16), suggesting higher quality of life and costs reduction. Conclusions Our real-life experience demonstrated the efficacy of Letermovir in reducing the incidence of CMV reactivation. Longer follow-up is needed to clarify advantages in terms of disease-free and overall survival. Further studies are needed to investigate the role of prophylaxis beyond day 100 in high risk patients, such as those who receive a T-depleted transplant or who develop aGVHD. The role of Letermovir prophylaxis on immuno-reconstitution and its cost-effectiveness remains to be evaluated. Disclosures Marco: Jazz: Consultancy; Insight,: Consultancy; Janssen: Consultancy. Ferrero: EUSA Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Gilead: Research Funding, Speakers Bureau; Morphosys: Research Funding; Incyte: Membership on an entity's Board of Directors or advisory committees; Clinigen: Membership on an entity's Board of Directors or advisory committees; Servier: Speakers Bureau.

“We Ain’t Nothing but White Trash”. The Ethnography of Poor Whites and the Politics of Stigma in Zora Neale Hurston’s Seraph on the Suwanee.

This article aims to demonstrate the documentary value of Zora Neale, Hurston’s descriptions, in her novel Seraph on the Suwanee, of the condition of the poor white US Southerners known as “crackers.” By, depicting a “cracker” woman’s upward social trajectory through, marriage, Hurston reveals the social and existential reality of this, segment of the white population. Her novel presents an objective, analysis of the crackers as a socio-historical group distinct from other, whites. However, Hurston also explores the subjective side of belonging to this discredited group by offering an account of her heroine’s experience of stigmatization.

Epidemiology, Risk Factors and Outcomes of Pneumomediastinum in Patients with Coronavirus Disease 2019: A Case-Control Study

Background: Since the beginning of the ongoing Coronavirus Disease 2019 (COVID-19) pandemic, pneumomediastinum has been reported in patients with COVID-19 pneumonia and acute respiratory distress syndrome. It has been suggested that pneumomediastinum may portend a worse outcome in such patients although no investigation has established this association definitively. Research Question: We hypothesized that the finding of pneumomediastinum in the setting of COVID-19 disease may be associated with a worse clinical outcome. The purpose of this study was to determine if the presence of pneumomediastinum was predictive of increased mortality in patients with COVID-19. Study Design and Methods: A retrospective case-control study utilizing clinical data and imaging for COVID-19 patients seen at our institution from 3/7/2020 to 5/20/2020 was performed. 87 COVID-19 positive patients with pneumomediastinum were compared to 87 COVID-19 positive patients without pneumomediastinum and to a historical group of patients with pneumomediastinum during the same time frame in 2019. Results: The incidence of pneumomediastinum was increased more than 6-fold during the COVID-19 pandemic compared to 2019 ( P = <.001). 1.5% of all COVID-19 patients and 11% of mechanically ventilated COVID-19 patients at our institution developed pneumomediastinum. Patients who developed pneumomediastinum had a significantly higher PEEP and lower P/F ratio than those who did not ( P = .002 and .033, respectively). Pneumomediastinum was not found to be associated with increased mortality ( P = .16, confidence interval [CI]: 0.89-2.09, 1.37). The presence of concurrent pneumothorax at the time of pneumomediastinum diagnosis was associated with increased mortality ( P = .013 CI: 1.15-3.17, 1.91). Conclusion: Pneumomediastinum is not independently associated with a worse clinical prognosis in COVID-19 positive patients. The presence of concurrent pneumothorax was associated with increased mortality.

Analysis of Distinct Feature Groups in the Credit Scoring Problem

Registration and financial data have been traditionally used for the credit scoring problem. However,slight improvements in the reliability of the scores positively impacts financial companies. Therefore, exploring newfeatures is a strategic task. This work analyzes the importance of new feature groups not commonly employed forthe credit scoring task and others already used. We categorized features from open credit scoring datasets, suchas German and Australian and compared their groups with the ones of a company dataset used in this work. Ourdataset contains unusual feature groups, such as historical, geolocation, web behavior, and demographic data. In ouranalyzes, we first conducted bivariate tests with each feature-pair to assess their individual importance. Secondly, weran XGBoost machine learning model with each feature group to evaluate each group importance. We also appliedfeature selection with binary Particle Swarm Optimization to assess the groups importance when combined. Next, weemployed correlation tests to find inner and inter-correlation among the features groups. Finally, we used the companydataset and employed AdaBoost, Multilayer Perceptron, and XGBoost algorithms to find the best model for the task.Some of our main findings were that the unusual features added a slight improvement to registration features. We alsodetected reasonable inner correlation among some feature groups and found that all groups were relevant for the taskwith the Historical Group as the most promising. Lastly, XGBoost obtained the best performance over AdaBoost andMultilayer-perceptron for the task.

Ambulance waiting and associated work flow improvement strategies: a pilot study to improve door-in-door-out time for thrombectomy patients in a primary stroke center

BackgroundRapid access to thrombectomy for patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) is critical for improving outcome. A major challenge for the ‘drip and ship’ model is reducing the door-in-door-out time (DIDO). We propose a new protocol with the aim of reducing DIDO, without adversely affecting emergency service usage time.MethodsConsecutive patients with suspected LVO AIS admitted to a Primary Stroke Center (PSC) from October 2018 to January 2021 were included. On arrival, the ambulance crew remained with the patient. Following immediate clinical and radiological evaluation, patients were transferred to the Comprehensive Stroke Center (CSC) by the same waiting crew. Key time metrics were collected and compared with historical data prior to the new protocol.Results27 patients had an LVO amenable for mechanical thrombectomy during the time period. There was a significant reduction in the DIDO times compared with the historical group (median 45 min vs 96 min; p<0.0001). There was no significant difference in ambulance usage time between the two time periods (median 53 min vs 45 min; p=0.530). There was an increase in ambulance usage time in FAST-positive patients not for transfer in the pilot group compared with FAST-positive patients not for transfer in the historical group (27 min vs 58 min; p<0.001). In addition, door-to-needle times (24 min vs 40 min; p=0.018) and door-to-CT times (11 min vs 25 min; p<0.0001) improved between the two groups.ConclusionOur data show a significant reduction in the DIDO for patients transferred for thrombectomy, with no adverse effects on ambulance usage time.

Lifestyle Habits among Pregnant Women in Denmark during the First COVID-19 Lockdown Compared with a Historical Period—A Hospital-Based Cross-Sectional Study

The first national lockdown in Denmark due to the COVID-19 pandemic was declared on 11 March 2020. From this date, national restrictions were imposed. We aimed to assess the potential influence of this first nationwide lockdown on exercise, alcohol consumption, and smoking in early pregnancy. Using a cross-sectional study based on routinely collected patient-reported data, we compared the lifestyle habits of women who were pregnant during the first phase of the pandemic (COVID-19 group) (n = 685) with those of women who were pregnant the year before (Historical group) (n = 787). We found a reduction in any exercise (PR = 0.91, 95% CI (0.84 to 0.99), in adherence to national recommendations of exercise (PR = 0.89, 95% CI (0.80 to 0.99), in cycling (15% vs. 28%, p < 0.0001), and swimming (0.3% vs. 3%, p = 0.0002) in the COVID-19 group compared with the Historical group. The prevalence of binge drinking was reduced in the COVID-19 group compared with the Historical group (PR = 0.80, 95% CI (0.68 to 0.93). In contrast, the prevalence of any weekly alcohol consumption and smoking cessation during pregnancy was similar between groups. Our findings indicate that national restrictions due to the COVID-19 pandemic influenced the lifestyle habits of pregnant women and should be addressed in antenatal counseling.