The Influence of the COVID-19 Pandemic on Emergency Medical Services to Out-of-Hospital Cardiac Arrests in a Low-Incidence Urban City: An Observational Epidemiological Analysis.

The Emergency Medical Services (EMS) system faced overwhelming challenges during the coronavirus disease 2019 (COVID-19) pandemic. However, further information is required to determine how the pandemic affected the EMS response and the clinical outcomes of out-of-hospital cardiac arrest (OHCA) patients in COVID-19 low-incidence cities. A retrospective study was conducted in Chiayi, Taiwan, a COVID-19 low-incidence urban city. We compared the outcomes and rescue records before (2018-2019) and during (2020-2021) the COVID-19 pandemic. A total of 567 patients before and 497 during the pandemic were enrolled. Multivariate analysis revealed that the COVID-19 pandemic had no significant influence on the achievement of return of spontaneous circulation (ROSC) and sustained ROSC but was associated with lower probabilities of survival to discharge (aOR = 0.43, 95% CI: 0.21-0.89, p = 0.002) and discharge with favorable neurologic outcome among OHCA patients (aOR = 0.35, 95% CI: 0.16-0.77, p = 0.009). Patients' ages and OHCA locations were also discovered to be independently related to survival results. The overall impact of longer EMS rescue times on survival outcomes during the pandemic was not significant, with an exception of the specific group that experienced prolonged rescue times (total EMS time > 21 min).

Validation of ICD-9-CM and ICD-10-CM Diagnostic Codes for Identifying Patients with Out-of-Hospital Cardiac Arrest in a National Health Insurance Claims Database.

Purpose: Taiwan's national health insurance (NHI) database is a valuable resource for large-scale epidemiological and long-term survival research for out-of-hospital cardiac arrest (OHCA). We developed and validated case definition algorithms for OHCA based on the International Classification of Diseases (ICD) diagnostic codes and billing codes for NHI reimbursement. Patients and Methods: Claims data and medical records of all emergency department visits from 2010 to 2020 were retrieved from the hospital's research-based database. Death-related diagnostic codes and keywords were used to identify potential OHCA cases, which were ascertained by chart reviews. We tested the performance of the developed OHCA algorithms and validated them on an external dataset. Results: The algorithm defining OHCA as any cardiac arrest (CA)-related ICD code in the first three diagnosis fields performed the best with a sensitivity of 89.5% (95% confidence interval [CI], 88.2-90.7%), a positive predictive value (PPV) of 90.6% (95% CI, 89.4-91.8%), and a kappa value of 0.900 (95% CI, 0.891-0.909). The second-best algorithm consists of any CA-related ICD code in any diagnosis field with a billing code for triage acuity level 1, achieving a sensitivity of 85.6% (95% CI, 84.1-87.0%), a PPV of 93.6% (95% CI, 92.5-94.5), and a kappa value of 0.894 (95% CI, 0.884-0.903). Both algorithms performed well in external validation. In subgroup analyses, the former algorithm performed the best in adult patients, outpatient claims, and during the ICD-9 era. The latter algorithm performed the best in the inpatient claims and during the ICD-10 era. The best algorithm for identifying pediatric OHCAs was any CA-related ICD code in the first three diagnosis fields with a billing code for triage acuity level 1. Conclusion: Our results may serve as a reference for future OHCA studies using the Taiwan NHI database.

Effect of Temporal Difference on Clinical Outcomes of Patients with Out-of-Hospital Cardiac Arrest: A Retrospective Study from an Urban City of Taiwan.

Circadian pattern influence on the incidence of out-of-hospital cardiac arrest (OHCA) has been demonstrated. However, the effect of temporal difference on the clinical outcomes of OHCA remains inconclusive. Therefore, we conducted a retrospective study in an urban city of Taiwan between January 2018 and December 2020 in order to investigate the relationship between temporal differences and the return of spontaneous circulation (ROSC), sustained (≥24 h) ROSC, and survival to discharge in patients with OHCA. Of the 842 patients with OHCA, 371 occurred in the daytime, 250 in the evening, and 221 at night. During nighttime, there was a decreased incidence of OHCA, but the outcomes of OHCA were significant poor compared to the incidents during the daytime and evening. After multivariate adjustment for influencing factors, OHCAs occurring at night were independently associated with lower probabilities of achieving sustained ROSC (aOR = 0.489, 95% CI: 0.285-0.840, p = 0.009) and survival to discharge (aOR = 0.147, 95% CI: 0.03-0.714, p = 0.017). Subgroup analyses revealed significant temporal differences in male patients, older adult patients, those with longer response times (≥5 min), and witnessed OHCA. The effects of temporal difference on the outcome of OHCA may be a result of physiological factors, underlying etiology of arrest, resuscitative efforts in prehospital and in-hospital stages, or a combination of factors.

Acute Transverse Myelitis after COVID-19 Vaccination.

The adverse effects of the COVID-19 vaccine have been discovered as the rapid application of the vaccines continues. Neurological complications such as transverse myelitis raise concerns as cases were observed in clinical trials. Transverse myelitis is a rare immune-mediated disease with spinal cord neural injury, resulting in neurological deficits in the motor, sensory, and autonomic system. Vaccine-related transverse myelitis is even rarer. We present a case of acute transverse myelitis after vaccination against COVID-19 with the ChAdOx1 nCOV-19 vaccine (AZD1222), which was the first case reported in Taiwan. Although it rarely occurs, post-vaccination neurological complications should not be ignored. As the pandemic of SARS-CoV-2 continues to spread and concern about vaccination efficacy and safety rises, heterologous vaccination were implemented in health public policy in several countries. A literature review of several clinical trials shows promising effects of mix-and-match vaccination. Further study on different combinations of vaccines can be expected.

Simulation Based Ambulance and Crew Decontamination Advise During COVID-19 Pandemic.

This study involved a simulation of transportation and basic life support on ambulances carrying coronavirus disease 2019 (COVID-19) patients, using a specially modified mannequin. The mannequin used can spew a fluorescent solution from its mouth to simulate the droplets or vomitus made by the patient and can be detected using ultraviolet light illumination. We determined that the most frequently contaminated areas of an ambulance in the driver's cabin are the left front door's outer handle, driver's handler, gear lever, and mat. The most frequently contaminated area in the rear patient's cabin is the rear door, rear door lining, and handle over the roof. The most frequently contaminated areas before the removal of personal protective equipment (PPE) are the lower chest to the belly area, bilateral hands, lower rim of the gown, and shoes. After the removal of PPE, traces of fluorescence were observed over the neck, hands, and legs. We therefore suggest taking a bath immediately after PPE removal.

The Effect of Implementing Mechanical Cardiopulmonary Resuscitation Devices on Out-of-Hospital Cardiac Arrest Patients in an Urban City of Taiwan.

High-quality cardiopulmonary resuscitation (CPR) is a key element in out-of-hospital cardiac arrest (OHCA) resuscitation. Mechanical CPR devices have been developed to provide uninterrupted and high-quality CPR. Although human studies have shown controversial results in favor of mechanical CPR devices, their application in pre-hospital settings continues to increase. There remains scant data on the pre-hospital use of mechanical CPR devices in Asia. Therefore, we conducted a retrospective cohort study between September 2018 and August 2020 in an urban city of Taiwan to analyze the effects of mechanical CPR devices on the outcomes of OHCA; the primary outcome was attainment of return of spontaneous circulation (ROSC). Of 552 patients with OHCA, 279 received mechanical CPR and 273 received manual CPR, before being transferred to the hospital. After multivariate adjustment for the influencing factors, mechanical CPR was independently associated with achievement of any ROSC (OR = 1.871; 95%CI:1.195-2.930) and sustained (≥24 h) ROSC (OR = 2.353; 95%CI:1.427-3.879). Subgroup analyses demonstrated that mechanical CPR is beneficial in shorter emergency medical service response time (≤4 min), witnessed cardiac arrest, and non-shockable cardiac rhythm. These findings support the importance of early EMS activation and high-quality CPR in OHCA resuscitation.

A 36-Hour Unplugged Full-Scale Exercise: Closing the Gaps in Interagency Collaboration between the Disaster Medical Assistance Team and Urban Search and Rescue Team in Disaster Preparedness in Taiwan.

INTRODUCTION: Disaster medical assistance team (DMAT) and urban search and rescue team (USAR) need to cooperate seamlessly to save lives in disasters, but related research is limited. OBJECTIVES: To estimate the disaster preparedness of the DMAT and the barriers affecting interagency cooperation between the DMAT and the USAR team. METHODS: This was an observational study of a full-scale exercise conducted in Taiwan from November 16 to 18, 2018. The exercise scenario simulated a magnitude 7 earthquake in Tainan City. DMATs from other counties were deployed and cooperated with local USAR teams to carry out disaster relief. Our study invited 7 experts to evaluate DMATs on disaster preparedness capabilities and the interagency collaboration between DMATs and USAR. RESULTS: A total of eight DMATs, consisting of 30 physicians, 65 nurses, 74 logisticians, 5 health bureau personnel, and 85 USAR teams, participated in this exercise. During the mission, 176 patients were treated. The capabilities of each team were generally consistent with the basic technical standards for type I emergency medical teams, but the compliance rates for basic local anesthesia, cold chain equipment for medication, rapid blood test tools, and sterilization devices were only 50%, 12.5%, 12.5%, and 9%, respectively. In addition, 53% of participants reported abnormal vital signs, indicating that it was a high-stress situation. Moreover, the main barriers to interagency collaboration were differing perspectives and poor mutual understanding. CONCLUSION: A full-scale exercise carried out jointly with DMATs and USAR teams was valuable for disaster preparedness, particularly in terms of understanding the weaknesses of those teams and the barriers to interagency collaboration.

Facial edema as the initial presentation of Henoch-Schonlein purpura in a 5-year-old boy.

The appearance of nonthrombocytic purpura is an important clue for the diagnosis of Henoch-Schonlein purpura (HSP). However, this classic skin lesion may be preceded by other symptoms such as abdominal pain and arthralgia, and the diagnosis may be delayed. Facial edema as a manifestation of HSP is typically observed in children younger than 2 years. We report a 5-year-old boy with facial edema at presentation; until 3 days later, the boy returned because of abdominal complication (intussusception) and developed purpura, the diagnosis of HSP was established.

Duplication of transverse colon: report of one case.

Alimentary tract duplications are very rare, with a reported incidence of 1 in 5000 live births. However, it rarely affects the transverse colon. We reported a case of duplication of the transverse colon in a 12-year-old boy with an unusual presentation mimicking megacolon. Barium enema revealed a large sac with massive fecal material retention in the left side of abdomen. Barium filling of the sac displacing bowel loops was noted on the post-evacuation film. He received a segmental resection of the transverse colon including the duplicated colon and end-to-end colo-colostomy. Pathology revealed whole muscle layer of colon compatible with duplication. No other associated anomaly was noted in this case. The case demonstrates three relatively uncommon presentations, including transverse colon location, late manifestation and dilated colon mimicking megacolon radiologically. It also emphasizes that barium enema with post-evacuation film aids in the preoperative diagnosis of duplication.

Obstructive jaundice as the presenting manifestation of Burkitt's lymphoma in a 4-year-old boy.

Obstructive jaundice often occurs as a late manifestation of non-Hodgkin's lymphoma (NHL), but has rarely been reported as a presenting manifestation, especially in children. We report a case of a 4-year-old boy with Burkitt's lymphoma (small non-cleaved cell NHL) who presented with obstructive jaundice, resulting from encasement of the common bile duct by the tumor. The patient underwent near-total excision of the tumor and biliary-enteric bypass to relieve the jaundice. Combined chemotherapy was not given because of refusal by his family. Two weeks after the operation, obstructive jaundice reappeared due to a large recurrent tumor compressing the liver hilum. He received chemotherapy and the jaundice disappeared within 6 days. Follow-up computed tomography 1 year later revealed total resolution of the tumor. Three conclusions are suggested by this case. First, although NHL presenting as obstructive jaundice is uncommon in children, it should be included in the differential diagnosis. Second, relief of obstructive jaundice can be effectively accomplished by chemotherapy alone. Third, chemotherapy should be given once NHL is diagnosed.