Background— Prior studies have identified key predictors of out-of-hospital cardiac arrest (OHCA), but differences exist in the magnitude of these findings. In this meta-analysis, we evaluated the strength of associations between OHCA and key factors (event witnessed by a bystander or emergency medical services [EMS], provision of bystander cardiopulmonary resuscitation [CPR], initial cardiac rhythm, or the return of spontaneous circulation). We also examined trends in OHCA survival over time. Methods and Results— An electronic search of PubMed, EMBASE, Web of Science, CINAHL, Cochrane DSR, DARE, ACP Journal Club, and CCTR was conducted (January 1, 1950 to August 21, 2008) for studies reporting OHCA of presumed cardiac etiology in adults. Data were extracted from 79 studies involving 142 740 patients. The pooled survival rate to hospital admission was 23.8% (95% CI, 21.1 to 26.6) and to hospital discharge was 7.6% (95% CI, 6.7 to 8.4). Stratified by baseline rates, survival to hospital discharge was more likely among those: witnessed by a bystander (6.4% to 13.5%), witnessed by EMS (4.9% to 18.2%), who received bystander CPR (3.9% to 16.1%), were found in ventricular fibrillation/ventricular tachycardia (14.8% to 23.0%), or achieved return of spontaneous circulation (15.5% to 33.6%). Although 53% (95% CI, 45.0% to 59.9%) of events were witnessed by a bystander, only 32% (95% CI, 26.7% to 37.8%) received bystander CPR. The number needed to treat to save 1 life ranged from 16 to 23 for EMS-witnessed arrests, 17 to 71 for bystander-witnessed, and 24 to 36 for those receiving bystander CPR, depending on baseline survival rates. The aggregate survival rate of OHCA (7.6%) has not significantly changed in almost 3 decades. Conclusions— Overall survival from OHCA has been stable for almost 30 years, as have the strong associations between key predictors and survival. Because most OHCA events are witnessed, efforts to improve survival should focus on prompt delivery of interventions of known effectiveness by those who witness the event.

Objective To determine the frequency of prescriptions for short term use of oral corticosteroids, and adverse events (sepsis, venous thromboembolism, fractures) associated with their use. Design Retrospective cohort study and self controlled case series. Setting Nationwide dataset of private insurance claims. Participants Adults aged 18 to 64 years who were continuously enrolled from 2012 to 2014. Main outcome measures Rates of short term use of oral corticosteroids defined as less than 30 days duration. Incidence rates of adverse events in corticosteroid users and non-users. Incidence rate ratios for adverse events within 30 day and 31-90 day risk periods after drug initiation. Results Of 1 548 945 adults, 327 452 (21.1%) received at least one outpatient prescription for short term use of oral corticosteroids over the three year period. Use was more frequent among older patients, women, and white adults, with significant regional variation (all P<0.001). The most common indications for use were upper respiratory tract infections, spinal conditions, and allergies. Prescriptions were provided by a diverse range of specialties. Within 30 days of drug initiation, there was an increase in rates of sepsis (incidence rate ratio 5.30, 95% confidence interval 3.80 to 7.41), venous thromboembolism (3.33, 2.78 to 3.99), and fracture (1.87, 1.69 to 2.07), which diminished over the subsequent 31-90 days. The increased risk persisted at prednisone equivalent doses of less than 20 mg/day (incidence rate ratio 4.02 for sepsis, 3.61 for venous thromboembolism, and 1.83 for fracture; all P<0.001). Conclusion One in five American adults in a commercially insured plan were given prescriptions for short term use of oral corticosteroids during a three year period, with an associated increased risk of adverse events.

Summary: Background  A majority of studies investigating the accuracy of ultrasound for detecting hepatocellular carcinoma (HCC) do not reflect how this test is used for surveillance vs. diagnosis.Aim  To determine the performance characteristics of surveillance with ultrasound for the detection of HCC, particularly early HCC as defined by the Milan criteria.Methods  A systematic literature review using the MEDLINE and SCOPUS databases yielded six studies that evaluated the accuracy of ultrasound for HCC at any stage and 13 studies that were specific to early HCC.Results  Surveillance ultrasound detected the majority of tumours before they presented clinically, with a pooled sensitivity of 94%. However, ultrasound was less effective for detecting early HCC with a sensitivity of 63%. Alpha‐fetoprotein provided no additional benefit to ultrasound. Meta‐regression analysis demonstrated a significantly higher sensitivity for early HCC with ultrasound every 6 months than with annual surveillance. Current studies have limitations such as verification bias and are of suboptimal quality.Conclusions  Surveillance with ultrasound demonstrates limited sensitivity for early HCC, although this may be improved by testing at 6‐month intervals. Currently available evidence evaluating surveillance ultrasound has significant limitations and future studies are necessary to determine optimal surveillance methods for early HCC.

Efforts to prevent health care–associated infection are among the priorities for the US Department of Health and Human Services¹ with the focus on common activities in the hospital setting, such as using bundles (defined as groups of effective practices) and checklists to prevent central line–associated bloodstream infection,² encouraging hand hygiene,³ and avoiding the use of urinary catheters.⁴ The estimated annual direct medical costs of health care–associated infections to US hospitals ranges from $28 billion to $45 billion, with about 1 in every 20 inpatients developing an infection related to their hospital care.⁵