Background: The use of extracorporeal cardiopulmonary resuscitation (ECPR) has improved survival in patients with cardiac arrest; however, factors predicting survival remain poorly characterized. A systematic review and meta-analysis was conducted to examine the predictors of survival of ECPR in pediatric patients. Methods: We searched EMBASE, PubMed, SCOPUS, and the Cochrane Library from 2010 to 2021 for pediatric ECPR studies comparing survivors and non-survivors. Thirty outcomes were analyzed and classified into 5 categories: demographics, pre-ECPR laboratory measurements, pre-ECPR co-morbidities, intra-ECPR characteristics, and post-ECPR complications. Results: Thirty studies (n = 3794) were included. Pooled survival to hospital discharge (SHD) was 44% (95% CI: 40%–47%, I 2 = 67%). Significant predictors of survival for pediatric ECPR include the pre-ECPR lab measurements of PaO 2 , pH, lactate, PaCO 2 , and creatinine, pre-ECPR comorbidities of single ventricle (SV) physiology, renal failure, sepsis, ECPR characteristics of extracorporeal membrane oxygenation (ECMO) duration, ECMO flow rate at 24 hours, cardiopulmonary resuscitation (CPR) duration, shockable rhythm, intra-ECPR neurological complications, and post-ECPR complications of pulmonary hemorrhage, renal failure, and sepsis. Conclusion: Prior to ECPR initiation, increased CPR duration and lactate levels had among the highest associations with mortality, followed by pH. After ECPR initiation, pulmonary hemorrhage and neurological complications were most predictive for survival. Clinicians should focus on these factors to better inform potential prognosis of patients, advise appropriate patient selection, and improve ECPR program effectiveness.

Introduction: The 2009 H1N1 pandemic resulted in a substantial increase in the use of extracorporeal cardiopulmonary resuscitation (ECPR). The concurrent release of guidelines by the French Ministry of Health also led to the standardization of ECPR protocol. We conducted a systematic review and meta-analysis to examine if the simultaneous development of guidelines and expanded usage led to an increase in survival to hospital discharge (SHD) in pediatric ECPR and to investigate if predictors of survival have changed since 2009. Methods: PubMed, SCOPUS, Google Scholar, Cochrane, and EMBASE were searched to identify studies examining survival outcome and predictors of survival for pediatric ECPR. A random-effects model was applied. Additional pre-specified subgroup analysis was performed using a fixed-effects model. A univariate meta-regression analysis was conducted. Results: The meta-analysis included 3,454 patients from 30 studies. Total survival rates have not improved in pediatric ECPR between subgroups (Mann-Whitney U test: p > 0.05). Extracorporeal membrane oxygenation (ECMO) duration for survivors was not significantly different than nonsurvivors before 2009 RR -0.02 [95% CI: -0.19 - 0.14], but was significantly lower than nonsurvivors after 2009 RR -0.32 [-0.48 - -0.15, p < 0.05]. Meta-regression analysis revealed the ratio of ECMO duration for survivors compared to non-survivors has significantly decreased from 1998 to 2020 (p < 0.05). Patient age was a significant predictor of survival pre-2009 RR but is not correlated with survival post-2009 (p > 0.05). PaO2 was significantly higher in survivors than nonsurvivors pre-2009 RR 0.15 [0.12 - 0.18, p < 0.05] but was not significantly different post-2009 (p > 0.05). End-tidal CO2, CPR duration, pre-CPR serum lactate, and pre-CPR creatinine were not significantly different (p > 0.05) between survivors and non-survivors in either pre-2009 or post-2009. Conclusion: Pediatric ECPR did not see major improvement in survival rates since 2009. In addition, predictors of survival for pediatric ECPR cases have changed over the last 10 years. As such, clinicians may be advised to rely much more heavily on recent research regarding predictors of survival in pediatric ECPR cases.

Study Objective: To examine the efficacy of duration of cardiopulmonary resuscitation (CPR) and duration of extracorporeal membrane oxygenation (ECMO) as predictors of survival in pediatric extracorporeal cardiopulmonary resuscitation (ECPR) patients outside the United States.Methods: We searched EMBASE, PubMed, SCOPUS, and the Cochrane Library from the years 2010 to 2020 for pediatric ECPR performed arrest outside the United States comparing survivor data to non-survivor data. Primary outcomes of interest were duration of CPR and duration of ECMO. Secondary outcomes of interest were age, sex, weight, pre-ECPR pH, and pre-ECPR lactate.Results: 17 studies (n ¼ 1848) were included. The average survival rate was 39.9%. In international ECPR cohorts, longer CPR duration (n ¼ 508, 10 studies) was demonstrated to be a significant predictor of survival, with the average survivor having 37.0 AE 28 minutes of CPR and the average non-survivor having 52.6 AE 48 minutes of CPR (Standardized Mean Difference (SMD) ¼ -0.47 [95% CI: -0.77 --0.17], I2 ¼ 43%). ECMO duration (n ¼ 1563, 12 studies) was not significantly associated with survival, with the average survivor having 98.0 AE 140 minutes and the average non-survivor having 114.3 AE 114 minutes of ECMO (SMD ¼ -0.16 [-0.37 -0.05], I2 ¼ 49%). Age (p ¼ 0.46) and female sex (p ¼ 0.056) were additionally not significantly associated with survival. Increased weight (p ¼ 0.047), elevated pre-ECPR lactate levels (p ¼ 0.01), and elevated pre-ECPR pH (p < 0.01) were significantly associated with increased mortality.Conclusion: In this cohort of international pediatric ECPR patients from the last ten years, the primary outcome of elevated CPR duration was significantly associated with increased risk of mortality. This suggests ECPR programs should prioritize ECPR initiation earlier in cardiac arrest cases to minimize CPR duration prior to ECPR commencement. In addition, increased weight, elevated, pre-ECPR lactate levels, and elevated pre-ECPR pH were associated with increased risk of mortality. Elevated ECMO duration, age, and sex were not associated with increased risk of mortality. These factors can help provide clinicians with more information on the potential prognosis of patients, appropriate patient selection, and ECPR program effectiveness.

Introduction: Nearly 350,000 out-of-hospital cardiac arrest (OHCA) cases occur annually in the United States, with a fatality rate nearing 90%. Quality of cardiopulmonary resuscitation (CPR) is known to significantly influence survival. Randomized controlled trials (RCT) on real-time audiovisual feedback (RTAVF) and active compression-decompression (ACD) devices show both provide substantial advantages to standard CPR. We conducted the first network meta-analysis comparing the efficacy of RTAVF and ACD devices in OHCA based on a literature review. Methods: Studies examining the efficacy of RTAVF or ACD devices to standard CPR by emergency medical personnel in OHCA cases were identified in PubMed, SCOPUS, Cochrane, Google Scholar, and Embase. Outcomes of interest were return of spontaneous circulation (ROSC), survival to hospital discharge (SHD), and favorable neurological recovery. Both a frequentist and Bayesian network meta-analysis were conducted. The p-values, P-scores and Surface under the Cumulative Ranking (SUCRA) scores were computed to analyze significance and effect size. Results: The search yielded 31 eligible studies (n = 35,575). RTAVF devices significantly improved ROSC (Risk Ratio (RR) 1.15, 95% CI: 1.09 - 1.22, p < 0.001, P-score > 0.999) and SHD (RR 1.16, 1.07 - 1.26, p < 0.001, P-score > 0.91), but did not significantly improve favorable neurological recovery (RR 1.05, 0.92 - 1.19, p > 0.05). ACD devices did not report significant improvement in either ROSC (RR 1.03, 0.99 - 1.08, p > 0.05) or SHD (RR 1.10, 0.99 - 1.21, p > 0.05), but did report significant benefits in favorable neurological outcome (RR 1.30, 1.07 - 1.58, p < 0.01, P-score > 0.97). Similar findings were also seen in SUCRA scores. Conclusion: We found RTAVF devices increased ROSC and SHD, while ACD devices increased favorable neurological recovery. Our meta-analysis supports the adoption of RTAVF devices, but an RCT directly comparing RTAVF with ACD devices is recommended.

BACKGROUND Online medical forums, such as Breastcancer.org, allow individuals to come together in a safe space to share personal details about themselves, diagnoses, and treatment plans. Such a space is meant to be anonymous in order to protect the identities of all patients involved. However, the information shared is anonymized only by the chosen username, and usernames on these forums can be used again by patients on other public social media websites. In addition, content posted by patients often contains sensitive information that can be used to uncover their identities. This threatens the privacy of patients by offering the opportunity to link their public-facing social media profiles with their private-facing profiles on online medical support groups. OBJECTIVE The aim of this study was to design a methodology that could analyze the dual privacy threat derived from username linkage and from disclosure of personal identifiable information (PII) or protected health information (PHI) for semi-anonymous medical forums. METHODS 12,000 usernames on Breastcancer.org were randomly selected and then cross-referenced with Facebook, Twitter, Instagram, and Reddit using an online tool called socialscan. The entropy of each username was then calculated as a proxy for username uniqueness using Dropbox’s zxcvbn tool. Using the username uniqueness probabilities, the expected number of profiles that could be linked to a public-facing social media profile was subsequently determined. Analysis was further conducted on the nature of PII and PHI being shared on these forums on a randomly chosen message board using Microsoft Presidio, a tool designed for scrubbing sensitive text. RESULTS Substantial reuse of usernames was detected between Breastcancer.org and any of the four social media sites. Out of these 12,000 sampled users, 169 patients on Breastcancer.org were expected to be linked to at least one other social media website. 66 patients were expected to be linked to Facebook, 96 to Twitter, 102 to Instagram, and 66 to Reddit. This analysis suggests that of Breastcancer.org’s 227,862 users, approximately 3,190 users in total can be linked to at least one of the four social media websites examined in this study solely based on username. In addition, when content from a randomly chosen thread was analyzed, each of the 2,781 posts from 64 patients contained an average of 9.5 pieces of PII. CONCLUSIONS These results demonstrate a substantial risk to patients on semi-anonymous medical forums with regards to medical privacy and the need to add warnings for patients when they are creating usernames. This tool, or a similar one, could be used by online medical support groups to warn patients when signing up for the platform to use different usernames for their public-facing and private-facing profiles. Such a warning would strengthen patient privacy.