Extracorporeal Life Support in Out‐of‐Hospital Refractory Cardiac Arrest

Out‐of‐Hospital refractory Cardiac Arrest (OHrCA) has a mortality rate between 90 and 95%. Since 2009, French medical academic societies have recommended the use of extracorporeal life support (ECLS) for OHrCA. According to these guidelines, patients were eligible for ECLS support if vital signs were still present during cardiopulmonary resuscitation (CPR), or if cardiac arrest was secondary to intoxication or hypothermia (≤32°C). Otherwise, patients would receive ECLS if (i) no‐flow duration was less than 5 min; (ii) time delays from CPR to ECLS start (low flow) were less than 100 min; and (iii) expiratory end tidal CO₂ (ETCO₂) was more than 10 mm Hg 20 min after initiating CPR. We have reported here our experience with ECLS in OHrCA according to the previous guidelines. We retrospectively analyzed mortality rates of patients supported with ECLS in case of OHrCA. From December 2009 to December 2013, 183 patients were assisted with ECLS, among which 32 cases were of OHrCA. Mean age for the OHrCA patients was 43.6 years. Over two‐thirds were male (71.9%). Causes of OHrCA included intoxication, isolated hypothermia <32°C, acute coronary syndrome, pulmonary edema, and other cardiac pathology. Despite adherence to protocols, only two patients (6.2%) with hypothermia and acute myocardium ischemia, respectively, could be discharged from hospital after cardiac recovery. Causes of death were brain death and multiple organ failure. Despite ECLS support setting in accordance with French guidelines in case of refractory OHrCA, mortality rates remained high. French ECLS support recommendations for OHrCA due to presumed cardiac cause should be re‐examined through new studies. Low flow duration should be improved by a shorter time of CPR before hospital transfer.     

Clinical risk factors for osteoporotic fracture: A population‐based prospective cohort study in Korea

Clinical risk factors (CRFs), either alone or in combination with bone mineral density, are used to determine the fracture risk for clinical assessment and to determine intervention thresholds. Because fracture risk is strongly affected by ethnicity and population‐specific differences, we sought to identify Korean‐specific CRFs for fracture, in combination with quantitative ultrasound (qUS) measurements of the radius and tibia. A total of 9351 subjects (4732 men and 4619 women) aged 40 to 69 years were followed for a mean of 46.3 ± 2.2 months. We obtained CRF information using a standardized questionnaire and measured anthropometric variables. Speed of sound at the radius (SoSR) and tibia (SoST) were measured by qUS. Fracture events were recorded using a questionnaire, and a height‐loss threshold was used as an indicator of vertebral fracture. Relative risks were calculated by Cox regression analysis. A total of 195 subjects (61 men and 134 women) suffered low‐trauma fractures. Older age, lower body mass index (BMI), and previous fracture history were positively associated with fracture risk in both sexes. Decreased hip circumference, lack of regular exercise, higher alcohol intake, menopause, and osteoarthritis history were further independent CRFs for fracture in women. However, neither SoSR nor SoST was independently associated with fracture risk. In this study, we identified the major Korean‐specific CRFs for fracture and found that smaller hip circumference was a novel risk factor. This information will allow optimal risk‐assessment targeting Koreans for whom treatment would provide the greatest benefit. © 2010 American Society for Bone and Mineral Research     

Dietary cadmium exposure and fracture incidence among men: A population‐based prospective cohort study

Cadmium is an osteotoxic metal present in food. It causes multiple fractures in those highly exposed and is associated with reduced bone mineral density at considerably lower exposures. Little is known about fracture rates following low‐level cadmium exposure. We assessed the associations between dietary cadmium exposure and fracture incidence. Within a population‐based prospective cohort of 22,173 Swedish men, we estimated individual dietary cadmium exposure using food frequency questionnaire data and levels of cadmium in food. The average intake was 19 µg/day. Hazard ratios (HRs) for any fracture and hip fracture were estimated using Cox's regression. During 10 years of follow‐up, we ascertained 2183 cases of any fracture and 374 hip fractures by computerized linkage of the cohort to registry data. Multivariable‐adjusted dietary cadmium intake was associated with a statistically significant 19% [HR = 1.19, 95% confidence interval (CI) 1.06–1.34] higher rate of any fracture comparing highest tertile with lowest (p ≤ .01 for trend). Moreover, men in the highest tertile of dietary cadmium and lowest tertile of fruit and vegetable consumption had a 41% higher rate of any fracture compared with contrasting tertiles. Hip fracture rates also were higher in the highest tertile of cadmium intake but only statistically significant among never smokers (HR = 1.70, 95% CI 1.04–2.77). Our results indicate that dietary cadmium exposure at general population levels is associated with an increased rate of fractures among men. This association was independent of smoking and was most pronounced among men with low fruit and vegetable consumption. © 2011 American Society for Bone and Mineral Research.     

Simulation‐based teaching versus point‐of‐care teaching for identification of basic transoesophageal echocardiography views: a prospective randomised study

In recent years, the use of transoesophageal echocardiography has increased in anaesthesia and intensive care. We explored the impact of two different teaching methods on the ability of echocardiography‐naïve subjects to identify cardiac anatomy associated with the 20 standard transoesophageal echocardiography imaging planes, and assessed trainees' satisfaction with these methods of training. Fifty‐two subjects were randomly assigned to one of two groups: a simulation‐based and a theatre‐based teaching group. Subjects undertook video‐based tests comprised of 20 multiple choice questions on echocardiography views before and after receiving echocardiography teaching. Subjects in simulation‐ and theatre‐based teaching groups scored 40% (30–40 [20–50])% and 35% (30–40 [15–55])% in the pre‐test, respectively (p = 0.52). Following echocardiography teaching, subjects within both groups improved upon their pre‐test knowledge (p < 0.001). Subjects in the simulation‐based teaching group significantly outperformed their theatre‐based group counterparts in the post‐intervention test (p = 0.0002).     

Nonresponse to a population‐based postdisaster postal questionnaire study

We examined nonparticipation in a 2‐year postdisaster mail survey of Norwegian tourists evacuated from countries affected by the 2004 tsunami. One hundred seventy‐one persons out of a random sample of 330 nonparticipants were telephone interviewed concerning disaster exposure, current posttraumatic stress reactions, and reasons for not participating. Fewer nonparticipants than participants had been in a place directly affected by the tsunami. Nonparticipants reported less perceived threat of death and lower levels of posttraumatic stress reactions. Reasons for not participating were “lack of interest or time” (39.2%), “lack of relevant experiences” (32.2%), and “too personal or emotionally disturbing” (15.2%). Our findings suggest that postdisaster studies may be biased in the direction of more severe disaster exposure and pronounced posttraumatic stress reactions.     

Quality of rectal cancer surgery and its relationship to surgeon and hospital caseload: a population‐based study

Aim A population‐based audit of all rectal cancers diagnosed in Ireland in 2007 has shown an inconsistent relationship between surgeon and hospital caseload and a range of quality measures. Better outcome for rectal cancer has been associated with increasing surgeon and hospital caseload, but there is less evidence of how this may relate to quality of care. Our aim was to examine how measures of quality in rectal cancer surgery related to surgeon and hospital workload and to outcome. Method All colorectal surgeons in Ireland participated in an audit of rectal cancer based on an evidence‐based instrument. Data were extracted from medical records by trained coders. Generalized linear mixed models were used to determine the relationship between surgeon or hospital caseload and measures of quality of care. Results Five hundred and eighty‐one (95%) of the 614 rectal cancers diagnosed in Ireland in 2007 were audited; 49 hospitals and 86 surgeons participated. Ten (28%) hospitals treated fewer than five cases and seven fewer than three. A positive relationship between caseload and quality was seen for a few measures, more frequently for hospital than surgeon caseload. The relationship between caseload and quality of care was inconsistent, suggesting these measures do not represent a single dimension of quality. One‐year survival was negatively associated with hospital caseload. There was no statistically significant relationship between survival and measures of quality of care. Discussion Quality of care was inconsistently influenced by surgeon and hospital caseload. Caseload may affect only one aspect of surgical management, such as the quality of preoperative workup, and is not necessarily related to the quality of other hospital care. Simple measures of outcome, such as survival, cannot represent the complexity of this relationship.     

Post‐transplant lymphoproliferative disorder following kidney transplantation: a population‐based cohort study

Post‐transplant lymphoproliferative disorder (PTLD) incidence is difficult to determine, mainly because both early and other lesions may go unrecognized and unregistered. Few studies have included systematic pathology review to maximize case identification and decide more accurately PTLD frequency after long‐term post‐transplantation follow‐up. A retrospective population‐based cohort study including all kidney transplant recipients at two Danish centres (1990–2011; population covered 3.1 million; 2175 transplantations in 1906 patients). Pathology reports were reviewed for all patient biopsies to identify possible PTLDs. Candidate PTLDs underwent histopathological review and classification. Seventy PTLD cases were identified in 2175 transplantations (3.2%). The incidence rate (IR) after first transplantation was 5.4 cases per 1000 patient‐years (95% CI: 4.0–7.3). Most PTLDs were monomorphic (58.5%), or early lesions (21.5%). Excluding early lesions and patients <18 years, IR was 3.7 (95% CI: 2.9–5.5). Ten patients with PTLD were retransplanted, 2 developing further PTLDs. Post‐transplant patient survival was inferior in patients with PTLD, while death‐censored graft survival was not. Using registry data together with extensive pathological review and long follow‐up, a rather high incidence of PTLD was found.