Large-diameter suction system reduces oropharyngeal evacuation time

Aspiration of vomitus is associated with significant morbidity and mortality. Standard suction equipment may be incapable of rapidly evacuating vomitus from the oropharynx. In this prospective, randomized, controlled bench trial, we compared a large-diameter suction system (5/8-inch open-bore suction tip and 3/4-inch tubing attached to a 1-inch pour spout) with two standard suction systems (small-diameter blunt-nosed and medium-diameter open-bore 1/4-inch suction tips connected to 1/4-inch tubing). Mean evacuation times from the mouth of a volunteer of 90 mL of water, activated charcoal, and Progresso vegetable soup were measured. All systems removed water within 3 s. With vegetable soup, however, both standard suction systems obstructed. Despite additional mechanical scooping with the standard suction wands, the large-diameter system significantly outperformed both standard systems, by 10 s with the soup and 40 s with the charcoal The reduction in oropharyngeal evacuation times of viscous and particulate material may have important clinical implications in the emergency management of the threatened airway.     

Frequency of changing suction canisters and suction tubing: a descriptive study.

There is little evidence to suggest the appropriate frequency for changing suction canisters and tubing in the gastroenterology setting. This survey was initiated to determine whether there was a community standard for this issue. A diverse geographic response from attendees at the 2006 Society of Gastroenterology Nurses and Associates revealed that there is no current "standard of practice." Findings were diverse and are reported on the basis of the size of the facility, type of facility, number of endoscopic procedure rooms, and number of endoscopic procedures per month. The majority of respondents (91%) used disposable suction devices. The authors recommend the need for well-designed, systematic studies to determine the appropriate frequency for changing suction canisters and tubing in the endoscopic setting.     

Solifenacin significantly improves all symptoms of overactive bladder syndrome

Overactive bladder syndrome (OAB) is a chronic condition characterised by urgency, with or without associated urge incontinence. Solifenacin succinate is a once daily, bladder selective antimuscarinic available in two doses (5 and 10 mg). The recommended dose is 5 mg once daily and can be increased to 10 mg once daily if 5 mg is well tolerated. This article presents pooled efficacy and safety data from four large, placebo-controlled, multinational phase III trials of solifenacin succinate with a total enrolment of over 2800 patients. Data from these trials show that solifenacin 5 and 10 mg once daily is significantly more effective than placebo at reducing urgency, incontinence, micturition frequency and nocturia and at increasing volume voided per micturition. Adverse events were mainly mild-to-moderate in all treatment groups. The results of these phase III trials support the use of solifenacin in the treatment of OAB.     

Inhibition of CD26 peptidase activity significantly improves engraftment of retrovirally transduced hematopoietic progenitors

It has previously been shown that inhibition of CD26 (DPPIV/dipeptidylpeptidase IV) peptidase activity improves homing of hematopoietic stem cells (HSCs) to the bone marrow and increases engraftment efficiency. Here, we demonstrate that treatment of retrovirally transduced mouse bone marrow cells with the tri-peptide Diprotin A (Ile-Pro-Ile), a specific inhibitor of CD26, significantly enhances engraftment of retrovirally transduced HSCs. Treatment of transduced bone marrow cells with Diprotin A permitted long-term expression of a retrovirally encoded MHC class I gene on multiple hematopoietic cell lineages after transplantation of a suboptimal number of transduced cells. Secondary transfer experiments revealed that expression of the transduced MHC class I gene resulted from engraftment of transduced HSCs. Expression of the allogeneic MHC class I antigen on bone marrow-derived cells following transplantation of Diprotin A-treated cells was sufficient to induce transplantation tolerance. Therefore, inhibition of CD26 activity significantly enhances engraftment of limited numbers of genetically modified HSCs, resulting in physiologically relevant levels of gene transfer.     

Preprocedural coronary CT angiography significantly improves success rates of PCI for chronic total occlusion

Chronic total occlusions of coronary arteries occur in about 20 % of patients with suspected coronary artery disease and are more frequent with increasing age. The success rate of interventions is lower (55–80 %) compared to conventional lesions (>90 %). Coronary CT angiography (coronary CTA) provides information about the occluded segment, which cannot be obtained from invasive angiograms (XA). We therefore hypothesized that preprocedural coronary CTA may improve success rates of percutaneous coronary intervention (PCI) for coronary arteries (CTO). 30 patients with chronic total coronary artery occlusions (mean age 73 years, 26 men) and predicted high complexity were imaged by coronary CTA prior to PCI for CTO. CT data sets were acquired with a 64 detector row dual source scanner and retrograde ECG gating, 0.6 mm collimation and z-flying focal spot, yielding isovoxel spatial resolution of about 0.4 mm. Based on the CT data sets, established complexity criteria for CTO (Euro CTO club, Di Mario et al. in EuroIntervention 3(1):30–43, 2007) were evaluated and compared to invasive coronary angiography. Three-dimensional volume-rendered images of the occluded coronary artery were displayed in the catheterization lab during PCI to guide the advancement of the wire. PCI success, defined as the ability to advance the guide wire into the distal lumen with thrombolysis in myocardial infarction III flow was compared to 43 controls without coronary CTA using propensity score matching based on established criteria of procedural success. The course of the occluded segments was visualized by coronary CTA in all cases. Calcification, lesion length, stump morphology and presence of side branches were underestimated by invasive angiograms when compared to coronary CTA. PCI success rate in 30 patients who underwent pre-procedural CTA was significantly higher than in patients without prior coronary CTA [unmatched: CT 90 % (27/30) vs. no CT 63 % (27/43), p = 0.009; matched: CT 88 % (22/25) vs. no CT 64 % (16/25) p = 0.03]. Through information not readily seen on invasive coronary angiography, coronary CTA can significantly enhance success rates of PCI for CTO.     

CPREzy improves performance of external chest compressions in simulated cardiac arrest

AIM OF THE STUDY: External chest compression (ECC) is an essential part of cardiopulmonary resuscitation and usually performed without any adjuncts. Although different supportive devices have been developed, none have yet been implemented as a standard procedure to guide rescuers in resuscitation. This study investigates the effects of the CPREzy-pad on ECC performed by first year medical students during simulated cardiac arrest. MATERIALS AND METHODS: Two hundred and two subjects were randomised and asked to perform 5 min of single-rescuer-CPR. Group 1 (n = 111) was taught classic ECC, followed by ECC with the CPREzy and was tested in ECC with the CPREzy. Group 2 (n = 91) was taught and tested in classic ECC only. One week later each group was divided: Group 1A was tested in ECC with the CPREzy again; Group 1B was tested in classic ECC. Group 2A was taught and tested in ECC with CPREzy; Group 2B was tested in classic ECC again. Primary endpoints were compression rate (90-110/min) and compression depth (40-50mm). RESULTS: Comparing groups 1 and 2, ECC was significantly superior with CPREzy (correct rate: 93.7% versus 19.8%, p < or = 0.01; depth: 71.2% versus 34.1%, p < or = 0.01). The group tested with CPREzy initially 1 week later (2A; n = 36) improved significantly in correct compression rate (19.8% versus 88.9%, p < or = 0.01) and compression depth (34.1% versus 75.0%, p < or = 0.02). The control-group (2B; n = 55) without CPREzy demonstrated poor performance in both evaluations (correct rate: 19.8% versus 25.5%, depth: 34.1% versus 43.6%). CONCLUSION: CPREzy as a simple portable and re-usable device is able to improve performance of ECC in simulated cardiac arrest.     

Sequential adaptation of perfusion and transport conditions significantly improves vascular construct recellularization and biomechanics

Recellularization of ex vivo‐derived scaffolds remains a significant hurdle primarily due to the scaffolds subcellular pore size that restricts initial cell seeding to the scaffolds periphery and inhibits migration over time. With the aim to improve cell migration, repopulation, and graft mechanics, the effects of a four‐step culture approach were assessed. Using an ex vivo‐derived vein as a model scaffold, human smooth muscle cells were first seeded onto its ablumen (Step 1: 3 hr) and an aggressive 0–100% nutrient gradient (lumenal flow under hypotensive pressure) was created to initiate cell migration across the scaffold (Step 2: Day 0 to 19). The effects of a prolonged aggressive nutrient gradient created by this single lumenal flow was then compared with a dual flow (lumenal and ablumenal) in Step 3 (Day 20 to 30). Analyses showed that a single lumenal flow maintained for 30 days resulted in a higher proportion of cells migrating across the scaffold toward the vessel lumen (nutrient source), with improved distribution. In Step 4 (Day 31 to 45), the transition from hypotensive pressure (12/8 mmHg) to normotensive (arterial‐like) pressure (120/80 mmHg) was assessed. It demonstrated that recellularized scaffolds exposed to arterial pressures have increased glycosaminoglycan deposition, physiological modulus, and Young's modulus. By using this stepwise conditioning, the challenging recellularization of a vein‐based scaffold and its positive remodeling toward arterial biomechanics were obtained.     

Use of an electronic decision support tool improves management of simulated in-hospital cardiac arrest

Introduction

Adherence to advanced cardiac life support (ACLS) guidelines during in-hospital cardiac arrest (IHCA) is associated with improved outcomes, but current evidence shows that sub-optimal care is common. Successful execution of such protocols during IHCA requires rapid patient assessment and the performance of a number of ordered, time-sensitive interventions. Accordingly, we sought to determine whether the use of an electronic decision support tool (DST) improves performance during high-fidelity simulations of IHCA.

Methods

After IRB approval and written informed consent was obtained, 47 senior medical students were enrolled. All participants were ACLS certified and within one month of graduation. Each participant was issued an iPod Touch device with a DST installed that contained all ACLS management algorithms. Participants managed two scenarios of IHCA and were allowed to use the DST in one scenario and prohibited from using it in the other. All participants managed the same scenarios. Simulation sessions were video recorded and graded by trained raters according to previously validated checklists.

Results

Performance of correct protocol steps was significantly greater with the DST than without (84.7% v 73.8%, p < 0.001) and participants committed significantly fewer additional errors when using the DST (2.5 errors vs. 3.8 errors, p < 0.012).

Conclusion

Use of an electronic DST provided a significant improvement in the management of simulated IHCA by senior medical students as measured by adherence to published guidelines.     

Presence of an arterial line improves response to simulated hypotension and pulseless electrical activity

With pulseless electrical activity (PEA) emerging as one of the leading cardiac arrest arrhythmias, the rapid response and accurate diagnosis of PEA is essential to improve survival rates. Although the use of invasive blood pressure monitoring to more quickly detect changes in blood pressure is widespread, evidence for its use is largely anecdotal and placement is not without risk. This is a prospective, multi-center, randomized controlled trial involving 58 senior anesthesiology residents undergoing a simulation of intraoperative PEA using high-fidelity simulation. Of the total 58 participants, 28 subjects were randomized to invasive blood pressure monitoring and 30 to non-invasive blood pressure monitoring in order to investigate the effects of arterial line information on the response time of ACLS-trained anesthesiology residents. Response times of subjects in the group provided with invasive blood pressure monitoring were faster to palpate pulses (6.5 s faster, p = .0470), initiate chest compressions (17 s faster, p = .004), and administer 1 mg of epinephrine (21 s faster, p = .0005. The absolute number of pharmacologic interventions was increased in the group with invasive blood pressure monitoring (p = .020). These findings suggest that noninvasive blood pressure monitoring and other readily available monitors are not as powerful as invasive blood pressure monitoring in influencing decision-making during a PEA event. As there is currently no specific blood pressure at which the patient is considered to be in PEA, future studies are necessary to clarify the correlation between the arterial line tracing and the appropriate trigger for ACLS initiation.     

Activated charcoal significantly reduces the amount of colchicine released from Gloriosa superba in simulated gastric and intestinal media

Background: Poisoning with Gloriosa superba, a plant containing colchicine, is common in Sri Lanka.

Objectives: This study was to estimate release of colchicine from 5?g of different parts of Gloriosa superba in simulated gastric and intestinal media, and examine the binding efficacy of activated charcoal (AC) to colchicine within this model.

Methods: A USP dissolution apparatus-II was used to prepare samples for analysis of colchicine using HPLC.

Results: Cumulative colchicine release from tuber in gastric media at 120?minutes was significantly higher (2883?μg/g) than in intestinal media (1015?μg/g) (p?Conclusions: The tuber released the highest quantity of colchicine. The colchicine release and elapse time to achieve saturated, equilibrium dissolution mainly depends on physicochemical properties of plant part. Significant in vitro binding of colchicine to AC suggests that AC has a role in decontamination of patients presenting to hospital after ingestion of Gloriosa superba.     

Policosanol supplementation significantly improves blood pressure among adults: A systematic review and meta-analysis of randomized controlled trials

Background and AimsPolicosanol contains a mixture of concentrated primary aliphatic alcohols extracted from sugar cane wax and is recognized as a cholesterol-lowering drug but previous studies reported that it could be helpful for reducing blood pressure as well. We aimed to systematically review all randomized control trials (RCTs) evaluating the efficacy of policosanol supplementation for lowering high blood pressure.Methods and ResultsThe following databases were searched up to March 2019: PubMed, Scopus, ISI Web of Science and the Cochrane library. Eligible RCTs were included if they investigate the effects of policosanol supplementation on systolic (SBP) and diastolic (DBP) blood pressure. Pooled effect size was measured using random effect model (DerSimmonon method). A total of nineteen studies with twenty-four arms were considered. Pooled effect size showed that SBP (WMD: −3.423 mmHg, 95% CI: −5.315, −1.531; p < 0.001) and DBP (WMD: −1.468 mmHg 95% CI: −2.632, −0.304, p = 0.013). decrease significantly after policosanol supplementation with significant heterogeneity among included studies (I² = 78.5% and 78.9% for SBP and DBP respectively). All subgroups showed a significant effect of policosanol supplementation except patients with mixed dyslipidemia for SBP and DBP and overweight subjects for DBP.ConclusionPolicosanol could lower SBP and DBP significantly; future long term studies are required to confirm these findings in the general population.     

胆汁排空时间及奥狄括约肌蠕动方向与胆囊切除后胆源性腹痛关系探讨

目的探讨胆汁排空时间及奥狄括约肌(SO)蠕动方向与胆囊切除术后胆源性腹痛之间的关系.方法对32例胆囊切除术后胆源性腹痛患者行内镜下逆行胰胆管造影(ERCP)检查,需行十二指肠乳头括约肌切开者则行内镜下十二指肠乳头括约肌切开术(EST);观察造影剂排空时间、胆管SO蠕动方向、胆胰管末端进入十二指肠的类型、胆总管远端生理狭窄段(NDS)长度.结果 32例胆囊切除后胆源性腹痛患者,造影剂排空时间≥45分钟者25例,有SO蠕动方向改变者24例,NDS≥10 mm者23例;24例SO蠕动方向改变者中逆向蠕动11例,同步收缩13例;23例NDS≥10 mm患者中21例造影剂排空时间>45分钟.结论胆汁排空时间延长及SO蠕动方向异常是胆囊切除术后胆源性腹痛的重要原因,而胆汁排空时间延长及SO蠕动方向异常与NDS过长明显相关.     

New visual feedback device improves performance of chest compressions by professionals in simulated cardiac arrest

Introduction

Quality of external chest compression (ECC) is a key component of Basic Life Support. Different approaches to improve rescuers’ performance have been evaluated, but few attempts have been made to invent simple devices to improve performance. This study evaluates a new visual feedback system for ECC for healthcare professionals.

Methods

Ninety-three healthcare professionals volunteered (14 emergency medical technicians, 45 paramedics, 34 physicians; age 32 ± 7.2 (range 21-61); 72% male) in this randomized cross-over study. All subjects were tested on a manikin (Skillreporter ResusciAnne^®, Laerdal, Stavanger, Norway) in identical mock cardiac arrest scenario and asked to perform 2 min of continuous ECC (secured airway): Group A (n = 46): ECC with device first, followed by ECC without device a minimum of 45 min later; group B (n = 47): vice versa. Primary endpoints: mean compression rate 90-120 min⁻¹; mean compression depth 38-51 mm. Data were analyzed using repeated measure logistic regression model for binary categorized endpoints and repeated measure ANOVA test for continuous endpoints.

Results

Correct compression depth was achieved by 45.2% of subjects (95%-CI: 30.5-64.9 mm) without vs. 73.1% (95%-CI: 40.3-57.4 mm) with device (p < 0.001); correct compression rate was achieved by 62.4% (95%-CI: 78-147.8 min⁻¹) without vs. 94.6% (95%-CI: 87.3-126.6 min⁻¹) with device (p < 0.001). Overall, 85% of the subjects thought the feedback system was helpful and 80.6% would use it if available.

Conclusions

The new visual feedback device significantly improved ECC performance (compression rate and depth) by healthcare professionals in simulated cardiac arrest. Most participants found the device easy to use.     

不同吸痰时间对重型颅脑损伤病人颅内压的影响

[目的 ]研究不同吸痰时间对重型颅脑损伤病人颅内压 (ICP)的影响。 [方法 ]将 3 0例重型颅脑损伤病人随机分为 3组 ,观察在吸痰压力为 2 0kPa ,吸痰时间分别为 5s、10s、2 0s时颅内压的变化。 [结果 ]在相同压力下进行吸痰 ,吸痰时间 5s和 10s对颅内压影响作用相似 ,2 0s则可引起颅内压过度升高。 5s与 10s吸痰有效率相似。 [结论 ]在 2 0kPa压力下最佳吸痰时间为 10s。     

The impact of manual defibrillation technique on no-flow time during simulated cardiopulmonary resuscitation

INTRODUCTION: Rapid defibrillation is the most effective strategy for establishing return of spontaneous circulation following cardiac arrest due to ventricular fibrillation. The aim of this study is to measure the delay due to of charging the defibrillator during chest compression in an attempt to reduce the duration of the pre-shock pause in between cessation of chest compressions and shock delivery as advocated by the American Heart Association (AHA) guidelines compared to charging the defibrillator immediately following rhythm analysis without resuming chest compressions as recommended by the European Resuscitation Council (ERC). METHODS: This was a randomised controlled cross over trial comparing pre-shock pause times when defibrillation was performed on a manikin according to the AHA and ERC guidelines using paddles and hands free defibrillation systems. RESULTS: The pre-shock pause between cessation of chest compression and shock delivery was significantly different between techniques (Friedman test, P<0.0001). ERC paddles technique had the greatest pre-shock pause (7.4 s [6.7-11.2]) followed by ERC hands free (7.0 s [6.5-8.5]) and AHA paddles (1.6 s [1.1-2.3]). AHA hands free took the least amount of time (1.5 s [0.8-1.5]). Extrapolating these data to older defibrillators with longer charge times saw pre-shock pause intervals of 9 s (Codemaster XL) and 12 s (Lifepak 20) with the ERC approach. CONCLUSION: This study demonstrated clinically significant delays to defibrillation by analysing and charging the defibrillator without performing concurrent chest compressions. In a simulated scenario, charging the defibrillator whilst performing chest compressions was perceived as safe and significantly reduced the pre-shock pause between cessation of chest compression and shock delivery.     

Transgene optimization significantly improves SIN vector titers, gp91phox expression and reconstitution of superoxide production in X-CGD cells

Gene therapy has proven to be of potential value for the correction of inherited hematopoietic disorders. However, the occurrence of severe side effects in some of the clinical trials has questioned the safety of this approach and has hampered the use of long terminal repeat-driven vectors for the treatment of a large number of patients. The development of self-inactivating (SIN) vectors with reduced genotoxicity provides an alternative to the currently used vectors. Our initial attempts to use SIN vectors for the correction of a myeloid disorder, chronic granulomatous disease, failed due to low vector titers and poor transgene expression. The optimization of the transgene cDNA (gp91(phox)) resulted in substantially increased titers and transgene expression. Most notably, transgene optimization significantly improved expression of a second cistron located downstream of gp91(phox). Thus, optimization of the transgene sequence results in higher expression levels and increased therapeutic index allowing the use of low vector copy numbers per transduced cell and weaker internal promoters.     

不同时机钻孔血肿清除引流术治疗高血压脑出血的疗效分析

目的通过回顾性分析不同时机钻孔血肿清除引流术治疗高血压脑出血的疗效,探讨最佳手术时机。方法对2005年11月至2013年11月间均采用钻孔血肿清除引流术式的78例高血压脑出血患者资料进行回顾性分析。根据手术时机分为超早期组(7 h以内)、早期组(7~24 h)、延期组(24~72 h),分析比较术后再出血率、病死率、3个月后远期疗效及并发症等。结果超早期组、早期组及延期组三组再出血率分别为33.3%、9.7%及7.7%。超早期组(7 h以内)再出血率高于早期组(7~24 h)及延期组(24~72 h),早期组与延期组再出血率相当。三组病死率分别为10.4%、11.1%及17.2%,三组病死率比较差异无显著性。远期疗效比较,超早期组与早期组的远期临床疗效相当,且均优于延期组。三组行钻孔血肿清除引流术术后无明显不良并发症。结论钻孔血肿清除引流术手术时机选在7~24 h为最佳,既有利于神经功能恢复又降低再出血风险。     

Triage rapid initial assessment by doctor (TRIAD) improves waiting time and processing time of the emergency department

Aim

To evaluate the effect of triage rapid initial assessment by doctor (TRIAD) on waiting time and processing time of an emergency department (ED) without extra staff.

Method

A senior emergency doctor was put into triage instead of a consultation cubicle for seven shifts of 9 hours each. All the patients were assessed and necessary interventions started at the time of triage. Waiting time and processing time of various categories of patients were compared with a control group that was sampled during the week before the trial period.

Results

In total, there were 1310 cases in the trial period and 1355 controls. Over a quarter (27%) of the patients received triage doctor interventions. The average waiting time was reduced by 38% and the average processing time by 23%. Patients without triage intervention also had a 24% shorter waiting time because of overall improvement in efficiency. Trauma patients and patients needing radiography particularly benefited from the new system. The waiting time and processing time of category 4 and 5 patients improved significantly as a result of more efficient processing of more urgent cases.

Conclusion

The waiting time and processing time of the ED were greatly reduced by TRIAD without extra manpower.