Improving the quality of cardiopulmonary resuscitation by training dedicated cardiac arrest teams incorporating a mechanical load-distributing device at the emergency department

Objective

Determine if implementing cardiac arrest teams trained with a ‘pit-crew’ protocol incorporating a load-distributing band mechanical CPR device (Autopulse™ ZOLL) improves the quality of CPR, as determined by no-flow ratio (NFR) in the first 10 min of resuscitation.

Methods

A phased, prospective, non-randomized, before–after cohort evaluation. Data collection was from April 2008 to February 2011. There were 100 before and 148 after cases. Continuous video and chest compression data of all study subjects were analyzed. All non-traumatic, collapsed patients aged 18 years and above presenting to the emergency department were eligible. Primary outcome was NFR. Secondary outcomes were return of spontaneous circulation (ROSC), survival to hospital admission and neurological outcome at discharge.

Main results

After implementation, mean total NFR for the first 5 min decreased from 0.42 to 0.27 (decrease = 0.15, 95% CI 0.10–0.19, p < 0.005), and from 0.24 to 0.18 (decrease = 0.06, 95% CI 0.01–0.11, p = 0.02) for the next 5 min. The mean time taken to apply Autopulse™ decreased from 208.8 s to 141.6 s (decrease = 67.2, 95% CI, 22.3–112.1, p < 0.005). The mean CPR ratio increased from 46.4% to 88.4% (increase = 41.9%, 95% CI 36.9–46.9, p < 0.005) and the mean total NFR for the first 10 min decreased from 0.33 to 0.23 (decrease = 0.10, 95% CI 0.07–0.14, p < 0.005).

Conclusion

Implementation of cardiac arrest teams was associated with a reduction in NFR in the first 10 min of resuscitation. Training cardiac arrest teams in a ‘pit-crew’ protocol may improve the quality of CPR at the ED.     

Is intraoperative dexmedetomidine a new option for postoperative pain treatment? A meta-analysis of randomized controlled trials

In the present meta-analysis, we assessed the efficacy and safety of intravenous administration of dexmedetomidine (DEX) compared with placebo or opioids for acute postoperative pain treatment in adults undergoing surgery. The meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement and the recommendations of the Cochrane Collaboration. Randomized controlled trials investigating perioperative administration of DEX were included. For dichotomous outcomes relative risks (RR; 95% confidence intervals [CI]) and for continuous outcomes mean differences (MD; 95% CI) were calculated. Twenty-eight randomized controlled trials including 1420 patients were finally included. Patients treated with DEX reported lower postoperative pain intensity (MD_{1 h postoperatively}: −1.59 U (numeric rating scale: 0 to 10) 95% CI: −2.37 to −0.82; P = .000001) and showed a lower postoperative opioid consumption (MD_{24 h postoperatively}: −17.24 mg; 95% CI: −24.38 to −10.10; P = .00001) compared with placebo. Additionally, the DEX group showed a lower RR for opioid-related adverse events (e.g. RR_{Nausea (postanesthesia care unit)}: 0.66; 95% CI: 0.43 to 1.02; P = .06). The most common adverse event in patients treated with DEX was intraoperative bradycardia with a RR of 2.66 (RR: 2.66; 95% CI: 1.54 to 4.58; P = .0004) compared with placebo. There is evidence that DEX administration leads to lower postoperative pain, reduced opioid consumption, and a lower risk for opioid-related adverse events. The comparison of DEX vs opioids for postoperative pain treatment is less clear due to limited data. The most common adverse event was intraoperative bradycardia after DEX administration. Therefore cautions in patients at risk are warranted, and large trials focusing on long-term outcomes after intraoperative DEX use are needed.     

Efficacy of low-level laser therapy applied at acupuncture points in knee osteoarthritis: a randomised double-blind comparative trial

Objective

To evaluate the efficacy of low-level laser therapy (LLLT) applied to acupuncture points on the knee joint in combination with exercise and advice in patients with knee osteoarthritis.

Design

Randomised, double-blind, comparative clinical trial.

Participants

Forty-nine patients with knee osteoarthritis were assigned at random into two groups: active laser group (n = 26) and placebo laser group (n = 23).

Intervention

Using a gallium aluminium arsenide laser device, patients received either active or placebo LLLT at five acupuncture points on the affected knee during nine sessions.

Outcome measures

Patients were assessed using a visual analogue scale (VAS) and the Saudi Knee Function Scale (SKFS) at baseline, the fifth treatment session, the last treatment session, 6 weeks post intervention and 6 months post intervention.

Results

VAS scores showed a significant improvement in the active laser group compared with the placebo laser group at 6 weeks post intervention [mean difference −1.3, 95% confidence interval (CI) of the difference −2.4 to −0.3; P = 0.014] and 6 months post intervention (mean difference −1.8, 95% CI of the difference −3.0 to −0.7; P = 0.003) using the independent samples test. SKFS scores also showed a significant improvement in the active laser group compared with the placebo laser group at the last treatment session (median difference −15, 95% CI of the difference −27 to −2; P = 0.035) and 6 months post intervention (median difference −21, 95% CI of the difference −34 to −7; P = 0.006) using the Mann–Whitney U test.

Conclusions

The results demonstrate that short-term application of LLLT to specific acupuncture points in association with exercise and advice is effective in reducing pain and improving quality of life in patients with knee osteoarthritis.     

Compliance effects in a randomised controlled trial of yoga for chronic low back pain: a methodological study

Study design

Methodological study nested within a multicentre randomised controlled trial (RCT) of yoga plus usual general practitioner (GP) care vs usual GP care for chronic low back pain.

Objective

To explore the treatment effects of non-compliance using three approaches in an RCT evaluating yoga for low back pain.

Summary of background data

A large multicentre RCT using intention-to-treat (ITT) analysis found that participants with chronic low back pain who were offered a 12-week progressive programme of yoga plus usual GP care had better back function than those offered usual GP care alone. However, ITT analysis can underestimate the effect of treatment in those who comply with treatment. As such, the data were analysed using other approaches to assess the problem of non-compliance. The main outcome measure was the self-reported Roland Morris Disability Questionnaire (RMDQ).

Methods

Complier average causal effect (CACE) analysis, per-protocol analysis and on-treatment analysis were conducted on the data of participants who were fully compliant, predefined as attendance of at least three of the first six sessions and at least three other sessions. The analysis was repeated for participants who had attended at least one yoga session (i.e. any compliance), which included participants who were fully compliant. Each approach was described, including strengths and weaknesses, and the results of the different approaches were compared with those of the ITT analysis.

Results

For the participants who were fully compliant (n = 93, 60%), a larger beneficial treatment effect was seen using CACE analysis compared with per-protocol, on-treatment and ITT analyses at 3 and 12 months. The difference in mean change in RMDQ score between randomised groups was −3.30 [95% confidence interval (CI) −4.90 to −1.70, P < 0.001] at 3 months and −2.23 (95% CI −3.93 to −0.53, P = 0.010) at 12 months for CACE analysis, −3.12 (95% CI −4.26 to −1.98, P < 0.001) at 3 months and −2.11 (95% CI −3.33 to −0.89, P = 0.001) at 12 months for per-protocol analysis, and −2.91 (95% CI −4.06 to −1.76, P < 0.001) at 3 months and −2.10 (95% CI −3.31 to −0.89, P = 0.001) at 12 months for on-treatment analysis. For the participants who demonstrated any compliance (n = 133, 85%), the results were generally consistent with the fully compliant group at 3 months, but the treatment effect was smaller. The difference in mean change in RMDQ score between randomised groups was −2.45 (95% CI −3.67 to −1.24) for CACE analysis, −2.30 (95% CI −3.43 to 1.17) for per-protocol analysis and −2.15 (95% CI −3.25 to −1.06) for on-treatment analysis, which was slightly less than that for ITT analysis. In contrast, at 12 months, per-protocol and on-treatment analyses showed a larger treatment effect compared with CACE and ITT analyses: per protocol analysis −1.86 (95% CI −3.02 to −0.71), on-treatment analysis −1.99 (95% CI −3.13 to −0.86) and CACE analysis −1.67 (95% CI −2.95 to −0.40).

Conclusion

ITT analysis estimated a slightly smaller treatment effect in participants who complied with treatment. When examining compliance, CACE analysis is more rigorous than per-protocol and on-treatment analyses. Using CACE analysis, the treatment effect was larger in participants who complied with treatment compared with participants who were allocated to treatment, and the difference between ITT and CACE analyses for the fully compliant group at 3 months was small but clinically important. Per-protocol and on-treatment analyses may produce unreliable estimates when the effect of treatment is small.

International Standard Randomised Trial Number Register

ISRCTN 81079604.     

Short-term improvement in insomnia symptoms predicts long-term improvements in sleep,pain, and fatigue in older adults with comorbid osteoarthritis and insomnia

In a primary care population of 367 older adults (aged ?60 years) with osteoarthritis (OA) pain and insomnia, we examined the relationship between short-term improvement in sleep and long-term sleep, pain, and fatigue outcomes through secondary analyses of randomized controlled trial data. Study participants, regardless of experimental treatment received, were classified either as improvers (?30% baseline to 2-month reduction on the Insomnia Severity Index [ISI]) or as nonimprovers. After controlling for treatment arm and potential confounders, improvers showed significant, sustained improvements across 18 months compared with nonimprovers in pain severity (P < 0.001, adjusted mean difference = −0.51 [95% CI: −0.80, −0.21), arthritis symptoms (P < 0.001, 0.63 [0.26, 1.00]), and fear avoidance (P = 0.009, −2.27 [−3.95, −0.58]) but not in catastrophizing or depression. Improvers also showed significant, sustained improvements in ISI (P < 0.001, −3.03 [−3.74, −2.32]), Pittsburgh Sleep Quality Index Total (P < 0.001, −1.45 [−1.97, −0.93]) and general sleep quality (P < 0.001, −0.28 [−0.39, −0.16]) scores, Flinders Fatigue Scale (P < 0.001, −1.99 [−3.01, −0.98]), and Dysfunctional Beliefs About Sleep Scale (P = 0.037, −2.44 [−4.74, −0.15]), but no improvements on the Functional Outcomes of Sleep Questionnaire or the Epworth Sleepiness Scale. We conclude that short-term (2-month) improvements in sleep predicted long-term (9- and 18-month) improvements for multiple measures of sleep, chronic pain, and fatigue. These improvements were not attributable to nonspecific benefits for psychological well-being, such as reduced depression. These findings are consistent with benefits of improved sleep for chronic pain and fatigue among older persons with osteoarthritis pain and comorbid insomnia if robust improvements in sleep are achieved and sustained. Trial Registration: ClinicalTrials.gov Identifier: NCT01142349.     

Short-term changes in median nerve neural tension after a suboccipital muscle inhibition technique in subjects with cervical whiplash: a randomised controlled trial

Objectives

To assess the immediate effect of a suboccipital muscle inhibition (SMI) technique on: (a) neck pain, (b) elbow extension range of motion during the upper limb neurodynamic test of the median nerve (ULNT-1), and (c) grip strength in subjects with cervical whiplash; and determine the relationships between key variables.

Design

Randomised, single-blind, controlled clinical trial.

Setting

Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Spain.

Participants

Forty subjects {mean age 34 years [standard deviation (SD) 3.6]} with Grade I or II cervical whiplash and a positive response to the ULNT-1 were recruited and distributed into two study groups: intervention group (IG) (n = 20) and control group (CG) (n = 20).

Interventions

The IG underwent the SMI technique for 4 minutes and the CG received a sham (placebo) intervention. Measures were collected immediately after the intervention.

Main outcome measures

The primary outcome was elbow range of motion during the ULNT-1, measured with a goniometer. The secondary outcomes were self-perceived neck pain (visual analogue scale) and free-pain grip strength, measured with a digital dynamometer.

Results

The mean baseline elbow range of motion was 116.0° (SD 10.2) for the CG and 130.1° (SD 7.8) for the IG. The within-group comparison found a significant difference in elbow range of motion for the IG [mean difference −15.4°, 95% confidence interval (CI) −20.1 to −10.6; P = 0.01], but not for the CG (mean difference −4.9°, 95% CI −11.8 to 2.0; P = 0.15). In the between-group comparison, the difference in elbow range of motion was significant (mean difference −10.5°, 95% CI −18.6 to −2.3; P = 0.013), but the differences in grip strength (P = 0.06) and neck pain (P = 0.38) were not significant.

Conclusion

The SMI technique has an immediate positive effect on elbow extension in the ULNT-1. No immediate effects on self-perceived cervical pain or grip strength were observed.     

Incidence,risk factors and clinical outcomes of peripherally inserted central catheter spontaneous dislodgment in oncology patients: A prospective cohort study

Purpose

Peripherally inserted central catheter (PICC) spontaneous dislodgment is insidious in onset and prone to cause complications. We performed a prospective cohort study to examine the incidence, risk factors and clinical results of PICC spontaneous dislodgment in oncology patients to facilitate successful early diagnosis, prophylaxis and management.

Patients and methods

Consecutive oncology patients, undergoing placement of PICCs, were enrolled and prospectively followed up until their catheters were removed or PICC spontaneous dislodgment presented. The patients with PICC spontaneous dislodgment or catheter-associated thrombosis (CRT) were followed up for an extra three months from the date of diagnosis. The main endpoint was PICC spontaneous dislodgment, and the sub-endpoints were CRT and catheter in-place time. The PICC insertion team, nurses, interventional radiologists and oncology doctors collected longitudinal data.

Results

Over a total of 60,894 days of cumulative follow-up, 21 out of 510 PICCs presented spontaneous dislodgment, leading to an incidence rate of 4.12%. The CRT rate of the group with PICC spontaneous dislodgment was much higher than that of the group without PICC spontaneous dislodgment (RR = 17.46, 95% CI: 8.29–36.82, p = 1.09 × 10⁻¹⁷). Five baseline exposure factors, including primary lung cancer, metastatic lung cancer, chest radiotherapy, vigorous coughing and severe vomiting, were significant risk factors of PICC spontaneous dislodgment. Basilic vein access (odds ratio [OR] = 0.39, 95% CI: 0.16–0.95, P = 0.04) was a protective factor against PICCSD in univariate analysis. Among these factors, the independent significant risk factors were vigorous coughing (OR = 6.14, 95% CI: 1.70–22.16, P = 0.01) and severe vomiting (OR = 3.70, 95% CI: 1.28–10.68, P = 0.02).

Conclusion

The incidence rate of PICC spontaneous dislodgment is 4.12% (0.34 per 1000 catheter-days); PICC spontaneous dislodgment significantly increases the risk of CRT and shortens catheter in-place time. Vigorous coughing and severe vomiting were independent risk factors of PICC spontaneous dislodgment among oncology patients.     

Effect on efficiency and cost-effectiveness when an observation unit is managed as a closed unit vs an open unit

Objective

To compare efficiency and cost-effectiveness of an observation unit (OU) when managed as a closed unit vs an open unit.

Methods

This observational, retrospective study of a 30-bed OU compared three time periods: Nov 2007 to Aug 2008 (period 1), Nov 2008 to Aug 2009 (period 2) and Nov 2010 to Aug 2011 (period 3). The OU was managed and staffed by non–emergency department physicians as an open unit during period 1, and a closed unit by emergency department physicians during periods 2 and 3.

Results

OU volume was greatest in period 3 (1 vs 3, 95% CI − 235.8 to − 127.9; 2 vs 3, 95% CI − 191.9 to − 84.095%). Periods 2 and 3 had shorter lengths of stay for discharged (1 vs 2, 95% CI − 6.6 to 1.7; 1 vs 3, 95% CI − 8.1 to − 3.1) and admitted (1 vs 2, 95% CI − 11.4 to − 8.6; 1 vs 3, 95% CI − 11.8 to − 9.0) patients, less admission rates (P < .001), and less 30-day all cause admission rates after discharge (P < .0001). Cost was less during periods 2 and 3 for direct (1 vs 2, 95% CI − 392.5 to − 305.9; 1 vs 3, 95% CI − 471.4 to − 388.4), indirect (1 vs 2, 95% CI − 249.5 to - 199.8; 1 vs 3, 95% CI − 187 to−139.4) and total cost (1 vs 2, 95% CI − 640.7 to − 507; 1 vs 3, 95% CI − 657.2 to − 529).

Conclusion

The same OU was more efficient and cost-effective when managed as a closed unit vs an open unit.     

The occurrence of shivering in cardiac arrest survivors undergoing therapeutic hypothermia is associated with a good neurologic outcome

Background

The incidence of shivering in cardiac arrest survivors who undergo therapeutic hypothermia (TH) is varied. Its occurrence is dependent on the integrity of multiple peripheral and central neurologic pathways. We hypothesized that cardiac arrest survivors who develop shivering while undergoing TH are more likely to have intact central neurologic pathways and thus have better neurologic outcome as compared to those who do not develop shivering during TH.

Methods

Prospectively collected data on consecutive adult patients admitted to a tertiary center from 1/1/2007 to 11/1/2010 that survived a cardiac arrest and underwent TH were retrospectively analyzed. Patients who developed shivering during the cooling phase of TH formed the “shivering” group and those that did not formed the “non-shivering” group. The primary end-point: Pittsburgh Cerebral Performance Category (CPC) scale; good (CPC 1–2) or poor (CPC 3–5) neurological outcome prior to discharge from hospital.

Results

Of the 129 cardiac arrest survivors who underwent TH, 34/94 (36%) patients in the “non-shivering” group as compared to 21/35 (60%) patients in the “shivering” group had good neurologic outcome (P = 0.02). After adjusting for confounders using binary logistic regression, occurrence of shivering (OR: 2.71, 95% CI 1.099–7.41, P = 0.04), time to return of spontaneous circulation (OR: 0.96, 95% CI 0.93–0.98, P = 0.004) and initial presenting rhythm (OR: 4.0, 95% CI 1.63–10.0, P = 0.002) were independent predictors of neurologic outcome.

Conclusion

The occurrence of shivering in cardiac arrest survivors who undergo TH is associated with an increased likelihood of good neurologic outcome as compared to its absence.     

TAOK3, a novel genome-wide association study locus associated with morphine requirement and postoperative pain in a retrospective pediatric day surgery population

Candidate gene studies have revealed limited genetic bases for opioid analgesic response variability. Genome-wide association studies facilitate impartial queries of common genetic variants, allowing identification of novel genetic contributions to drug effect. Illumina (Illumina Inc, San Diego, CA, USA) single nucleotide polymorphism (SNP) arrays were used to investigate SNP associations with total morphine requirement as a quantitative trait locus and with postoperative pain in a retrospective population of opioid-naïve children ages 4–18 years who had undergone day surgery tonsillectomy and adenoidectomy. In an independent replication cohort, significant genome-wide association studies-identified SNPs were assayed using TaqMan probes. Among 617 comprehensively phenotyped children, the 277 subjects of European Caucasian (EC) ancestry demonstrated nominal association between morphine dose and a series of novel SNPs (top rs795484, P = 1.01 × 10⁻⁶ and rs1277441, P = 2.77 × 10⁻⁶) at the TAOK3 locus. Age, body mass index, and physical status were included covariates. Morphine requirement averaged 132.4 μg/kg (SD 40.9). Each minor allele at rs795484 (guanine [G] > adenine [A]) contributed +17.6 μg/kg (95% confidence interval [CI] 10.7–24.4) to dose. Effect direction and magnitude were replicated in an independent cohort of 75 EC children (P < 0.05). No association with morphine dose was detected in African Americans (AA) (n = 241). Postoperative pain scores ?7/10 were associated with rs795484 (G > A) in the EC cohort (odds ratio 2.35, 95% CI 1.56-3.52, P < 0.00005) and this association replicated in AA children (odds ratio 1.76, 95% CI 1.14-2.71, P < 0.01). Variants in TAOK3 encoding the serine/threonine-protein kinase, TAO3, are associated with increased morphine requirement in children of EC ancestry and with increased acute postoperative pain in both EC and AA subjects.     

Patients with musculoskeletal conditions do less vigorous physical activity and have poorer physical fitness than population controls: a cross-sectional study

Objectives

To compare physical activity and physical fitness in patients with various musculoskeletal conditions receiving physiotherapy in primary care with population controls.

Design

Cross-sectional.

Participants

One hundred and sixty-seven patients with musculoskeletal conditions receiving physiotherapy in primary care and 313 population controls from various settings and geographical areas.

Main outcome measures

Physical activity was measured with the International Physical Activity Questionnaire short-form (IPAQ-sf) and reported in metabolic equivalents (METs). The 6-minute walk test and 30-second sit-to-stand test reflected cardiorespiratory endurance and muscular strength, respectively.

Results

Differences in physical activity between the groups were explored using the Mann–Whitney U-test. The patient group reported significantly less vigorous activity compared with the control group {median 0 [interquartile range (IQR) 0 to 960] vs median 240 [IQR 0 to 1440] MET minutes/week, respectively)} (P = 0.001). A similar proportion of patients (68%) and controls (75%) reached the recommended level of health-enhancing physical activity (P = 0.11). Linear regression analyses adjusted for age, body mass index and gender showed significantly poorer fitness in the patient group compared with the control group, reflected by the 6-minute walk test and the 30-second sit-to-stand test {mean difference 69 m [95% confidence interval (CI) 52 to 85; P ≤ 0.001] and six repetitions [95% CI 5 to 7; P ≤ 0.001], respectively}.

Conclusions

Patients with various long-term musculoskeletal conditions receiving physiotherapy in primary care had significantly poorer physical fitness and reported less vigorous physical activity compared with population controls.     

Genome-wide analysis of single nucleotide polymorphisms and copy number variants in fibromyalgia suggest a role for the central nervous system

Fibromyalgia (FM) is a highly disabling syndrome defined by a low pain threshold and a permanent state of pain. The mechanisms explaining this complex disorder remain unclear, and its genetic factors have not yet been identified. With the aim of elucidating FM genetic susceptibility factors, we selected 313 FM cases having low comorbidities, and we genotyped them on the Illumina 1 million duo array. Genotypic data from 220 control women (Illumina 610k array) was obtained for genome-wide association scan (GWAS) analysis. Copy number variants in FM susceptibility were analyzed by array comparative genomic hybridization (aCGH) experiments on pooled samples using the Agilent 2 × 400K platform. No single nucleotide polymorphism (SNP) reached GWAS association threshold, but 21 of the most associated SNPs were chosen for replication in 952 cases and 644 controls. Four of the SNPs selected for replication showed a nominal association in the joint analysis, and rs11127292 (MYT1L) was found to be associated to FM with low comorbidities (P = 4.28 × 10⁻⁵, odds ratio [95% confidence interval] = 0.58 [0.44–0.75]). aCGH detected 5 differentially hybridized regions. They were followed up, and an intronic deletion in NRXN3 was demonstrated to be associated to female cases of FM with low levels of comorbidities (P = .021, odds ratio [95% confidence interval] = 1.46 [1.05–2.04]). Both GWAS and aCGH results point to a role for the central nervous system in FM genetic susceptibility. If the proposed FM candidate genes were further validated in replication studies, this would highlight a neurocognitive involvement in agreement with latest reports.     

Performance evaluation of a new high throughput Mindray BS-2000M1 clinical chemistry system

Objective

To evaluate the photometry technical and analytical performance of a newly launched Mindray BS-2000M1 clinical chemistry system (BS-2000M1).

Design and Methods

The photometric parameters were evaluated according to the China Food and Drug Administration (CFDA) Automatic Chemistry Analyzer Guideline. The precision, accuracy, linearity and interference were evaluated according to CLSI protocols EP5-A2, EP9-A2, EP6-A and EP7-A2 respectively. The trueness verification on Ca^2 +, Mg^2 +, P⁻ and Cl⁻ was conducted by comparing with the reference methods using fresh samples.

Results

The photometer accuracy, precision, linearity, stability and stray light at 340 nm were acceptable. The within-run coefficients of variation (CVs) ranged from 0.16% to 2.13% and the total CV ranged from 0.64% to 4.12%. A good correlation (R > 0.95) of method comparison between BS-2000M1 and our reference system was observed for most of the parameters tested with exception of Ca^2 + (R = 0.85), Mg^2 + (R = 0.71), P⁻ (R = 0.96, Slope = 0.88), Cl⁻ (R = 0.93), and ASO (R = 0.94, Slope = 0.93, intercept = − 8.81). The trueness verification on Ca^2 +, Mg^2 +, P⁻ and Cl⁻ showed acceptable results on both BS-2000M1 and our reference systems. Linearity study showed acceptable linearity range for all parameters. Significant interferences occurred for some evaluated parameters, but were identical to the manufacturer statement.

Conclusions

Mindray BS-2000M1 achieved the desirable photometry technical and analytical performance, and is therefore suitable for its utilization in modern clinical laboratories.     

Delaying a shock after takeover from the automated external defibrillator by paramedics is associated with decreased survival

Introduction

The purpose of this study was to investigate whether the takeover by Advanced Life Support [ALS] trained ambulance paramedics from rescuers using an automated external defibrillator [AED] delays shocks and if this delay is associated with decreased survival after out-of-hospital cardiac arrest [OHCA].

Methods

We analyzed continuous ECG recordings of LIFEPAK AEDs and associated manual defibrillator recordings of OHCA of presumed cardiac cause, prospectively collected from July 2005 to July 2009. The primary outcome measure was survival to discharge. Among 693 patients treated with AEDs, 110 had a shockable initial rhythm and a shockable rhythm during ALS takeover. We measured the time interval between the expected shock if the AED would remain attached to the patient and the first observed shock given by the manual defibrillator [shock timing].

Results

Survival was 62% (13/21) if the shock was given early (<−20 s), 52% (11/21; odds ratio [OR] = 0.68, ns) if given on time (−20 to 20 s), 29% (10/34; OR = 0.26, 95% confidence interval [CI] = 0.08-0.81; P = 0.02) if the shock was 20-150 s delayed and 21% (7/34; OR = 0.16, 95% CI = 0.05-0.54; P = 0.003) if the shock was delayed >150 s. The OR for trend was 0.41, 95% CI = 0.25-0.71; P = 0.001. The association between shock timing and survival was significant for patients with more than 150 s shock delay (OR = 0.19; 95% CI = 0.04-0.71; P = 0.02) or for trend in shock timing (0.42, 95% CI = 0.20-0.84; P = 0.02) after multivariable adjustment for prognostic factors age and slope of ventricular fibrillation.

Conclusions

ALS takeover delays the next shock delivery in almost two-third of cases. This delay is associated with decreased survival.     

A pilot investigation of the association of genetic polymorphisms regulating corticotrophin-releasing hormone with posttraumatic stress and depressive symptoms in medical-surgical intensive care unit survivors

Purpose

To determine if single nucleotide polymorphisms of the corticotrophin-releasing hormone binding protein (CRHBP, rs10055255) and CRH receptor type 1 (CRHR1, rs1876831) were associated with posttraumatic stress disorder (PTSD) and depressive symptoms following medical-surgical intensive care unit (ICU) hospitalization.

Materials and Methods

We extracted DNA for genotyping from saliva samples of 93 ICU patients enrolled in a prospective cohort investigation. Follow-up interviews conducted 3 and 12-months post-ICU included assessment of PTSD symptoms with the PTSD Checklist-Civilian Version and depressive symptoms with the Patient Health Questionnaire–9.

Results

Homozygosity for the CRHBP rs10055255 T allele was associated with significantly fewer post-ICU PTSD (β = − 10.8, 95% confidence interval [95% CI], − 17.7 to − 3.9; P = .002) and depressive symptoms (β = − 3.7, 95% CI, − 6.7 to − 0.7; P = .02). Carrying a CRHR1 rs1876831 C allele was associated with significantly more post-ICU depressive symptoms compared to T/T homozygotes (C/T heterozygtes: β = 6.9, 95% CI, 1.2-12.6; P = .02; C/C homozygotes: β = 5.8; 95% CI: 0.2-11.3; P = .04). These associations remained significant after adjustment for age, race, illness severity, and in-ICU steroid exposure.

Conclusions

Despite a small sample size, our findings suggest a potential role for genetic variants of CRHBP and CRHR1 in the development of post-ICU psychiatric morbidity.     

TNF-α blockade improves early post-resuscitation survival and hemodynamics in a swine model of ischemic ventricular fibrillation

Aim of the study

Inflammatory cytokines have been implicated in the pathophysiology of post cardiac arrest syndrome, including myocardial dysfunction and hypotension, often leading to multi-organ system dysfunction and death. We hypothesized that administration of infliximab after return of spontaneous circulation (ROSC) would ameliorate hypotension and myocardial dysfunction and prolong survival.

Methods

Domestic swine were anesthetized and instrumented. Balloon occlusion of the LAD coronary artery just distal to the first septal perforator was performed and VF followed spontaneously in all animals. After 7 min, chest compressions, defibrillation, and standard ACLS resuscitation was performed. Animals achieving ROSC (N = 32) were randomized to receive infliximab (5 mg/kg, n = 16) or vehicle (250 mL normal saline, n = 16) immediately post-ROSC and survival and hemodynamics were monitored for 3 h.

Results

There were no differences in prearrest hemodynamic variables, TNF-α levels, or resuscitation variables between groups. Both groups demonstrated a time dependent decline in mean arterial pressure (MAP) and stroke work (SW) post-ROSC with a nadir at 1 h followed by recovery over hours 2 and 3. This decline was blunted in infliximab-treated swine (1-h between group difference in MAP 21 mm Hg, 95% CI 3–38 mm Hg and SW 6.7 gm-m, 95% CI 0.4–13 at 1 h). Left ventricular systolic dp/dt fell in the vehicle group (−437 mm Hg/s, 95% CI −183 to −690) but did not in the infliximab group. Tau rose only in the vehicle group (44 ms, 95% CI 1–87). Short-term survival was higher in the infliximab group (Kaplan–Meier p = 0.022).

Conclusions

Blockade of TNF-α in the immediate post-ROSC period improved survival and hemodynamic parameters in this swine model of ischemic VF.     

The effect of a physiotherapy education compared with a non-healthcare education on the attitudes and beliefs of students towards functioning in individuals with back pain: An observational, cross-sectional study

Objectives

To investigate the difference in attitudes: (1) between first and fourth year physiotherapy students towards functioning in individuals with back pain; and (2) between physiotherapy students and non-healthcare students towards functioning in individuals with back pain.

Design

Observational, cross-sectional study.

Setting

Glasgow Caledonian University, Scotland, UK.

Participants

First year physiotherapy (n = 61) and non-healthcare students (n = 61), and fourth year physiotherapy (n = 62) and non-healthcare students (n = 62).

Main outcomes

All participants completed the Health Care Providers’ Pain and Impairment Relationship Scale (range 15 to 105). This questionnaire measures attitudes towards functioning in individuals with back pain.

Results

Fourth year physiotherapy students had more positive attitudes towards functioning in individuals with back pain than first year physiotherapy students [57.4 vs 66.6 (mean difference −9.2, 95% confidence interval −12.2 to −6.1, P < 0.01)]. Similarly, fourth year non-healthcare students had more positive attitudes towards functioning in individuals with back pain compared with first year non-healthcare students [69.2 vs 65.3 (mean difference −3.9, 95% confidence interval −7.2 to −0.5, P = 0.03)]. Physiotherapy students had more positive attitudes than non-healthcare students in the first year [66.6 vs 69.2 (mean difference −2.6, 95% confidence interval −5.5 to 0.4, P = 0.08)] and the fourth year [57.4 vs 65.3 (mean difference −7.9, 95% confidence interval −11.4 to −4.4, P < 0.01)] of study.

Conclusion

These findings suggest that physiotherapy education brings about positive student attitudes towards functioning in individuals with back pain. This may be partly attributable to receiving a university degree education, but would appear to be further enhanced by specifically receiving a physiotherapy degree. This may facilitate students to become more evidence-based practitioners following qualification.     

The association between headache and elevated blood pressure among patients presenting to an ED

Background

Elevated blood pressure (BP) and headache have long been linked in the medical literature, although data on association are conflicting. We used previously collected data to address these related aims: (1) using the National Hospital Ambulatory Medical Care Survey (NHAMCS), we determined whether elevated BP is more likely in patients who present to an emergency department (ED) with headache than in patients who present with other complaints; (2) using data collected in 3 ED-based migraine clinical trials, we determined the association between improvement in headache pain and improvement in BP among patients who present to an ED with migraine and elevated BP; (3) using the data from the migraine clinical trials, we also determined if an elevated baseline BP identifies a group of patients less likely to respond to standard migraine treatment.

Methods

We analyzed 2 distinct data sets. The first, NHAMCS, is a national probability sample of all US ED visits. The second is a compilation of data gathered during 3 ED-based migraine randomized controlled trials. We defined elevated BP as follows: moderate elevation—systolic BP (SBP) ≥ 150 mm Hg or diastolic BP (DBP) ≥ 95 mm Hg; marked elevation—SBP ≥ 165 mm Hg or DBP ≥ 100 mm Hg; and severe elevation—SBP ≥ 180 mm Hg or DBP ≥ 110 mm Hg. We report the association between headache and elevated BP in NHAMCS using odds ratios (ORs) with 95% confidence intervals (CI). We report the correlation coefficient and r² for the association between improvement in BP and improvement in headache pain in our clinical trials data set. Finally, using our clinical trials database, we determined the influence of elevated BP at baseline on response to migraine medication by constructing a linear regression model in which the dependent variable was improvement in 0 to 10 pain score between baseline and 1 hour, and the primary predictor variable was presence or absence of elevated BP at baseline.

Results

Headache was the primary complaint in 3.7% (95% CI, 3.4-4.0%) of all US ED visits, corresponding to 4.8 million (95% CI, 4.2-5.4 million) patient visits. Among US ED patients, those with headache were more likely than patients with other chief complaints to have markedly (OR, 1.37; 95% CI, 1.16-1.61) or severely elevated BP (OR, 1.49; 95% CI, 1.17-1.90). In our clinical trials data set of patients with migraine with moderately elevated BP, there was no correlation between improvement in pain score and improvement in SBP (r = − 0.07, r² = 0, P = .465) or DBP (r = − 0.03, r² = 0, P = .75). Similarly, there was no correlation between improvement in headache and improvement in BP among patients with migraine with markedly elevated BP (for SBP, r = − 0.19, r² = 0.04, P = .89; for DBP, r = − 0.02, r² = 0, P = .87), nor among patients with severely elevated BP (for SBP, r = 0.06, r² = 0, P = .81; for DBP, r = 0.03, r² = 0, P = .90). Patients with moderately elevated BP had slightly less improvement in their 0 to 10 pain score than patients with BPs below this cutoff (− 0.6; 95% CI, − 1.2 to − 0.1; P = .03). This was more pronounced among patients with markedly elevated BP (− 0.9; 95% CI, − 1.7 to − 0.2).

Conclusions

Although there is an association between elevated BP and headache among patients presenting to an ED, improvement in headache is not associated with improvement in BP.     

Coagulopathy and traumatic shock: Characterizing hemostatic function during the critical period prior to fluid resuscitation

Aims

Identifying early changes in hemostatic clot function as a result of tissue injury and hypoperfusion may provide important information regarding the mechanisms of traumatic coagulopathy. A combat-relevant swine model was used to investigate the development of coagulopathy during trauma by monitoring hemostatic function during increasing severity of shock.

Methods

Swine were injured (soft tissue + femur fracture) and hemorrhaged while continuously monitoring Oxygen Debt (OD) by indirect calorimetry at the airway. Hemostatic function was assessed by Thrombelastography (TEG), Prothrombin Time (PT), Partial Thromboplastin Time (PTT), and fibrinogen concentration and compared before hemorrhage (D0) and during shock when OD = 40 and 80 ml/kg. An instrumented sham group was used for comparison.

Results

N = 23 swine (N = 18 hemorrhage, N = 5 sham) weighing 45 ± 6 kg were studied after removing an average of 34 ± 14% of blood volume during hemorrhage. Hgb, Hct, platelet counts, PT and PTT did not change with increasing OD (p < 0.05). Fibrinogen was reduced significantly by OD = 40 ml/kg (mean diff. = −59.9 mg/dl, 95% CI diff. [−95.1, −24.6]). TEG parameters representing clot initiation (R) and polymerization (K and Alpha Angle) did not change with increasing OD during shock (p > 0.053). Clot strength (MA) was reduced in the hemorrhage group by OD = 80 ml/kg (mean diff. = −4.1 mm, 95% CI diff. [−7.4, −0.8]).

Conclusion

In this swine model of traumatic shock, fibrinogen was significantly reduced and an isolated reduction in clot strength (MA) was found with increasing OD. Fibrinogen consumption and altered platelet function may account for the earliest changes in hemostatic function during traumatic shock.     

Factors affecting survival from avalanche burial—A randomised prospective porcine pilot study

Background and aim

The majority of avalanche victims who sustain complete burial die within 35 min due to asphyxia and injuries. After 35 min, survival is possible only in the presence of a patent airway, and an accompanying air pocket around the face may improve survival. At this stage hypothermia is assumed to be an important factor for survival because rapid cooling decreases oxygen consumption; if deep hypothermia develops before cardiac arrest, hypothermia may be protective and prolong the time that cardiac arrest can be survived. The aim of the study was to investigate the combined effects of hypoxia, hypercapnia and hypothermia in a porcine model of avalanche burial.

Methods

Eight piglets were anaesthetised, intubated and buried under snow, randomly assigned to an air pocket (n = 5) or ambient air (n = 3) group.

Results

Mean cooling rates in the first 10 min of burial were −19.7 ± 4.7 °C h⁻¹ in the air pocket group and −13.0 ± 4.4 °C h⁻¹ in the ambient air group (P = 0.095); overall cooling rates between baseline and asystole were −4.7 ± 1.4 °C h⁻¹ and −4.6 ± 0.2 °C h⁻¹ (P = 0.855), respectively. In the air pocket group cardiac output (P = 0.002), arterial oxygen partial pressure (P = 0.001), arterial pH (P = 0.002) and time to asystole (P = 0.025) were lower, while arterial carbon dioxide partial pressure (P = 0.007) and serum potassium (P = 0.042) were higher compared to the ambient air group.

Conclusion

Our results demonstrate that hypothermia may develop in the early phase of avalanche burial and severe asphyxia may occur even in the presence of an air pocket.