What Are the Etiology and Epidemiology of Out‐of‐hospital Pediatric Cardiopulmonary Arrest in Ontario,Canada?

Background: Pediatric cardiopulmonary arrest (CPA) outside of the hospital has a very high mortality rate. Objectives: To evaluate the etiology and initial compromise of pediatric CPA cases in hopes of developing strategies to improve out‐of‐hospital resuscitation. Methods: The Ontario Prehospital Advanced Life Support (OPALS) study was a large multicenter initiative to evaluate the impact of emergency medical services (EMS) programs on 17 communities with 40,000 critically ill and injured patients who were older than 11 years. As part of this study, the authors conducted a retrospective observational cohort study that included all children younger than 18 years of age with out‐of‐hospital CPA, during an 11‐year period from 1991–2002. CPA was defined as patient being pulseless, apneic, and requiring chest compressions. Data were collected from ambulance call reports and centralized dispatch data and were reviewed by two independent investigators. Results: There were 503 children with CPA in the sample. Mean age was 5.6 years (range, 0–17 yr); 58.4% of patients were male, and 37.8% were younger than 1 year of age. Cardiopulmonary resuscitation (CPR) first was started by a bystander in 32.4% of cases, whereas 66.0% were unwitnessed arrests. Initial rhythms were asystole 77.2% of the time, pulseless electrical activity 16.4% of the time, and ventricular fibrillation or ventricular tachycardia 4% of the time. Annual incidence was 9.1/100,000 children. CPA was witnessed in 34.0% of cases; 80.7% of these were bystander‐witnessed, and 18.1% were EMS‐witnessed. Primary pathogenic cause of arrest was medical in 61.2% of cases, trauma in 37.2% of cases, and indeterminate in 1.6% of cases. Initial underlying physiologic compromise of witnessed arrests was judged to be respiratory in 39.8% of cases, sudden collapse (presumed electrical) in 16.4% of cases, progressive shock in 1.2% of cases, and indeterminate in 42.6% of cases. Presumed etiology was trauma, 37.6%; sudden infant death syndrome (SIDS), 20.3%; and respiratory disease, 11.6%, most commonly. Survival to hospital discharge was 2.0%. Conclusions: This is one of the largest population‐based, prospective cohorts of pediatric CPA reported to date, and it reveals that most pediatric arrests are unwitnessed and receive no bystander CPR. Those that are witnessed most often are caused by respiratory arrests or trauma. Trauma, SIDS, and respiratory disease are the most common etiologies overall. These data are vital to planning large resuscitation trials looking at specific interventions (i.e., increasing bystander CPR) and highlight the need for better strategies for prevention and early recognition.     

休克期切痂对烫伤大鼠全身和肠道局部免疫功能的影响

目的　观察休克期切痂对烫伤大鼠全身和肠道局部免疫功能的影响 ,探讨其可能的机制。　方法　选用 96只Wistar大鼠。取其中 2 4只大鼠的躯干部皮肤冻存于液氮中 ,另取 8只作正常对照组。余下 6 4只造成 30 %TBSAⅢ度烫伤后 ,随机分为A组 2 4只 ,伤后不作任何处理 ;B组 2 4只 ,伤后 2 4h腹腔注射等渗盐水 5 0ml/kg,一次性切痂后用上述冻存异体皮覆盖 ;C组 1 6只 ,伤后 72h进行处理 ,方法同B组。检测A、B组大鼠伤后 2、4、8d和C组伤后 4、8d及正常对照组大鼠的脾淋巴细胞增殖功能、血浆和肠组织白细胞介素 (IL)2水平、肠黏液分泌型免疫球蛋白A(sIgA)及肠组织中二胺氧化酶 (DAO)含量的变化。　结果　各时相点下A、B、C组大鼠脾淋巴细胞增殖功能、血浆IL 2水平、肠组织IL 2及肠黏液sIgA含量均较正常对照组减少。B组伤后 4、8d和C组伤后 8d的脾淋巴细胞增殖功能接近正常对照组 ,血浆和肠组织IL 2水平明显高于A组 (P <0.0 1)。伤后 4、8d,B组肠黏液sIgA含量分别为 (3.5 1± 2 .1 4 )、(3.0 3± 0 .95 )mg/g,C组分别为 (1 .4 0± 0 .6 4 )、(1 .5 2± 1 .2 6 )mg/g,B组较C组增加近 1倍 (P 0.0 1 )。A组伤后 4、8d肠组织DAO活性低于正常对照组和B组 (P 0.0 5)。结论　休克期切痂有助于烫伤大鼠全身和肠道     

The oxidation of body fuel stores in cancer patients.

In an attempt to define the mechanism of weight loss in cancer patients, fat and carbohydrate oxidation rates were calculated in 93 patients. Seventy patients with colorectal or gastric cancer were compared with a control group of 23 patients with nonmalignant illness. Twenty-seven patients with cancer and 13 control patients had lost more than 10% of their pre-illness body weight. Fat and carbohydrate oxidation rates were derived from measurements of oxygen consumption, carbon dioxide production, and urinary nitrogen excretion. Patients with cancer had significantly higher fat oxidation rates (p less than 0.01) and significantly lower carbohydrate oxidation rates (p less than 0.05) when compared with controls. Weight-losing cancer patients had significantly higher fat oxidation rates when compared with weight-stable cancer patients (p less than 0.02), weight-stable controls (p less than 0.01), and weight-losing controls (p less than 0.02). Cancer patients with liver metastases (N = 14) had significantly higher fat oxidation rates (p less than 0.01) and significantly lower carbohydrate oxidation rates (p less than 0.01) compared with cancer patients who had localized disease. There were no significant differences among the groups with respect to resting energy expenditure when expressed as kilocalorie per kilogram lean body mass per day. The presence of cancer appears to be associated with abnormal fat and carbohydrate metabolism. The increased rate of fat oxidation seen in patients with cancer, especially those with weight loss or liver metastases, may be a significant factor in the development of cancer cachexia.     

Psychological,situational, and gender predictors of cardiovascular reactivity to stress: A multivariate approach

This study examined whether relationships between anger expression, hostility, social evaluative anxiety, and a presumed mechanism for coronary heart disease development, cardiovascular reactivity (CVR) to stress, are moderated by stress situation and gender and whether such relationships are attenuated by inadequate assessments. Subjects (47 men, 47 women) were assigned randomly to either a Harassment or a Social Evaluation condition, under which they performed a reaction time task. SBP, DBP, and HR measures were recorded during baseline and task. Multiple regression analyses indicated that expressed anger was related to CVR only among men in the Harassment condition; that hostile men who express anger showed the most CVR across situations, and that the traits assessed here did not predict CVR among women. Results suggest that assessments of coronary-risk and interventions to reduce risk may need to take into account attitudes, styles of emotional expression, environmental factors, and gender.This research was supported in part by an NIMH predoctoral fellowship (F31MH09836) awarded to John W. Burns and by a grant from the American Heart Association (89-01-3G) awarded to Edward S. Katkin.     

Tumor vascular signals in renal masses: detection with Doppler US

The vascularity of 49 renal masses (26 malignant and 23 benign lesions) was investigated with duplex Doppler ultrasound. Doppler signals obtained at the margins of renal masses were defined as "tumor signals" when the Doppler-shifted frequency of the lesion exceeded the frequency shift in the ipsilateral main renal artery. These exceeded 2.5 kHz with a 3-MHz insonating frequency. Among the 26 renal masses that subsequently proved to be malignant, tumor signals were obtained in 15 of 18 (83%) untreated renal cell carcinomas, in three of four Wilms tumors, and in two patients with metastases to the kidney, but not in the one patient with lymphoma. None of the 23 benign renal masses demonstrated tumor signals. Tumor vascularity in malignant lesions gives rise to abnormal, high-velocity, Doppler-shifted signals that can help in the differential diagnosis of renal masses.     

Silent supraglottic carcinoma

In a review of 51 consecutive patients with previously untreated squamous cell carcinoma of the supraglottic larynx, five (9.8%) patients were found to have no mucosal abnormality on initial evaluation by both computed tomography (CT) and direct laryngoscopy. All five patients who manifested submucosal disease had at least one endoscopic procedure done with a biopsy negative for cancer before definitive diagnosis, resulting in an average delay from initial endoscopy to diagnosis of 19.8 weeks. These inapparent or "silent" neoplasms present unique problems in regard to establishing a diagnosis by routine biopsy techniques, even though CT reliably demonstrates their presence. Early diagnosis requires aggressive biopsy techniques based on CT findings.     

Image-directed percutaneous biopsies with a biopsy gun

Core tissue for histologic study is believed by many pathologists to be more diagnostic than material from needle aspiration. Recently, a biopsy "gun" has been introduced, which simplifies core biopsies. With this device, 182 biopsies of multiple anatomic sites were performed with ultrasonic, computed tomographic, and fluoroscopic guidance and 18-gauge needles. High-quality histopathologic specimens were obtained in 177 of the biopsies, and diagnostic target tissue was obtained in 167. Only three significant complications occurred: one bleeding complication that required transfusion and two cases of pneumothorax that necessitated placement of chest tubes. The biopsy gun eliminated the disjointed movements of conventional "skinny" needle biopsies, and none of the samples demonstrated significant "crush" artifact or obscuring blood, problems that are commonly associated with manual biopsy techniques. Patient discomfort was decreased with this system compared with that of manual biopsies, and the total procedure time was reduced. Because of these distinct advantages, the authors now use the biopsy gun exclusively for all percutaneous biopsies and recommend that other institutions consider the use of this biopsy method.     

Chronic stressors and maternal depression: implications for prevention.

We report on the use of an instrument to measure exposure to stressors among 149 women presenting with their children for pediatric care at an urban primary care center. Overall, 38.3 percent of the women had significant levels of depressive symptoms; 71.4 percent of those in the "high stress" group had an adjusted prevalence odds ratio of 5.00 [95% CI = 2.12, 11.82]. We conclude that screening in the pediatric office is feasible for identifying women at high risk of becoming depressed.     

The activation of red blood cell transketolase in groups of patients especially at risk from thiamin deficiency

Erythrocyte transketolase activation by thiamin diphosphate has been studied in elderly patients with moderate or severe chronic dementia, acute alcoholic admissions and chronic alcoholics with evidence of brain damage, mostly of the Wernicke-Korsakoff type. Significantly more patients in each group than controls showed abnormal activation of transketolase, not only by 0.3 mM thiamin diphosphate (TDP) but also in further activation by increase to 3 mM. This indicated the presence in a proportion of the alcoholic and the demented patients of an abnormal enzyme variant, similar to that previously found in vitro. The modified transketolase activation test may warn not only of marginal thiamin deficiency but also independently, of susceptibility to brain damage in patients at risk.