Global Health and Emergency Care: A Resuscitation Research Agenda—Part 2

At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session to develop a research agenda for resuscitation was held. Two articles are the result of that discussion. This second article addresses data collection, management, and analysis and regionalization of postresuscitation care, resuscitation programs, and research examples around the world and proposes a strategy to strengthen resuscitation research globally. There is a need for reliable global statistics on resuscitation, international standardization of data, and development of an electronic standard for reporting data. Regionalization of postresuscitation care is a priority area for future research. Large resuscitation clinical research networks are feasible and can give valuable data for improvement of service and outcomes. Low‐cost models of population‐based research, and emphasis on interventional and implementation studies that assess the clinical effects of programs and interventions, are needed to determine the most cost‐effective strategies to improve outcomes. The global challenge is how to adapt research findings to a developing world situation to have an effect internationally.     

Azathioprine‐induced Sweet's syndrome: A case series and review of the literature

We present three patients with azathioprine‐induced Sweet's syndrome (AISS) who attended our tertiary institution within a 12‐month period. Established associations exist between Sweet's syndrome and some medications; however, to date links to azathioprine are tentative. While there are case reports of AISS, most have occurred in patients with inflammatory bowel disease (IBD), an underlying predisposition for Sweet's syndrome. Our case series adds to the evidence that the entity of AISS truly exists independent of confounding factors such as concurrent IBD.     

Orthodontic retention: why when and how?

Retention is normally required after active orthodontic tooth movement to hold the teeth in their new positions. This article reviews the principles of orthodontic retention and describes common retention regimes and appliances.     

Structural determinants of ion permeation in CRAC channels

CRAC channels generate Ca²⁺ signals critical for the activation of immune cells and exhibit an intriguing pore profile distinguished by extremely high Ca²⁺ selectivity, low Cs⁺ permeability, and small unitary conductance. To identify the ion conduction pathway and gain insight into the structural bases of these permeation characteristics, we introduced cysteine residues in the CRAC channel pore subunit, Orai1, and probed their accessibility to various thiol-reactive reagents. Our results indicate that the architecture of the ion conduction pathway is characterized by a flexible outer vestibule formed by the TM1-TM2 loop, which leads to a narrow pore flanked by residues of a helical TM1 segment. Residues in TM3, and specifically, E190, a residue considered important for ion selectivity, are not close to the pore. Moreover, the outer vestibule does not significantly contribute to ion selectivity, implying that Ca²⁺ selectivity is conferred mainly by E106. The ion conduction pathway is sufficiently narrow along much of its length to permit stable coordination of Cd²⁺ by several TM1 residues, which likely explains the slow flux of ions within the restrained geometry of the pore. These results provide a structural framework to understand the unique permeation properties of CRAC channels.     

"Early-peak" carbon monoxide production in certain erythropoietic disorders

The "early-labeled" peak (ELP) of 14CO excretion following injection of glycine-2-14C was used to study erythropoiesis in a patient with sideroblastic anemia and in four subjects with myeloproliferative disorders. The ELP was greatly enlarged in all patients, as compared with a normal volunteer. The contour of the peaks from the hematologically abnormal subjects suggested the presence of increased erythroid heme degradation. In the patient with sideroblastic anemia, all hours of the early peak were significantly reduced after transfusion. This was interpreted to mean that even the earliest or "nonerythroid" phase of the peak is influenced by erythropoietic activity, at least under conditions of erythropoietic stress.     

Association of neighborhood characteristics with incidence of out-of-hospital cardiac arrest and rates of bystander-initiated CPR: Implications for community-based education intervention

Objective

A 10-fold regional variation in survival after out-of-hospital cardiac arrest (OHCA) has been reported in the United States, which partly relates to variability in bystander cardiopulmonary resuscitation (CPR) rates. In order for resources to be focused on areas of greatest need, we conducted a geospatial analysis of variation of CPR rates.

Methods

Using 2010–2011 data from Durham, Mecklenburg, and Wake counties in North Carolina participating in the Cardiac Arrest Registry to Enhance Survival (CARES) program, we included all patients with OHCA for whom resuscitation was attempted. Geocoded data and logistic regression modeling were used to assess incidence of OHCA and patterns of bystander CPR according to census tracts and factors associated herewith.

Results

In total, 1466 patients were included (median age, 65 years [interquartile range 25]; 63.4% men). Bystander CPR by a layperson was initiated in 37.9% of these patients. High-incidence OHCA areas were characterized partly by higher population densities and higher percentages of black race as well as lower levels of education and income. Low rates of bystander CPR were associated with population composition (percent black: OR, 3.73; 95% CI, 2.00–6.97 per 1% increment in black patients; percent elderly: 3.25; 1.41–7.48 per 1% increment in elderly patients; percent living in poverty: 1.77, 1.16–2.71 per 1% increase in patients living in poverty).

Conclusions

In 3 counties in North Carolina, areas with low rates of bystander CPR can be identified using geospatial data, and education efforts can be targeted to improve recognition of cardiac arrest and to augment bystander CPR rates.     

The Characteristics and Impact of a Hospitalist-staffed Post-discharge Clinic

Background

Limited primary care access and care discontinuities hamper care for patients following hospital discharge. As the proportion of inpatient care delivered by hospitalists continues to increase, hybrid models that incorporate hospitalists in post-discharge care may ameliorate this problem.

Methods

We established a post-discharge clinic staffed by hospitalists in a large academic urban primary care practice in October 2009. We compared visits of recently hospitalized patients seen in the post-discharge clinic with post-discharge visits elsewhere in the practice, including patient demographics, health care utilization, and duration from discharge, using generalized estimating equations to account for repeated hospitalizations.

Results

Patients seen in the post-discharge clinic and elsewhere in the practice were generally similar, although patients seen in the post-discharge clinic were particularly likely to be black and receive primary care from residents. Relative to other patients seen following discharge, patients in the post-discharge clinic were seen 8.45 ± 0.43 days earlier (P <.001). Among all 10,845 discharges of Healthcare Associates patients between 2009 and 2011, patients were 40% more likely to be seen within a week of discharge when the post-discharge clinic was open than when it was closed (adjusted odds ratio 1.41; 95% confidence interval, 1.25-1.57).

Conclusion

In this primary care practice, a hospitalist-staffed post-discharge clinic was associated with substantially shorter time to first post-hospitalization visit and with improvement in the overall likelihood of an early visit among all hospitalized patients. It was particularly used by black patients and those seen by residents, in whom access tends to be most fragmented, and may represent a novel approach to the problem of post-discharge care.