Alternative Approach to Improving Survival of Patients With Out-of-Hospital Primary Cardiac Arrest

Out-of-hospital cardiac arrest (OHCA) is a common cause of death. In spite of recurring updates of guidelines, the survival of patients with OHCA was essentially unchanged from the mid 1970s to the mid 2000s, averaging 7.6% for all OHCA and 17.7% for OHCA due to ventricular fibrillation. In the past, changes in one's approach to resuscitation had to await the semi-decennial publications of guidelines. Following approved guidelines (at times based on consensus), survival rates of patients with OHCA were extremely variable, with only a few areas having good results. An alternative approach to improving survival is to use continuous quality improvement (CQI), a process often used to address public health problems. Continuous quality improvement advocates that one obtain baseline data and, if not optimal, make changes and continuously re-evaluate the results. Using CQI, we instituted cardiocerebral resuscitation as an alternative approach and found significant improvement in survival of patients with OHCA. The changes we made to the therapy of patients with primary OHCA, called cardiocerebral resuscitation, were based primarily on extensive experimental laboratory data. Using cardiocerebral resuscitation as a model for CQI, neurologically intact survival of patients with OHCA in ventricular fibrillation improved in 2 rural counties in Wisconsin, from 15% to 39%, and in 60 emergency medical systems in Arizona, to 38%. By advocating chest compression only CPR for bystanders of patients with primary OHCA and encouraging the use of cardiocerebral resuscitation by emergency medical systems, survival of patients with primary cardiac arrest in Arizona increased over a 5-year period from 17.7% to 33.7%. We recommend that all emergency medical systems determine their baseline survival rates of patients with OHCA and a shockable rhythm, and consider implementing the CQI approach if the community does not have a neurologically intact survival rate of at least 30%

Myocardial Perfusion Pressure: A Predictor of 24Hour Survival During Prolonged Cardiac Arrest in Dogs

Myocardial perfusion pressure, defined as the aortic diastolic pressure minus the right atria1 diastolic pressure, correlates with coronary blood flow during cardiopulmonary resuscitation (CPR) and predicts initial resuscitation success. Whether this hemodynamic parameter can predict 24-h survival is not known. We examined the relationship between myocardial perfusion pressure and 24-h survival in 60 dogs that underwent prolonged (20 min) ventricular fibrillation and CPR. Forty-two (70%) animals were initially resuscitated and 20 (33%) survived for 24 h. Myocardial perfusion pressure was significantly greater when measured at 5, 10, 15 and 20 min of ventricular fibrillation in the resuscitated animals than in the non-resuscitated animals (P \u3c 0.01). Likewise, the myocardial perfusion pressure was also greater in the animals that survived 24 h than in animals that were resuscitated, but died before 24 h (P \u3c 0.02). Myocardial perfusion pressure measured after 10 min of CPR was 11 2 mmHg in animals never resuscitated, 20 3 mmHg in those resuscitated that died before 24 h and 29 2 mmHg in those that survived 24 h (P \u3c 0.05). A myocardial perfusion pressure at 10 min of CPR of 20 mmHg or less is an excellent predictor of poor survival (negative predictive value = 96%). Myocardial perfusion pressure is a useful index of CPR effectiveness and therefore may be a useful guide in helping to optimize resuscitation efforts

Changes in Expired End-Tidal Carbon Dioxide During Cardiopulmonary Resuscitation in Dogs: A Prognostic Guide for Resuscitation Efforts

Expired end-tidal carbon dioxide (PCO2) measurements made during cardiopulmonary resuscitation have correlated with cardiac output and coronary perfusion pressure when wide ranges of blood flow are included. The utility of such measurements for predicting resuscitation outcome during the low flow state associated with closed chest cardiopulmonary resuscitation remains uncertain. Expired end-tidal PCO2 and coronary perfusion pressures were measured in 15 mongrel dogs undergoing 15 min of closed chest cardiopulmonary resuscitation after a 3 min period of untreated ventricular fibrillation. In six successfully resuscitated dogs, the mean expired end-tidal PCO2 was significantly higher than that in nine nonresuscitated dogs only after 14 min of cardiopulmonary resuscitation (6.2 ± 1.2 versus 3.4 ± 0.8 mmHg; p \u3c 0.05). No differences in expired end-tidal PCO2 values were found at 2, 7 or 12 min of cardiopulmonary resuscitation. A significant decline in end-tidal PCO2 levels during the resuscitation effort was seen in the nonresuscitated group (from 6.3 ± 0.8 to 3.4 ± 0.8 mmHg; p \u3c 0.05); while the successfully resuscitated group had constant PCO2 levels throughout the 15 min of cardiac arrest (ranging from 6.8 ± 1.1 to 6.2 ± 1.2 mmHg). Changes in expired PCO2 levels during cardiopulmonary resuscitation may be a useful noninvasive predictor of successful resuscitation and survival from cardiac arrest

Gasping in Response to Basic Resuscitation Efforts: Observation in a Swine Model of Cardiac Arrest

Objective. To analyze the effect of basic resuscitation efforts on gasping and of gasping on survival. Methods. This is secondary analysis of a previously reported study comparing continuous chest compressions (CCC CPR) versus chest compressions plus ventilation (30:2 CPR) on survival. 64 swine were randomized to 1 of these 2 basic CPR approaches after either short (3 or 4 minutes) or long (5 or 6 minutes) durations of untreated VF. At 12 minutes of VF, all received the same Guidelines 2005 Advanced Cardiac Life Support. Neurologically status was evaluated at 24 hours. A score of 1 is normal, 2 is abnormal, such as not eating or drinking normally, unsteady gait, or slight resistance to restraint, 3 severely abnormal, where the animal is recumbent and unable to stand, 4 is comatose, and 5 is dead. For this analysis a neurological outcome score of 1 or 2 was classified as “good”, and a score of 3, 4, or 5 was classified as “poor.” Results. Gasping was more likely to continue or if absent, to resume in the animals with short durations of untreated VF before basic resuscitation efforts. With long durations of untreated VF, the frequency of gasping and survival was better in swine receiving CCC CPR. In the absence of frequent gasping, intact survival was rare in the long duration of untreated VF group. Conclusions. Gasping is an important phenomenon during basic resuscitation efforts for VF arrest and in this model was more frequent with CCC-CPR

Plasma cholesterol levels and brain development in preterm newborns.

BackgroundTo assess whether postnatal plasma cholesterol levels are associated with microstructural and macrostructural regional brain development in preterm newborns.MethodsSixty preterm newborns (born 24-32 weeks gestational age) were assessed using MRI studies soon after birth and again at term-equivalent age. Blood samples were obtained within 7 days of each MRI scan to analyze for plasma cholesterol and lathosterol (a marker of endogenous cholesterol synthesis) levels. Outcomes were assessed at 3 years using the Bayley Scales of Infant Development, Third Edition.ResultsEarly plasma lathosterol levels were associated with increased axial and radial diffusivities and increased volume of the subcortical white matter. Early plasma cholesterol levels were associated with increased volume of the cerebellum. Early plasma lathosterol levels were associated with a 2-point decrease in motor scores at 3 years.ConclusionsHigher early endogenous cholesterol synthesis is associated with worse microstructural measures and larger volumes in the subcortical white matter that may signify regional edema and worse motor outcomes. Higher early cholesterol is associated with improved cerebellar volumes. Further work is needed to better understand how the balance of cholesterol supply and endogenous synthesis impacts preterm brain development, especially if these may be modifiable factors to improve outcomes

Distribution of plantar pressure in healthy controls and patients with type 1 and 2 diabetes

WSTĘP. Celem pracy jest ocena rozkładu podeszwowych nacisków w grupie osób zdrowych i chorych na cukrzycę typu 1 i 2 przy obecności lub braku neuropatii ruchowo-czuciowej. Opisane badania stanowią wstęp do opracowania pierwszego polskiego obuwia profilaktycznego, uwzględniającego odciążenie miejsc wysokiego ryzyka owrzodzenia na stopie. MATERIAŁ I METODY. Przebadano grupę 215 zdrowych osób, 56 osób chorych na cukrzycę typu 1, 61 chorych na cukrzycę typu 2. Badano zaawansowanie przewlekłych powikłań cukrzycy, szczególnie neuropatii, którą oceniano na podstawie skali NDS, NSS i przewodnictwa nerwowego. Pomiar nacisku [N/cm2] wykonano za pomocą systemu Emed-SF V2.1. WYNIKI BADAŃ. Wśród osób zdrowych stwierdzono największe naciski pod 2 (38,8 N/cm2) i 3 głową (33,4 N/cm2) kości śródstopia. Podobne wyniki uzyskano w populacji osób chorych na cukrzycę typu 1. U chorych na cukrzycę typu 2 ciśnienie pod 2 (45,5 N/cm2), 3 (39,6 N/cm2), 4 (31,8 N/cm2) głową kości śródstopia było statystycznie istotnie wyższe w porównaniu z populacją zdrowych osób. Podobnie wysokie ciśnienie stwierdzono pod 3 i 4 głową kości śródstopia w cukrzycy typu 2 powikłanej neuropatią. WNIOSKI. 1. Miejscami największego nacisku u osób zdrowych są: paluch, pięta, 2 i 3 głowa kości śródstopia. 2. U chorych na cukrzycę typu 2 naciski na 2, 3, 4 i 5 głowie kości śródstopia są istotnie statystycznie większe niż u osób zdrowych i chorych na cukrzycę typu 1. 3. U chorych na cukrzycę typu 2 powikłaną neuropatią ruchową i czuciową najwyższe naciski występują na 3 i 4 głowie kości śródstopia i różnią się one istotnie statystycznie od grupy osób zdrowych. 4. Szczególnych zabiegów prewencyjnych w postaci odciążenia główek kości śródstopia wymagają chorzy na cukrzycę typu 2, zwłaszcza powikłaną neuropatią ruchowo-czuciową.OBJECTIVE. To investigate the distribution of plantar pressures in healthy subjects and in patients with type 1 and 2 diabetes with or without sensorimotor neuropathy (SMN). The paper opens a series of studies aiming at the construction of the first Polish prophylactic footwear, which would offload the sites at high risk of plantar foot ulceration. MATERIAL AND METHODS. We studied 215 healthy subjects, 56 patients with type 1 diabetes, and 61 patients with type 2 diabetes. Chronic complications of diabetes were evaluated, especially neuropathy based upon NDS score, NSS score and neural conduction. We used the Emed-SF V2.1 system to measure plantar pressures [N/cm2]. RESULTS. Among the healthy individuals the highest pressures were observed below the second and the third metatarsal head (38,8 N/cm2 and 33,4 N/cm2, respectively). Similar results were found in the group of type 1 diabetes patients. However, the patients with type 2 diabetes mellitus had statistically significant higher pressures below the second, the third, and the fourth metatarsal head when compared with non-diabetic controls (45,5 N/cm2, 39,6 N/cm2, 31,8 N/cm2, respectively). Similar results below the third and fourth metatarsal head were observed in the group of type 2 diabetes patients complicated by diabetic neuropathy. CONCLUSIONS. 1. The highest pressures in healthy subjects were identified under great toe, the second and third metatarsal head. 2. Patients with type 2 diabetes have significantly higher pressures under the second through fifth metatarsal heads as compared with healthy subjects and type 1 diabetics. 3. In patients with type 2 diabetes complicated by SMN the highest pressures are found under the third and fourth metatarsal head, being significantly different from healthy subjects. 4. Special preventive procedures i.e. offloading metatarsal heads are necessary in patients with type 2 diabetes, especially those with concomitant SMN

The metaRbolomics Toolbox in Bioconductor and beyond

Metabolomics aims to measure and characterise the complex composition of metabolites in a biological system. Metabolomics studies involve sophisticated analytical techniques such as mass spectrometry and nuclear magnetic resonance spectroscopy, and generate large amounts of high-dimensional and complex experimental data. Open source processing and analysis tools are of major interest in light of innovative, open and reproducible science. The scientific community has developed a wide range of open source software, providing freely available advanced processing and analysis approaches. The programming and statistics environment R has emerged as one of the most popular environments to process and analyse Metabolomics datasets. A major benefit of such an environment is the possibility of connecting different tools into more complex workflows. Combining reusable data processing R scripts with the experimental data thus allows for open, reproducible research. This review provides an extensive overview of existing packages in R for different steps in a typical computational metabolomics workflow, including data processing, biostatistics, metabolite annotation and identification, and biochemical network and pathway analysis. Multifunctional workflows, possible user interfaces and integration into workflow management systems are also reviewed. In total, this review summarises more than two hundred metabolomics specific packages primarily available on CRAN, Bioconductor and GitHub

A tale of two societies : The doing of qualitative comparative research in Hong Kong and Britain

This article explores the challenges and opportunities for methodological innovation arising from an exploratory, cross-national, qualitative study of women’s lives in Hong Kong and Britain. We begin by briefly outlining the aims of our study and its original research design, based on life history interviews with young adult women and their mothers in each location.We then turn to a discussion of how this was modified as we recruited participants and conducted the interviews, including the use of vignettes. We aim to be transparent about some of the problems of implementing a symmetrical approach to generating qualitative data in very different socio-cultural settings compounded by the practical difficulties of geographical distance between team members. We argue for a flexible approach that takes account of local cultural sensibilities rather than trying to follow rigidly identical procedures, recognising also that, in any qualitative research team, there will be differences in approach that affect the data produced. We highlight some of the insights yielded by the problems we encountered and, in particular, an accidental innovation that occurred through an ad hoc decision to conduct focus groups with the young women, which we call ‘cross-cultural data feedback’. This innovation involved our participants in contributing to cross cultural comparison and also brought taken-for-granted assumptions in each setting into sharp relief, as well as sensitising us to issues that proved important in analysing our data. This leads us to raise issues of interpreting and analysing data from differing socio-cultural locations and translating between cultures. We conclude with some recommendations including the potential for the future development of our method of cross-cultural data feedback

Pre-existing autoimmunity is associated with increased severity of COVID-19: A retrospective cohort study using data from the National COVID Cohort Collaborative (N3C)

Identifying individuals with a higher risk of developing severe COVID-19 outcomes will inform targeted or more intensive clinical monitoring and management. To date, there is mixed evidence regarding the impact of pre-existing autoimmune disease (AID) diagnosis and/or immunosuppressant (IS) exposure on developing severe COVID-19 outcomes.A retrospective cohort of adults diagnosed with COVID-19 was created in the National COVID Cohort Collaborative enclave. Two outcomes, life-threatening disease, and hospitalization were evaluated by using logistic regression models with and without adjustment for demographics and comorbidities.Of the 2,453,799 adults diagnosed with COVID-19, 191,520 (7.81%) had a pre-existing AID diagnosis and 278,095 (11.33%) had a pre-existing IS exposure. Logistic regression models adjusted for demographics and comorbidities demonstrated that individuals with a pre-existing AID (OR = 1.13, 95% CI 1.09 - 1.17; P< 0.001), IS (OR= 1.27, 95% CI 1.24 - 1.30; P< 0.001), or both (OR = 1.35, 95% CI 1.29 - 1.40; P< 0.001) were more likely to have a life-threatening COVID-19 disease. These results were consistent when evaluating hospitalization. A sensitivity analysis evaluating specific IS revealed that TNF inhibitors were protective against life-threatening disease (OR = 0.80, 95% CI 0.66- 0.96; P=0.017) and hospitalization (OR = 0.80, 95% CI 0.73 - 0.89; P< 0.001).Patients with pre-existing AID, exposure to IS, or both are more likely to have a life-threatening disease or hospitalization. These patients may thus require tailored monitoring and preventative measures to minimize negative consequences of COVID-19