Hipotermia para la neuroprotección en adultos después de la reanimación cardiopulmonar

ResumenAntecedentesEs difícil lograr un buen resultado neurológico después de un paro cardíaco. Las intervenciones durante la fase de reanimación y el tratamiento en las primeras horas después del evento son críticas. Las pruebas experimentales indican que la hipotermia terapéutica es beneficiosa, y se han publicado varios estudios clínicos sobre este tema.ObjetivosSe realizó una revisión sistemática y un metanálisis para evaluar la efectividad de la hipotermia terapéutica en pacientes que sufrieron un paro cardíaco. Las principales medidas de resultado fueron los resultados neurológicos, la supervivencia y los eventos adversos. Se propuso realizar el análisis de los datos de los pacientes individuales si estaban disponibles, y de subgrupos según la situación del paro cardíaco.Estrategia de búsquedaSe hicieron búsquedas en las siguientes bases de datos: Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL) (The Cochrane Library, 2007, número 1); MEDLINE (1971 hasta enero 2007); EMBASE (1987 hasta enero 2007); CINAHL (1988 hasta enero 2007); PASCAL (2000 hasta enero 2007); y BIOSIS (1989 hasta enero 2007).Criterios de selecciónSe incluyeron todos los ensayos controlados aleatorios que evaluaron la efectividad de la hipotermia terapéutica en los pacientes después de un paro cardíaco, sin restricciones de idiomas. Los estudios estaban restringidos a las poblaciones adultas que recibieron el enfriamiento con cualquier método, aplicado en las seis horas siguientes al paro cardíaco.Obtención y análisis de los datosSe introdujeron en la base de datos las medidas de validez, la intervención, los parámetros de las medidas de resultado y variables iniciales adicionales. Se realizó metanálisis sólo en un subconjunto de estudios comparables con heterogeneidad insignificante. En estos estudios se contó con los datos de los pacientes individuales.Resultados principalesaSe incluyeron en la revisión sistemática cuatro ensayos y un resumen con datos sobre 481 pacientes. La calidad de los estudios incluidos fue buena en tres de los cinco estudios incluidos. En los tres estudios comparables sobre los métodos de enfriamiento convencional todos los autores proporcionaron datos de los pacientes individuales. Con métodos de enfriamiento convencional, los pacientes en el grupo con hipotermia tuvieron mayor probabilidad de alcanzar una mejor puntuación de las categorías de rendimiento cerebral de 1 o 2 (CRC, escala de 5 puntos; 1 = buen rendimiento cerebral, a 5 = muerte cerebral) durante la estancia hospitalaria (datos de los pacientes individuales; RR, 1,55, IC del 95%: 1,22 a 1,96) y tuvieron mayor probabilidad de sobrevivir al alta hospitalaria (datos de los pacientes individuales; RR, 1,35, IC del 95%: 1,10 a 1,65) comparados con la atención estándar después de la reanimación. En la totalidad de los estudios no hubo diferencias significativas de los eventos adversos informados entre la hipotermia y el control.Conclusiones de los autoresLos métodos de enfriamiento convencional para inducir la hipotermia terapéutica leve parecen mejorar la supervivencia y el estado neurológico después de un paro cardíaco. Esta revisión apoya la mejor práctica médica actual recomendada por las International Resuscitation Guidelines (Guías internacionales de reanimación).Resumen en términos sencillosEnfriamiento del cuerpo después de un paro cardíacoHasta la fecha, aproximadamente un décimo a un tercio de los pacientes reanimados con éxito dejan el hospital para reiniciar una vida independiente. Estudios clínicos han mostrado que este resultado puede mejorarse con el enfriamiento del cuerpo aproximadamente a 33°C durante varias horas después de un paro cardíaco. Se incluyeron cinco ensayos aleatorios con datos de un total de 481 supervivientes de un paro cardíaco. Los pacientes en los que se usaron los métodos de enfriamiento convencional tuvieron mayor probabilidad de salir del hospital sin daño cerebral importante y de sobrevivir al alta hospitalaria. No se informaron eventos adversos específicos del enfriamiento. En resumen, actualmente hay pruebas que apoyan el uso del enfriamiento convencional para inducir la hipotermia leve en las primeras horas después de la restauración de la circulación espontánea en los supervivientes de un paro cardíaco

Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial

Objective To determine which bedside method of detecting inadvertent endobronchial intubation in adults has the highest sensitivity and specificity

Performance of a Qualitative Point-of-Care Strip Test to Detect DOAC Exposure at the Emergency Department:A Cohort-Type Cross-Sectional Diagnostic Accuracy Study

An accurate point-of-care test for detecting effective anticoagulation by direct oral anticoagulants (DOACs) in emergencies is an unmet need. We investigated the accuracy of a urinary qualitative strip test (DOAC Dipstick) to detect relevant DOAC exposure in patients who presented to an emergency department. In this prospective single-center cohort-type cross-sectional study, adults on DOAC treatment were enrolled. We assessed clinical sensitivity and specificity of DOAC Dipstick factor Xa and thrombin inhibitor pads to detect DOAC plasma levels ≥30 ng/mL using urine samples as the testing matrix. Liquid chromatography coupled with tandem-mass spectrometry was used as the reference standard method for plasma and urine measurement of DOAC concentrations. Of 293 patients enrolled, 265 patients were included in the analysis, of whom 92 were treated with rivaroxaban, 65 with apixaban, 77 with edoxaban, and 31 with dabigatran. The clinical sensitivity and specificity of the dipstick on urine samples to detect ≥30 ng/mL dabigatran plasma levels were 100% (95% confidence interval [CI]: 87–100%) and 98% (95% CI: 95–99%), respectively. The sensitivity and specificity of the dipstick to detect ≥30 ng/mL factor Xa inhibitor plasma levels were 97% (95% CI: 94–99%) and 69% (95% CI: 56–79%), respectively. The DOAC Dipstick sensitively identified effective thrombin and factor Xa inhibition in a real-world cohort of patients presenting at an emergency department. Therefore, the dipstick might provide a valuable test to detect relevant DOAC exposure in emergencies, although further studies will be needed to confirm these findings

Which treatment for low back pain? A factorial randomised controlled trial comparing intravenous analgesics with oral analgesics in the emergency department and a centrally acting muscle relaxant with placebo over three days [ISRCTN09719705]

BACKGROUND: About two thirds of adults suffer from backpain at some time during their life. In the emergency room many patients with acute back pain are treated with intravenous non-steroidal analgesics. Whether this treatment is superior to oral administration of non-steroidal analgesics is unknown. Intravenous administration, however, requires considerable amounts of resources and accounts for high workload in busy clinics. In the further course centrally acting muscle relaxants are prescribed but the effectiveness remains unclear. The objective of this study is on the one hand to compare the effectiveness of intravenous with oral non-steroidal analgesics for acute treatment and on the other hand to compare the effectiveness of a centrally active muscle relaxant with placebo given for three days after presentation to the ED (emergency department). METHODS/DESIGN: This study is intended as a randomised controlled factorial trial mainly for two reasons: (1) the sequence of treatments resembles the actual proceedings in every-day clinical practice, which is important for the generalisability of the results and (2) this design allows to take interactions between the two sequential treatment strategies into account. There is a patient preference arm included because patients preference is an important issue providing valuable information: (1) it allows to assess the interaction between desired treatment and outcome, (2) results can be extrapolated to a wider group while (3) conserving the advantages of a fully randomised controlled trial. CONCLUSION: We hope to shed more light on the effectiveness of treatment modalities available for acute low back pain

Performance of the QuickVue Influenza A+B Rapid Test for Pandemic H1N1 (2009) Virus Infection in Adults

To investigate the diagnostic accuracy of the QuickVue® Influenza A+B rapid test we conducted a prospective observational study in which this rapid test was compared with a real-time reverse transcription polymerase chain reaction (RT-PCR) for pandemic influenza A H1N1 (2009) infection in Austrian adults. The sensitivity, specificity, and positive and negative predictive values of the QuickVue test compared with the RT-PCR were 26% (95% CI 18–35), 98% (95% CI 92–100), 94% (95% CI 80–99) and 50% (95% CI 42–58), respectively. The prevalence of pandemic H1N1 (2009) virus infection among the 209 patients included in the study was 57%. Our data suggest that a positive QuickVue test provides considerable information for the diagnosis of pandemic influenza A H1N1 (2009) virus infection in young adults but that a negative QuickVue test result should, if relevant for patient management or public health measures, be verified using PCR

A multicentre, patient- and assessor-blinded, non-inferiority, randomised and controlled phase II trial to compare standard and torque teno virus-guided immunosuppression in kidney transplant recipients in the first year after transplantation:TTVguideIT

Background: Immunosuppression after kidney transplantation is mainly guided via plasma tacrolimus trough level, which cannot sufficiently predict allograft rejection and infection. The plasma load of the non-pathogenic and highly prevalent torque teno virus (TTV) is associated with the immunosuppression of its host. Non-interventional studies suggest the use of TTV load to predict allograft rejection and infection. The primary objective of the current trial is to demonstrate the safety, tolerability and preliminary efficacy of TTV-guided immunosuppression. Methods: For this purpose, a randomised, controlled, interventional, two-arm, non-inferiority, patient- and assessor-blinded, investigator-driven phase II trial was designed. A total of 260 stable, low-immunological-risk adult recipients of a kidney graft with tacrolimus-based immunosuppression and TTV infection after month 3 post-transplantation will be recruited in 13 academic centres in six European countries. Subjects will be randomised in a 1:1 ratio (allocation concealment) to receive tacrolimus either guided by TTV load or according to the local centre standard for 9 months. The primary composite endpoint includes the occurrence of infections, biopsy-proven allograft rejection, graft loss, or death. The main secondary endpoints include estimated glomerular filtration rate, graft rejection detected by protocol biopsy at month 12 post-transplantation (including molecular microscopy), development of de novo donor-specific antibodies, health-related quality of life, and drug adherence. In parallel, a comprehensive biobank will be established including plasma, serum, urine and whole blood. The date of the first enrolment was August 2022 and the planned end is April 2025. Discussion: The assessment of individual kidney transplant recipient immune function might enable clinicians to personalise immunosuppression, thereby reducing infection and rejection. Moreover, the trial might act as a proof of principle for TTV-guided immunosuppression and thus pave the way for broader clinical applications, including as guidance for immune modulators or disease-modifying agents.</p

CPR in medical schools: learning by teaching BLS to sudden cardiac death survivors – a promising strategy for medical students?

BACKGROUND: Cardiopulmonary resuscitation (CPR) training is gaining more importance for medical students. There were many attempts to improve the basic life support (BLS) skills in medical students, some being rather successful, some less. We developed a new problem based learning curriculum, where students had to teach CPR to cardiac arrest survivors in order to improve the knowledge about life support skills of trainers and trainees. METHODS: Medical students who enrolled in our curriculum had to pass a 2 semester problem based learning session about the principles of cardiac arrest, CPR, BLS and defibrillation (CPR-D). Then the students taught cardiac arrest survivors who were randomly chosen out of a cardiac arrest database of our emergency department. Both, the student and the Sudden Cardiac Death (SCD) survivor were asked about their skills and knowledge via questionnaires immediately after the course. The questionnaires were then used to evaluate if this new teaching strategy is useful for learning CPR via a problem-based-learning course. The survey was grouped into three categories, namely "Use of AED", "CPR-D" and "Training". In addition, there was space for free answers where the participants could state their opinion in their own words, which provided some useful hints for upcoming programs. RESULTS: This new learning-by-teaching strategy was highly accepted by all participants, the students and the SCD survivors. Most SCD survivors would use their skills in case one of their relatives goes into cardiac arrest (96%). Furthermore, 86% of the trainees were able to deal with failures and/or disturbances by themselves. On the trainer's side, 96% of the students felt to be well prepared for the course and were considered to be competent by 96% of their trainees. CONCLUSION: We could prove that learning by teaching CPR is possible and is highly accepted by the students. By offering a compelling appreciation of what CPR can achieve in using survivors from SCD as trainees made them go deeper into the subject of resuscitation, what also might result in a longer lasting benefit than regular lecture courses in CPR