Diagnosis of out-of-hospital cardiac arrest by emergency medical dispatch : A diagnostic systematic review

Introduction: Cardiac arrest is a time-sensitive condition requiring urgent intervention. Prompt and accurate recognition of cardiac arrest by emergency medical dispatchers at the time of the emergency call is a critical early step in cardiac arrest management allowing for initiation of dispatcher-assisted bystander CPR and appropriate and timely emergency response. The overall accuracy of dispatchers in recognizing cardiac arrest is not known. It is also not known if there are specific call characteristics that impact the ability to recognize cardiac arrest. Methods: We performed a systematic review to examine dispatcher recognition of cardiac arrest as well as to identify call characteristics that may affect their ability to recognize cardiac arrest at the time of emergency call. We searched electronic databases for terms related to "emergency medical dispatcher", "cardiac arrest", and "diagnosis", among others, with a focus on studies that allowed for calculating diagnostic test characteristics (e.g. sensitivity and specificity). The review was consistent with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method for evidence evaluation. Results: We screened 2520 article titles, resulting in 47 studies included in this review. There was significant heterogeneity between studies with a high risk of bias in 18 of the 47 which precluded performing meta-analyses. The reported sensitivities for cardiac arrest recognition ranged from 0.46 to 0.98 whereas specificities ranged from 0.32 to 1.00. There were no obvious differences in diagnostic accuracy between different dispatching criteria/algorithms or with the level of education of dispatchers. Conclusion: The sensitivity and specificity of cardiac arrest recognition at the time of emergency call varied across dispatch centres and did not appear to differ by dispatch algorithm/criteria used or education of the dispatcher, although comparisons were hampered by heterogeneity across studies. Future efforts should focus on ways to improve sensitivity of cardiac arrest recognition to optimize patient care and ensure appropriate and timely resource utilization.Peer reviewe

Clinical ethics revisited

A decade ago, we reviewed the field of clinical ethics; assessed its progress in research, education, and ethics committees and consultation; and made predictions about the future of the field. In this article, we revisit clinical ethics to examine our earlier observations, highlight key developments, and discuss remaining challenges for clinical ethics, including the need to develop a global perspective on clinical ethics problems

Near-Infrared and Optical Observations of Type Ic SN 2021krf: Luminous Late-time Emission and Dust Formation

We present near-infrared (NIR) and optical observations of the Type Ic supernova (SN Ic) SN 2021krf obtained between days 13 and 259 at several ground-based telescopes. The NIR spectrum at day 68 exhibits a rising $K$-band continuum flux density longward of $\sim$ 2.0 $\mu$m, and a late-time optical spectrum at day 259 shows strong [O I] 6300 and 6364 \r{A} emission-line asymmetry, both indicating the presence of dust, likely formed in the SN ejecta. We estimate a carbon-grain dust mass of $\sim$ 2 $\times$ 10$^{-5}$ M$_{\odot}$ and a dust temperature of $\sim$ 900 - 1200 K associated with this rising continuum and suggest the dust has formed in SN ejecta. Utilizing the one-dimensional multigroup radiation hydrodynamics code STELLA, we present two degenerate progenitor solutions for SN 2021krf, characterized by C-O star masses of 3.93 and 5.74 M$_{\odot}$, but with the same best-fit $^{56}$Ni mass of 0.11 M$_{\odot}$ for early times (0-70 days). At late times (70-300 days), optical light curves of SN 2021krf decline substantially more slowly than that expected from $^{56}$Co radioactive decay. Lack of H and He lines in the late-time SN spectrum suggests the absence of significant interaction of the ejecta with the circumstellar medium. We reproduce the entire bolometric light curve with a combination of radioactive decay and an additional powering source in the form of a central engine of a millisecond pulsar with a magnetic field smaller than that of a typical magnetar.Comment: Accepted for publication in ApJ, 27 pages, 21 figures, 6 tables. Previous arXiv submission (arXiv:2211.00205) replaced after acceptanc

Renal Denervation Update From the International Sympathetic Nervous System Summit:JACC State-of-the-Art Review

Three recent renal denervation studies in both drug-naïve and drug-treated hypertensive patients demonstrated a significant reduction of ambulatory blood pressure compared with respective sham control groups. Improved trial design, selection of relevant patient cohorts, and optimized interventional procedures have likely contributed to these positive findings. However, substantial variability in the blood pressure response to renal denervation can still be observed and remains a challenging and important problem. The International Sympathetic Nervous System Summit was convened to bring together experts in both experimental and clinical medicine to discuss the current evidence base, novel developments in our understanding of neural interplay, procedural aspects, monitoring of technical success, and others. Identification of relevant trends in the field and initiation of tailored and combined experimental and clinical research efforts will help to address remaining questions and provide much-needed evidence to guide clinical use of renal denervation for hypertension treatment and other potential indications

Bedside rationing by general practitioners: A postal survey in the Danish public healthcare system

<p>Abstract</p> <p>Background</p> <p>It is ethically controversial whether medical doctors are morally permitted to ration the care of their patients at the bedside. To explore whether general practitioners in fact do ration in this manner we conducted a study within primary care in the Danish public healthcare system. The purpose of the study was to measure the extent to which general practitioners (GPs) would be willing to factor in cost-quality trade-offs when prescribing medicine, and to discover whether, and if so to what extent, they believe that patients should be informed about this.</p> <p>Methods</p> <p>Postal survey of 600 randomly selected Danish GPs, of which 330 responded to the questionnaire. The Statistical Package for the Social Sciences (SPSS, version 14.0) was used to produce general descriptive statistics. Significance was calculated with the McNemar and the chi-square test. The main outcome measures of the study were twofold: an assessment of the proportion of GPs who, in a mainly hypothetical setting, would consider cost-quality trade-offs relevant to their clinical decision-making given their economic impact on the healthcare system; and a measure of the extent to which they would disclose this information to patients.</p> <p>Results</p> <p>In the hypothetical setting 95% of GPs considered cost-quality trade-offs relevant to their clinical decision-making given the economic impact of such trade-offs on the healthcare system. In all 90% stated that this consideration had been relevant in clinical decision-making within the last month. In the hypothetical setting 55% would inform their patients that they considered a cost-quality trade-off relevant to their clinical decisions given the economic impact of such trade-offs on the healthcare system. The most common reason (68%) given for not wanting to inform patients about this matter was the belief that the information would not prove useful to patients. In the hypothetical setting cost-quality trade-offs were considered relevant significantly more often in connection with concerns about costs to the patient (86%) than they were in connection with concerns about costs to the healthcare system (55%; p < 0.001).</p> <p>Conclusion</p> <p>Although readiness to consider cost-quality trade-offs relevant to clinical decisions is prevalent among GPs in Denmark, only half of GPs would disclose to patients that they consider this relevant to their clinical decision-making. The results of this study raise two important ethical problems. First, under Danish law physicians are required to inform patients about all equal treatments. The fact that only a few GPs would inform their patients about all of the relevant treatments therefore seems to contravene Danish law. Second, it is ethically controversial that physicians act as economic gatekeepers.</p

SN 2019ehk: A Double-peaked Ca-rich Transient with Luminous X-Ray Emission and Shock-ionized Spectral Features

We present panchromatic observations and modeling of the Calcium-rich supernova (SN) 2019ehk in the star-forming galaxy M100 (d ≈ 16.2 Mpc) starting 10 hr after explosion and continuing for ~300 days. SN 2019ehk shows a double-peaked optical light curve peaking at t = 3 and 15 days. The first peak is coincident with luminous, rapidly decaying Swift-XRT–discovered X-ray emission (L_x ≈ 10⁴¹ erg s⁻¹ at 3 days; L_x ∝ t⁻³), and a Shane/Kast spectral detection of narrow Hα and He II emission lines (v ≈ 500 km s⁻¹) originating from pre-existent circumstellar material (CSM). We attribute this phenomenology to radiation from shock interaction with extended, dense material surrounding the progenitor star at r (0.1–1) × 10¹⁷ cm. The photometric and spectroscopic properties during the second light-curve peak are consistent with those of Ca-rich transients (rise-time of t_r = 13.4 ± 0.210 days and a peak B-band magnitude of M_B = −15.1 ± 0.200 mag). We find that SN 2019ehk synthesized (3.1 ± 0.11) × 10⁻² M_⊙ of ⁵⁶Ni and ejected M_(ej) = (0.72 ± 0.040) M⊙ total with a kinetic energy E_k = (1.8 ± 0.10) × 10⁵⁰ erg. Finally, deep HST pre-explosion imaging at the SN site constrains the parameter space of viable stellar progenitors to massive stars in the lowest mass bin (~10 M_⊙) in binaries that lost most of their He envelope or white dwarfs (WDs). The explosion and environment properties of SN 2019ehk further restrict the potential WD progenitor systems to low-mass hybrid HeCO WD+CO WD binaries

Strong Carbon Features and a Red Early Color in the Underluminous Type Ia SN 2022xkq

We present optical, infrared, ultraviolet, and radio observations of SN 2022xkq, an underluminous fast-declining type Ia supernova (SN Ia) in NGC 1784 ($\mathrm{D}\approx31$ Mpc), from $<1$ to 180 days after explosion. The high-cadence observations of SN 2022xkq, a photometrically transitional and spectroscopically 91bg-like SN Ia, cover the first days and weeks following explosion which are critical to distinguishing between explosion scenarios. The early light curve of SN 2022xkq has a red early color and exhibits a flux excess which is more prominent in redder bands; this is the first time such a feature has been seen in a transitional/91bg-like SN Ia. We also present 92 optical and 19 near-infrared (NIR) spectra, beginning 0.4 days after explosion in the optical and 2.6 days after explosion in the NIR. SN 2022xkq exhibits a long-lived C I 1.0693 $\mu$m feature which persists until 5 days post-maximum. We also detect C II $\lambda$6580 in the pre-maximum optical spectra. These lines are evidence for unburnt carbon that is difficult to reconcile with the double detonation of a sub-Chandrasekhar mass white dwarf. No existing explosion model can fully explain the photometric and spectroscopic dataset of SN 2022xkq, but the considerable breadth of the observations is ideal for furthering our understanding of the processes which produce faint SNe Ia.Comment: 38 pages, 16 figures, accepted for publication in ApJ, the figure 15 input models and synthetic spectra are now available at https://zenodo.org/record/837925

Cognitive Bias in Ambiguity Judgements:Using Computational Models to Dissect the Effects of Mild Mood Manipulation in Humans

Positive and negative moods can be treated as prior expectations over future delivery of rewards and punishments. This provides an inferential foundation for the cognitive (judgement) bias task, now widely-used for assessing affective states in non-human animals. In the task, information about affect is extracted from the optimistic or pessimistic manner in which participants resolve ambiguities in sensory input. Here, we report a novel variant of the task aimed at dissecting the effects of affect manipulations on perceptual and value computations for decision-making under ambiguity in humans. Participants were instructed to judge which way a Gabor patch (250ms presentation) was leaning. If the stimulus leant one way (e.g. left), pressing the REWard key yielded a monetary WIN whilst pressing the SAFE key failed to acquire the WIN. If it leant the other way (e.g. right), pressing the SAFE key avoided a LOSS whilst pressing the REWard key incurred the LOSS. The size (0-100 UK pence) of the offered WIN and threatened LOSS, and the ambiguity of the stimulus (vertical being completely ambiguous) were varied on a trial-by-trial basis, allowing us to investigate how decisions were affected by differing combinations of these factors. Half the subjects performed the task in a 'Pleasantly' decorated room and were given a gift (bag of sweets) prior to starting, whilst the other half were in a bare 'Unpleasant' room and were not given anything. Although these treatments had little effect on self-reported mood, they did lead to differences in decision-making. All subjects were risk averse under ambiguity, consistent with the notion of loss aversion. Analysis using a Bayesian decision model indicated that Unpleasant Room subjects were ('pessimistically') biased towards choosing the SAFE key under ambiguity, but also weighed WINS more heavily than LOSSes compared to Pleasant Room subjects. These apparently contradictory findings may be explained by the influence of affect on different processes underlying decision-making, and the task presented here offers opportunities for further dissecting such processes