Summary Introduction Previous studies have documented poor quality CPR during real life resuscitation attempts. This study investigated whether poor quality CPR during advanced life support training ...could be contributing to poor performance in clinical practice. Methods Observational study of quality of CPR during advanced life support training courses before and after the implementation of the European Resuscitation Council Guidelines 2005 into the ALS course. The quality of chest compressions were downloaded from a manikin and direct observations of no-flow time; pre-shock pauses were recorded. Results 94 cardiac arrest simulations were studied (46 before implementation of Guidelines 2005 and 48 after). Delays in starting CPR, inadequate compression depth, prolonged interruptions of chest compressions and excessive pre-shock pauses were identified. The introduction of Guidelines 2005 resulted in improvements in the number of compressions given per minute and a reduction in no-flow time and duration of pre-shock pauses, but overall the quality of CPR performed during the ALS course remained poor. There was little evidence of performance improving over successive simulations as the course progressed. Conclusion The implementation of Guidelines 2005 into the ALS course appear to have improved the process of CPR by reducing no-flow time during simulated CPR. However, the quality of CPR during ALS training remains sub-optimal. Delays in starting CPR, inadequate compression depth, excessive interruptions in chest compressions and prolonged pre-shock pauses mirror observations from clinical practice. Strategies to improve CPR performance during ALS training should be explored and potentially may result in improvements in clinical practice.
Survival after out-of-hospital cardiac arrest is closely linked to the quality of CPR, but in real life, resuscitation during prehospital care and ambulance transport is often suboptimal. Mechanical ...chest compression devices deliver consistent chest compressions, are not prone to fatigue and could potentially overcome some of the limitations of manual chest compression. However, there is no high-quality evidence that they improve clinical outcomes, or that they are cost effective. The Prehospital Randomised Assessment of a Mechanical Compression Device In Cardiac Arrest (PARAMEDIC) trial is a pragmatic cluster randomised study of the LUCAS-2 device in adult patients with non-traumatic out-of-hospital cardiac arrest.
The primary objective of this trial is to evaluate the effect of chest compression using LUCAS-2 on mortality at 30 days post out-of-hospital cardiac arrest, compared with manual chest compression. Secondary objectives of the study are to evaluate the effects of LUCAS-2 on survival to 12 months, cognitive and quality of life outcomes and cost-effectiveness.
Ambulance service vehicles will be randomised to either manual compression (control) or LUCAS arms. Adult patients in out-of-hospital cardiac arrest, attended by a trial vehicle will be eligible for inclusion. Patients with traumatic cardiac arrest or who are pregnant will be excluded. The trial will recruit approximately 4000 patients from England, Wales and Scotland. A waiver of initial consent has been approved by the Research Ethics Committees. Consent will be sought from survivors for participation in the follow-up phase.
The trial will assess the clinical and cost effectiveness of the LUCAS-2 mechanical chest compression device.
The trial is registered on the International Standard Randomised Controlled Trial Number Registry (ISRCTN08233942).
Prospective cohort/predictive validity study.
To determine the predictive validity of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients with ...patellofemoral pain syndrome (PFPS) have a positive immediate response to lumbopelvic manipulation.
Quadriceps muscle function in patients with PFPS was recently shown to improve following treatment with lumbopelvic manipulation. No previous study has determined if individuals with PFPS experience symptomatic relief of activity-related pain immediately following this manipulation technique.
Fifty subjects (26 male, 24 female; age range, 18-45 years) with PFPS underwent a standardized history and physical examination. After the evaluation, each subject performed 3 typically pain-producing functional activities (squatting, stepping up a 20-cm step, and stepping down a 20-cm step). The pain level perceived during each activity was rated on a numerical pain scale (0 representing no pain and 10 the worst possible pain). Following the assessment, all subjects were treated with a lumbopelvic manipulation, which was immediately followed by retesting the 3 functional activities to determine if there was any change in pain ratings. An immediate overall 50% or greater reduction in pain, or moderate or greater improvement on a global rating of change questionnaire, was considered a treatment success. Likelihood ratios (LRs) were calculated to determine which examination items were most predictive of treatment outcome.
Data for 49 subjects were included in the data analysis, of which 22 (45%) had a successful outcome. Five predictor variables were identified. The most powerful predictor of treatment success was a side-to-side difference in hip internal rotation range of motion greater than 14 masculine (+LR, 4.9). If this variable was present, the chance of experiencing a successful outcome improved from 45% to 80%.
A CPR was developed to predict an immediate successful response to lumbopelvic manipulation in patients with PFPS. However, in light of a limited sample size and omission of potentially meaningful predictor variables, future studies are necessary to validate the CPR.
► Associations between PCBs and thymic involution in UK harbour porpoises was tested. ► Associations between PCBs and thymic cysts in UK harbour porpoises was tested. ► Thymic involution was ...associated with nutritional status and sexual maturity. ► PCBs and thymic involution was associated when total PCB>17mg/kg lipid weight. ► Development of thymic cysts appears predominantly age-related.
The associations between polychlorinated biphenyls (PCBs) exposure and involution of lymphoid tissue and development of epithelial-lined cysts in the thymus of UK-stranded harbour porpoises (Phocoena phocoena) (n=170) were tested. Percentage of thymic lymphoid tissue (%TLT) was histologically quantified. Multiple regression analyses (n=169) demonstrated significant positive correlation between %TLT and nutritional status (p<0.001) and significant negative association between %TLT and onset of sexual maturity (p<0.001). However, in a subgroup of porpoises with total PCB levels above a proposed threshold of toxicity (>17mg/kg lipid weight) (n=109), the negative association between %TLT (as dependent variable) and summed blubber concentrations of 25 chlorobiphenyl congeners (∑25CBs) remained significant (p<0.01) along with nutritional status (p<0.001) and onset of sexual maturity (p<0.001). These results suggest PCB-induced immuno suppression may be occurring in harbour porpoises in UK waters but only at concentrations that exceed proposed toxicity thresholds for marine mammals. In contrast, development of thymic cysts appears predominantly age-related.
ObjectiveTo determine the quality and diagnostic accuracy of in-hospital adult clinical emergency calls.DesignProspective observational study.SettingThree National Health Service acute hospitals in ...England.ParticipantsAdult patients sustaining an in-hospital cardiac arrest (CA) or medical emergency (ME) which required activation of the hospital resuscitation team between 1 December 2009 and 30 April 2010.Main outcome measuresEmergency call duration, emergency team dispatch time, diagnostic accuracy of emergency call (sensitivity/specificity), thematic analysis of emergency call, patient outcomes (return of spontaneous circulation and survival to hospital discharge).ResultsThere were 426 adult resuscitation team activations. There was variability in emergency call duration ranging from 6 to 92 s (median 15 s; IQR 12–19). The sensitivity and specificity of calls for a CA was 91% (86.4–94.6%) and 62% (55.5–68.7%), respectively. Sensitivity did not change with call duration but specificity increased from 38% (25.8–51.0%) for the shortest calls to 82% (69.5–89.6%) for longer calls; p=0.03. The return of spontaneous circulation rate was 38% for calls when the patient was confirmed as in CA upon arrival of the resuscitation team. Survival to hospital discharge rates was higher in patients with shorter call durations (26%) than calls with longer call duration (12%); p=0.028. Five themes emerged identifying reasons for the increased call delay.ConclusionThere is variability in duration and diagnostic accuracy of in-hospital emergency calls. This is associated with delayed activation of the emergency response. The attempt to differentiate between ME and CA is a source of confusion. A single clinical emergency response for CA and ME calls may provide a more focused and timely emergency response.
The highly dynamic response of a continuously injected liquid fuel jet to rotating detonation waves is a critical parameter in the design, performance optimization, and modeling of a rotating ...detonation engine (RDE). In this work, this response is spatio-temporally resolved from the fuel injection point to the detonation channel using planar laser-induced fluorescence (PLIF) at imaging rates up to 1 MHz. A rotating detonation combustor (RDC) is operated on hydrogen and air to sustain stable detonation waves that interact in a one-way coupled manner with a single liquid fuel jet that propagates into the combustion chamber with cycle periods of ∼250 µs. Diesel is utilized as a realistic fuel surrogate with higher aromatic compounds to enable fluorescence excitation using the 355 nm third-harmonic output of a burst-mode Nd:YAG laser. By optimizing the technique to accommodate orders of magnitude variations in the fuel density throughout the injection process, the PLIF data enable measurements of (i) the overall refill dynamics after the arrival of the detonation wave, (ii) changes in the liquid spray trajectory with microsecond temporal resolution, and (iii) the time required to reestablish the quasi-steady axial refilling process as a function of peak chamber pressure relative to the air- and liquid-injector pressure drops. As the passage of the detonation wave imparts significant changes in the momentum flux ratio, the qualitative liquid break-up process and spatial distribution of the spray also vary significantly in time. Only as the injection system recovers late in the cycle does the fuel spray eventually return to a quasi-steady position and allow comparisons with theoretical jet trajectories. These data, enabled by ultra-high-speed PLIF imaging, represent some of the first detailed measurements for quantifying the dynamic response and recovery of liquid jets exposed to periodic detonations in an operating RDC.
Cardiac arrest affects 30-35, 000 hospitalised patients in the UK every year. For these patients to be given the best chance of survival, high quality cardiopulmonary resuscitation (CPR) must be ...delivered, however the quality of CPR in real-life is often suboptimal. CPR feedback devices have been shown to improve CPR quality in the pre-hospital setting and post-event debriefing can improve adherence to guidelines and CPR quality. However, the evidence for use of these improvement methods in hospital remains unclear. The CPR quality improvement initiative is a prospective cohort study of the Q-CPR real-time feedback device combined with post-event debriefing in hospitalised adult patients who sustain a cardiac arrest.
The primary objective of this trial is to assess whether a CPR quality improvement initiative will improve rate of return of sustained spontaneous circulation in in-hospital-cardiac-arrest patients. The study is set in one NHS trust operating three hospital sites. Secondary objectives will evaluate: any return of spontaneous circulation; survival to hospital discharge and patient cerebral performance category at discharge; quality of CPR variables and cardiac arrest team factors.
All three sites will have an initial control phase before any improvements are implemented; site 1 will implement audiovisual feedback combined with post event debriefing, site 2 will implement audiovisual feedback only and site 3 will remain as a control site to measure any changes in outcome due to any other trust-wide changes in resuscitation practice. All adult patients sustaining a cardiac arrest and receiving resuscitation from the hospital cardiac arrest team will be included. Patients will be excluded if; they have a Do-not-attempt resuscitation order written and documented in their medical records, the cardiac arrest is not attended by a resuscitation team, the arrest occurs out-of-hospital or the patient has previously participated in this study. The trial will recruit a total of 912 patients from the three hospital sites.
This trial will evaluate patient and process focussed outcomes following the implementation of a CPR quality improvement initiative using real-time audiovisual feedback and post event debriefing.
ISRCTN56583860.
Context: Implementing the Affordable Care Act (ACA) in 2014 will require effective enrollment and outreach efforts to previously uninsured individuals now eligible for coverage. Methods: From 1996 to ...2013, the Health Communication Research Laboratory conducted more than 40 original studies with more than 30,000 participants to learn how to improve the reach to and effectiveness of health information for low-income and racial/ethnic minority populations. We synthesized the findings from this body of research and used them to inform current challenges in implementing the ACA. Findings: We found empirical support for 5 recommendations regarding partnerships, outreach, messages and messengers, life priorities of low-income individuals and families, and the information environment. We translated these into 12 action steps. Conclusions: Health communication science can inform the development and execution of strategies to increase the public's understanding of the ACA and to support the enrollment of eligible individuals into Medicaid or the Health Insurance Marketplace.
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