OBJECTIVES
We sought to assess the effect of baseline ejection fraction on survival difference between patients with life-threatening ventricular arrhythmias who were treated with an antiarrhythmic ...drug (AAD) or implantable cardioverter-defibrillator (ICD).
BACKGROUND
The Antiarrhythmics Versus Implantable Defibrillators (AVID) study demonstrated improved survival in patients with ventricular fibrillation or ventricular tachycardia with a left ventricular ejection fraction (LVEF) ≤0.40 or hemodynamic compromise.
METHODS
Survival differences between AAD-treated and ICD-treated patients entered into the AVID study (patients presenting with sustained ventricular arrhythmia associated with an LVEF ≤0.40 or hemodynamic compromise) were compared at different levels of ejection fraction.
RESULTS
In patients with an LVEF ≥0.35, there was no difference in survival between AAD-treated and ICD-treated patients. A test for interaction was not significant, but had low power to detect an interaction. For patients with an LVEF 0.20 to 0.34, there was a significantly improved survival with ICD as compared with AAD therapy. In the smaller subgroup with an LVEF <0.20, the same magnitude of survival difference was seen as that in the 0.20 to 0.34 LVEF subgroup, but the difference did not reach statistical significance.
CONCLUSIONS
These data suggest that patients with relatively well-preserved LVEF (≥0.35) may not have better survival when treated with the ICD as compared with AADs. At a lower LVEF, the ICD appears to offer improved survival as compared with AADs. Prospective studies with larger patient numbers are needed to assess the effect of relatively well-preserved ejection fraction (≥0.35) on the relative treatment effect of AADs and the ICDs.
This paper presents the characterization of a resistive HVDC reference divider and methods to establish a traceability. The divider is designed for use as a laboratory reference for calibration of ...HVDC measuring systems up to 1000 kV. Targeting a measurement uncertainty of 20 ppm at full voltage has put a focus on the temperature coefficients of the resistors, elimination of humidity dependence and control of leakage currents in the high voltage arm.
The automatic external defibrillator is a simple device that can be used by nonprofessional rescuers to treat cardiac arrest. In 1287 consecutive patients with out-of-hospital cardiac arrest, we ...assessed the results of initial treatment with this device by firefighters who arrived first at the scene, as compared with the results of standard defibrillation administered by paramedics who arrived slightly after the firefighters. Of 276 patients who were initially treated by firefighters using the automatic defibrillator, 84 (30 percent) survived to hospital discharge (expected rate according to a logistic model, 17 percent; P less than 0.001), as compared with 44 (19 percent) of 228 patients when fire-fighters delivered only basic cardiopulmonary resuscitation and the first defibrillation was performed after the arrival of the paramedic team. Few patients with conditions other than ventricular fibrillation survived. In a multivariate analysis of characteristics that influenced survival after ventricular fibrillation, a better survival rate was related to a witnessed collapse (odds ratio, 3.9; 95 percent confidence interval, 2.0 to 7.6), younger age (odds ratio, 1.2; 95 percent confidence interval, 1.0 to 1.4), the presence of "coarse" (higher-amplitude) fibrillation (odds ratio, 4.2; 95 percent confidence interval, 1.6 to 11.0), a shorter response time for paramedics (odds ratio, 1.4; 95 percent confidence interval, 1.0 to 2.1), and initial treatment by firefighters using an automatic external defibrillator (odds ratio, 1.8; 95 percent confidence interval, 1.1 to 2.9). These findings support the widespread use of the automatic external defibrillator as an important part of the treatment of out-of-hospital cardiac arrest, although the overall impact of the use of this device on community survival rates is still uncertain.
A number of factors have previously been shown to be predictive of survival from out-of-hospital ventricular fibrillation. These include witnessed collapse, prompt initiation of cardiopulmonary ...resuscitation, early application of defibrillation, and younger age. Arrests occurring away from home are also associated with improved survival. Additionally, hospital mortality after successful resuscitation has been related to a history of congestive heart failure as well as to some of the factors noted above. An association of prearrest comorbidity with outcome has not been systematically evaluated.
We define here a comorbidity index, which is constructed from histories of chronic conditions as well as a number of recent symptoms in 282 victims of out-of-hospital VF. This indicator of comorbidity is strongly associated with outcome (P = .004). However, when analyzing a comprehensive set of predictors of survival after out-of-hospital ventricular fibrillation, including the index of comorbidity, we could identify overall only about one fourth of the variation that one might hope to account for.
Comorbidity appears to be an important (but usually overlooked) predictor of survival from out-of-hospital ventricular fibrillation. However, most of the statistical variability in predicting survival remains unexplained when we consider comorbidity in conjunction with previously identified predictors of survival.
A Controlled Trial of Erenumab for Episodic Migraine Goadsby, Peter J; Reuter, Uwe; Hallström, Yngve ...
New England journal of medicine/The New England journal of medicine,
11/2017, Letnik:
377, Številka:
22
Journal Article
Recenzirano
Odprti dostop
We tested erenumab, a fully human monoclonal antibody that inhibits the calcitonin gene-related peptide receptor, for the prevention of episodic migraine.
We randomly assigned patients to receive a ...subcutaneous injection of either erenumab, at a dose of 70 mg or 140 mg, or placebo monthly for 6 months. The primary end point was the change from baseline to months 4 through 6 in the mean number of migraine days per month. Secondary end points were a 50% or greater reduction in mean migraine days per month, change in the number of days of use of acute migraine-specific medication, and change in scores on the physical-impairment and everyday-activities domains of the Migraine Physical Function Impact Diary (scale transformed to 0 to 100, with higher scores representing greater migraine burden on functioning).
A total of 955 patients underwent randomization: 317 were assigned to the 70-mg erenumab group, 319 to the 140-mg erenumab group, and 319 to the placebo group. The mean number of migraine days per month at baseline was 8.3 in the overall population; by months 4 through 6, the number of days was reduced by 3.2 in the 70-mg erenumab group and by 3.7 in the 140-mg erenumab group, as compared with 1.8 days in the placebo group (P<0.001 for each dose vs. placebo). A 50% or greater reduction in the mean number of migraine days per month was achieved for 43.3% of patients in the 70-mg erenumab group and 50.0% of patients in the 140-mg erenumab group, as compared with 26.6% in the placebo group (P<0.001 for each dose vs. placebo), and the number of days of use of acute migraine-specific medication was reduced by 1.1 days in the 70-mg erenumab group and by 1.6 days in the 140-mg erenumab group, as compared with 0.2 days in the placebo group (P<0.001 for each dose vs. placebo). Physical-impairment scores improved by 4.2 and 4.8 points in the 70-mg and 140-mg erenumab groups, respectively, as compared with 2.4 points in the placebo group (P<0.001 for each dose vs. placebo), and everyday-activities scores improved by 5.5 and 5.9 points in the 70-mg and 140-mg erenumab groups, respectively, as compared with 3.3 points in the placebo group (P<0.001 for each dose vs. placebo). The rates of adverse events were similar between erenumab and placebo.
Erenumab administered subcutaneously at a monthly dose of 70 mg or 140 mg significantly reduced migraine frequency, the effects of migraines on daily activities, and the use of acute migraine-specific medication over a period of 6 months. The long-term safety and durability of the effect of erenumab require further study. (Funded by Amgen and Novartis; STRIVE ClinicalTrials.gov number, NCT02456740 .).
Out-of-hospital sudden cardiac arrest is a key area in which to study the dual problem of the poorer health status of minority populations and their poorer access to the health care system. We ...proposed to examine the relationship between race (Black/White) and survival.
We determined the incidence and outcome of cardiac arrests in Seattle for which medical assistance was requested.
Over a 26-month period, the age-adjusted incidence of out-of-hospital cardiac arrest was twice as great in Blacks than in Whites (3.4 vs 1.6 per 1000 aged 20 and over). The initial resuscitation rate was markedly poorer in the Black victims (17.1% vs 40.7%), and rates of survival to hospital discharge were also lower in Blacks (9.4% vs 17.1%). Both effective initial resuscitation and survival were significantly related to White race following adjustment for other covariates.
The differences in outcomes were not fully explained by features of the collapse or relevant service factors. Possible explanations include delays in instituting therapy, less bystander-initiated cardiopulmonary resuscitation, poorer levels of health, and differences in the underlying cardiac disorders.
Global food production is identified as a great threat to the environment. In combination with technical advances in agriculture, dietary change is suggested to be necessary to reduce the ...environmental impact of the food system. In this article a systematic review assessing the environmental impact of dietary change is performed. The aims are to i) evaluate the scientific basis of dietary scenario analysis, ii) estimate the potential environmental effects of dietary change, iii) identify methodological aspects of importance for outcome and iv) identify current gaps in knowledge. The review includes 14 peer-reviewed journal articles assessing the GHG emissions and land use demand of in total 49 dietary scenarios. The results suggest that dietary change, in areas with affluent diet, could play an important role in reaching environmental goals, with up to 50% potential to reduce GHG emissions and land use demand associated with the current diet. The choice of functional unit, system boundaries and methods for scenario development and accounting for uncertainties are methodological aspects identified to have major influence on the quality and results of dietary scenario analysis. Further understanding of dietary change as a measure for more sustainable food systems requires improved knowledge of uncertainty in dietary scenario studies, environmental impact from substitutes and complements to meat and the effect of dietary change in different groups of populations and geographical locations. (C) 2014 Elsevier Ltd. All rights reserved.
To test the hypothesis that in survivors of myocardial infarction, the suppression of ventricular premature depolarizations improves survival free of cardiac arrest and arrhythmic death.
...International, prospective, multicenter, randomized, placebo-controlled trial.
University and community hospitals.
A total of 3549 patients with myocardial infarction and left ventricular dysfunction.
Administration of encainide, flecainide, moricizine, or placebo to suppress ventricular premature depolarizations.
Overall survival and survival free of cardiac arrest or arrhythmic death were compared in patients randomized to long-term, active antiarrhythmic drug therapy vs corresponding placebo, using the stratified log rank statistic.
At 1 year from the time of randomization to blinded therapy, 95% of placebo-treated patients vs 90% of active drug-treated patients remained alive (P = .0006). Similarly, at 1 year, 96% of placebo-treated patients vs 93% of active drug-treated patients remained free of cardiac arrest or arrhythmic death (P = .003).
The suppression of asymptomatic or mildly symptomatic ventricular arrhythmias after myocardial infarction does not improve survival and can increase mortality. Treatment strategies designed solely to suppress these arrhythmias should no longer be followed.
Objectives: Our objectives are to describe details of the dispatcher assisted cardiopulmonary resuscitation (CPR) instruction program we implemented during a 12 years study and to provide estimates ...of the potential number of out-of-hospital cardiac arrests that might benefit from such instruction based on data from the last 77 months.
Methods: Basic data were obtained for all episodes of out-of-hospital cardiac arrest in the city of Seattle, as well as all emergency medical services (EMS) dispatches for suspected cardiac arrest. In addition to EMS run reports, data sources included audio tapes of dispatches, and interviews of callers. These data were used in a potential benefit analysis.
Results: Over a period of 77 months, 54% (3320/6130) of cardiac arrests received advanced cardiac life support (ACLS) by Seattle Fire Department emergency medical technicians (EMTs) and paramedics. We estimated that 29.9% (994/3320) of cardiac arrests in Seattle treated by EMS could have theoretically benefited from dispatcher assisted CPR. No serious adverse consequences of a dispatcher assisted CPR program were observed. Failure to identify a cardiac arrest by dispatchers was largely attributed to deviation from a well-defined protocol. However, non-arrests identified, initially as arrests appeared to be unavoidable.
Conclusions: In the city of Seattle, some 29.9% of all out-of-hospital cardiac arrest victims who received ACLS had the potential to benefit from dispatcher assisted CPR.
Objectivos: os nossos objectivos são descrever detalhes do programa de reanimação cardio-pulmonar (RCP) com instruções por operador telefónico que implementamos durante ao longo de 12 anos e estimar do número potencial de paragens cardı́acas extra-hospitalares que podem ter beneficiado dessas instruções, com base nos dados dos últimos 77 meses.
Métodos: foram obtidos dados básicos de todos os episódios de paragem cardı́aca extra-hospitalar na cidade de Seattle, bem como todas as chamadas operadas pelos serviços médicos de emergência (SEM) por suspeita de paragem cardı́aca. Além dos relatórios feitos pelos SEM, as fontes de dados incluı́ram gravações audio das chamadas e entrevistas às pessoas que fizeram o telefonema. Estes dados foram utilizados para analisar o benefı́cio potencial.
Resultados: Durante um perı́odo de 77 meses, 54% (3320/6139) das paragens cardı́acas receberam Suporte Avançado de Vida (SAV) por técnicos de emergência médica (TEM) e paramédicos do Departamento de Bombeiros de Seattle. Estimamos que 29.9% (994/3320) das paragens cardı́acas em Seattle tratadas pelo SEM teriam em teoria beneficiado de tratamento de paragem cardı́aca assistido por operador telefónico. Não se observaram consequências adversas graves nos programas de tratamento de PCR assistido por operadores telefónicos. A incapacidade dos operadores em identificar uma paragem cardı́aca foi atribuı́da na grande maioria a desvios de um protocolo bem definido. No entanto, situações de não paragem, identificadas inicialmente como paragem, parecem ser inevitáveis.
Conclusões: Na cidade de Seattle, cerca de 29.9% de todas as paragens cardı́acas extra-hospitalares que receberam ACLS tinham potencial para beneficiar de tratamento da PCR assistido por operador telefónico.
Objetivos: Nuestros objetivos son describir detalles del programa de instrucciones de reanimación cardiopulmonar(RCP) asistida por despachador telefónico que implementamos en un estudio de 12 años, y proveer estimación del número potencial de paros cardı́acos extrahospitalarios que podrı́an beneficiarse con tales instrucciones, basados en datos de los últimos 77 meses.
Métodos: Se obtuvieron los datos básicos de todos los episodios de paro cardı́aco extrahospitalario en la ciudad de Seattle, al igual que todos los despachos de servicios de emergencias médicas (EMS) para sospechas de paros cardı́acos. Además de los reportes de salidas de EMS, la fuente de datos incluyó las cintas de audio de los despachos y entrevistas con los solicitantes. Estos datos fueron usados en un análisis de beneficio potencial.
Resultados : En un perı́odo de 77 meses, 54% de los llamados (3320/6130) de los llamados por paro cardı́aco recibieron soporte cardı́aco vital avanzado por los técnicos en emergencias médicas (EMTs) y paramédicos del Departamento de Bomberos de Seattle. Estimamos que el 29.9% (994/3320) de los paros cardı́acos en Seattle tratados por los EMS podrı́an beneficiarse teóricamente con RCP asistida por despachador. No se observaron consecuencias adversas de los programas de RCP asistida por despachador. La falla en la identificación de paro cardı́aco fue atribuida grandemente a desviación del protocolo bien definido. Sin embargo, no parecen evitables cuadros que no resultaron ser paros y que inicialmente como paros.
Conclusiones: En la ciudad de Seattle, el 29.9% de todos los paros cardı́acos extrahospitalarios que recibieron ACLS tuvieron el potencial de beneficiarse con RCP asistida por despachador.
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