Spontaneous Pneumothorax Outcome Study (SPOT phase I): a 2-year review

Spontaneous pneumothorax: time to rethink management?

There are substantial differences in international guidelines for the management of pneumothorax and much geographical variation in clinical practice. These discrepancies have, in part, been driven by a paucity of high-quality evidence. Advances in diagnostic techniques have increasingly allowed the identification of lung abnormalities in patients previously labelled as having primary spontaneous pneumothorax, a group in whom recommended management differs from those with clinically apparent lung disease. Pathophysiological mechanisms underlying pneumothorax are now better understood and this may have implications for clinical management. Risk stratification of patients at baseline could help to identify subgroups at higher risk of recurrent pneumothorax who would benefit from early intervention to prevent recurrence. Further research into the roles of conservative management, Heimlich valves, digital air-leak monitoring, and pleurodesis at first presentation might lead to an increase in their use in the future.

Interventional strategies associated with improvements in survival for out-of-hospital cardiac arrests in Singapore over 10 years

AIM

We aim to study if there has been an improvement in survival for Out-of-Hospital Cardiac Arrest (OHCA) in Singapore, the effects of various interventional strategies over the past 10 years, and identify strategies that contributed to improved survival.

METHODS

Rates of OHCA survival were compared between 2001-2004 and 2010-2012, using nationwide data for all OHCA presenting to EMS and public hospitals. A multivariate logistic regression model for survival to discharge was constructed to identify strategies with significant impact.

RESULTS

A total of 5453 cases were included, 2428 cases from 2001 to 2004 and 3025 cases from 2010 to 2012. There was significant improvement in Utstein (witnessed, shockable) survival to discharge from 2001-2004 (2.5%) to 2010-2012 (11.0%), adjusted odds ratio (OR) 9.6 [95% CI: 2.2-41.9]). Overall survival to discharge increased from 1.6% to 3.2% (adjusted OR 2.2 [1.5-3.3]). Bystander CPR rates increased from 19.7% to 22.4% (p=0.02). The multivariate regression model (adjusted for important non-modifiable risk factors) showed that response time <8min (OR 1.5 [1.0-2.3]), bystander AED (OR 5.8 [2.0-16.2]), and post-resuscitation hypothermia (OR 30.0 [11.5-78.0]) were significantly associated with survival to hospital discharge. Conversely, pre-hospital epinephrine (OR 0.6 [0.4-0.9]) was associated negatively with survival.

CONCLUSIONS

OHCA survival has improved in Singapore over the past 10 years. Improvement in response time, public AEDs and post-resuscitation hypothermia appear to have contributed to the increase in survival. Singapore's experience might suggest that developing EMS systems should focus on reducing times to basic life support, including bystander defibrillation and post-resuscitation care.

Review of management of primary spontaneous pneumothorax: is the best evidence clearer 15 years on?

In 1993 Emergency Medicine Australasia (then Emergency Medicine [Fremantle]) published a therapeutic review on the management of spontaneous pneumothorax. That review found a lack of high-quality evidence on which to base management decisions and a variety of therapeutic options without clear superiority one over another. Now, almost 15 years later, the present paper aims to revisit the evidence base to see if management choices are clearer.