Abstract P2-12-11: Does conservative surgery treatment for locally advanced breast cancer safe after neoadjuvant treatment?

BACKGROUND:

The aim of this study was to assess the oncological efficacy of breast conserving surgery (BCS) after neoadjuvant chemotherapy in patients with local advanced breast cancer.

PATIENTS AND METHODS:

A retrospective cohort study was conducted with locally advanced breast cancer invasive (Stage IIb to III) treated at ICESP, an oncologic referral center between 2008 and 2016. Endpoints were disease free survival (DFS), local disease free survival (LDFS) and overall survival (OS). Multivariable analyses were performed using Cox proportional hazards models.

RESULTS:

530 patients were included, 26% (138) were stage IIB, 41.9% (222) IIIA, 29.6% (157) IIIB and 2.5% (13) IIIA. 88.8% (470) were invasive ductal carcinoma. The mean age was 51.5(23-95). 95.5% and 4.5% were submitted Neoadjuvant Chemotherapy and Hormone therapy, respectively. The BCS were performed in 24.5% (130) patients versus 75.5% (400) of mastectomies. The mean follow up was 36.4(0.16-80.2) months. There were no differences in local disease free-survival 59 (95%CI 58-61) versus 60 (95%CI 57-60); p=0.4 and overall survival 56.2 (95%CI 52-60) versus 59.3(95%CI 53-65); p= 0.24 for mastectomy and BCS. The disease free survival was lower at mastectomy group 51.4 (95%CI 49-53) versus 56,8 (95%CI 53-59); p=0.01. Logistic regression models were significant only for cancer stage both patterns, although the results were better for masses, particularly when kinetic assessments were included (LR 12.8; p = 0.005)

CONCLUSION:

In our population, the BCS does not affect the overall and local disease-free survival rates, which seems to be safe to perform in patients who desire to conserve the breast after neoadjuvant treatment.

Citation Format: Boufelli G, Mota BS, Franca FC, Doria MT, Maesaka JY, Ricci MD, Piato JRM, Rocha FBC, Giribela AHG, Gonçalves R, Masili-Oku S, Mano MS, Chala LF, Thompson BM, Baracat EC, Filassi JR. Does conservative surgery treatment for locally advanced breast cancer safe after neoadjuvant treatment? [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-11.

Effect of ACL deficiency on MCL strains and joint kinematics

The knee joint is partially stabilized by the interaction of multiple ligament structures. This study tested the interdependent functions of the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) by evaluating the effects of ACL deficiency on local MCL strain while simultaneously measuring joint kinematics under specific loading scenarios. A structural testing machine applied anterior translation and valgus rotation (limits 100 N and 10 N m, respectively) to the tibia of ten human cadaveric knees with the ACL intact or severed. A three-dimensional motion analysis system measured joint kinematics and MCL tissue strain in 18 regions of the superficial MCL. ACL deficiency significantly increased MCL strains by 1.8% (p<0.05) during anterior translation, bringing ligament fibers to strain levels characteristic of microtrauma. In contrast, ACL transection had no effect on MCL strains during valgus rotation (increase of only 0.1%). Therefore, isolated valgus rotation in the ACL-deficient knee was nondetrimental to the MCL. The ACL was also found to promote internal tibial rotation during anterior translation, which in turn decreased strains near the femoral insertion of the MCL. These data advance the basic structure-function understanding of the MCL, and may benefit the treatment of ACL injuries by improving the knowledge of ACL function and clarifying motions that are potentially harmful to secondary stabilizers.

Effect of dermatan sulfate glycosaminoglycans on the quasi-static material properties of the human medial collateral ligament

The glycosaminoglycan of decorin, dermatan sulfate (DS), has been suggested to contribute to the mechanical properties of soft connective tissues such as ligaments and tendons. This study investigated the mechanical function of DS in human medial collateral ligaments (MCL) using nondestructive shear and tensile material tests performed before and after targeted removal of DS with chondroitinase B (ChB). The quasi-static elastic material properties of human MCL were unchanged after DS removal. At peak deformation, tensile and shear stresses in ChB treated tissue were within 0.5% (p>0.70) and 2.0% (p>0.30) of pre-treatment values, respectively. From pre- to post-ChB treatment under tensile loading, the tensile tangent modulus went from 242+/-64 to 233+/-57 MPa (p=0.44), and tissue strain at peak deformation went from 4.3+/-0.3% to 4.4+/-0.3% (p=0.54). Tissue hysteresis was unaffected by DS removal for both tensile and shear loading. Biochemical analysis confirmed that 90% of DS was removed by ChB treatment when compared to control samples, and transmission electron microscopy (TEM) imaging further verified the degradation of DS by showing an 88% reduction (p<.001) of sulfated glycosaminoglycans in ChB treated tissue. These results demonstrate that DS in mature knee MCL tissue does not resist tensile or shear deformation under quasi-static loading conditions, challenging the theory that decorin proteoglycans contribute to the elastic material behavior of ligament.

An historical commentary on the physiological effects of music: Tomatis, Mozart and neuropsychology

This article provides an overview of the theoretical underpinnings of the Tomatis Method, along with a commentary on other forms of sound/music training and the need for research. A public debate was sparked over the "Mozart Effect." This debate has turned out to be unfortunate because the real story is being missed. The real story starts with Alfred Tomatis, M.D., scientist and innovator. Dr. Tomatis was the first to develop a technique using modified music to stimulate the rich interconnections between the ear and the nervous system to integrate aspects of human development and behavior. The originating theories behind the Tomatis Method are reviewed to describe the ear's clear connection to the brain and the nervous system. The "neuropsychology of sound training" describes how and what the Tomatis Method effects. Since Dr. Tomatis opened this field in the mid 20th century, no fewer than a dozen offshoot and related systems of training have been developed. Though each new system of treatment makes claims of effectiveness, no research exists to substantiate their claims. Rather, each simplified system bases its "right to exist and advertise" on the claimed relationship to Tomatis and his complex Method. Research is desperately needed in this area. The 50 years of clinical experience and anecdotal evidence amassed by Tomatis show that sound stimulation can provide a valuable remediation and developmental training tool for people of all ages. Offshoot systems have watered down the Tomatis Method without research to guide the decisions of simplifying the techniques and equipment.

1998-1999 SAEM emergency medicine faculty salary and benefits survey

OBJECTIVES

The Society for Academic Emergency Medicine (SAEM) commissioned an emergency medicine (EM) faculty salary and benefits survey for all 1998 residency review committee (RRC)-EM-accredited programs using the SAEM fourth-generation survey instrument. Responses were collected by SAEM and blinded from the investigators.

METHODS

Blinded program and individual faculty data were entered into a customized version of FileMaker Pro, a relational database program with a built-in statistical package. Salary data were sorted by program region, faculty title, American Board of Emergency Medicine (ABEM) certification, academic rank, years postresidency, program size, and whether data were reported to the American Association of Medical Colleges (AAMC). Demographic data were analyzed with regard to numerous criteria, including department staffing levels, ED volumes, ED length of stay, department income sources, salary incentive components, and specific type and value of fringe benefits offered. Data were compared with those from previous SAEM studies.

RESULTS

Seventy-three of 120 (61%) accredited programs responded, yielding usable data for 70 programs and 965 full-time faculty among the four AAMC regions. Mean salaries were reported as follows: all faculty, $167,478; first-year faculty, $140,616; programs reporting data to the AAMC, $161,794; programs not reporting data to the AAMC, $165,724. Mean salaries as reported by AAMC region: northeast, $167,876; south, $160,586; midwest, $190,957; west, $148,977.

CONCLUSIONS

Reported salaries for full-time EM residency faculty continue to rise. Significant regional differences in salaries have been present in all four SAEM surveys. Nonclinical hours are compensated at approximately one-half the rate paid for clinical hours. The demographic data indicate that EM residency faculty are working at the upper extremes of numbers of patient encounters per physician, patient acuity levels, and department lengths of stay.

1995-1996 SAEM emergency medicine faculty salary/benefits survey

OBJECTIVE

The Society for Academic Emergency Medicine (SAEM) commissioned an emergency medicine (EM) faculty salary and benefit survey for all 1995 Residency Review Committee in Emergency Medicine (RRC-EM)-accredited programs using the SAEM third-generation survey instrument. Responses were collected by SAEM and blinded from the investigators.

POPULATION

Seventy-six of 112 (68%) accredited programs responded, yielding data for 1,032 full-time faculty among the four Association of American Medical Colleges (AAMC) regions.

METHODS

Blinded program and individual faculty data were entered into a customized version of Filemaker Pro, a relational database program with a built-in statistical package. Salary data were sorted by 115 separate criteria such as program regions, faculty title, American Board of Emergency Medicine (ABEM) certification, academic rank, years postresidency, program size, and whether data were reported to AAMC. Demographic data from 132 categories were analyzed and included number of staff and residents per shift, number of intensive care unit (ICU) beds, obstacles to hiring new staff, and specific type and value of fringe benefits offered. Data were compared with those from the 1990 and 1992 SAEM and the 1995-96 AAMC studies.

RESULTS

Mean salaries were reported as follows: all faculty, $158,100; first-year faculty, $131,074; programs reporting data to AAMC, $152,198; programs not reporting data to AAMC, $169,251. Mean salaries as reported by AAMC region: northeast, $155,909; south, $155,403; midwest, $172,260; west, $139,930. Mean salaries as reported by program financial source: community, $175,599; university, $152,878; municipal, $141,566.

CONCLUSIONS

Reported salaries for full-time EM residency faculty continue to rise. Salaries in programs reporting data to the AAMC are considerably lower than those not reporting. The gap between ABEM-certified and non-ABEM-certified faculty continues to widen. Residency-trained faculty are now shown to earn more than non-residency-trained faculty. Significant regional differences in salaries have been present in all three SAEM surveys.

Selenium regulation of selenium-dependent glutathione peroxidases in animals and transfected CHO cells

Glutathione peroxidase (GPX1) was the first identified selenium-dependent enzyme, and this enzyme has been most useful as a biochemical indicator of selenium (Se) status and the parameter of choice for determining Se requirements. We have continued to study Se regulation of GPX1 to better understand the underlying mechanism and to gain insight into how cells themselves regulate nutrient status. In progressive Se deficiency in rats, GPX1 activity, protein and mRNA all decrease in a dramatic, coordinated and exponential fashion such that Se-deficient GPX1 mRNA levels are 6-15% of Se-adequate levels. mRNA levels for other Se-dependent proteins are far less decreased in the same animals. The mRNA levels for a second Se-dependent peroxidase, phospholipid hydroperoxide glutathione peroxidase (GPX4), are little affected by Se deficiency, demonstrating that Se regulation of GPX1 is unique. Se regulation of GPX1 activity in growing male and female rats shows that the Se requirement is 100 ng/g diet, based on liver GPX1 activity; use of GPX1 mRNA as the parameter indicates that the Se requirement is nearer to 50 ng Se/g diet in both male and female rats. This approach will readily detect an altered dietary Se requirement, as shown by the incremental increases in dietary Se requirement by 150, 100 or 50 ng Se/g diet in Se-deficient rat pups repleted with Se for 3, 7 or 14 d, respectively. Studies with CHO cells stably transfected with recombinant GPX1 also show that overexpression of GPX1 does not alter the minimum level of media Se necessary for Se-adequate levels of GPX1 activity or mRNA. We hypothesize that classical GPX1 has an integral biological role in the mechanism used by cells to regulate Se status, making GPX1 an especially useful and effective parameter for determining Se requirements in animals.

Western Nebraska family (family D) with autosomal dominant parkinsonism

The etiology of Parkinson's disease (PD) remains uncertain. Environmental influences may have an important role, but genetic factors have been firmly implicated in several recently reported kindreds. We studied a family (family D) whose ancestors probably immigrated to the United States from England. The pedigree contains 188 individuals spanning six generations with 18 affected members. Autosomal dominant inheritance is present. Typical levodopa-responsive PD with bradykinesia, rigidity, resting tremor, and impaired postural reflexes develops. Eye movement abnormalities, pyramidal and cerebellar signs, sensory disturbances, and orthostatic blood pressure changes do not occur. Disease progression is slow. PET with [18F]-6-fluoro-L-dopa (FD) performed on an affected individual revealed decreased uptake of FD in a pattern consistent with PD. Autopsy performed on another affected individual demonstrated neuronal and pigmentary loss, gliosis, and Lewy bodies in the substantia nigra pars compacta. This large kindred appears to represent a neurodegenerative disorder closely resembling, if not identical to, idiopathic PD.

Iontophoretic treatment of herpetic whitlow

Herpetic whitlow can be a vector for spread of infection, especially among health care professionals. Until now, treatment has been inadequate. In two patients with documented herpetic infections of the finger, the antiviral drug idoxuridine was applied to the lesions by cathodal iontophoresis. Results were characterized by rapid relief of discomfort and swelling, rapid appearance and coalescence of vesicles, and rapid healing, with reduced pain and little or no paresthesia. No recurrences have been noted in the two patients after 42 and 38 months. The positive beneficial results indicate that aggressive iontophoretic treatment for herpetic whitlow is useful and justified.

Digoxin levels in prehospital sudden-death syndrome

Digitalis toxicity is common and has been associated with ventricular dysrhythmias. Digoxin levels in patients who suffer prehospital sudden death have never been studied. This study measured digoxin levels in a population of sudden-death patients. During the 15-week study period, 252 patients in cardiac arrest were seen by an urban paramedic system. During daytime hours, paramedics were requested to obtain a blood sample from sudden-death patients; the samples were subsequently analyzed for digoxin by means of radioimmunoassay. Thirty-nine patients had measured digoxin levels drawn; 28 (71.8%) were in the therapeutic range (0.5-2.1 ng/mL), and four (10.2%) were in the toxic range (greater than 2.1 ng/mL). The patients with toxic dogoxin levels and those with nontoxic levels had similar resuscitation rates (50.0% vs. 34.3%, P = NS), but none were found in ventricular fibrillation. Emergency medical services personnel should consider digoxin toxicity as a potential etiology of arrest.

Development of a staff training program at the Wesley Hospital

This paper reports the development of a staff training program at The Wesley Hospital in response to perceived needs. A training needs analysis identified priorities for training. Three courses have been run: decision making workshops, stress management workshops, and an assertion seminar. The design of these courses, and staff responses are discussed. Future developments in the training program are proposed.

Calcium: limited indications, some danger

Calcium chloride has been advocated since the 1920s for the resuscitation of asystole, electromechanical dissociation (EMD), and ventricular fibrillation. Reports of side effects and complications have been numerous. Studies of calcium assays following American Heart Association recommended dosages have shown dangerously elevated serum levels. Large retrospective clinical studies in Milwaukee and Tampa have found no evidence of improved survival with calcium chloride in asystole and EMD. A prospective randomized double-blind study comparing calcium chloride and saline controls in the Milwaukee Paramedic system for asystole and EMD using standard AHA protocols showed no statistically significant difference in resuscitation rates or long-term survival between the calcium and no-calcium groups for the rhythm of asystole. Although patients with EMD had statistically improved resuscitation rates when calcium chloride was given, only one of the patients survived to hospital discharge. Because of the low rates of resuscitation and long-term survival in patients presenting in asystole and EMD, proving that calcium chloride does not enhance survival would require large multicenter trials. However, since no controlled study has ever documented significant benefit, its routine use in asystole and EMD cannot be supported. Calcium has long been used in medical treatment of hypocalcemic and hyperkalemic states and should be administered in moribund patients who have the proper clinical history and clinical signs of hypocalcemia.

Prophylactic lidocaine in the prehospital patient with chest pain of suspected cardiac origin

The prophylactic use of lidocaine in the patient with cardiac chest pain has been reported to reduce the incidence of sudden death from ventricular dysrhythmias in the hospital setting, but few studies have been done in the early prehospital phase. We conducted a randomized, prospective study comparing the effects of lidocaine versus no lidocaine in stable patients presenting with chest pain to a paramedic system. In a one-year period, 446 patients qualified for the study; 222 received lidocaine and 224 did not. The overall hospital mortality of the two groups was 8.1% and 6.7%, respectively (P = .35). Four patients in each group developed sudden death in the prehospital and emergency department settings with ventricular dysrhythmia as the precipitating rhythm. One hundred twenty-nine (29%) had an acute myocardial infarction. The lidocaine and control group contained 68 and 61 of the patients, respectively, with an overall mortality rate of 14.7% and 13.1% (P = .45). The development of significant dysrhythmias (frequent premature ventricular contractions, ventricular tachycardia, bradycardia, second- and third-degree heart blocks) after initiation into the study was similar in both groups of patients. The use of lidocaine was a factor in decreasing systolic blood pressure (P less than 0.03) but did not appear to be clinically significant. For stable patients presenting with chest pain of suspected cardiac origin, prophylactic lidocaine in the prehospital setting was not effective in preventing life-threatening dysrhythmias, but clinically significant side effects were not noted either.

Decision making in prehospital sudden cardiac arrest

Many studies of prehospital resuscitation report on selected populations. We examined a series of 445 unselected nontraumatic cardiac arrests. Emergency cardiac care (ECC) was not initiated in 126 (28%). ECC was begun in 319 (78%), but was terminated in 132 (33%). Ninety-four (21%) were admitted to the hospital with palpable pulses and organized rhythm (successful resuscitation/save rate for patients presenting in ventricular fibrillation was 50%/25%. Multivariate regression analysis was used to identify the relative importance of significant variables in predicting survival, and the analysis identified the presence of ventricular fibrillation, short paramedic response times, and short paramedic treatment times.

Rib radiographs for trauma: useful or wasteful?

In trauma to the chest, the clinical impression and the physical findings of rib fractures are nonspecific. Fractures often are not seen on initial films. The principal diagnostic goal should be the detection of significant complications (pneumothorax, hemothorax, major vascular injury, or pulmonary contusion) requiring admission. The therapeutic effort should be to provide pain relief and prevent the delayed development of atelectasis or pneumonia in patients with painful chest wall injuries, whether or not a fracture is detected initially. An upright posteroanterior chest radiograph has the greatest yield in detecting fractures and complications resulting from them. Tomograms and expiratory, oblique, and "coned-down" views should not be done routinely. The use of these more specific examinations may be indicated, however, in such cases as trauma to ribs 1 to 3 or 9 to 12. Their selective use in isolated cases (trauma to ribs 1 to 3 or 9 to 12) and suspected child abuse may indicate the need for these more specific examinations. Because detection of pulmonary complications of chest trauma is most important, a delayed or repeat upright posteroanterior chest radiograph may be the most cost-effective second radiograph. Significant medical care cost savings may be appreciated by limiting the use of specific rib views to instances in which it might influence the patient's therapy.

Effects of rapid infusion with high pressure and large-bore i.v. tubing on red blood cell lysis and warming

A prototype large-bore intravenous tubing was developed and tested. Mean flow rates for blood (Hct 45%) and tap water were determined for several catheters at 600 mm Hg, 300 mm Hg, and gravity flow and were statistically analyzed by calculating the 95% confidence intervals. The degree of hemolysis during high pressure and flow was determined by measuring the plasma free hemoglobin using the spectrophotometric method. To determine if cold banked blood can be adequately warmed at high flow rates, thermocouples were used to measure the blood temperature before and after rapid infusion through a blood warmer. Results included maximum flow rates of 1,764 mL/min for tap water, and 1,714 mL/min for blood (Hct 45%) at 600 mm Hg through the large-bore tubing and an 8.5-F catheter. Flow rates for other pressure and catheter combinations were tabulated. The plasma-free hemoglobin increased slightly compared to controls with high pressure (less than or equal to 600 mm Hg) and flow rates. The increase correlated with less than 1% red blood cell lysis in all trials. When 13 C blood was infused through a warmer, blood temperature increased to 25.3 C at the maximum flow rate of 732 mL/min. Slightly higher heat gain resulted with slower infusion rates. We conclude that the prototype large-bore tubing and up to 600 mm Hg pressure provide rapid flow rates without significant hemolysis. Blood warming may be inadequate at higher flow rates.

Intraosseous infusion: an alternative route of pediatric intravascular access

Substantial difficulties can be encountered when establishing rapid intravascular access in critically ill children. The historic technique of tibial intraosseous infusion is presented as an alternate intravenous route in children less than 3 years old. Review of the literature reveals this technique to be a rapid, reliable method with an acceptably low complication rate. Substances absorbed through the marrow, flow rates, technical difficulties, and complications are discussed.

Comparison of clinical CPR studies in Milwaukee and elsewhere in the United States

As we mark the 25th anniversary of the clinical application of closed-chest cardiopulmonary resuscitation (SCPR), it is time to look back and analyze the progress we have made in the resuscitation of sudden death syndrome. Recent studies of SCPR's effectiveness have yielded mixed results, in comparison to early studies that were universally favorable. The continued toll of neurologic injury following SCPR resuscitation, and reinforcement of the importance of defibrillation in resuscitation, stimulate us to find improved forms of SCPR and improved methods of resuscitation delivery in emergency medical systems.

Traumatic cardiac arrest: scope of paramedic services

The challenge of the 1960s to ambulance care provision was the stimulus for the emergence of prehospital advanced life support (ALS) being provided by paramedic personnel. While services for cardiac disease have been accepted, paramedic activities for the trauma victim continue to be a concern for many trauma surgeons. The capability and success rate of treatment, and the time spent at the scene and during transport to the hospital have raised questions about the overall need for paramedic services. Our study period was from January 1, 1981, to December 31, 1982, and it covered 95 clinically dead trauma victims who were first seen and subsequently treated by paramedics working in a medically controlled emergency medical services system. Endotracheal intubation was successful in 81 of the patients (85%). Esophageal obturator airway use was viewed as unsuccessful intubation. Intravenous (IV) access utilizing 16-gauge angiocaths was placed successfully by a peripheral or jugular vein in 70 patients (74%). Thirty-three patients averaged 860 mL volume infusion (30 to 3,000 mL). Average scene time was 22 minutes. Scene time of patients with unsuccessful IV and endotracheal intubation was 14 minutes (P = .07). Fourteen patients (14.7%) were admitted to the operating room or intensive care unit. Only three of the study group (3.2%) survived.

Effects of high infusion pressure and large-bore tubing on intravenous flow rates

An in vitro study was conducted to determine the maximum flow rates that can be obtained with commercially available intravenous (IV) catheters, when infusion pressure and IV tubing size are modified. Standard tubing (3.2 mm ID) and two sizes of experimental large-bore tubing (5.0 mm and 6.4 mm ID) were tested with tap water and diluted packed cells (hematocrit 45) at 600 mm Hg, 300 mm Hg, and gravity flow infusion pressure. The maximum flow rate obtained was 3,158 ml/min for tap water and 3,000 ml/min for diluted packed cells. The increases in flow rates from gravity to 300 mm Hg and from gravity to 600 mm Hg are significant (P less than 0.05) and provide up to 197% and 341% increases, respectively, for all catheter/tubing combinations tested. Large-bore tubing is most effective when used in conjunction with large-bore catheters. For the 8.5 French catheter, a change from standard (3.2 mm ID) to large-bore (6.4 mm ID) tubing resulted in a statistically significant (P less than 0.05) increase in flow rate of more than 200% regardless of infusion pressure.

Pre-hospital IAC-CPR versus standard CPR: paramedic resuscitation of cardiac arrests

Recent studies evaluating interposed abdominal compression cardiopulmonary resuscitation (IAC-CPR) have demonstrated a significant increase in cardiac output, mean arterial pressure, and cerebral perfusion, as compared with standard CPR. A clinical evaluation of IAC-CPR effectiveness on resuscitation outcome has not been reported. A prospective randomized study comparing IAC-CRP with standard CPR for resuscitation of prehospital cardiopulmonary arrest was undertaken using the Milwaukee County Paramedic System. The patients were randomized following endotracheal intubation into IAC-CPR and standard CPR groups. Since October 1983, 291 patients have qualified for the study group. Of these, 146 patients had standard CPR, and 45 (31%) were successfully resuscitated. Of the 145 patients treated with IAC-CPR, 40 (28%) were successfully resuscitated. Chi-square analysis reveals no significant difference between these groups. To determine whether abdominal compression increases regurgitation, the frequency of emesis before and after intubation was analyzed. No significant difference was found between the IAC-CPR and standard CPR groups. Thus, IAC-CPR applied by paramedics in the field to patients following intubation does not improve cardiac resuscitation rates.

Effect of circumferential pneumatic compression devices on digital flow

We reviewed the effects of circumferential pneumatic compression suits (CPCS) when applied to normal and ischemic limbs without prior application of prehospital orthopedic traction devices beneath the garment. The digital arterial toe pressures of 11 normal and six claudicating limbs were measured with the trouser applied and the limbs pressurized to 40, 60, 80, and 100 mm Hg. In addition, normal limbs had the Hare traction device and the Sager splint applied prior to application of the trouser and retesting of the digital arterial flow. We conclude that CPCS prevents flow into the limbs, and this may potentiate the development of compartment syndromes in the previously traumatized or ischemic limbs. Normal limbs with traction devices already applied may be at a higher risk for compartment syndromes, and we suggest that patients with fractured limbs who are in need of CPCS not have the traction device applied.

Cardiorespiratory arrest and resuscitation of children

Ninety-one patients had cardiorespiratory arrest in a children's hospital emergency department over six years. Only five children survived, three with severe neurologic sequelae. The records of 40 other children in the same community resuscitated by paramedics, but taken to other hospitals, were reviewed and there were three survivors. The causes and outcomes of resuscitation of children are clearly different from those of adults. Cardiac disease and ventricular arrhythmias are uncommon. Neurologically intact survival was seen only in those children who received immediate resuscitation and responded promptly. Research in cerebral resuscitation at the cellular level is promising for the future. Prevention of some cardiorespiratory arrests through accident prevention and earlier recognition of serious infections is possible now.

"PALS for life!" A required trauma-oriented pediatric advanced life support course for pediatric and emergency medicine housestaff

While advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) courses have become accepted standards for physicians who care for the critically ill and injured patient, only recently have pediatric advanced life support (PALS) courses been developed. The American Academy of Pediatrics has shown renewed interest in pediatric cardiopulmonary arrest after impressive gains made in adult resuscitation. The American Heart Association filled a void by including new chapters on Pediatric and Neonatal Resuscitation in the Textbook of Advanced Cardiac Life Support, 1981. A joint committee of AHA and AAP is seeking to unify course objectives and materials for standard curriculum. Because trauma is the most common cause of death and disability in children, pediatric trauma life support measures should be incorporated into any program directed toward emergency physicians and pediatricians who function in an emergency department or rural primary care setting. The Department of Pediatrics and Surgery and its division of Emergency Medicine has developed and implemented a PALS curriculum which is different from most other programs in that emphasis has been placed on pediatric trauma in addition to traditional cardiac (ACLS) resuscitation. This 20-hour program combines a modified ACLS curriculum with specific pediatric trauma lectures and laboratory sessions. It includes a canine surgical procedure lab and modified ATLS skill stations. At the completion of the course, students are eligible for ACLS certification. In the two years in which the course was given, 39 pediatric houseofficers were enrolled in the course.(ABSTRACT TRUNCATED AT 250 WORDS)

Bystander CPR in prehospital coarse ventricular fibrillation

Prehospital bystander cardiopulmonary resuscitation (CPR) was studied to determine if it affected the outcome of defibrillation. Four hundred twenty-one consecutive witnessed cardiopulmonary arrests presenting with the initial rhythm of coarse ventricular fibrillation treated by the Milwaukee County Paramedic System from January 1980 to June 1982 were analyzed. Pediatric, trauma, and poisoning patients and those receiving intravenous or endotracheal medications before defibrillation (58) were excluded. Immediate professional bystander CPR (physician, nurse, EMT) and citizen bystander CPR were compared to a control group receiving no bystander CPR until arrival of EMS personnel. A successful defibrillation occurred if defibrillation prior to administration of medication produced an effective cardiac rhythm with pulses. Eighty-eight of the 363 remaining patients (24%) converted with initial defibrillations. While the group receiving professional bystander CPR had a higher successful defibrillation rate than did the no-CPR group (35% vs 22%, P less than .04), citizen bystander CPR and no-CPR groups had similar successful defibrillation rates (24% vs 22%, no significant difference). One hundred eighty-six of the 363 patients (51%) were transported to a hospital with a rhythm and a pulse (a successful resuscitation). Ninety-seven of the 363 patients (27%) were discharged alive from the hospital (a save). Patients who were converted successfully using initial "quick-look" defibrillations were far more likely to be successfully resuscitated (79/88 [90%] vs 107/275 [39%], P greater than .0001) and to be discharged alive from the hospital (54/88 [61%] vs 43/275 [16%], P greater than .0001) than were those who required further advanced cardiac life support techniques.(ABSTRACT TRUNCATED AT 250 WORDS)

Recommended helmet removal techniques in a cervical spine injured patient

Helmet removal techniques in the absence of C-spine injuries have been developed and promulgated. Utilizing a cadaver model, these techniques were demonstrated to adversely affect pre-existing C-spine injury. Removal of helmets with cast cutters is recommended.

Atropine in asystole: human studies

Current research supporting the use of atropine for asystole is limited. Reported in the literature are the cases of 26 patients who presented with a rhythm of asystole. Of these, only eight were clearly in refractory asystole after epinephrine and sodium bicarbonate, only seven were prehospital patients, and only two were delineated as being intubated. Despite such limited data, atropine has been advocated for asystole, and use of the drug is included in the recommendations of the American Heart Association. We undertook a retrospective review of our prehospital experience with refractory asystole for a four-year period from January 1979 to December 1982. All patients with trauma or poisoning and all pediatric arrests were excluded. All patients who received calcium chloride during resuscitation also were excluded. One hundred seventy patients presented in cardiorespiratory arrest with an initial rhythm of asystole. Of these, 84 remained in refractory asystole after receiving epinephrine and sodium bicarbonate. Forty-three patients in this group received atropine. The successful resuscitation rate in the atropine group was 14% (6/43), while in the control group it was 0% (0/41) (P less than .04). A successful resuscitation was defined as conveyance of a patient with a rhythm and a pulse to an emergency department. Patients were compared for age, sex, witnessing of arrest, cardiac history, and cardiac drugs. No other significant differences were noted between groups. No patient who received atropine for refractory asystole was discharged alive.

Calcium chloride: reassessment of use in asystole

Calcium chloride has been advocated since the 1920s for resuscitation of asystole and ventricular fibrillation. Most reports have been anecdotal, and have failed to substantiate its effectiveness. In two large retrospective series with a collective experience of 181 patients, investigators reviewed the effectiveness of calcium chloride in asystole and did not support its use. A prospective, randomized, double-blind study comparing calcium chloride with saline in the prehospital setting was done. Patients with trauma or pediatric arrests were excluded. During the period from October 1982 to October 1983, a total of 32 patients with witnessed arrests presented with a rhythm of asystole and were refractory to epinephrine, bicarbonate, and atropine. The rate of successful resuscitation in the calcium group was 5.6% (1/18), and there were no successful resuscitations (0/14) in the saline group (P = .37). A successful resuscitation was defined as conveyance of a patient with a rhythm and pulse to an emergency department. Groups were analyzed for sex, age, cardiac history, and cardiac drugs, and there were no statistically significant differences. No patient who was successfully resuscitated in the field was discharged alive from the hospital. Calcium chloride is of no value in resuscitating refractory asystole in the prehospital cardiac arrest setting.

Immediate countershock treatment of asystole

While rapid intervention with basic cardiac life support and prompt delivery of prehospital care using advanced cardiac life support (ACLS) have yielded impressive results in the resuscitation of other arrest rhythms, very little improvement has been shown in the rates of resuscitation from asystole. Anecdotal reports list instances in which patients in asystole have had normal cardiac activity restored after defibrillation. Current ACLS protocols for initial evaluation recommend a single-lead "quick-look" interpretation of cardiac rhythm using portable defibrillator paddles. Under these conditions, ventricular fibrillation could masquerade as, or be misinterpreted as, asystole. We report preliminary field results in a medically controlled paramedic system using "quick-look" interpretation and immediate defibrillation of "asystole" by well-trained paramedics. Following initial countershock, standard ACLS protocols for asystole were used. For an eight-month period 119 patients were entered into the study and compared to system controls of asystolic patients presenting in the previous year. While ten patients (8.4%) showed an immediate rhythm change after initial countershock and six of ten reached the hospital with a rhythm and a pulse, no statistically significant comparison could be made regarding improved resuscitation or survival rates. The finding of no statistically significant deterioration of resuscitation or survival rates, however, justifies the continuation of the study.

Interposed abdominal compression CPR versus standard CPR in prehospital cardiopulmonary arrest: preliminary results

Recent studies evaluating interposed abdominal compression cardiopulmonary resuscitation (IAC-CPR) have demonstrated a significant increase in cardiac output, mean arterial pressure, and cerebral perfusion compared with standard CPR. A clinical evaluation of IAC-CPR effectiveness on resuscitation outcome has not been reported. A prospective, randomized study comparing IAC-CPR with standard CPR for resuscitation of prehospital cardiopulmonary arrest was developed utilizing the Milwaukee County Paramedic System. When the paramedics arrive, standard CPR is initiated or continued, and countershocks are delivered when appropriate. The patients are randomized into IAC-CPR and standard CPR groups immediately following endotracheal intubation. Abdominal compression force is standardized to 100 mm Hg +/- 20 mm Hg by using a simple airfilled bladder and gauge to monitor each compression. Resuscitations are conducted according to standard advanced cardiac life support guidelines through continuous radio-telemetry contact with a base physician. Since October 1983, 140 patients have qualified for the study group. Seventy patients had standard CPR and 30% (21/70) were admitted to the emergency department with a rhythm and pulse, as were 34% (24/70) of the patients treated with IAC-CPR. The difference between study groups was not significant. To determine if abdominal compression increases regurgitation, the frequency of emesis before and after intubation was analyzed. No significant difference was found between the IAC-CPR and standard CPR groups.(ABSTRACT TRUNCATED AT 250 WORDS)

A randomized comparison study of bretylium tosylate and lidocaine in resuscitation of patients from out-of-hospital ventricular fibrillation in a paramedic system

A prospective, randomized study using either bretylium tosylate (BT) or lidocaine (L) as the first-line antiarrhythmic for patients in refractory ventricular fibrillation was conducted using the Milwaukee County Paramedic System. If the patient did not respond to the initial American Heart Association protocol, BT (10 to 30 mg/kg total) or L (2 to 3 mg/kg total) was given randomly as the first antiarrhythmic. If the patient failed to convert, the alternate antiarrhythmic was given. In the L group, 81% (39/48) of the patients obtained an organized electrical rhythm and 56% (27/48) converted to a rhythm with a pulse. The resuscitation rate (admission to an emergency department with pulse) was 23% (11/48), and the save rate was 10.4% (5/48). In the BT group, 74% (32/43) obtained an organized electrical rhythm, 35% (15/43) were converted, 23% (10/43) were resuscitated, and 5% (2/43) were saved. The only significant difference in outcome was that L converted patients better than did BT (P less than .05). Of the 24 patients known to be on digitalis preparations prior to arrest, 41% (5/12) in the L group were resuscitated and 16% (2/12) were resuscitated in the BT group. Data were analyzed for witnessed arrest outcome and for patients given multiple antiarrhythmics.

The precordial thump

The American Heart Association (AHA) currently recommends the precordial thump as the initial maneuver in treatment of ventricular tachycardia (VT) and monitored ventricular fibrillation (VF). These recommendations are based largely on anecdotal reports of successful "thump-version" of asystole, VF, and VT. The Milwaukee County Paramedic System follows the AHA guidelines in the treatment of VT and VF. The precordial thump is included in the advanced cardiac life support (ACLS) paramedic training program, and has been used in our approach to the pulseless, nonbreathing patient. During an eight-month period, 50 pulseless, nonbreathing patients received precordial thumps during ACLS resuscitative attempts. Twenty-seven patients who developed monitored VT and 23 patients with monitored VF were thumped. Three of 27 patients (11%) with VT were thumped into a supraventricular rhythm, 12 of 27 patients (44%) remained in VT, and 12 of 27 patients were thumped from VT into more malignant rhythms: three, into asystole; eight, into VF; and one, into an idioventricular/electromechanical dissociation rhythm. A total of 23 patients were thumped without effect. Subsequently, using countershock and medications, 12 of these 23 patients were successfully resuscitated. In the prehospital setting the precordial thump is usually not beneficial, and may be detrimental. Thus its use as the initial maneuver in treating the cardiac arrest patient with VT or VF in this setting cannot be supported. The presence of acidosis and hypoxia may explain why prehospital precordial thump responses differ from those seen in the hospital environment.

Experimental cervical spine injury model: evaluation of airway management and splinting techniques

We evaluated airway management maneuvers and the effects of cervical splinting on a model of an injured spinal column. X-ray films of a fresh cadaver verified a normal cervical spine. C5-C6 instability was created surgically and documented radiologically with flexion and extension maneuvers. Basic and advanced airway techniques were performed and were documented radiologically. The procedures were then repeated using different types of splinting. Chin lift, jaw thrust, esophageal obturator airway (EOA), and endotracheal intubation can cause extension, widening, and/or anterior subluxation. A two-piece, semirigid soft cervical collar may minimize flexion but not extension of the spine. With the Velcro in back, soft collars minimize flexion; with Velcro in front, they minimize extension. Standard nonsurgical airway management techniques appear to aggravate preexisting injuries. The soft collar and semirigid collar do little to prevent movement, and their presence may serve only as a warning to physicians that a neck injury may be present.

The effect of tensional load on isolated embryonic chick tendons in organ culture

Digital flexor tendons isolated from 17-18 day embryonic chickens were cultured intact, either on steel mesh grids, or in an apparatus designed to apply a mechanical load to the tissue. Tendons cultured without an applied load continued to synthesize protein and glycosaminoglycans throughout a 7-day period, but DNA synthesis decreased during this time. Increases in both protein and DNA synthesis were observed in tendons experimentally loaded for 48-72 h. Glycosaminoglycan production by tendons isolated from 17-day embryos was also increased in loaded tendons, sulfated GAG being increased more than hyaluronic acid. The same loading regime applied to tendons from 18-day embryos produced a smaller, yet significant increase in sulfated glycosaminoglycans but hyaluronate production was reduced. These investigations demonstrate that embryonic chicken tendons can be maintained in a viable state in organ culture and may provide a useful model for studies of the effects of mechanical forces on the synthetic capability and structure of connective tissue cells.

The relationship of the level of training and area of medical specialization with registrant performance in an advanced trauma life-support course

Approved advanced trauma life-support (ATLS) programs were given to 160 residents and practitioners of various specialties, utilizing a standardized 50-item, multiple-choice posttest. Level of training (practitioner v resident) and area of medical specialization with registrant performance on total score and in specific subcontent areas of ATLS were evaluated by subjecting total and subcontent percent scores to a two-way analysis of variance and Newman-Keuls pairwise comparisons. Practitioners outperformed the residents in the subcontent area of abdominal injuries, P less than .05. In specialization, emergency medicine outperformed internal medicine specialists, P less than .05. Pairwise differences among specialists were not statistically significant. In airway problems, surgeons and internists were outperformed by emergency medicine, whereas in burns, emergency medicine and family practitioners significantly outperformed the surgeons. Emergency medicine outperformed internal medicine, P less than .05, in subcontent area of extremity injuries. We conclude that registrants are likely to benefit from an ATLS course, but preliminary evidence would seem to justify some "tailoring" of the ATLS curriculum for different registrant specialty groups.

Resuscitation time in ventricular fibrillation--a prognostic indicator

Length of resuscitation in prehospital ventricular fibrillation patients was studied to define its relationship to survival. Five hundred sixty-five patients presenting with the initial rhythm of ventricular fibrillation to the Milwaukee County Paramedic System between January 1978 and April 1982 were resuscitated successfully. Pediatric patients and patients with trauma, poisoning, and drowning were excluded. Of the 565 resuscitated patients, 262 (46%) were discharged alive and 303 (54%) died during hospitalization. For all 565 patients the resuscitation time and times from arrival of paramedics until the first sustained pulse were plotted against survival to define a curve. The curve demonstrated rapidly declining survival rates for resuscitation time up to 20 minutes; thereafter, survival declined more gradually with respect to resuscitation time. The mean resuscitation time for those eventually discharged alive was 12.6 minutes, which was statistically shorter (P less than .0001) than the mean resuscitation time of 23.9 minutes for those who eventually died. The overall survival curve of witnessed arrest patients was not statistically different from that of unwitnessed patients. The survival curve of those patients receiving bystander cardiopulmonary resuscitation (CPR) was similar to the curve of those who received no CPR. We conclude that resuscitation time is a heretofore undefined significant predictor of survival of resuscitated prehospital ventricular fibrillation patients.