Long COVID-19 syndrome: association of cardiopulmonary impairment with a persistent platelet activation

Background

A considerable proportion of patients do not fully recover from COVID-19 infection and report symptoms that persist beyond the initial phase of infection: this condition is defined long-COVID-19 syndrome (LCS). LCS can involve lungs as well as several extrapulmonary organs, including the cardiovascular system. The risk and 1-year burden of cardiovascular diseases (CVD) is increased in COVID-19 survivors, even in subjects at low risk of CVD. Recently, we documented that acute COVID-19 infection induces altered platelet activation state characterized by a prothrombotic phenotype and by the formation of platelet-leukocyte aggregates (PLA), that may be involved in the pulmonary microthrombi found in autoptic specimens. No data are yet available on the contribution of platelet activation to residual pulmonary impairment and procoagulant potential in LCS patients.

Purpose

To study platelet activation status, microvesicle (MV) profile, platelet thrombin generation capacity (pTGC) in LCS patients enrolled at 6 months after resolution of the acute phase (6mo-FU), compared to acute COVID-19 infection patients.

Methods

6mo-FU COVID-19 patients (n=24) with established LCS were enrolled at Centro Cardiologico Monzino. Residual pulmonary impairment was assessed by Cardiopulmonary Exercise Testing (CPET) and 64-rows-CT scan evaluation. Platelet activation (P-selectin, Tissue Factor [TF] and PLA) and MV profile were assessed by flow cytometry; pTGC by calibrated automated thrombogram. 46 patients enrolled during acute COVID-19 infection and 46 healthy subjects (HS) were used for comparison.

Results

Dispnea in LCS patients was confirmed by CPET showing compromised alveolus-capillary membrane diffusion and residual pulmonary impairment. TF+-platelet and -MV levels were 3-fold (1.5% [1.2–2.9] vs 2.4% [1.6–5.7]) and 2-fold (217/μl [137–275] vs 435/μl [275–633]) lower at 6mo-FU compared to acute phase, being comparable to HS. pTGC behaved similarly. At 6mo-FU, the MV profile, in terms of total number and cell origin, returned to physiological levels. Conversely, although lower than that measured in acute phase, a 2.5-fold higher platelet P-selectin expression (6.9% [3–13.5] vs 11.7% [5.2–18.9]) and PLA formation (35.5% [27.4–46.8] vs 67.7% [45.7–85.3]) was observed at 6mo-FU compared to HS. Interestingly, a significant correlation between PLA formation and residual pulmonary impairment was observed (r=−0.423; p=0.02).

Conclusion

These data strengthen the hypothesis that the presence of PLA in the bloodstream, and thus also in the pulmonary microcirculation, may contribute to support pulmonary dysfunction still observed in LCS patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Italian Ministry of Health (Ricerca Corrente 2020 MPP COVID4)

Resources and outcome impact of routine availability of computed tomography perfusion

Funding Acknowledgements

Type of funding sources: None.

Background

Stress computed tomography perfusion (Stress-CTP) is a functional technique that can be added to coronary computed tomography angiography (cCTA) to improve the management of patients with suspected coronary artery disease (CAD).

Purpose

To determine the impact of routine availability of Stress-CTP added to cCTA in terms of downstream testing, radiation exposure and outcome in patients with high risk or known CAD.

Methods

Patients symptomatic for chest pain, known for CAD, with previous revascularization or with increased pre-test likelihood of CAD, referred for clinically indicated cCTA with Stress-CTP were prospectively enrolled. Data regarding evaluability, overall radiation exposure, invasive and non-invasive downstream testing, hospitalizations, revascularizations, major adverse cardiac events (MACE) as unstable angina, non-fatal myocardial infarction and cardiovascular death after index test were collected at follow-up.

Results

263 consecutive patients were prospectively enrolled (mean age: 65 ± 9 years; male: 79%), of which 162 (62%) had previous revascularization. The mean follow-up was 323 ± 175 days. cCTA and Stress-CTP were fully evaluable in 95% and 99%, respectively. Obstructive CAD and inducible ischaemia were found in 170 (65%) and 129 (49%) subjects, respectively. No significant difference was found between patients with presence or absence of perfusion defects in terms of downstream non-invasive testing (p: 0.229), while patients with inducible ischaemia had more downstream invasive testing, increased overall radiation exposure, more hospitalizations for cardiovascular reasons and revascularization (all endpoints with p: < 0.001). No differences were detected between patients with inducible ischaemia treated with revascularization after index test and patients without inducible ischaemia, even if with obstructive CAD, treated medically in terms of MACE.

Conclusions

Routine implementation of cCTA with Stress-CTP is associated with subsequent low rate of other non-invasive testing, low overall radiation exposure in case of negative Stress-CTP and good prognosis if clinical management is based on combined anatomical and functional information.

Coexistence of axial spondyloarthritis and thromboangiitis obliterans in a young woman

A peculiar coexistence of axial spondyloarthritis and ischemia of the feet and the fourth finger of the left hand in a young woman, who was a heavy smoker, is discussed in this report. This picture was considered within the context of thromboangiitis obliterans. Positivity of anti-nuclear antibodies and mild elevation of inflammatory parameters were noted. Computed tomography angiograms of upper and lower limbs showed luminal narrowing and occlusion of the left humeral, left anterior/posterior tibial and right anterior tibial arteries. Daily iloprost perfusions were started, and smoking cessation was strongly recommended. Coldness and rest pain in the distal extremities improved within a few weeks. The possibility that spondyloarthritis might precede the clinical picture of thromboangiitis obliterans should be considered in heavy smokers.

Training and simulation for patient safety

BACKGROUND

Simulation-based medical education enables knowledge, skills and attitudes to be acquired for all healthcare professionals in a safe, educationally orientated and efficient manner. Procedure-based skills, communication, leadership and team working can be learnt, be measured and have the potential to be used as a mode of certification to become an independent practitioner.

RESULTS

Simulation-based training initially began with life-like manikins and now encompasses an entire range of systems, from synthetic models through to high fidelity simulation suites. These models can also be used for training in new technologies, for the application of existing technologies to new environments and in prototype testing. The level of simulation must be appropriate to the learners' needs and can range from focused tuition to mass trauma scenarios. The development of simulation centres is a global phenomenon which should be encouraged, although the facilities should be used within appropriate curricula that are methodologically sound and cost-effective.

DISCUSSION

A review of current techniques reveals that simulation can successfully promote the competencies of medical expert, communicator and collaborator. Further work is required to develop the exact role of simulation as a training mechanism for scholarly skills, professionalism, management and health advocacy.

When minutes count--the fallacy of accurate time documentation during in-hospital resuscitation

The purpose of this study is to examine the commonly held assumption that time is measured and documented accurately during resuscitation from cardiac arrest in the hospital.

METHODS

A two-pronged approach was used to evaluate the accuracy of time documentation and measurement. First, two existing databases-the National Registry of Cardiopulmonary Resuscitation (NRCPR) and a 240-bed hospital's repository of cardiac arrest records-were evaluated for completeness and accuracy of documentation on resuscitation records of times required for calculating the Utstein gold-standard process intervals-recognition of pulselessness to starting cardiopulmonary resuscitation (CPR), delivery of first defibrillation shock, successful intubation, and epinephrine (adrenaline) administration. Second, nurses from a 900-bed hospital were interviewed to determine timepieces used during resuscitations, and timepieces were assessed for coherence and precision.

RESULTS

: From the NRCPR database that included 10,689 pulseless cardiac arrests submitted by 176 hospitals, time data for calculating the Utstein intervals were missing for 10.9% of the interventions; negative intervals were calculated for 4%. From 232 consecutive resuscitation records from the 240-bed hospital, 85 records were identified from non-monitored units with staff who provided only CPR. Defibrillation, intubation and epinephrine administration were delayed until after arrival of advanced life support (ALS) responders; unlikely intervals of 0 min from event recognition to these ALS interventions were calculated for 11.5%. Sixty-seven nurses from the 900-bed hospital were interviewed; when documenting information during resuscitations, 21 (31.3%) reported using only patient room clocks, 30 (44.8%) only their watches, and 16 (23.9%) several timepieces. In all in-patient units in the same hospital, 241 timepieces (nurses' and physicians' watches, clocks in patient rooms, defibrillator clocks, central station monitors, and nursing station clocks) were compared to atomic time. The mean absolute time difference from atomic clock was 2.83 min (S.D. +/-5.9 min), median 1.88 min, and range 52.1 min slow to 72.85 min fast. There was no difference among timepieces (P = 0.35).

CONCLUSIONS

Missing time data, negative calculated Utstein gold-standard process intervals, unlikely intervals of 0 min from arrest recognition to ALS interventions in units with CPR providers only, use of multiple timepieces for recording time data during the same event, and wide variation in coherence and precision of timepieces bring into question the ability to use time intervals to evaluate resuscitation practice in the hospital. Practitioners, researchers and manufacturers of resuscitation equipment must come together to create a method to collect and document accurately essential resuscitation time elements. Our ability to enhance the resuscitation process and improve patient outcomes requires that this be done.

Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa)

Outcome after cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation, effective chest compressions, and advanced life support. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress toward international consensus on science and resuscitation guidelines. Despite the development of Utstein templates to standardize research reports of cardiac arrest, international registries have yet to be developed. In April 2002, a task force of the International Liaison Committee on Resuscitation (ILCOR) met in Melbourne, Australia, to review worldwide experience with the Utstein definitions and reporting templates. The task force revised the core reporting template and definitions by consensus. Care was taken to build on previous definitions, changing data elements and operational definitions only on the basis of published data and experience derived from those registries that have used Utstein-style reporting. Attention was focused on decreasing the complexity of the existing templates and addressing logistical difficulties in collecting specific core and supplementary (ie, essential and desirable) data elements recommended by previous Utstein consensus conferences. Inconsistencies in terminology between in-hospital and out-of-hospital Utstein templates were also addressed. The task force produced a reporting tool for essential data that can be used for both quality improvement (registries) and research reports and that should be applicable to both adults and children. The revised and simplified template includes practical and succinct operational definitions. It is anticipated that the revised template will enable better and more accurate completion of all reports of cardiac arrest and resuscitation attempts. Problems with data definition, collection, linkage, confidentiality, management, and registry implementation are acknowledged and potential solutions offered. Uniform collection and tracking of registry data should enable better continuous quality improvement within every hospital, emergency medical services system, and community.

Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries

Outcome following cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation, effective chest compressions, and advanced life support. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress toward international consensus on science and resuscitation guidelines. Despite the development of Utstein templates to standardize research reports of cardiac arrest, international registries have yet to be developed. In April 2002 a task force of ILCOR met in Melbourne, Australia, to review worldwide experience with the Utstein definitions and reporting templates. The task force revised the core reporting template and definitions by consensus. Care was taken to build on previous definitions, changing data elements and operational definitions only on the basis of published data and experience derived from those registries that have used Utstein-style reporting. Attention was focused on decreasing the complexity of the existing templates and addressing logistical difficulties in collecting specific core and supplementary (i.e., essential and desirable) data elements recommended by previous Utstein consensus conference. Inconsistencies in terminology between in-hospital and out-of-hospital Utstein templates were also addressed. The task force produced a reporting tool for essential data that can be used for both quality improvement (registries) and research reports and that should be applicable to both adults and children. The revised and simplified template includes practical and succinct operational definitions. It is anticipated that the revised template will enable better and more accurate completion of all reports of cardiac arrest and resuscitation attempts. Problems with data definition, collection, linkage, confidentiality, management, and registry implementation are acknowledged and potential solutions offered. Uniform collection and tracking of registry data should enable better continuous quality improvement within every hospital, EMS system, and community.

Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation

The National Registry of Cardiopulmonary Resuscitation (NRCPR) is an American Heart Association (AHA)-sponsored, prospective, multisite, observational study of in-hospital resuscitation. The NRCPR is currently the largest registry of its kind. The purpose of this article is to describe the NRCPR and to provide the first comprehensive, Utstein-based, standardized characterization of in-hospital resuscitation in the United States. All adult (>/=18 years of age) and pediatric (<18 years of age) patients, visitors, employees, and staff within a facility (including ambulatory care areas) who experience a resuscitation event are eligible for inclusion in the NRCPR database. Between January 1, 2000, and June 30, 2002, 14720 cardiac arrests that met inclusion criteria occurred in adults at the 207 participating hospitals. An organized emergency team is available 24 h a day, 7 days a week in 86% of participating institutions. The three most common reasons for cardiac arrest in adults were (1) cardiac arrhythmia, (2) acute respiratory insufficiency, and (3) hypotension. Overall, 44% of adult in-hospital cardiac arrest victims had a return of spontaneous circulation (ROSC); 17% survived to hospital discharge. Despite the fact that a primary arrhythmia was one of the precipitating events in nearly one half of adult cardiac arrests, ventricular fibrillation (VF) was the initial pulseless rhythm in only 16% of in-hospital cardiac arrest victims. ROSC occurred in 58% of VF cases, yielding a survival-to-hospital discharge rate of 34% in this subset of patients. An automated external defibrillator was used to provide initial defibrillation in only 1.4% of patients whose initial cardiac arrest rhythm was VF. Neurological outcome in discharged survivors was generally good. Eighty-six percent of patients with Cerebral Performance Category-1 (CPC-1) at the time of hospital admission had a postarrest CPC-1 at the time of hospital discharge.

Performance improvement in transfusion medicine. What do nurses need and want?

Transfusion medicine is a complex process dependent on a variety of professionals interacting effectively and efficiently across time and distance. To perform safely, professionals depend on their own knowledge and skills, the knowledge and skills of others, and the overall effectiveness of operating systems. Nursing is an essential link in the process. To be effective, nurses need to practice in environments that recognize the importance of reducing error and improving safety through use of nonpunitive system approaches to analyzing near misses and errors. The "off-with-their-heads" approach must be eliminated. To increase efficiency, pathologists and nurses should collaborate on form development, evaluation, and implementation. Documentation regarding transfusions needs to be simplified and coordinated. Knowledgeable staff is an essential element of safe systems. Basic knowledge should never be assumed. Mechanisms to monitor knowledge of key processes along with ongoing feedback and remediation are necessary to maximize performance. Working together, nursing and transfusion specialists will improve transfusion services.

Developing a culturally competent work force: an opportunity for collaboration

This article describes a collaborative project formed between three major community systems--education, health care, and the business sector--to respond to the specialized cultural needs of a growing Hispanic population in a large public health care system in Dallas, TX. Two specific strategies, short-term cultural immersion and the development of a nurse exchange program with a "sister" hospital in Mexico, assist health care personnel to learn the language and the culture of Mexico. Findings from process evaluation suggest that these initiatives are essential and beneficial to changing individual views and developing knowledge and skills. Community partnerships requiring a significant commitment to a continuum of efforts from top administrative levels to the individual level facilitate institutional responses to the challenge of developing a culturally skilled health work force.

In-hospital first-responder automated external defibrillation: what critical care practitioners need to know

Despite the development and widespread implementation of Basic Life Support and Advanced Cardiac Life Support, the percentage of patients who survive in-hospital cardiac arrest has remained stable at approximately 15%. Although survival rates may approach 90% in coronary care units, survival rates plummet outside of these units. The lower survival rates for cardiac arrest that occur outside of the coronary care unit may relate to the time elapsed between the onset of ventricular fibrillation and first defibrillation. The advent of automated external defibrillators has made it possible to decrease the time elapsed before first defibrillation in non-critical care areas of the hospital. First responders need only recognize that the patient is unresponsive, apneic, and pulseless before attaching and activating the automated external defibrillator. Our research shows that, as part of Basic Life Support training, non-critical care nurses can learn to use the device and can retain the knowledge and skill over time. Establishing an in-hospital automated external defibrillator program requires commitment from administration, physicians, and nursing personnel. Critical care practitioners should be aware of this technology and the literature that supports its safety and effectiveness when used by non-critical care first responders. Critical care nurses are in a unique position to effect changes that will decrease the time between the onset of cardiac arrest and first defibrillation.

In-hospital first-responder automated external defibrillation: what critical care practitioners need to know

Despite the development and widespread implementation of Basic Life Support and Advanced Cardiac Life Support, the percentage of patients who survive in-hospital cardiac arrest has remained stable at approximately 15%. Although survival rates may approach 90% in coronary care units, survival rates plummet outside of these units. The lower survival rates for cardiac arrest that occur outside of the coronary care unit may relate to the time elapsed between the onset of ventricular fibrillation and first defibrillation. The advent of automated external defibrillators has made it possible to decrease the time elapsed before first defibrillation in non-critical care areas of the hospital. First responders need only recognize that the patient is unresponsive, apneic, and pulseless before attaching and activating the automated external defibrillator. Our research shows that, as part of Basic Life Support training, non-critical care nurses can learn to use the device and can retain the knowledge and skill over time. Establishing an in-hospital automated external defibrillator program requires commitment from administration, physicians, and nursing personnel. Critical care practitioners should be aware of this technology and the literature that supports its safety and effectiveness when used by non-critical care first responders. Critical care nurses are in a unique position to effect changes that will decrease the time between the onset of cardiac arrest and first defibrillation.

Resuscitation training: a time for reassessment

The goal of resuscitation education is to impart the knowledge and skills necessary to successfully resuscitate a victim of cardiopulmonary arrest. This goal can be accomplished only if the interactions among the instructor, learner, and curriculum are optimized. Instructors must have a clear understanding of educational theory and a thorough grasp of the program materials. Learners must be motivated and committed to developing and maintaining a high level of competence. The in-hospital chain of survival for the resuscitation response system must be reorganized to include determination of the appropriateness of resuscitation and provision of first-responder defibrillation capability. Using creativity and flexibility to meet these goals, nurses can improve the practice and potential outcome of resuscitation.

Patient-focused care: a response to the healthcare crisis

During this time of major challenges and transitions in the healthcare industry, as both healthcare professionals and consumers, nurses are in a pivotal position to become active, informed advocates for reasonable, rational changes within a system in which we have a truly unique perspective. In this environment, it is critical that nurses understand the need for change so that we can critically analyze work redesign initiatives for their likelihood to positively or negatively impact the healthcare system at a global or local level. It will then be possible to explore the transformation of the healthcare delivery system, the concept of patient-focused care, and the impact on the healthcare workforce of the future with particular attention to the practice of intravenous nursing.

Organizing and implementing a hospital-wide first-responder automated external defibrillation program: strengthening the in-hospital chain of survival

First-responder automated external defibrillation (AED) in the hospital is consistent with the American Heart Association's (AHA) early defibrillation standard or care. With trained personnel and automated external defibrillators immediately available, early defibrillation should have a greater impact on survival than early cardiopulmonary resuscitation (CPR). Therefore, in our hospitals we modified basic life support to include automated external defibrillation (BLS-AED) for all personnel who are expected to respond to a cardiac arrest, with rapid defibrillation taking priority over CPR. We describe how we organized and implemented this hospital-wide first-responder BLS-AED program. Planning the process includes gaining support from key leaders who are responsible for resuscitation practice, and identifying the target audience of the training program. Hospital unit needs for AED or conventional defibrillation and equipment must be identified, the training program developed, and existing policies and procedures modified. Several barriers to implementation may exist. Education about the efficacy and safety of AED and experience once the BLS-AED program is in place can overcome attitudes and bias. Concerns about the cost of equipment and training must be addressed. Program evaluation may include patient issues such as measuring the time to the first defibrillation and patient outcome; as well as training and retention issues.

Strengthening the in-hospital chain of survival with rapid defibrillation by first responders using automated external defibrillators: training and retention issues

STUDY OBJECTIVE

To determine whether staff outside critical care areas who were proficient in basic life support (BLS) could be easily trained to use automated external defibrillators (AEDs) and whether they would retain these skills.

DESIGN

Prospective, longitudinal cohort series.

SETTING

Two university teaching hospitals.

PARTICIPANTS

One hundred forty nurses who had previously learned BLS and constituted the staff from three medical/surgical nursing units from each study hospital.

INTERVENTIONS

The nurses were taught how to use the Heartstart 1000s, a lightweight portable shock-advisory AED, in a 2-hour class with an instructor and manikin-to-student ratio of 1:5. The course emphasized hands-on practice of the BLS-AED algorithm on a computerized manikin.

RESULTS

Using a similar scenario, each nurse was evaluated on the computerized manikin immediately after training (posttest). At 1 to 3, 4 to 6, and 7 to 9 months after the initial training, convenience samples of the cohort in three different groups were evaluated for retention. Satisfactory performance was defined as delivery of the first AED shock within 2 minutes of recognition of the arrest. At the posttest after training, 139 of 140 nurses (99%) demonstrated satisfactory performance. Of 77 nurses evaluated, 31 of 32 at 1 to 3 months, 18 of 18 at 4 to 6 months, and 24 of 27 at 7 to 9 months after initial training (95% overall) performed satisfactorily.

CONCLUSION

As has been demonstrated with prehospital emergency personnel, nurses outside critical care areas who are proficient in BLS can easily learn and retain the knowledge and skills to use AEDs. Automated external defibrillation, a BLS skill, should be incorporated into BLS programs (BLS-AED) for all hospital personnel expected to respond to a patient in cardiac arrest, with rapid defibrillation taking priority over CPR.

The problem of poor retention of cardiopulmonary resuscitation skills may lie with the instructor, not the learner or the curriculum

Many studies (several even before American Heart Association recommended in 1973 that lay public be trained in cardiopulmonary resuscitation (CPR] have documented that retention of CPR skills is poor, unaffected by modifications in curriculum or whether the students are lay or professional. We chose to investigate what actually occurs during a CPR course, and gained the following insights: despite clearly defined curricula, we found that instructors did not teach in a standardized way. Practice time was limited and errors in performance were not corrected. Instructors consistently rated the students' overall performance as acceptable; at the same time, using the same checklist, we consistently rated performance as unacceptable. The checklist is an inaccurate tool for evaluating CPR performance. Despite the poor performance that we documented, students and instructors were satisfied with the courses and believed that the level of performance was high. As a result of these studies, we discovered that the problem of poor retention of CPR skills may lie not with the learner or the curriculum, but with the instructor. But, since lives are being saved with bystander CPR, does this documented poor retention matter? Perhaps the solution is not only to improve instructor training to make certain that students receive adequate practice time and accurate skill evaluation, but also to modify the criteria for correct performance when testing for retention. These criteria should be based on the minimum CPR skills that are required to sustain life for the critical 4-8 min before defibrillation and other advanced cardiac life support are delivered.

Effect of crush lesion on ganglioside radiolabelling patterns in rat sciatic nerve

Left sciatic nerves in rats were crushed and allowed to regenerate for variable periods of time up to 14 days; uncrushed right nerves from the same animals were used as controls. Two days before killing the rats, both L-5 dorsal root ganglia (DRG) were injected with 100 microcuries [3H]glucosamine. Gangliosides were purified separately from sciatic nerve (SN) distal to the crush site, lumbosacral trunk (LST) proximal to the crush site, and the injected DRG. Changes in major glycoconjugate classes were previously reported; in this study total gangliosides were separated by high performance thin layer chromatography, located by autofluorography and radioactivity was measured by liquid scintillography. In control DRG, major radiolabelled gangliosides were GM3 and LM1; in control LST and SN, GD1b and GT1b were the major ones. During day two and four following crush, GM3 and LM1 decreased in DRG, but at one and two weeks were at normal and elevated levels, respectively; there were inverse changes in GD3, GT1b and GQ1b. GD1b, GT1b and GQ1b were lower in crushed than in control LST and SN between days zero and four. In LST, GM3 and LM1 remained constant for four days, but were elevated at one and two weeks, whereas GD1a was elevated at all times. Indeed, GD1a is the major recently synthesized ganglioside that is transported into LST and SN two to four days after trauma, suggesting that it may play an important role in regeneration. Indices of oligosaccharide complexity and degree of sialylation indicated that between two and four days following crush, gangliosides in DRG had more complex oligosaccharides and more sialic acid residues than in either controls or in DRG of crushed nerves at one and two weeks post-crush. The degrees of ganglioside sialylation and oligosaccharide complexity in crushed LST and SN were lower than in control specimens between one and seven days after crush. Changes in the ganglioside composition of peripheral nerve following trauma may be important for axonal regeneration.

Measuring cardiopulmonary resuscitation performance: a comparison of the Heartsaver checklist to manikin strip

Both checklists and recording manikin strips (strips) are used for evaluation of cardiopulmonary resuscitation (CPR) performance. To examine their relationship, we simultaneously evaluated single rescuer CPR of 255 subjects using both checklists and strips. For Group 1 (N = 192; general public tested in Heartsaver course) we compared the total number of initial ventilations and compressions judged to be correct by checklists with those judged to be correct by strips. For Group II (N = 63; physicians, nurses, general public tested in retention studies) we compared each subjects checklist with their own strip for evaluation of correct ventilations and compressions. In Group I, CPR was judged to be correct two to four times more frequently by checklists than by strips. In Group II, all correlations were poor. The most common disagreements were with performances evaluated as correct by checklist but not by strip. Therefore, the current checklist may be a poor instrument for measuring CPR. More accurate evaluation should improve learning and therefore improve outcome following cardiac arrest.

Effect of crush lesion on radiolabelling of ganglioside in rat peripheral nerve

Left sciatic nerves of adult male Sprague-Dawley rats were crushed and allowed to recover for 0, 1, 2, 4, 7, or 14 days. At each of these times both L-5 dorsal root ganglia were injected with 100 microCi of [3H]glucosamine. Two days later, dorsal root ganglia, lumbosacral trunks, and sciatic nerves were removed bilaterally. The amounts of radiolabelled ganglioside in crushed lumbosacral trunks were consistently higher than in the controls, with the largest difference occurring within 2 days from simultaneous crush and injection to killing (specimens labelled day 0). The largest difference in the amount of radiolabelled ganglioside between crushed and control sciatic nerve (4-9 days from crush to killing) occurred later than that of lumbosacral trunk, but no significant difference occurred within the first 3 days following crush. There was only a slightly higher radioactivity in gangliosides totalled from all three anatomical specimens of crushed than in control nerves. The neutral nonganglioside lipid and acid-precipitable fraction followed patterns of synthesis and accumulation similar to those of the gangliosides. These findings indicate that after nerve crush gangliosides, glucosamine-labelled neutral nonganglioside lipids, and glycoproteins accumulate close to the proximal end of the regenerating axon. This accumulation could serve as a reservoir to increase the ganglioside concentration in the growth cone membrane.

Advanced cardiac life support refresher course using standardized objective-based Mega Code testing

The American Heart Association (AHA) recommends that those whose daily work requires knowledge and skills in advanced cardiac life support (ACLS) not only be trained in ACLS, but also be given a refresher training at least every 2 yr. However, AMA offers no recommended course for retraining; no systematic studies of retraining have been conducted on which to base these recommendations. In this paper we review and present our recommendation for a standardized approach to refresher training. Using the goals and objectives of the ACLS training program as evaluation criteria, we tested with the Mega Code a sample population who had previously been trained in ACLS. The results revealed deficiencies in ACLS knowledge and skills in the areas of assessment, defibrillation, drug therapy, and determining the cause of an abnormal blood gas value. We combined this information with our knowledge of other deficiencies identified during actual resuscitation attempts and other basic life-support and ACLS teaching experiences. We then designed a refresher course which was consistent with the overall goals and objectives of the ACLS training program, but which placed emphasis on the deficiencies identified in the pretesting. We taught our newly designed refresher course in three sessions, which included basic life support, endotracheal intubation, arrhythmia recognition and therapeutic modalities, defibrillation, and Mega Code practice. In a fourth session, using Mega Code testing, we evaluated knowledge and skill learning immediately after training. We similarly tested retention 2 to 4 months later. Performance immediately after refresher training showed improvement in all areas where performance had been weak.(ABSTRACT TRUNCATED AT 250 WORDS)

Retention of cardiopulmonary resuscitation skills by physicians, registered nurses, and the general public

To evaluate retention of CPR skills by medical residents (MDs), registered nurses (RNs), we tested single-rescuer CPR skills of 21 MDs, 17 RNs, and 21 laypersons using recording manikin and American Heart Association criteria. All study participants had been trained from 4 to 12 months before testing. No MD or RN and only one layperson performed each step correctly and in proper sequence. If calls for assistance were eliminated, one additional layperson, two MDs, and two RNs performed correctly. There were no significant differences between the MDs and RNs. MDs and RNs did better (p less than .01) in assessment compared to laypersons, but some individuals in each group initiated ventilations and compressions without assessing need. There was no difference in the ability to perform ventilations; all three groups did poorly. MDs and RNs performed compression skills better than laypersons (p less than .01), but all had difficulty with rate and depth of compressions. Moreover, only one-third of the general public demonstrated correct hand placement. Despite more training and experience, MD and RN performance was comparable to layperson performance. These data suggest that improving basic life-support skills could save more lives.

Use of the Mega Code to evaluate team leader performance during advanced cardiac life support

The Mega Code is a simulated cardiac arrest during which students practice as members of a team and learn to integrate the knowledge and skills of advanced cardiac life support (ACLS). This study used the Mega Code and American Heart Association (AHA) standards to evaluate 32 medical residents (MDs) and nine critical care nurses (RNs) in the role of ACLS team leader. All had been previously trained in ACLS. The testing sequence included ventricular fibrillation (VF) refractory to initial countershock (defib), asystole after second defib, recurrent VF after drug therapy, and finally sinus rhythm after third defib. A blood gas report indicated respiratory acidosis and hypoxemia. Assessment of patient status was poor in both groups, although MDs did significantly (p = .001) better than RNs. Other problem areas were drug therapy and trouble-shooting are not adequately stressed in the AHA ACLS curriculum; moreover, there is no lecture that specifically addresses the team approach to resuscitation and the role of team leader. We found that the Mega Code effectively evaluated individual and group performance. Results of objective-based Mega Code testing can be used both to improve ACLS curriculum and to indicate areas to be stressed during refresher training.

Can better basic and advanced cardiac life support improve outcome from cardiac arrest?

The effect of basic and advanced cardiac life support (BLS and ACLS) on long-term survival is dependent upon both the response time and the quality of intervention. Retention research using the results of classroom testing as indirect indicators has shown that performance of BLS and ACLS skills is poor. This suggests that BLS and ACLS courses do not teach the knowledge and skills well, the information is too difficult to retain, testing procedures are faulty, and/or the performance standards are unrealistic. To maximize the likelihood of successful resuscitation from cardiac arrest, we propose the following: (a) simplify the BLS procedures; (b) simplify the BLS and ACLS curricula; (c) simplify teaching strategies; (d) simplify testing based on what steps are required to sustain life; (e) define objective criteria for knowledge acquisition and skill performance; (f) base refresher training on diagnosed deficiencies and evaluate innovative ways to improve retention; (g) develop a resuscitation record to provide accurate documentation of patient status, dysrhythmias, therapy, and responses to therapy; (h) develop a process evaluation tool to evaluate individual and group performances during actual resuscitation; and (i) form an international consortium of BLS and ACLS investigators.

The effect of time since training on house officers' retention of cardiopulmonary resuscitation skills

Currently, the American Heart Association (AHA) recommends that physicians be certified in cardiopulmonary resuscitation (CPR) every two years. This study was undertaken to determine the effects of time since training on retention of CPR skills of physicians and to identify at what point performance deteriorates to a level requiring retraining with supervised practice. The physicians' performance of CPR one year or less after training was compared with that of more than one year after training. Thirty-three medical residents who had been taught CPR by the same instructor were tested without warning for one-person CPR on a recording mannikin. Performance was evaluated according to AHA Heartsaver criteria. The data were analyzed by organizing all CPR steps or behavioral objectives into three categories: assessment, skills (which included ventilation and compression), and sequence (which included calls for assistance). The data suggest that the knowledge of CPR sequence remains stable and that assessment improves while skill performance deteriorates after one year. This apparent contradiction in overall CPR performance may relate to the effect of experience. Assessment may improve because of involvement in actual resuscitations in the hospital. Deterioration of skills may reflect the fact that senior residents do not actually perform CPR, but become team leaders and thereby lose their skills, or that poor performance is not corrected in actual "code" situations. If a two-year certification standard is maintained, CPR skill testing at least every 12 months should be considered. If skills have deteriorated, hands-on-practice should be undertaken at that time.