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Radin AK, Shaw J, Brown SP, Flint H, Fouts T, McCue E, Skeie A, Peña C, Youell J, Ratzliff A, Powers DM, Biss M, Lemon H, Sandoval D, Hartmann J, Hammar E, Doty-Jones A, Wilson J, Austin G, Chan KCG, Zheng Z, Fruhbauerova M, Ross M, Stright M, Pullen S, Edwards C, Walton M, Kerbrat A, Comtois KA. Comparative effectiveness of safety planning intervention with instrumental support calls (ISC) versus safety planning intervention with two-way text message caring contacts (CC) in adolescents and adults screening positive for suicide risk in emergency departments and primary care clinics: Protocol for a pragmatic randomized controlled trial. Contemp Clin Trials 2023; 131:107268. [PMID: 37321352 PMCID: PMC10530453 DOI: 10.1016/j.cct.2023.107268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/24/2023] [Accepted: 06/11/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Suicide is a leading cause of death in adolescents and adults in the US. Follow-up support delivered when patients return home after an emergency department (ED) or primary care encounter can significantly reduce suicidal ideation and attempts. Two follow-up models to augment usual care including the Safety Planning Intervention have high efficacy: Instrumental Support Calls (ISC) and Caring Contacts (CC) two-way text messages, but they have never been compared to assess which works best. This protocol for the Suicide Prevention Among Recipients of Care (SPARC) Trial aims to determine which model is most effective for adolescents and adults with suicide risk. METHODS The SPARC Trial is a pragmatic randomized controlled trial comparing the effectiveness of ISC versus CC. The sample includes 720 adolescents (12-17 years) and 790 adults (18+ years) who screen positive for suicide risk during an ED or primary care encounter. All participants receive usual care and are randomized 1:1 to ISC or CC. The state suicide hotline delivers both follow-up interventions. The trial is single-masked, with participants unaware of the alternative treatment, and is stratified by adolescents/adults. The primary outcome is suicidal ideation and behavior, measured using the Columbia Suicide Severity Rating Scale (C-SSRS) screener at 6 months. Secondary outcomes include C-SSRS at 12 months, and loneliness, return to crisis care for suicidality, and utilization of outpatient mental health services at 6 and 12 months. DISCUSSION Directly comparing ISC and CC will determine which follow-up intervention is most effective for suicide prevention in adolescents and adults.
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Affiliation(s)
- Anna K Radin
- St. Luke's Health System, Applied Research Division, Boise, ID, United States.
| | - Jenny Shaw
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Siobhan P Brown
- University of Washington, Department of Biostatistics, Seattle, WA, United States
| | - Hilary Flint
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Tara Fouts
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Elizabeth McCue
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Anton Skeie
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Cecelia Peña
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Jonathan Youell
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Anna Ratzliff
- University of Washington, Department of Psychiatry and Behavioral Sciences,, Seattle, WA, United States
| | - Diane M Powers
- University of Washington, Department of Psychiatry and Behavioral Sciences,, Seattle, WA, United States
| | - Matthew Biss
- Idaho Crisis and Suicide Hotline, Boise, ID, United States; SPARC Lived Experience Advisory Board, ID, United States
| | - Hannah Lemon
- Idaho Crisis and Suicide Hotline, Boise, ID, United States
| | | | | | | | - Amelia Doty-Jones
- St. Luke's Health System, Behavioral Health Service Line, Boise, ID, United States
| | - Jacob Wilson
- St. Luke's Health System, Behavioral Health Service Line, Boise, ID, United States; Cornerstone Whole Healthcare Organization, Inc., McCall, ID, United States
| | - George Austin
- Idaho Crisis and Suicide Hotline, Boise, ID, United States
| | - Kwun C G Chan
- University of Washington, Department of Biostatistics, Seattle, WA, United States
| | - Zihan Zheng
- University of Washington, Department of Biostatistics, Seattle, WA, United States
| | - Martina Fruhbauerova
- University of Washington, Department of Psychiatry and Behavioral Sciences,, Seattle, WA, United States
| | - Michelle Ross
- St. Luke's Health System, Behavioral Health Service Line, Boise, ID, United States
| | - Megan Stright
- St. Luke's Health System, Behavioral Health Service Line, Boise, ID, United States
| | - Samuel Pullen
- St. Luke's Health System, Behavioral Health Service Line, Boise, ID, United States; Novant Health, Psychiatry and Mental Health Institute, Winston-Salem, NC, United States; Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, Durham, NC, United States
| | - Christopher Edwards
- St. Luke's Health System, Behavioral Health Service Line, Boise, ID, United States; National Staffing Solutions (Contracted Provider for Optum Serve), Twin Falls, ID, United States
| | - Michael Walton
- St. Luke's Health System, Behavioral Health Service Line, Boise, ID, United States
| | - Amanda Kerbrat
- University of Washington, Department of Psychiatry and Behavioral Sciences,, Seattle, WA, United States
| | - Katherine Anne Comtois
- University of Washington, Department of Psychiatry and Behavioral Sciences,, Seattle, WA, United States
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Ilich A, Gernsheimer TB, Triulzi DJ, Herren H, Brown SP, Holle LA, Lucas AT, de Laat B, El Kassar N, Wolberg AS, May S, Key NS. Absence of hyperfibrinolysis may explain lack of efficacy of tranexamic acid in hypoproliferative thrombocytopenia. Blood Adv 2023; 7:900-908. [PMID: 36044391 PMCID: PMC10025092 DOI: 10.1182/bloodadvances.2022008255] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/29/2022] [Accepted: 08/21/2022] [Indexed: 11/20/2022] Open
Abstract
The American Trial Using Tranexamic Acid (TXA) in Thrombocytopenia (A-TREAT, NCT02578901) demonstrated no superiority of TXA over placebo in preventing World Health Organization (WHO) grade 2 or higher bleeding in patients with severe thrombocytopenia requiring supportive platelet transfusion following myeloablative therapy for hematologic disorders. In this ancillary study, we sought to determine whether this clinical outcome could be explained on the basis of correlative assays of fibrinolysis. Plasma was collected from A-TREAT participants (n = 115) before the initiation of study drug (baseline) and when TXA was at steady-state trough concentration (follow-up). Global fibrinolysis was measured by 3 assays: euglobulin clot lysis time (ECLT), plasmin generation (PG), and tissue-type plasminogen activator (tPA)-challenged clot lysis time (tPA-CLT). TXA was quantified in follow-up samples by tandem mass spectrometry. Baseline samples did not demonstrate fibrinolytic activation by ECLT or tPA-CLT. Furthermore, neither ECLT nor levels of plasminogen activator inhibitor-1, tPA, plasminogen, alpha2-antiplasmin, or plasmin-antiplasmin complexes were associated with a greater risk of WHO grade 2+ bleeding. TXA trough concentrations were highly variable (range, 0.7-10 μg/mL) and did not correlate with bleeding severity, despite the fact that plasma TXA levels correlated strongly with pharmacodynamic assessments by PG (Spearman r, -0.78) and tPA-CLT (r, 0.74). We conclude that (1) no evidence of fibrinolytic activation was observed in these patients with thrombocytopenia, (2) trough TXA concentrations varied significantly between patients receiving the same dosing schedule, and (3) tPA-CLT and PG correlated well with TXA drug levels.
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Affiliation(s)
- Anton Ilich
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Terry B. Gernsheimer
- Department of Medicine/Hematology and Seattle Cancer Care Alliance, University of Washington, Seattle, WA
| | | | - Heather Herren
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Lori A. Holle
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Andrew T. Lucas
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Bas de Laat
- Synapse Research Institute, Maastricht, The Netherlands
| | - Nahed El Kassar
- Division of Blood Diseases and Resources, National Heart Lung and Blood Institute, Washington, DC
| | - Alisa S. Wolberg
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Nigel S. Key
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Radin AK, Shaw J, Brown SP, Torres J, Harper M, Flint H, Fouts T, McCue E, Skeie A, Peña C, Youell J, Doty-Jones A, Wilson J, Flinn L, Austin G, Chan KCG, Zheng Z, Fruhbauerova M, Walton M, Kerbrat A, Comtois KA. Comparative effectiveness of two versions of a caring contacts intervention in healthcare providers, staff, and patients for reducing loneliness and mental distress: A randomized controlled trial. J Affect Disord 2023; 331:442-451. [PMID: 36963515 DOI: 10.1016/j.jad.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 03/10/2023] [Accepted: 03/12/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Caring Contacts can effectively reduce suicide ideation, attempts, and death. In published clinical trials, Caring Contacts were sent by someone who knew the recipient. At scale, Caring Contacts programs rarely introduce the recipient and sender. It is not known whether receiving Caring Contacts from someone unknown is as effective as messages from someone the recipient has met. METHODS Pragmatic randomized controlled trial comparing Caring Contacts with (CC+) versus without an introductory phone call (CC). Recruitment occurred January-July 2021, with outcomes assessed at 6 months. Participants were primary care patients or healthcare providers/staff reporting adverse mental health outcomes on a qualifying survey. Participants were sent 11 standardized caring text messages over 6 months; when participants replied, they received personalized unscripted responses. CC+ calls were semi-structured. The primary outcome was loneliness (NIH Toolkit). RESULTS Participants included 331 patients (mean [SD] age: 45.5 [16.4], 78.9 % female) and 335 healthcare providers/staff (mean [SD] age: 40.9 [11.8], 86.6 % female). There were no significant differences in loneliness at 6 months by treatment arm in either stratum. In patients, mean (SD) loneliness was 61.9 (10.7) in CC, and 60.8 (10.3) in CC+, adjusted mean difference of -1.0 (95 % CI: -3.0, 1.0); p-value = 0.31. In providers/staff, mean (SD) loneliness was 61.2 (11) in CC, and 61.3 (11.1) in CC+, adjusted mean difference of 0.2 (95 % CI: -1.8, 2.2); p-value = 0.83. LIMITATIONS Study population was 93 % white which may limit generalizability. CONCLUSIONS Including an initial phone call added operational complexity without significantly improving the effectiveness of a Caring Contacts program.
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Affiliation(s)
- Anna K Radin
- St. Luke's Health System, Applied Research Division, Boise, ID, United States.
| | - Jenny Shaw
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Siobhan P Brown
- University of Washington, Department of Biostatistics, Seattle, WA, United States
| | - Jessica Torres
- Idaho Crisis and Suicide Hotline, Boise, ID, United States
| | - Maggie Harper
- Idaho Crisis and Suicide Hotline, Boise, ID, United States
| | - Hilary Flint
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Tara Fouts
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Elizabeth McCue
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Anton Skeie
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Cecelia Peña
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Jonathan Youell
- St. Luke's Health System, Applied Research Division, Boise, ID, United States
| | - Amelia Doty-Jones
- St. Luke's Health System, Behavioral Health Service Line, Boise, ID, United States
| | - Jacob Wilson
- St. Luke's Health System, Behavioral Health Service Line, Boise, ID, United States
| | - Lee Flinn
- Idaho Crisis and Suicide Hotline, Boise, ID, United States
| | - George Austin
- Idaho Crisis and Suicide Hotline, Boise, ID, United States
| | - Kwun C G Chan
- University of Washington, Department of Biostatistics, Seattle, WA, United States
| | - Zihan Zheng
- University of Washington, Department of Biostatistics, Seattle, WA, United States
| | - Martina Fruhbauerova
- University of Washington, Department of Psychiatry and Behavioral Sciences, Center for Suicide Prevention & Recovery, Seattle, WA, United States
| | - Michael Walton
- St. Luke's Health System, Behavioral Health Service Line, Boise, ID, United States
| | - Amanda Kerbrat
- University of Washington, Department of Psychiatry and Behavioral Sciences, Center for Suicide Prevention & Recovery, Seattle, WA, United States
| | - Katherine Anne Comtois
- University of Washington, Department of Psychiatry and Behavioral Sciences, Center for Suicide Prevention & Recovery, Seattle, WA, United States
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Agusala V, Dale P, Khera R, Brown SP, Idris AH, Link MS, Mody P. Variation in coronary angiography use in Out-of-Hospital cardiac arrest. Resuscitation 2022; 181:79-85. [PMID: 36332772 DOI: 10.1016/j.resuscitation.2022.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Multiple studies have examined the association of early coronary angiography (CAG) among out-of-hospital cardiac arrest (OHCA) patients with conflicting results. However, patterns of use of CAG among OHCA patients in real-world settings are not well-described. METHODS Utilizing data from the Resuscitation Outcomes Consortium's Continuous Chest Compressions trial for our analysis, we stratified patients based on initial arrest rhythm and ST-elevation on initial post-resuscitation electrocardiogram (ECG) and examined the rates of CAG in resuscitated patients. We also examined the rates of CAG across different trial clusters in the overall study population as well as in pre-specified patient subgroups RESULTS: Of 26,148 patients in the CCC trial, 5,608 survived to hospital admission and were enrolled in the study. Among them, 26 % underwent CAG. Patients with ST-elevation underwent CAG at a significantly higher rate than patients presenting without ST-elevation (70 % vs 31 %, p < 0.001). Similarly, patients presenting with shockable rhythms underwent CAG more frequently compared with patients with non-shockable rhythms (28 % vs 5 %, p < 0.001). There was marked variation in CAG frequency across different trial clusters with the proportion of patients within a trial cluster receiving CAG ranging from 4 % - 41 %. The proportion varied more among patients with ST-elevation (16 % - 82 %) or initial shockable rhythm (11 % - 75 %) compared with no ST-elevation (2 % - 28 %) or initial non-shockable rhythm (0 % - 19 %). CONCLUSION Among a national cohort of OHCA patients, large variation in the use of CAG exists, highlighting the existing uncertainty regarding perceived benefit from early CAG in OHCA.
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Affiliation(s)
- Vijay Agusala
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Patrick Dale
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Rohan Khera
- Yale University School of Medicine, New Haven, CT, United States
| | - Siobhan P Brown
- University of Washington, Seattle, Washington, United States
| | - Ahamed H Idris
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mark S Link
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Purav Mody
- University of Texas Southwestern Medical Center, Dallas, TX, United States.
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5
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Nichol G, Brown SP. Reply to Je Hyeok Oh. Resuscitation 2021; 169:188. [PMID: 34619298 DOI: 10.1016/j.resuscitation.2021.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Affiliation(s)
- G Nichol
- University of Washington, Seattle, WA, United States.
| | - S P Brown
- University of Washington, Seattle, WA, United States
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Dyson K, Brown SP, May S, Sayre M, Colella M, Daya MR, Roth R, Nichol G. Community lessons to understand resuscitation excellence (culture): Association between emergency medical services (EMS) culture and outcome after out-of-hospital cardiac arrest. Resuscitation 2020; 156:202-209. [PMID: 32979404 DOI: 10.1016/j.resuscitation.2020.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/19/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The large geographic variation in outcome after out-of-hospital cardiac arrest (OHCA) is not well explained by traditional patient and emergency medical services (EMS) characteristics. A 'culture of excellence' in resuscitation within an EMS is believed to be an important factor that influences quality of care and outcome in patients with OHCA. However, whether a culture of excellence is associated with improved survival after OHCA is not known. METHODOLOGY We linked survey responses from EMS agency medical directors related to resuscitation culture to a retrospective analysis of prospectively collected data from the Resuscitation Outcomes Consortium (ROC) Epistry - Cardiac Arrest. We used a multivariable random effects model to assess whether EMS culture strategies were associated with OHCA survival to hospital discharge. RESULTS Of the 46 EMS medical directors surveyed, 35 (76%) provided a complete response. Included were n = 66,597 cases of OHCA who received attempted resuscitation by one of n = 123 EMS agencies from July 1, 2010, through June 30, 2015. Overall survival to discharge was 11%. Organizational values and goals were independently associated with survival to hospital discharge in all OHCAs (adjusted odds ratio [AOR] 1.27, 95% confidence interval [CI] 1.09-1.48) and the subgroup restricted to bystander witnessed OHCAs with initial shockable rhythm (AOR 1.55, 95% CI 1.21-1.99). CONCLUSIONS An organizational goal to improve OHCA survival was independently associated with improved survival to discharge. EMS agencies looking to improve OHCA survival should consider implementing an organizational goal to improve OHCA survival and empower quality improvement personnel to drive that goal.
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Affiliation(s)
- Kylie Dyson
- Department of Epidemiology and Preventive Medicine, Monash University, VIC, Australia.
| | - Siobhan P Brown
- University of Washington Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Susanne May
- University of Washington Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Michael Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Mario Colella
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Ronald Roth
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Graham Nichol
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA, United States
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Brown SP, Shoben AB. Information growth for sequential monitoring of clinical trials with a stepped wedge cluster randomized design and unknown intracluster correlation. Clin Trials 2020; 17:176-183. [DOI: 10.1177/1740774520901488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background/aims In a stepped wedge study design, study clusters usually start with the baseline treatment and then cross over to the intervention at randomly determined times. Such designs are useful when the intervention must be delivered at the cluster level and are becoming increasingly common in practice. In these trials, if the outcome is death or serious morbidity, one may have an ethical imperative to monitor the trial and stop before maximum enrollment if the new therapy is proven to be beneficial. In addition, because formal monitoring allows for the stoppage of trials when a significant benefit for new therapy has been ruled out, their use can make a research program more efficient. However, use of the stepped wedge cluster randomized study design complicates the implementation of standard group sequential monitoring methods. Both the correlation of observations introduced by the clustered randomization and the timing of crossover from one treatment to the other impact the rate of information growth, an important component of an interim analysis. Methods We simulated cross-sectional stepped wedge study data in order to evaluate the impact of sequential monitoring on the Type I error and power when the true intracluster correlation is unknown. We studied the impact of varying intracluster correlations, treatment effects, methods of estimating the information growth, and boundary shapes. Results While misspecified information growth can impact both the Type I error and power of a study in some settings, we observed little inflation of the Type I error and only moderate reductions in power across a range of misspecified information growth patterns in our simulations. Conclusion Taking the study design into account and using either an estimate of the intracluster correlation from the ongoing study or other data in the same clusters should allow for easy implementation of group sequential methods in future stepped wedge designs.
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Affiliation(s)
- Siobhan P Brown
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Abigail B Shoben
- Division of Biostatistics, The Ohio State University, Columbus, OH, USA
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8
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May S, Brown SP, Schmicker RH, Emerson SS, Nkwopara E, Ginsburg AS. Non-inferiority designs comparing placebo to a proven therapy for childhood pneumonia in low-resource settings. Clin Trials 2019; 17:129-137. [PMID: 31814441 DOI: 10.1177/1740774519888460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS After a new treatment is recommended to be first-line treatment for a specific indication, outcome and population, it may be unethical to use placebo as a comparator in trials for that setting. Nevertheless, in specific circumstances, use of a placebo group might be warranted, for example, when it is believed that an active treatment may not be efficacious or cost-effective for a specific subpopulation. An example is antibiotic treatment for pneumonia, which may not be effective for many patients taking it due to the emergence of antibiotic-resistant strains or the high prevalence of viral and low prevalence of bacterial pneumonia. METHODS We explore the applicability of different design options in cases where the benefit of an established treatment is questioned, with particular emphasis on issues that arise in a low-resource setting. Using the example of a clinical trial comparing the effectiveness of placebo versus amoxicillin in treating children 2-59 months of age with fast breathing pneumonia in Lilongwe, Malawi, we discuss the pros and cons of superiority versus non-inferiority designs, an intent-to-treat versus as-treated analysis and the use and interpretation of one- versus two-sided confidence intervals. RESULTS We find that a non-inferiority design using an intent-to-treat analysis is the most appropriate design and analysis option. In addition, the presentation of one- versus two-sided confidence intervals can depend on the results but can maintain type I error. CONCLUSION In the setting where the benefit of a previously established beneficial treatment is questioned, a non-inferiority design that includes placebo as the tested treatment option can be the most appropriate design option.
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Affiliation(s)
- Susanne May
- UW Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Siobhan P Brown
- UW Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Robert H Schmicker
- UW Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Scott S Emerson
- UW Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
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McCollum ED, Brown SP, Nkwopara E, Mvalo T, May S, Ginsburg AS. Development of a prognostic risk score to aid antibiotic decision-making for children aged 2-59 months with World Health Organization fast breathing pneumonia in Malawi: An Innovative Treatments in Pneumonia (ITIP) secondary analysis. PLoS One 2019; 14:e0214583. [PMID: 31220085 PMCID: PMC6586284 DOI: 10.1371/journal.pone.0214583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 03/14/2019] [Indexed: 01/19/2023] Open
Abstract
Background Due to increasing antimicrobial resistance in low-resource settings, strategies to rationalize antibiotic treatment of children unlikely to have a bacterial infection are needed. This study’s objective was to utilize a database of placebo treated Malawian children with World Health Organization (WHO) fast breathing pneumonia to develop a prognostic risk score that could aid antibiotic decision making. Methods We conducted a secondary analysis of children randomized to the placebo group of the Innovative Treatments in Pneumonia (ITIP) fast breathing randomized, controlled, noninferiority trial. Participants were low-risk HIV-uninfected children 2–59 months old with WHO fast breathing pneumonia in Lilongwe, Malawi. Study endpoints were treatment failure, defined as either disease progression at any time on or before Day 4 of treatment or disease persistence on Day 4, or relapse, considered as the recurrence of pneumonia or severe disease among previously cured children between Days 5 and 14. We utilized multivariable linear regression and stepwise model selection to develop a model to predict the probability of treatment failure or relapse. Results Treatment failure or relapse occurred in 11.5% (61/526) of children included in this analysis. The final model incorporated the following predictors: heart rate terms, mid-upper arm circumference, malaria status, water source, family income, and whether or not a sibling or other child in the household received childcare outside the home. The model’s area under the receiver operating characteristic score was 0.712 (95% confidence interval 0.66, 0.78) and it explained 6.1% of the variability in predicting treatment failure or relapse (R2, 0.061). For the model to categorize all children with treatment failure or relapse correctly, 77% of children without treatment failure or relapse would require antibiotics. Conclusion The model had inadequate discrimination to be appropriate for clinical application. Different strategies will likely be required for models to perform accurately among similar pediatric populations.
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Affiliation(s)
- Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington Clinical Trial Center, Seattle, Washington, United States of America
| | | | - Tisungane Mvalo
- University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Susanne May
- Department of Biostatistics, University of Washington Clinical Trial Center, Seattle, Washington, United States of America
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Pollack RA, Brown SP, May S, Rea T, Kudenchuk PJ, Weisfeldt ML. Bystander automated external defibrillator application in non-shockable out-of-hospital cardiac arrest. Resuscitation 2019; 137:168-174. [DOI: 10.1016/j.resuscitation.2019.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/09/2019] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
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Dyson K, Brown SP, May S, Smith K, Koster RW, Beesems SG, Kuisma M, Salo A, Finn J, Sterz F, Nürnberger A, Morrison LJ, Olasveengen TM, Callaway CW, Shin SD, Gräsner JT, Daya M, Ma MHM, Herlitz J, Strömsöe A, Aufderheide TP, Masterson S, Wang H, Christenson J, Stiell I, Vilke GM, Idris A, Nishiyama C, Iwami T, Nichol G. International variation in survival after out-of-hospital cardiac arrest: A validation study of the Utstein template. Resuscitation 2019; 138:168-181. [PMID: 30898569 DOI: 10.1016/j.resuscitation.2019.03.018] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/11/2019] [Accepted: 03/10/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Out-of-hospital cardiac arrest (OHCA) survival varies greatly between communities. The Utstein template was developed and promulgated to improve the comparability of OHCA outcome reports, but it has undergone limited empiric validation. We sought to assess how much of the variation in OHCA survival between emergency medical services (EMS) across the globe is explained by differences in the Utstein factors. We also assessed how accurately the Utstein factors predict OHCA survival. METHODS We performed a retrospective analysis of patient-level prospectively collected data from 12 OHCA registries from 12 countries for the period 1 Jan 2006 through 31 Dec 2011. We used generalized linear mixed models to examine the variation in survival between EMS agencies (n=232). RESULTS Twelve registries contributed 86,759 cases. Patient arrest characteristics, EMS treatment and patient outcomes varied across registries. Overall survival to hospital discharge was 10% (range, 6% to 22%). Overall survival with Cerebral Performance Category of 1 or 2 (available for 8/12 registries) was 8% (range, 2% to 20%). The area-under-the-curve for the Utstein model was 0.85 (Wald CI: 0.85-0.85). The Utstein factors explained 51% of the EMS agency variation in OHCA survival. CONCLUSIONS The Utstein factors explained 51% of the variation in survival to hospital discharge among multiple large geographically separate EMS agencies. This suggests that quality improvement and public health efforts should continue to target modifiable Utstein factors to improve OHCA survival. Further study is required to identify the reasons for the variation that is incompletely understood.
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Affiliation(s)
- Kylie Dyson
- Centre for Research and Evaluation, Ambulance Victoria, VIC, Australia; Department of Epidemiology and Preventive Medicine, Monash University, VIC, Australia.
| | - Siobhan P Brown
- University of Washington Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Susanne May
- University of Washington Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Karen Smith
- Centre for Research and Evaluation, Ambulance Victoria, VIC, Australia; Department of Epidemiology and Preventive Medicine, Monash University, VIC, Australia; University of Western Australia, Perth, WA, Australia
| | | | | | - Markku Kuisma
- Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Ari Salo
- Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Judith Finn
- School of Nursing, Midwifery and Paramedicine, Curtin University, WA, Australia; University of Western Australia, WA, Australia; Department of Epidemiology and Preventive Medicine, Monash University, VIC, Australia
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, and Municipal Ambulance Service, Vienna, Austria
| | - Alexander Nürnberger
- Department of Emergency Medicine, Medical University of Vienna, and Municipal Ambulance Service, Vienna, Austria
| | - Laurie J Morrison
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital and Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Sang Do Shin
- Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Jan-Thorsten Gräsner
- Department of Anesthesiology and Intensive Medicine, University-Medical Center Hospital, Schleswig-Campus Kiel, Kiel, Germany
| | - Mohamud Daya
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States
| | | | - Johan Herlitz
- Prehospen-Centre of Prehospital Research; Faculty of Caring Science, Work-Life and Social Welfare, University of Borås, Sweden
| | - Anneli Strömsöe
- School of Health and Social Sciences, University of Dalarna, Falun, Sweden
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Siobhán Masterson
- On behalf of the National Out-of-Hospital Cardiac Arrest Register (OHCAR). Discipline of General Practice, National University of Ireland, Galway, Ireland and National Ambulance Service, Health Service Executive, Dublin, Ireland
| | - Henry Wang
- Department of Emergency Medicine, University of Texas Health Science Center, Houston, TX, United States
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Gary M Vilke
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, United States
| | - Ahamed Idris
- Department of Emergency Medicine, University of Texas Southwester, Dallas, TX, United States
| | - Chika Nishiyama
- Department of Critical Care Nursing, Kyoto University Graduate School of Human Health Science, Kyoto, Japan
| | - Taku Iwami
- Kyoto University Health Service, Kyoto, Japan
| | - Graham Nichol
- University of Washington - Harborview Center for Prehospital Emergency Care, Departments of Emergency Medicine and Medicine, University of Washington, Seattle, WA, United States
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12
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Pollack RA, Brown SP, Rea T, Aufderheide T, Barbic D, Buick JE, Christenson J, Idris AH, Jasti J, Kampp M, Kudenchuk P, May S, Muhr M, Nichol G, Ornato JP, Sopko G, Vaillancourt C, Morrison L, Weisfeldt M. Impact of Bystander Automated External Defibrillator Use on Survival and Functional Outcomes in Shockable Observed Public Cardiac Arrests. Circulation 2018; 137:2104-2113. [PMID: 29483086 DOI: 10.1161/circulationaha.117.030700] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 01/04/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Survival following out-of-hospital cardiac arrest (OHCA) with shockable rhythms can be improved with early defibrillation. Although shockable OHCA accounts for only ≈25% of overall arrests, ≈60% of public OHCAs are shockable, offering the possibility of restoring thousands of individuals to full recovery with early defibrillation by bystanders. We sought to determine the association of bystander automated external defibrillator use with survival and functional outcomes in shockable observed public OHCA. METHODS From 2011 to 2015, the Resuscitation Outcomes Consortium prospectively collected detailed information on all cardiac arrests at 9 regional centers. The exposures were shock administration by a bystander-applied automated external defibrillator in comparison with initial defibrillation by emergency medical services. The primary outcome measure was discharge with normal or near-normal (favorable) functional status defined as a modified Rankin Score ≤2. Survival to hospital discharge was the secondary outcome measure. RESULTS Among 49 555 OHCAs, 4115 (8.3%) observed public OHCAs were analyzed, of which 2500 (60.8%) were shockable. A bystander shock was applied in 18.8% of the shockable arrests. Patients shocked by a bystander were significantly more likely to survive to discharge (66.5% versus 43.0%) and be discharged with favorable functional outcome (57.1% versus 32.7%) than patients initially shocked by emergency medical services. After adjusting for known predictors of outcome, the odds ratio associated with a bystander shock was 2.62 (95% confidence interval, 2.07-3.31) for survival to hospital discharge and 2.73 (95% confidence interval, 2.17-3.44) for discharge with favorable functional outcome. The benefit of bystander shock increased progressively as emergency medical services response time became longer. CONCLUSIONS Bystander automated external defibrillator use before emergency medical services arrival in shockable observed public OHCA was associated with better survival and functional outcomes. Continued emphasis on public automated external defibrillator utilization programs may further improve outcomes of OHCA.
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Affiliation(s)
- Ross A Pollack
- Johns Hopkins University School of Medicine, Baltimore, MD (R.A.P., M.W.)
| | | | - Thomas Rea
- University of Washington, Seattle (T.R., P.K.).,King County Emergency Medical Services, Public Health, Seattle, WA (T.R., P.K.)
| | - Tom Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee (T.A., J.J.)
| | - David Barbic
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada (D.B., J.C.)
| | - Jason E Buick
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada (J.E.B, L.M.)
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada (D.B., J.C.)
| | - Ahamed H Idris
- Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas (A.H.I.)
| | - Jamie Jasti
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee (T.A., J.J.)
| | - Michael Kampp
- Department of Emergency Medicine, Oregon Health and Science University, Portland (M.K.)
| | - Peter Kudenchuk
- University of Washington, Seattle (T.R., P.K.).,King County Emergency Medical Services, Public Health, Seattle, WA (T.R., P.K.)
| | - Susanne May
- Johns Hopkins University School of Medicine, Baltimore, MD (R.A.P., M.W.)
| | - Marc Muhr
- Clark County Emergency Medical Services, Vancouver, WA (M.M.)
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, Seattle (G.N.)
| | - Joseph P Ornato
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.)
| | - George Sopko
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.S.)
| | - Christian Vaillancourt
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Canada (C.V.)
| | - Laurie Morrison
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada (J.E.B, L.M.).,Division of Emergency Medicine, Department of Medicine, University of Toronto, Ottawa, Canada (L.M.)
| | - Myron Weisfeldt
- Johns Hopkins University School of Medicine, Baltimore, MD (R.A.P., M.W.)
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13
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Nichol G, Brown SP, Perkins GD, Kim F, Sterz F, Broeckel Elrod JA, Mentzelopoulos S, Lyon R, Arabi Y, Castren M, Larsen P, Valenzuela T, Graesner JT, Youngquist S, Khunkhlai N, Wang HE, Ondrej F, Sastrias JMF, Barasa A, Sayre MR. What change in outcomes after cardiac arrest is necessary to change practice? Results of an international survey. Resuscitation 2016; 107:115-20. [PMID: 27565860 DOI: 10.1016/j.resuscitation.2016.08.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 08/01/2016] [Accepted: 08/04/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Efficient trials of interventions for patients with out-of-hospital cardiac arrest (OHCA) should have adequate but not excess power to detect a difference in outcomes. The minimum clinically important difference (MCID) is the threshold value in outcomes observed in a trial at which providers should choose to adopt a treatment. There has been limited assessment of MCID for outcomes after OHCA. Therefore, we conducted an international survey of individuals interested in cardiac resuscitation to define the MCID for a range of outcomes after OHCA. METHODS A brief survey instrument was developed and modified by consensus. Included were open-ended responses. The survey included an illustrative example of a hypothetical randomized study with distributions of outcomes based on those in a public use datafile from a previous trial. Elicited information included the minimum significant difference required in an outcome to change clinical practice. The population of interest was emergency physicians or other practitioners of acute cardiovascular research. RESULTS Usable responses were obtained from 160 respondents (50% of surveyed) in 46 countries (79% of surveyed). MCIDs tended to increase as baseline outcomes increased. For a population of patients with 25% survival to discharge and 20% favorable neurologic status at discharge, the MCID were median 5 (interquartile range [IQR] 3, 10) percent for survival to discharge; median 5 (IQR 2, 10) percent for favorable neurologic status at discharge, median 4 (IQR 2, 9) days of ICU-free survival and median 4 (IQR 2, 8) days of hospital-free survival. CONCLUSION Reported MCIDs for outcomes after OHCA vary according to the outcome considered as well as the baseline rate of achieving it. MCIDs of ICU-free survival or hospital-free survival may be useful to accelerate the rate of evidence-based change in resuscitation care.
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Affiliation(s)
| | | | - Gavin D Perkins
- University of Warwick, Warwick, UK; Heart of England NHS Foundation Trust, Coventry, UK
| | | | - Fritz Sterz
- Medical University of Vienna, Vienna, Austria
| | | | | | | | - Yaseen Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Maaret Castren
- Department of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | | | | | | | | | - Nalinas Khunkhlai
- Department of Emergency Medicine & Narenthorn EMS Center Rajavithi Hospital, Ministry of Public Health, Thailand
| | - Henry E Wang
- University of Alabama at Birmingham, Birmingham, AL, USA
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14
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Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med 2016; 374:1711-22. [PMID: 27043165 DOI: 10.1056/nejmoa1514204] [Citation(s) in RCA: 262] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Antiarrhythmic drugs are used commonly in out-of-hospital cardiac arrest for shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, but without proven survival benefit. METHODS In this randomized, double-blind trial, we compared parenteral amiodarone, lidocaine, and saline placebo, along with standard care, in adults who had nontraumatic out-of-hospital cardiac arrest, shock-refractory ventricular fibrillation or pulseless ventricular tachycardia after at least one shock, and vascular access. Paramedics enrolled patients at 10 North American sites. The primary outcome was survival to hospital discharge; the secondary outcome was favorable neurologic function at discharge. The per-protocol (primary analysis) population included all randomly assigned participants who met eligibility criteria and received any dose of a trial drug and whose initial cardiac-arrest rhythm of ventricular fibrillation or pulseless ventricular tachycardia was refractory to shock. RESULTS In the per-protocol population, 3026 patients were randomly assigned to amiodarone (974), lidocaine (993), or placebo (1059); of those, 24.4%, 23.7%, and 21.0%, respectively, survived to hospital discharge. The difference in survival rate for amiodarone versus placebo was 3.2 percentage points (95% confidence interval [CI], -0.4 to 7.0; P=0.08); for lidocaine versus placebo, 2.6 percentage points (95% CI, -1.0 to 6.3; P=0.16); and for amiodarone versus lidocaine, 0.7 percentage points (95% CI, -3.2 to 4.7; P=0.70). Neurologic outcome at discharge was similar in the three groups. There was heterogeneity of treatment effect with respect to whether the arrest was witnessed (P=0.05); active drugs were associated with a survival rate that was significantly higher than the rate with placebo among patients with bystander-witnessed arrest but not among those with unwitnessed arrest. More amiodarone recipients required temporary cardiac pacing than did recipients of lidocaine or placebo. CONCLUSIONS Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT01401647.).
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Affiliation(s)
- Peter J Kudenchuk
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Siobhan P Brown
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Mohamud Daya
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Thomas Rea
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Graham Nichol
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Laurie J Morrison
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Brian Leroux
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Christian Vaillancourt
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Lynn Wittwer
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Clifton W Callaway
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - James Christenson
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Debra Egan
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Joseph P Ornato
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Myron L Weisfeldt
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Ian G Stiell
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Ahamed H Idris
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Tom P Aufderheide
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - James V Dunford
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - M Riccardo Colella
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Gary M Vilke
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Ashley M Brienza
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Patrice Desvigne-Nickens
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Pamela C Gray
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Randal Gray
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Norman Seals
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Ron Straight
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
| | - Paul Dorian
- From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington-Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) - all in Washington; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.); Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver - all in Canada; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.); National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) - both in Maryland; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.); the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire-Rescue Department (N.S.) - both in Dallas; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire-Rescue Department (J.V.D.) - both in San Diego; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.)
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15
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Tijssen JA, Prince DK, Morrison LJ, Atkins DL, Austin MA, Berg R, Brown SP, Christenson J, Egan D, Fedor PJ, Fink EL, Meckler GD, Osmond MH, Sims KA, Hutchison JS. Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest. Resuscitation 2015; 94:1-7. [PMID: 26095301 DOI: 10.1016/j.resuscitation.2015.06.012] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 05/26/2015] [Accepted: 06/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Survival is less than 10% for pediatric patients following out-of-hospital cardiac arrest. It is not known if more time on the scene of the cardiac arrest and advanced life support interventions by emergency services personnel are associated with improved survival. AIM This study was performed to determine which times on the scene and which prehospital interventions were associated with improved survival. METHODS We studied patients aged 3 days to 19 years old with out-of-hospital cardiac arrest, using the Resuscitation Outcomes Consortium cardiac arrest database from 11 North American regions, from 2005 to 2012. We evaluated survival to hospital discharge according to on-scene times (<10, 10 to 35 and >35 min). RESULTS Data were available for 2244 patients (1017 infants, 594 children and 633 adolescents). Infants had the lowest rate of survival (3.7%) compared to children (9.8%) and adolescents (16.3%). Survival improved over the 7 year study period especially among adolescents. Survival was highest in the 10 to 35 min on-scene time group (10.2%) compared to the >35 min. group (6.9%) and the <10 min. group (5.3%, p=0.01). Intravenous or intra-osseous access attempts and fluid administration were associated with improved survival, whereas advanced airway attempts were not associated with survival and resuscitation drugs were associated with worse survival. CONCLUSIONS In this observational study, a scene time of 10 to 35 min was associated with the highest survival, especially among adolescents. Access for fluid resuscitation was associated with increased survival but advanced airway and resuscitation drugs were not.
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Affiliation(s)
- Janice A Tijssen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, London Health Sciences Centre, University of Western Ontario, London, ON, Canada; The Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - David K Prince
- Data Coordinating Center, Resuscitation Outcomes Consortium, University of Washington, Seattle, WA, United States
| | - Laurie J Morrison
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dianne L Atkins
- Stead Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Michael A Austin
- Department of Emergency Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Robert Berg
- Departments of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States
| | - Siobhan P Brown
- Data Coordinating Center, Resuscitation Outcomes Consortium, University of Washington, Seattle, WA, United States
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Debra Egan
- Division of Cardiovascular Sciences, Heart Failure and Arrhythmias Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Preston J Fedor
- Division of Emergency Medicine, Department of Surgery, University of Texas Southwestern, Dallas, TX, United States
| | - Ericka L Fink
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Centre, Pittsburgh, PA, United States
| | - Garth D Meckler
- Division of Emergency Medicine, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Martin H Osmond
- Division of Emergency Medicine, Department of Pediatrics, The University of Ottawa, Ottawa, ON, Canada; Children's Hospital of Eastern Ontario, The University of Ottawa, Ottawa, ON, Canada
| | - Kathryn A Sims
- Data Coordinating Center, Resuscitation Outcomes Consortium, University of Washington, Seattle, WA, United States
| | - James S Hutchison
- Department of Critical Care and Neuroscience and Mental Health Research Program, The Hospital for Sick Children, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, Faculty of Medicine and Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
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16
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Sutton RM, Case E, Brown SP, Atkins DL, Nadkarni VM, Kaltman J, Callaway C, Idris A, Nichol G, Hutchison J, Drennan IR, Austin M, Daya M, Cheskes S, Nuttall J, Herren H, Christenson J, Andrusiek D, Vaillancourt C, Menegazzi JJ, Rea TD, Berg RA. A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality--A report from the ROC epistry-cardiac arrest. Resuscitation 2015; 93:150-7. [PMID: 25917262 DOI: 10.1016/j.resuscitation.2015.04.010] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/20/2015] [Accepted: 04/11/2015] [Indexed: 10/23/2022]
Abstract
AIM High-quality cardiopulmonary resuscitation (CPR) may improve survival. The quality of CPR performed during pediatric out-of-hospital cardiac arrest (p-OHCA) is largely unknown. The main objective of this study was to describe the quality of CPR performed during p-OHCA resuscitation attempts. METHODS Prospective observational multi-center cohort study of p-OHCA patients ≥ 1 and < 19 years of age registered in the Resuscitation Outcomes Consortium (ROC) Epistry database. The primary outcome was an a priori composite variable of compliance with American Heart Association (AHA) guidelines for both chest compression (CC) rate and CC fraction (CCF). Event compliance was defined as a case with 60% or more of its minute epochs compliant with AHA targets (rate 100-120 min(-1); depth ≥ 38 mm; and CCF ≥ 0.80). In a secondary analysis, multivariable logistic regression was used to evaluate the association between guideline compliance and return of spontaneous circulation (ROSC). RESULTS Between December 2005 and December 2012, 2564 pediatric events were treated by EMS providers, 390 of which were included in the final cohort. Of these events, 22% achieved AHA compliance for both rate and CCF, 36% for rate alone, 53% for CCF alone, and 58% for depth alone. Over time, there was a significant increase in CCF (p < 0.001) and depth (p = 0.03). After controlling for potential confounders, there was no significant association between AHA guideline compliance and ROSC. CONCLUSIONS In this multi-center study, we have established that there are opportunities for professional rescuers to improve prehospital CPR quality. Encouragingly, CCF and depth both increased significantly over time.
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Affiliation(s)
- Robert M Sutton
- The Children's Hospital of Philadelphia, 34th Street, Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Erin Case
- Resuscitations Outcome Consortium, 1107 NE 45th Street, Suite 505, Seattle, WA 98105-4680, United States.
| | - Siobhan P Brown
- Resuscitations Outcome Consortium, 1107 NE 45th Street, Suite 505, Seattle, WA 98105-4680, United States.
| | - Dianne L Atkins
- University of Iowa Carver College of Medicine, Stead Family Department of Pediatrics, Iowa City, IA 52242, United States.
| | - Vinay M Nadkarni
- The Children's Hospital of Philadelphia, 34th Street, Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Jonathan Kaltman
- National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, Bethesda, MD 20817, United States.
| | - Clifton Callaway
- University of Pittsburgh, 400A Iroquois, 3600 Forbes Avenue, Pittsburgh, PA 15260, United States.
| | - Ahamed Idris
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8579, United States.
| | - Graham Nichol
- Resuscitation Outcome Consortium Clinical Trial Center, University of Washington, Seattle, WA 98104, United States.
| | - Jamie Hutchison
- The Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada M5G 1X8.
| | - Ian R Drennan
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, Canada M5B 1W8.
| | - Michael Austin
- University of Ottawa, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, Canada K1Y 4E9.
| | - Mohamud Daya
- Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode CDW-EM, Portland, OR 97239-3098, United States.
| | - Sheldon Cheskes
- Sunnybrook Center for Prehospital Medicine, 77 Browns Line, Toronto, ON, Canada M8W 3S2.
| | - Jack Nuttall
- Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, United States.
| | - Heather Herren
- Resuscitations Outcome Consortium, 1107 NE 45th Street, Suite 505, Seattle, WA 98105-4680, United States.
| | - James Christenson
- Department of Emergency Medicine, University of British Columbia Faculty of Medicine, Room 3300 3rd Floor, 910 West 10th Avenue, Vancouver, BC, Canada V5Z 1M9.
| | - Dug Andrusiek
- School of Medical Sciences, Faculty of Health, Engineering and Science, Edith Cowan University, Building 19, Room 129d, 270 Joondalup Dr. Joondalup, Western Australia 6023, Australia.
| | - Christian Vaillancourt
- University of Ottawa, The Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, Room F649, 1053 Carling Avenue, Ottawa, ON, Canada K1Y 4E9.
| | - James J Menegazzi
- University of Pittsburgh, 3600 Forbes Avenue, Pittsburgh, PA 15261, United States.
| | - Thomas D Rea
- University of Washington, 206 3rd Avenue South, Seattle, WA 98104, United States.
| | - Robert A Berg
- The Children's Hospital of Philadelphia, 34th Street, Civic Center Boulevard, Philadelphia, PA 19104, United States.
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17
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Brown SP, Wang H, Aufderheide TP, Vaillancourt C, Schmicker RH, Cheskes S, Straight R, Kudenchuk P, Morrison L, Colella MR, Condle J, Gamez G, Hostler D, Kayea T, Ragsdale S, Stephens S, Nichol G. A randomized trial of continuous versus interrupted chest compressions in out-of-hospital cardiac arrest: rationale for and design of the Resuscitation Outcomes Consortium Continuous Chest Compressions Trial. Am Heart J 2015; 169:334-341.e5. [PMID: 25728722 DOI: 10.1016/j.ahj.2014.11.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 11/03/2014] [Indexed: 01/18/2023]
Abstract
The Resuscitation Outcomes Consortium is conducting a randomized trial comparing survival with hospital discharge after continuous chest compressions without interruption for ventilation versus currently recommended American Heart Association cardiopulmonary resuscitation with interrupted chest compressions in adult patients with out-of-hospital cardiac arrest without obvious trauma or respiratory cause. Emergency medical services perform study cardiopulmonary resuscitation for 3 intervals of manual chest compressions (each ~2 minutes) or until restoration of spontaneous circulation. Patients randomized to the continuous chest compression intervention receive 200 chest compressions with positive pressure ventilations at a rate of 10/min without interruption in compressions. Those randomized to the interrupted chest compression study arm receive chest compressions interrupted for positive pressure ventilations at a compression:ventilation ratio of 30:2. In either group, each interval of compressions is followed by rhythm analysis and defibrillation as required. Insertion of an advanced airway is deferred for the first ≥6 minutes to reduce interruptions in either study arm. The study uses a cluster randomized design with every-6-month crossovers. The primary outcome is survival to hospital discharge. Secondary outcomes are neurologically intact survival and adverse events. A maximum of 23,600 patients (11,800 per group) enrolled during the post-run-in phase of the study will provide ≥90% power to detect a relative change of 16% in the rate of survival to discharge, 8.1% to 9.4% with overall significance level of 0.05. If this trial demonstrates improved survival with either strategy, >3,000 premature deaths from cardiac arrest would be averted annually.
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18
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Popat R, Cornforth DM, McNally L, Brown SP. Collective sensing and collective responses in quorum-sensing bacteria. J R Soc Interface 2015; 12:20140882. [PMID: 25505130 PMCID: PMC4305403 DOI: 10.1098/rsif.2014.0882] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 11/12/2014] [Indexed: 11/21/2022] Open
Abstract
Bacteria often face fluctuating environments, and in response many species have evolved complex decision-making mechanisms to match their behaviour to the prevailing conditions. Some environmental cues provide direct and reliable information (such as nutrient concentrations) and can be responded to individually. Other environmental parameters are harder to infer and require a collective mechanism of sensing. In addition, some environmental challenges are best faced by a group of cells rather than an individual. In this review, we discuss how bacteria sense and overcome environmental challenges as a group using collective mechanisms of sensing, known as 'quorum sensing' (QS). QS is characterized by the release and detection of small molecules, potentially allowing individuals to infer environmental parameters such as density and mass transfer. While a great deal of the molecular mechanisms of QS have been described, there is still controversy over its functional role. We discuss what QS senses and how, what it controls and why, and how social dilemmas shape its evolution. Finally, there is a growing focus on the use of QS inhibitors as antibacterial chemotherapy. We discuss the claim that such a strategy could overcome the evolution of resistance. By linking existing theoretical approaches to data, we hope this review will spur greater collaboration between experimental and theoretical researchers.
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Affiliation(s)
- R Popat
- Centre for Immunity, Infection and Evolution, School of Biological Sciences, University of Edinburgh, Edinburgh EH9 3JT, UK
| | - D M Cornforth
- Centre for Immunity, Infection and Evolution, School of Biological Sciences, University of Edinburgh, Edinburgh EH9 3JT, UK Molecular Biosciences, University of Texas at Austin, 2500 Speedway NMS 3.254, Austin, TX 78712, USA
| | - L McNally
- Centre for Immunity, Infection and Evolution, School of Biological Sciences, University of Edinburgh, Edinburgh EH9 3JT, UK
| | - S P Brown
- Centre for Immunity, Infection and Evolution, School of Biological Sciences, University of Edinburgh, Edinburgh EH9 3JT, UK
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19
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Kudenchuk PJ, Brown SP, Daya M, Morrison LJ, Powell J, Leroux B, Dorian P. Regarding manuscript: "resuscitation outcomes consortium-amiodarone, lidocaine, or placebo study: rationale and methodology behind out-of-hospital cardiac arrest antiarrhythmic drug trial". Am Heart J 2014; 168:e19-20. [PMID: 25262274 DOI: 10.1016/j.ahj.2014.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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20
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Stiell IG, Brown SP, Nichol G, Cheskes S, Vaillancourt C, Callaway CW, Morrison LJ, Christenson J, Aufderheide TP, Davis DP, Free C, Hostler D, Stouffer JA, Idris AH. What is the optimal chest compression depth during out-of-hospital cardiac arrest resuscitation of adult patients? Circulation 2014; 130:1962-70. [PMID: 25252721 DOI: 10.1161/circulationaha.114.008671] [Citation(s) in RCA: 237] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The 2010 American Heart Association guidelines suggested an increase in cardiopulmonary resuscitation compression depth with a target >50 mm and no upper limit. This target is based on limited evidence, and we sought to determine the optimal compression depth range. METHODS AND RESULTS We studied emergency medical services-treated out-of-hospital cardiac arrest patients from the Resuscitation Outcomes Consortium Prehospital Resuscitation Impedance Valve and Early Versus Delayed Analysis clinical trial and the Epistry-Cardiac Arrest database. We calculated adjusted odds ratios for survival to hospital discharge, 1-day survival, and any return of circulation. We included 9136 adult patients from 9 US and Canadian cities with a mean age of 67.5 years, mean compression depth of 41.9 mm, and a return of circulation of 31.3%, 1-day survival of 22.8%, and survival to hospital discharge of 7.3%. For survival to discharge, the adjusted odds ratios were 1.04 (95% CI, 1.00-1.08) for each 5-mm increment in compression depth, 1.45 (95% CI, 1.20-1.76) for cases within 2005 depth range (>38 mm), and 1.05 (95% CI, 1.03-1.08) for percentage of minutes in depth range (10% change). Covariate-adjusted spline curves revealed that the maximum survival is at a depth of 45.6 mm (15-mm interval with highest survival between 40.3 and 55.3 mm) with no differences between men and women. CONCLUSIONS This large study of out-of-hospital cardiac arrest patients demonstrated that increased cardiopulmonary resuscitation compression depth is strongly associated with better survival. Our adjusted analyses, however, found that maximum survival was in the depth interval of 40.3 to 55.3 mm (peak, 45.6 mm), suggesting that the 2010 American Heart Association cardiopulmonary resuscitation guideline target may be too high. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00394706.
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Affiliation(s)
- Ian G Stiell
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.).
| | - Siobhan P Brown
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Graham Nichol
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Sheldon Cheskes
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Christian Vaillancourt
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Clifton W Callaway
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Laurie J Morrison
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - James Christenson
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Tom P Aufderheide
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Daniel P Davis
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Cliff Free
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Dave Hostler
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - John A Stouffer
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Ahamed H Idris
- From the Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (I.G.S., C.V.); Clinical Trials Center, Department of Biostatistics (S.P.B., G.N.) and Department of Medicine (G.N.), University of Washington, Seattle, WA; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA (G.N.); Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), and Division of Emergency Medicine, Department of Medicine (L.J.M.), University of Toronto, Toronto, Ontario, Canada; Rescu, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada (S.C., L.J.M.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (C.W.C., D.H.); Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada (J.C.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (T.P.A.); Department of Emergency Medicine, University of California, San Diego, CA (D.P.D.); Camas Fire Department, Camas, WA (C.F.); Central Washington University, Ellensburg, WA (J.A.S.); Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (A.H.I.)
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Lothamer K, Brown SP, Mattox JD, Jumpponen A. Comparison of root-associated communities of native and non-native ectomycorrhizal hosts in an urban landscape. Mycorrhiza 2014; 24:267-280. [PMID: 24221903 DOI: 10.1007/s00572-013-0539-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 10/28/2013] [Indexed: 06/02/2023]
Abstract
Non-native tree species are often used as ornamentals in urban landscapes. However, their root-associated fungal communities remain yet to be examined in detail. Here, we compared richness, diversity and community composition of ectomycorrhizosphere fungi in general and ectomycorrhizal (EcM) fungi in particular between a non-native Pinus nigra and a native Quercus macrocarpa across a growing season in urban parks using 454-pyrosequencing. Our data show that, while the ectomycorrhizosphere community richness and diversity did not differ between the two host, the EcM communities associated with the native host were often more species rich and included more exclusive members than those of the non-native hosts. In contrast, the ectomycorrhizosphere communities of the two hosts were compositionally clearly distinct in nonmetric multidimensional ordination analyses, whereas the EcM communities were only marginally so. Taken together, our data suggest EcM communities with broad host compatibilities and with a limited numbers of taxa with preference to the non-native host. Furthermore, many common fungi in the non-native Pinus were not EcM taxa, suggesting that the fungal communities of the non-native host may be enriched in non-mycorrhizal fungi at the cost of the EcM taxa. Finally, while our colonization estimates did not suggest a shortage in EcM inoculum for either host in urban parks, the differences in the fungi associated with the two hosts emphasize the importance of using native hosts in urban environments as a tool to conserve endemic fungal diversity and richness in man-made systems.
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Affiliation(s)
- K Lothamer
- Division of Biology, Kansas State University, Manhattan, KS, 66506, USA
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22
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Cheskes S, Schmicker RH, Verbeek PR, Salcido DD, Brown SP, Brooks S, Menegazzi JJ, Vaillancourt C, Powell J, May S, Berg RA, Sell R, Idris A, Kampp M, Schmidt T, Christenson J. The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial. Resuscitation 2013; 85:336-42. [PMID: 24513129 DOI: 10.1016/j.resuscitation.2013.10.014] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 08/30/2013] [Accepted: 10/04/2013] [Indexed: 01/03/2023]
Abstract
BACKGROUND Previous research has demonstrated significant relationships between peri-shock pause and survival to discharge from out-of-hospital shockable cardiac arrest (OHCA). OBJECTIVE To determine the impact of peri-shock pause on survival from OHCA during the ROC PRIMED randomized controlled trial. METHODS We included patients in the ROC PRIMED trial who suffered OHCA between June 2007 and November 2009, presented with a shockable rhythm and had CPR process data for at least one shock. We used multivariable logistic regression to determine the association between peri-shock pause duration and survival to hospital discharge. RESULTS Among 2006 patients studied, the median (IQR) shock pause duration was: pre-shock pause 15s (8, 22); post-shock pause 6s (4, 9); and peri-shock pause 22.0 s (14, 31). After adjusting for Utstein predictors of survival as well as CPR quality measures, the odds of survival to hospital discharge were significantly higher for patients with pre-shock pause <10s (OR: 1.52, 95% CI: 1.09, 2.11) and peri-shock pause <20s (OR: 1.82, 95% CI: 1.17, 2.85) when compared to patients with pre-shock pause ≥ 20s and peri-shock pause ≥ 40s. Post-shock pause was not significantly associated with survival to hospital discharge. Results for neurologically intact survival (Modified Rankin Score ≤ 3) were similar to our primary outcome. CONCLUSIONS In patients with cardiac arrest presenting in a shockable rhythm during the ROC PRIMED trial, shorter pre- and peri-shock pauses were significantly associated with higher odds of survival. Future cardiopulmonary education and technology should focus on minimizing all peri-shock pauses.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Judy Powell
- University of Washington, Seattle, WA, United States
| | - Susanne May
- University of Washington, Seattle, WA, United States
| | - Robert A Berg
- Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States
| | - Rebecca Sell
- University of California/San Diego, San Diego, CA, United States
| | - Ahamed Idris
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mike Kampp
- Oregon Health and Science University, Portland, OR, United States
| | - Terri Schmidt
- Oregon Health and Science University, Portland, OR, United States
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Wang HE, Brown SP, MacDonald RD, Dowling SK, Lin S, Davis D, Schreiber MA, Powell J, van Heest R, Daya M. Association of out-of-hospital advanced airway management with outcomes after traumatic brain injury and hemorrhagic shock in the ROC hypertonic saline trial. Emerg Med J 2013; 31:186-91. [PMID: 23353663 DOI: 10.1136/emermed-2012-202101] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Prior studies suggest adverse associations between out-of-hospital advanced airway management (AAM) and patient outcomes after major trauma. This secondary analysis of data from the Resuscitation Outcomes Consortium Hypertonic Saline Trial evaluated associations between out-of-hospital AAM and outcomes in patients suffering isolated severe traumatic brain injury (TBI) or haemorrhagic shock. METHODS This multicentre study included adults with severe TBI (GCS ≤8) or haemorrhagic shock (SBP ≤70 mm Hg, or (SBP 71-90 mm Hg and heart rate ≥108 bpm)). We compared patients receiving out-of-hospital AAM with those receiving emergency department AAM. We evaluated the associations between airway strategy and patient outcomes (28-day mortality, and 6-month poor neurologic or functional outcome) and airway strategy, adjusting for confounders. Analysis was stratified by (1) patients with isolated severe TBI and (2) patients with haemorrhagic shock with or without severe TBI. RESULTS Of 2135 patients, we studied 1116 TBI and 528 shock; excluding 491 who died in the field, did not receive AAM or had missing data. In the shock cohort, out-of-hospital AAM was associated with increased 28-day mortality (adjusted OR 5.14; 95% CI 2.42 to 10.90). In TBI, out-of-hospital AAM showed a tendency towards increased 28-day mortality (adjusted OR 1.57; 95% CI 0.93 to 2.64) and 6-month poor functional outcome (1.63; 1.00 to 2.68), but these differences were not statistically significant. Out-of-hospital AAM was associated with poorer 6-month TBI neurologic outcome (1.80; 1.09 to 2.96). CONCLUSIONS Out-of-hospital AAM was associated with increased mortality after haemorrhagic shock. The adverse association between out-of-hospital AAM and injury outcome is most pronounced in patients with haemorrhagic shock.
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Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, University of Alabama School of Medicine, , Birmingham, Albama, USA
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Glover BM, Brown SP, Morrison L, Davis D, Kudenchuk PJ, Van Ottingham L, Vaillancourt C, Cheskes S, Atkins DL, Dorian P. Wide variability in drug use in out-of-hospital cardiac arrest: a report from the resuscitation outcomes consortium. Resuscitation 2012; 83:1324-30. [PMID: 22858552 DOI: 10.1016/j.resuscitation.2012.07.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 05/17/2012] [Accepted: 07/05/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite the publication and dissemination of the Advanced Cardiac Life Support guidelines, variability in the use of drugs during resuscitation from out-of-hospital cardiac arrest may exist between different Emergency Medical Services throughout North America. The purpose of this study was to characterize the use of such drugs and evaluate their relationship to cardiac arrest outcomes. METHODS AND RESULTS The Resuscitation Outcomes Consortium Registry-Cardiac Arrest collects out-of-hospital cardiac arrest data from 264 Emergency Medical Services agencies in 11 geographical locations in the U.S. and Canada. Multivariable logistic regression was used to assess the association between drug use, characteristics of the cardiac arrest and a pulse at emergency department arrival and survival to discharge. A total of 16,221 out-of-hospital cardiac arrests were attended by 74 Emergency Medical Services agencies. There was a considerable variability in the administration of amiodarone and lidocaine for the treatment of shock resistant ventricular tachycardia/ventricular fibrillation. For non-shockable rhythms, atropine use ranged from 29 to 95% and sodium bicarbonate use ranged from 0.2 to 73% across agencies in the 89% of agencies that used the drug. Epinephrine use ranged from 57 to 98% within agencies. Neither lidocaine nor amiodarone was associated with a survival benefit while there was an inverse relationship between the administration of epinephrine, atropine and sodium bicarbonate and survival to hospital discharge. CONCLUSIONS There is considerable variability among Emergency Medical Services agencies in their use of pharmacological therapy for out-of-hospital cardiac arrests which may be resolved by performing large randomized trials examining effects on survival.
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Aufderheide TP, Nichol G, Rea TD, Brown SP, Leroux BG, Pepe PE, Kudenchuk PJ, Christenson J, Daya MR, Dorian P, Callaway CW, Idris AH, Andrusiek D, Stephens SW, Hostler D, Davis DP, Dunford JV, Pirrallo RG, Stiell IG, Clement CM, Craig A, Van Ottingham L, Schmidt TA, Wang HE, Weisfeldt ML, Ornato JP, Sopko G. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med 2011; 365:798-806. [PMID: 21879897 PMCID: PMC3204381 DOI: 10.1056/nejmoa1010821] [Citation(s) in RCA: 166] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The impedance threshold device (ITD) is designed to enhance venous return and cardiac output during cardiopulmonary resuscitation (CPR) by increasing the degree of negative intrathoracic pressure. Previous studies have suggested that the use of an ITD during CPR may improve survival rates after cardiac arrest. METHODS We compared the use of an active ITD with that of a sham ITD in patients with out-of-hospital cardiac arrest who underwent standard CPR at 10 sites in the United States and Canada. Patients, investigators, study coordinators, and all care providers were unaware of the treatment assignments. The primary outcome was survival to hospital discharge with satisfactory function (i.e., a score of ≤3 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating greater disability). RESULTS Of 8718 patients included in the analysis, 4345 were randomly assigned to treatment with a sham ITD and 4373 to treatment with an active device. A total of 260 patients (6.0%) in the sham-ITD group and 254 patients (5.8%) in the active-ITD group met the primary outcome (risk difference adjusted for sequential monitoring, -0.1 percentage points; 95% confidence interval, -1.1 to 0.8; P=0.71). There were also no significant differences in the secondary outcomes, including rates of return of spontaneous circulation on arrival at the emergency department, survival to hospital admission, and survival to hospital discharge. CONCLUSIONS Use of the ITD did not significantly improve survival with satisfactory function among patients with out-of-hospital cardiac arrest receiving standard CPR. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.).
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Affiliation(s)
- Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Rankin DJ, Rocha EPC, Brown SP. What traits are carried on mobile genetic elements, and why? Heredity (Edinb) 2011; 106:1-10. [PMID: 20332804 PMCID: PMC3183850 DOI: 10.1038/hdy.2010.24] [Citation(s) in RCA: 190] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 01/28/2010] [Accepted: 02/02/2010] [Indexed: 01/22/2023] Open
Abstract
Although similar to any other organism, prokaryotes can transfer genes vertically from mother cell to daughter cell, they can also exchange certain genes horizontally. Genes can move within and between genomes at fast rates because of mobile genetic elements (MGEs). Although mobile elements are fundamentally self-interested entities, and thus replicate for their own gain, they frequently carry genes beneficial for their hosts and/or the neighbours of their hosts. Many genes that are carried by mobile elements code for traits that are expressed outside of the cell. Such traits are involved in bacterial sociality, such as the production of public goods, which benefit a cell's neighbours, or the production of bacteriocins, which harm a cell's neighbours. In this study we review the patterns that are emerging in the types of genes carried by mobile elements, and discuss the evolutionary and ecological conditions under which mobile elements evolve to carry their peculiar mix of parasitic, beneficial and cooperative genes.
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Affiliation(s)
- D J Rankin
- Department of Biochemistry, University of Zürich, Zürich, Switzerland.
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27
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Hung I, Wong A, Howes AP, Anupõld T, Past J, Samoson A, Mo X, Wu G, Smith ME, Brown SP, Dupree R. Determination of NMR interaction parameters from double rotation NMR. J Magn Reson 2007; 188:246-59. [PMID: 17707665 DOI: 10.1016/j.jmr.2007.07.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 07/18/2007] [Accepted: 07/19/2007] [Indexed: 05/16/2023]
Abstract
It is shown that the anisotropic NMR parameters for half-integer quadrupolar nuclei can be determined using double rotation (DOR) NMR at a single magnetic field with comparable accuracy to multi-field static and MAS experiments. The (17)O nuclei in isotopically enriched l-alanine and OPPh(3) are used as illustrations. The anisotropic NMR parameters are obtained from spectral simulation of the DOR spinning sideband intensities using a computer program written with the GAMMA spin-simulation libraries. Contributions due to the quadrupolar interaction, chemical shift anisotropy, dipolar coupling and J coupling are included in the simulations. In l-alanine the oxygen chemical shift span is 455 +/- 20 ppm and 350 +/- 20 ppm for the O1 and O2 sites, respectively, and the Euler angles are determined to an accuracy of +/- 5-10 degrees . For cases where effects due to heteronuclear J and dipolar coupling are observed, it is possible to determine the angle between the internuclear vector and the principal axis of the electric field gradient (EFG). Thus, the orientation of the major components of both the EFG and chemical shift tensors (i.e., V(33) and delta(33)) in the molecular frame may be obtained from the relative intensity of the split DOR peaks. For OPPh(3) the principal axis of the (17)O EFG is found to be close to the O-P bond, and the (17)O-(31)P one-bond J coupling ((1)J(OP)=161 +/- 2 Hz) is determined to a much higher accuracy than previously.
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Affiliation(s)
- I Hung
- Physics Department, University of Warwick, Coventry, UK
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Biron DG, Ponton F, Marché L, Galeotti N, Renault L, Demey-Thomas E, Poncet J, Brown SP, Jouin P, Thomas F. 'Suicide' of crickets harbouring hairworms: a proteomics investigation. Insect Mol Biol 2006; 15:731-42. [PMID: 17201766 DOI: 10.1111/j.1365-2583.2006.00671.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Despite increasing evidence of host phenotypic manipulation by parasites, the underlying mechanisms causing infected hosts to act in ways that benefit the parasite remain enigmatic in most cases. Here, we used proteomics tools to identify the biochemical alterations that occur in the head of the cricket Nemobius sylvestris when it is driven to water by the hairworm Paragordius tricuspidatus. We characterized host and parasite proteomes during the expression of the water-seeking behaviour. We found that the parasite produces molecules from the Wnt family that may act directly on the development of the central nervous system (CNS). In the head of manipulated cricket, we found differential expression of proteins specifically linked to neurogenesis, circadian rhythm and neurotransmitter activities. We also detected proteins for which the function(s) are still unknown. This proteomics study on the biochemical pathways altered by hairworms has also allowed us to tackle questions of physiological and molecular convergence in the mechanism(s) causing the alteration of orthoptera behaviour. The two hairworm species produce effective molecules acting directly on the CNS of their orthoptera hosts.
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Affiliation(s)
- D G Biron
- GEMI, UMR CNRS/IRD 2724, IRD, 911 av. Agropolis BP 64501, Montpellier cedex 5, France.
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29
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Laver M, Forgan EM, Brown SP, Charalambous D, Fort D, Bowell C, Ramos S, Lycett RJ, Christen DK, Kohlbrecher J, Dewhurst CD, Cubitt R. Spontaneous symmetry-breaking vortex lattice transitions in pure niobium. Phys Rev Lett 2006; 96:167002. [PMID: 16712261 DOI: 10.1103/physrevlett.96.167002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2005] [Indexed: 05/09/2023]
Abstract
We report an extensive investigation of magnetic vortex lattice (VL) structures in single crystals of pure niobium with the magnetic field applied parallel to a fourfold symmetry axis, so as to induce frustration between the cubic crystal symmetry and hexagonal VL coordination expected in an isotropic situation. We observe new VL structures and phase transitions; all the VL phases observed (including those with an exactly square unit cell) spontaneously break some crystal symmetry. One phase even has the lowest possible symmetry of a two-dimensional Bravais lattice. This is quite unlike the situation in high-Tc or borocarbide superconductors, where VL structures orient along particular directions of high crystal symmetry. The causes of this behavior are discussed.
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Affiliation(s)
- M Laver
- Institut Laue-Langevin, BP 156, F-38042 Grenoble, France
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30
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Gilardi R, Mesot J, Brown SP, Forgan EM, Drew A, Lee SL, Cubitt R, Dewhurst CD, Uefuji T, Yamada K. Square vortex lattice at anomalously low magnetic fields in electron-doped Nd1.85Ce0.15CuO4. Phys Rev Lett 2004; 93:217001. [PMID: 15601051 DOI: 10.1103/physrevlett.93.217001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2004] [Indexed: 05/24/2023]
Abstract
We report here on the first direct observations of the vortex lattice in the bulk of electron-doped Nd1.85Ce0.15CuO4 single crystals. Using small-angle neutron scattering, we have observed a square vortex lattice with the nearest neighbors oriented at 45 degrees from the Cu-O bond direction, which is consistent with theories based on the d-wave superconducting gap. However, the square symmetry persists down to unusually low magnetic fields. Moreover, the diffracted intensity from the vortex lattice is found to decrease rapidly with increasing magnetic field.
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Affiliation(s)
- R Gilardi
- Laboratory for Neutron Scattering, ETH Zurich and PSI Villigen, CH-5232 Villigen PSI, Switzerland
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Abstract
We explore from both theoretical and empirical perspectives the hypothesis that a significant part of the worldwide variability in human birthweight results from adaptive responses to local selective pressures. We first developed an agent-based model to simulate the process of evolutionary selection on life history strategy, and then we performed a comparative analysis across 89 countries worldwide. The model illustrates that optimal birthweight depends on which fitness-reducing risk locally predominates (somatic diseases, parasitic diseases or adverse environmental conditions). When fitness variations between individuals mainly result from somatic diseases (e.g. industrialized countries), or conversely from infectious and parasitic diseases (e.g. developing countries), selection is expected to favour individuals producing larger children. Conversely, when environmental risks increase in relative importance, selective pressures for producing children with high birthweight are reduced. The comparative analysis supports these theoretical expectations, in particular the finding that birthweight is higher than predicted in highly parasitized countries.
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Affiliation(s)
- F Thomas
- Centre d'Etude sur le Polymorphisme des Micro-Organismes CEPM/UMR CNRS-IRD 9926 Equipe: Evolution des Systèmes Symbiotiques, IRD, Montpellier Cedex, France.
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32
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Brown SP, Charalambous D, Jones EC, Forgan EM, Kealey PG, Erb A, Kohlbrecher J. Triangular to square flux lattice phase transition in YBa2Cu3O7. Phys Rev Lett 2004; 92:067004. [PMID: 14995265 DOI: 10.1103/physrevlett.92.067004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2003] [Indexed: 05/24/2023]
Abstract
We have used the technique of small-angle neutron scattering to observe magnetic flux lines directly in a YBa2Cu3O7 single crystal at fields higher than previously reported. For field directions close to perpendicular to the CuO2 planes, we find that the flux lattice structure changes smoothly from a distorted triangular coordination to nearly perfectly square as the magnetic induction approaches 11 T. The orientation of the square flux lattice is as expected from recent d-wave theories but is 45 degrees from that recently observed in La(1.83)Sr(0.17)CuO(4+delta).
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Affiliation(s)
- S P Brown
- School of Physics and Astronomy, University of Birmingham, Birmingham B15 2TT, United Kingdom.
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33
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Abstract
Although very common under natural conditions, the consequences of multiple enemies (parasites, predators, herbivores, or even 'chemical' enemies like insecticides) on investment in defence has scarcely been investigated. In this paper, we present a simple model of the joint evolution of two defences targeted against two enemies. We illustrate how the respective level of each defence can be influenced by the presence of the two enemies. Furthermore, we investigate the influences of direct interference and synergy between defences. We show that, depending on certain conditions (costs, interference or synergy between defences), an increase in selection pressure by one enemy can have dramatic effects on defence against another enemy. It is generally admitted that increasing the encounter rate with a second natural enemy can decrease investment in defence against a first enemy, but our results indicate that it may sometimes favour resistance against the first enemy. Moreover, we illustrate that the global defence against one enemy can be lower when only this enemy is present: this has important implications for experimental measures of resistance, and for organisms that invade an area with less enemies or whose community of enemies is reduced. We discuss possible implications of the existence of multiple enemies for conservation biology, biological control and chemical control.
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Affiliation(s)
- K Poitrineau
- Génétique et Environnement, ISEM, Université Montpellier II, Montpellier 5, France.
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Brown SP, De Lorgeril J, Joly C, Thomas F. FIELD EVIDENCE FOR DENSITY-DEPENDENT EFFECTS IN THE TREMATODE MICROPHALLUS PAPILLOROBUSTUS IN ITS MANIPULATED HOST, GAMMARUS INSENSIBILIS. J Parasitol 2003; 89:668-72. [PMID: 14533671 DOI: 10.1645/ge-3122] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Numerous studies have demonstrated that parasites with complex life cycles frequently manipulate the phenotype of their hosts to increase their transmission rate. Little is known, however, concerning density-dependent processes within infrapopulations of manipulative parasites--whether parasites cooperate to manipulate the host, whether competition counteracts with these potential cooperative benefits, or both. Here we explored these ideas, focusing on the association between the manipulative trematode Microphallus papillorobustus and its second intermediate host, the gammarid Gammarus insensibilis. From the data collected in the field, we found no evidence that co-occurring M. papillorobustus individuals benefit from the presence of conspecifics; instead, individuals in larger infrapopulations suffered reduced size and fecundity. Thus, the net effect of increasing density suggests that competition rather than cooperation is the dominant force in infrapopulations of M. papillorobustus.
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Affiliation(s)
- S P Brown
- Institut des Sciences de l'Evolution, Université Montpellier 2, Place Eugène Bataillon 34095, Montpellier Cedex 05, France
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35
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Brown SP, Loot G, Teriokhin A, Brunel A, Brunel C, Guégan JF. Host manipulation by Ligula intestinalis: a cause or consequence of parasite aggregation? Int J Parasitol 2002; 32:817-24. [PMID: 12062552 DOI: 10.1016/s0020-7519(02)00013-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Previous investigations suggest that the infection of the cyprinid roach, Rutilus rutilus, with the larval plerocercoid forms of the cestode, Ligula intestinalis, creates behavioural and morphological changes in the fish host, potentially of adaptive significance to the parasite in promoting transmission to definitive avian hosts. Here we consider whether these behavioural changes are important in shaping the distribution of parasite individuals across the fish population. An examination of field data illustrates that fish infected with a single parasite were more scarce than expected under the negative binomial distribution, and in many months were more scarce than burdens of two, three or more, leading to a bimodal distribution of worm counts (peaks at 0 and >1). This scarcity of single-larval worm infections could be accounted for a priori by a predominance of multiple infection. However, experimental infections of roach gave no evidence for the establishment of multiple worms, even when the host was challenged with multiple intermediate crustacean hosts, each multiply infected. A second hypothesis assumes that host manipulation following an initial single infection leads to an increased probability of subsequent infection (thus creating a contagious distribution). If manipulated fish are more likely to encounter infected first-intermediate hosts (through microhabitat change, increased ingestion, or both), then host manipulation could act as a powerful cause of aggregation. A number of scenarios based on contagious distribution models of aggregation are explored, contrasted with alternative compound Poisson models, and compared with the empirical data on L. intestinalis aggregation in their roach intermediate hosts. Our results indicate that parasite-induced host manipulation in this system can function simultaneously as both a consequence and a cause of parasite aggregation. This mutual interaction between host manipulation and parasite aggregation points to a set of ecological interactions that are easily missed in most experimental studies of either phenomenon.
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Affiliation(s)
- S P Brown
- Department of Zoology, University of Cambridge, Downing Street, UK.
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Brown SP, Pérez-Torralba M, Sanz D, Claramunt RM, Emsley L. Determining hydrogen-bond strengths in the solid state by NMR: the quantitative measurement of homonuclear J couplings. Chem Commun (Camb) 2002:1852-3. [PMID: 12271641 DOI: 10.1039/b205324a] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Hydrogen-bonding strengths in the solid state are quantitatively determined by the accurate measurement of 15N-15N J couplings using a straightforward 2D MAS NMR spinecho approach.
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Affiliation(s)
- S P Brown
- Laboratoire de Stéréochimie et des Interactions Moléculaires, UMR 5532 CNRS/ENS, Ecole Normale Supérieure de Lyon, 69364 Lyon, France
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Abstract
Concomitant immunity (CI) against macroparasites describes a state of effective anti-larval immunity coupled with persistent adult infection. Experimental studies indicate that immunologically concealed adult worms might promote anti-larval immunity via the release of cross-reactive antigens, thus creating a barrier against continual infection and restricting burden size within the host. CI offers an important potential benefit to established worms by preventing overcrowding within the host. Thus, CI may be interpreted as akin to vaccination; relatively long-lived adult worms 'vaccinate' their host with larval surface antigens and so benefit from reduced conspecific competition. The shared responsibility for host vaccination among adult worms leads to a problem of collective action. Here, we build on earlier analytical findings about the evolutionary forces that shape cooperation among parasites in order to produce a stochastic simulation model of macroparasite social evolution. First, we theoretically investigate a parasite adaptation hypothesis of CI and demonstrate its plausibility under defined conditions, despite the possibility of evolutionary 'cheats'. Then we derive a set of predictions for testing the hypothesis that CI is partly a host-manipulative parasite adaptation. Evidence in support of this model would present an unusual case of adaptive population regulation.
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Affiliation(s)
- S P Brown
- Department of Zoology, University of Cambridge, Downing Street, Cambridge CB2 3EJ, UK.
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Brown SP, Spiess HW. Advanced solid-state NMR methods for the elucidation of structure and dynamics of molecular, macromolecular, and supramolecular systems. Chem Rev 2001; 101:4125-56. [PMID: 11740929 DOI: 10.1021/cr990132e] [Citation(s) in RCA: 436] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- S P Brown
- Max-Planck-Institut für Polymerforschung, Postfach 3148, D-55021 Mainz, Germany
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39
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Abstract
Numerous studies have demonstrated that parasites with complex life-cycles can cause phenotypic modifications in their hosts that lead to an increased rate of transmission, and suggest that these modifications are the result of parasitic adaptations to manipulate the host. Little attention is paid, however, to separating the possibility of adaptive host manipulation from incidental (if fortuitous) side-effects of infection. In this study we combine statistical and analytical tools to interpret the impact of the macroparasite Ligula intestinalis L. (Cestoda, Pseudophyllidea) on the behaviour of its intermediate fish host (the roach, Rutilus rutilus L.), using field data on a natural system. Two distinct sets of generalized linear models agree that both the presence and the intensity of infection contribute to a modified behavioural response in the host. This was illustrated by a preference for the lake-edge in infected fish during autumn. Furthermore, the effect of parasites upon their host is heterogeneous with respect to parasite size, with larger parasite individuals having a disproportionate impact. A series of game-theoretic models of adaptive host manipulation illustrate a potential rationale for a size-dependent manipulation strategy in parasites. These findings illustrate the potential complexity and functionality of the impact of L. intestinalis upon its fish host, which together reduce the parsimony of the alternative 'incidental effect' hypothesis.
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Affiliation(s)
- S P Brown
- Department of Zoology, University of Cambridge, UK.
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Abstract
The study of quorum-sensing bacteria has revealed a widespread mechanism of coordinating bacterial gene expression with cell density. By monitoring a constitutively produced signal molecule, individual bacteria can limit their expression of group-beneficial phenotypes to cell densities that guarantee an effective group outcome. In this paper, we attempt to move away from a commonly expressed view that these impressive feats of coordination are examples of multicellularity in prokaryotic populations. Here, we look more closely at the individual conflict underlying this cooperation, illustrating that, even under significant levels of genetic conflict, signalling and resultant cooperative behaviour can stably exist. A predictive two-trait model of signal strength and of the extent of cooperation is developed as a function of relatedness (reflecting multiplicity of infection) and basic population demographic parameters. The model predicts that the strength of quorum signalling will increase as conflict (multiplicity of infecting strains) increases, as individuals attempt to coax more cooperative contributions from their competitors, leading to a devaluation of the signal as an indicator of density. Conversely, as genetic conflict increases, the model predicts that the threshold density for cooperation will increase and the subsequent strength of group cooperation will be depressed.
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Affiliation(s)
- S P Brown
- Department of Zoology, University of Cambridge, UK.
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Abstract
The authors assessed previously unexplored processes by which information seeking and self-efficacy contribute to self-regulatory effectiveness in industrial selling. They assessed the synergistic interaction of inquiry and monitoring with respect to role clarity and tested whether this interaction was further moderated by self-efficacy. Results indicated that the role-clarifying effects of feedback inquiry and monitoring were contingent rather than independent. Role clarity increased as the combination of inquiry and monitoring increased. Furthermore, these joint effects were moderated by self-efficacy, such that high-self-efficacy employees were able to effectively use the combination of inquiry and monitoring to clarify role expectations, whereas low-self-efficacy employees were not. Implications for theory, practice, and future research are discussed.
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Affiliation(s)
- S P Brown
- Department of Marketing, Edwin L. Cox School of Business, Southern Methodist University, Dallas, Texas 75275-0333, USA.
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42
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Abstract
In European freshwater, cyprinid fish may be heavily infected by plerocercoids of the pseudophyllidea cestode Ligula intestinalis (L.). During their development, these parasites grow rapidly to a large size in the fish's body cavity, characteristically distending the abdomen. In this study, the influence of this tapeworm on roach (Rutilus rutilus L.) morphology was analyzed. Forty-five infected and 45 uninfected roach were collected from the Lavernose-Lacasse gravel pit in Toulouse, south western France and examined for 40 morphological measurements to study phenotypic modification of the body and 14 bilateral characters for an analysis of asymmetry. Results indicate that the degree of bilateral asymmetry does not change between infected and uninfected roach, despite the strong host-morphological modifications such as deformation of the abdomen, fin displacements at the level of the tail, and sagging of the vertebral column. The intensity of abdominal distension and fish morphology changes depends on the total parasite biomass present. Differences were observed in morphology at different levels of infection, which relate to established effects of L. intestinalis on the physiology and behavior of intermediate hosts. These morphological changes induced by the parasite could increase trophic transmission to the definitive avian hosts.
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Affiliation(s)
- G Loot
- C.E.S.A.C., U.M.R. 5576 C.N.R.S, UPS, Université Paul Sabatier, Toulouse, France
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Abstract
Many species of deciduous trees display striking colour changes in autumn. Here, we present a functional hypothesis: bright autumn coloration serves as an honest signal of defensive commitment against autumn colonizing insect pests. According to this hypothesis, individuals within a signalling species show variation in the expression of autumn coloration, with defensively committed trees producing a more intense display. Insects are expected to be averse to the brightest tree individuals and, hence, preferentially colonize the least defensive hosts. We predicted that tree species suffering greater insect damage would, on average, invest more in autumn-colour signalling than less troubled species. Here, we show that autumn coloration is stronger in species facing a high diversity of damaging specialist aphids. Aphids are likely to be an important group of signal receivers because they are choosy, damaging and use colour cues in host selection. In the light of further aspects of insect and tree biology, these results support the notion that bright autumn colours are expensive handicap signals revealing the defensive commitment of individual trees to autumn colonizing insect pests.
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Affiliation(s)
- W D Hamilton
- Department of Zoology, University of Oxford, South Parks Road, Oxford OX1 3PS, UK
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Brown SP, Zhu XX, Saalwächter K, Spiess HW. An investigation of the hydrogen-bonding structure in bilirubin by 1H double-quantum magic-angle spinning solid-state NMR spectroscopy. J Am Chem Soc 2001; 123:4275-85. [PMID: 11457194 DOI: 10.1021/ja004231h] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The complex hydrogen-bonding arrangement in the biologically important molecule bilirubin IXalpha is probed by using 1H double-quantum (DQ) magic-angle spinning (MAS) NMR spectroscopy. Employing fast MAS (30 kHz) and a high magnetic field (16.4 T), three low-field resonances corresponding to the different hydrogen-bonding protons are resolved in a 1H MAS NMR spectrum of bilirubin. These resonances are assigned on the basis of the proton-proton proximities identified from a two-dimensional rotor-synchronized 1H DQ MAS NMR spectrum. An analysis of 1H DQ MAS spinning-sideband patterns for the NH protons in bilirubin allows the quantitative determination of proton-proton distances and the geometry. The validity of this procedure is proven by simulated spectra for a model three-spin system, which show that the shortest distance can be determined to a very high degree of accuracy. The distance between the lactam and pyrrole NH protons in bilirubin is determined to be 0.186 +/- 0.002 nm (corresponding to a dominant dipolar coupling constant of 18.5 +/- 0.5 kHz). The analysis also yields a distance between the lactam NH and carboxylic acid OH protons of 0.230 +/- 0.008 nm (corresponding to a perturbing dipolar coupling constant of 9.9 +/- 1.0 kHz) and an H-H-H angle of 122 +/- 4 degrees. Finally, a comparison of 1H DQ MAS spinning-sideband patterns for bilirubin and its dimethyl ester reveals a significantly longer distance between the two NH protons in the latter case.
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Affiliation(s)
- S P Brown
- Max-Planck-Institut für Polymerforschung, Postfach 3148, D-55021 Mainz, Germany
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45
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Ochsenfeld C, Brown SP, Schnell I, Gauss J, Spiess HW. Structure assignment in the solid state by the coupling of quantum chemical calculations with NMR experiments: a columnar hexabenzocoronene derivative. J Am Chem Soc 2001; 123:2597-606. [PMID: 11456929 DOI: 10.1021/ja0021823] [Citation(s) in RCA: 134] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We present a quantum chemical ab initio study which demonstrates a new combined experimental and theoretical approach, whereby a comparison of calculated and experimental (1)H NMR chemical shifts allows the elucidation of structural arrangements in solid-state molecular ensembles, taking advantage of the marked sensitivity of the (1)H chemical shift to intermolecular interactions. Recently, Brown et al. have shown that, under fast magic-angle spinning (MAS) at 35 kHz, the resolution in a (1)H NMR spectrum of the solid phase of an alkyl-substituted hexabenzocoronene (HBC) derivative is sufficient to observe the hitherto unexpected resolution of three distinct aromatic resonances ( J. Am. Chem. Soc. 1999, 121, 6712). Exploiting the additional information about proton proximities provided by (1)H double-quantum (DQ) MAS NMR spectroscopy, it was shown that the results are qualitatively consistent with the aromatic cores packing in a manner similar to that in unsubstituted HBC. Using the HBC-C(12) molecule as an example, we show here that the new combined experimental and theoretical approach allows the observed (1)H chemical shifts to be related in a quantitative manner to the intermolecular structure. In the quantum chemical calculations, a series of model systems of stacked HBC oligomers are used. On account of the marked dependence of the (1)H chemical shift to ring currents arising from nearby aromatic rings, the calculated (1)H chemical shifts are found to be very sensitive to the stacking arrangement of the HBC molecules. Moreover, the ring current effect is found to be particularly long range, with a considerable influence of the second neighbor, at a distance of 700 pm, being observed.
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Affiliation(s)
- C Ochsenfeld
- Institut für Physikalische Chemie, Universität Mainz, D-55099 Mainz, Germany
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Abstract
Human visual perception and many visual system neurons adapt to the luminance and contrast of the stimulus. Here we describe a form of contrast adaptation that occurs in the retina. This adaptation had a local scale smaller than the dendritic or receptive fields of single ganglion cells and was insensitive to pharmacological manipulation of amacrine cell function. These results implicate the bipolar cell pathway as a site of contrast adaptation. The time required for contrast adaptation varied with stimulus size, ranging from approximately 100 ms for the smallest stimuli, to seconds for stimuli the size of the receptive field. The differing scales and time courses of these effects suggest that multiple types of contrast adaptation are used in viewing natural scenes.
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Affiliation(s)
- S P Brown
- Program in Neuroscience, Goldenson 228, Harvard Medical School, Boston, Massachusetts 02115, USA
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Abstract
This study replicates, integrates, and extends prior research on the dispositional, contextual, and cognitive antecedents of feedback-seeking behavior. Regression analysis was used to analyze data collected from a sample of salespeople (N = 310) from 2 Fortune 500 companies. The study hypotheses were supported with the following results. First, the individual disposition of learning goal orientation and the contextual factors of leader consideration and leader initiation of structure influenced cognitions about the perceived cost and value of feedback seeking. Second, the strength of the relationship of learning goal orientation with the cost and value perceptions was moderated by the leadership style of the supervisor.
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Affiliation(s)
- D VandeWalle
- Organizational Behavior and Business Policy Department, Cox School of Business, Southern Methodist University, P.O. Box 750333, Dallas, Texas 75275-0333, USA.
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48
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Abstract
We studied the fine spatial structure of the receptive fields of retinal ganglion cells and its relationship to the dendritic geometry of these cells. Cells from which recordings had been made were microinjected with Lucifer yellow, so that responses generated at precise locations within the receptive field center could be directly compared with that cell's dendritic structure. While many cells with small receptive fields had domeshaped sensitivity profiles, the majority of large receptive fields were composed of multiple regions of high sensitivity. The density of dendritic branches at any one location did not predict the regions of high sensitivity. Instead, the interactions between a ganglion cell's dendritic tree and the local mosaic of bipolar cell axons seem to define the fine structure of the receptive field center.
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Affiliation(s)
- S P Brown
- Program in Neuroscience, Harvard Medical School, Boston, Massachusetts 02115, USA
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Baldwin PJ, Paisley AM, Brown SP. [Qualifications profile of specialty graduate education for surgical assistant physicians from the viewpoint of surgically active senior surgeons]. Chirurg 2000; 71:suppl 110-4. [PMID: 10875024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Affiliation(s)
- P J Baldwin
- University Department of Surgery, Royal Infirmary of Edinburgh, UK
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Groom K, Brown SP. Caesarean section controversy. The rate of caesarean sections is not the issue. BMJ 2000; 320:1072-3; author reply 1074. [PMID: 10764376 PMCID: PMC1117951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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