Association of Bystander and First-Responder Intervention With Survival After Out-of-Hospital Cardiac Arrest in North Carolina, 2010-2013

IMPORTANCE

Out-of-hospital cardiac arrest is associated with low survival, but early cardiopulmonary resuscitation (CPR) and defibrillation can improve outcomes if more widely adopted.

OBJECTIVE

To examine temporal changes in bystander and first-responder resuscitation efforts before arrival of the emergency medical services (EMS) following statewide initiatives to improve bystander and first-responder efforts in North Carolina from 2010-2013 and to examine the association between bystander and first-responder resuscitation efforts and survival and neurological outcome.

DESIGN, SETTINGS, AND PARTICIPANTS

We studied 4961 patients with out-of-hospital cardiac arrest for whom resuscitation was attempted and who were identified through the Cardiac Arrest Registry to Enhance Survival (2010-2013). First responders were dispatched police officers, firefighters, rescue squad, or life-saving crew trained to perform basic life support until arrival of the EMS.

EXPOSURES

Statewide initiatives to improve bystander and first-responder interventions included training members of the general population in CPR and in use of automated external defibrillators (AEDs), training first responders in team-based CPR including AED use and high-performance CPR, and training dispatch centers in recognition of cardiac arrest.

MAIN OUTCOMES AND MEASURES

The proportion of bystander and first-responder resuscitation efforts, including the combination of efforts between bystanders and first responders, from 2010 through 2013 and the association between these resuscitation efforts and survival and neurological outcome.

RESULTS

The combination of bystander CPR and first-responder defibrillation increased from 14.1% (51 of 362; 95% CI, 10.9%-18.1%) in 2010 to 23.1% (104 of 451; 95% CI, 19.4%-27.2%) in 2013 (P < .01). Survival with favorable neurological outcome increased from 7.1% (82 of 1149; 95% CI, 5.8%-8.8%) in 2010 to 9.7% (129 of 1334; 95% CI, 8.2%-11.4%) in 2013 (P = .02) and was associated with bystander-initiated CPR. Adjusting for age and sex, bystander and first-responder interventions were associated with higher survival to hospital discharge. Survival following EMS-initiated CPR and defibrillation was 15.2% (30 of 198; 95% CI, 10.8%-20.9%) compared with 33.6% (38 of 113; 95% CI, 25.5%-42.9%) following bystander-initiated CPR and defibrillation (odds ratio [OR], 3.12; 95% CI, 1.78-5.46); 24.2% (83 of 343; 95% CI, 20.0%-29.0%) following bystander CPR and first-responder defibrillation (OR, 1.70; 95% CI, 1.06-2.71); and 25.2% (109 of 432; 95% CI, 21.4%-29.6%) following first-responder CPR and defibrillation (OR, 1.77; 95% CI, 1.13-2.77).

CONCLUSIONS AND RELEVANCE

Following a statewide educational intervention on rescusitation training, the proportion of patients receiving bystander-initiated CPR and defibrillation by first responders increased and was associated with greater likelihood of survival. Bystander-initiated CPR was associated with greater likelihood of survival with favorable neurological outcome.

Insertion of nucleotides opposite apurinic/apyrimidinic sites in deoxyribonucleic acid during in vitro synthesis: uniqueness of adenine nucleotides

M13 DNA containing 20-30 apurinic/apyrimidinic (AP) sites per intact circular molecule was prepared by growing phage on an ung- dut- Escherichia coli mutant and treating the DNA with uracil N-glycosylase. AP sites obstruct in vitro DNA synthesis catalyzed by E. coli pol I. The position at which termination of synthesis occurs was determined for four enzymes. T4 DNA polymerase terminates one nucleotide before putative AP sites. DNA pol I, AMV reverse transcriptase, and DNA polymerase alpha terminate synthesis either before or at the site of an AP lesion depending on the particular sequence. We determined the identity of the nucleotide inserted opposite an AP site by synthesizing up to the lesion in a first-stage reaction using T4 DNA polymerase and then determining elongation in a second stage. Purines are inserted opposite AP sites more readily than pyrimidines, and dATP is more efficient than dGTP in promoting such elongation. The DNA-dependent conversion of dNTP to dNMP was determined in mixtures of all four dNTP's by using AP DNA. The production of dAMP from dATP occurs most readily. We conclude that there is an inherent specificity for the incorporation of adenine nucleotides opposite AP sites in this in vitro system. Insofar as the model system reflects in vivo mutational events, our data suggest that depurination should produce transversions and depyrimidination should produce transitions.

Quality of life and psychological well being in polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with poor quality of life (QoL) and high levels of depression. Existing research is confounded by small sample sizes and inconsistent use of control groups.

METHODS

Depression and QoL were assessed in women with PCOS and healthy controls (n = 1359). The polycystic ovary syndrome health-related QoL questionnaire (PCOSQ) was modified to include an acne subscale.

RESULTS

Seventy-one percentage of women with PCOS who were taking anti-androgen (AA) medication and 67% not taking AA medication were classified as depressed. Women with PCOS had lower QoL on all seven factors of the modified PCOSQ (emotional disturbance, weight, infertility, acne, menstrual symptoms, menstrual predictability and hirsutism). Weight was the largest contributor to poor QoL for women taking and not taking AA medication. Women taking AA medications, independent of diagnosis, generally had better QoL than women not taking them.

CONCLUSIONS

This large study refines our understanding of depression and QoL in PCOS and demonstrates the need to regularly review the psychological health of women with PCOS.

Measured enthusiasm: does the method of reporting trial results alter perceptions of therapeutic effectiveness?

OBJECTIVE

To compare clinicians' ratings of therapeutic effectiveness when different trial end points were presented as percent reductions in relative compared with absolute risk and as numbers of patients treated to avoid one adverse outcome.

DESIGN

Survey, with random allocation of two questionnaires.

SETTING

Toronto teaching hospitals.

RESPONDENTS

Convenience sample of 100 faculty and housestaff in internal medicine and family medicine.

INTERVENTION

One questionnaire presented results for three end points of the Helsinki Heart Study as separate drug trials using only absolute differences in events; the other showed the same end points as relative differences. Both questionnaires included a fourth "trial," showing person-years of treatment needed to prevent one myocardial infarction.

MAIN OUTCOME MEASURE

The "trials" were each rated on an 11-point scale, from treatment "harmful" to "very effective."

RESULTS

Respondents' ratings of effectiveness varied with the end point. Controlling for end point, ratings of effectiveness by the 50 participants receiving absolute event data were lower than those by 50 participants responding to relative risk reductions (P < 0.001); however, no end-point difference was more than 0.6 scale points. For a "trial" reporting that 77 persons were treated for 5 years to prevent one myocardial infarction, mean ratings were 2.3 or 1.8 scale points lower, respectively (both P < 0.001), than when the same data were shown as relative or absolute risk reductions.

CONCLUSIONS

Clinicians' views of drug therapies are affected by the common use of relative risk reductions in both trial reports and advertisements, by end-point emphasis, and, above all, by underuse of summary measures that relate treatment burden to therapeutic yields in a clinically relevant manner.

Methylation-induced blocks to in vitro DNA replication

Single-stranded primed M13mp2 templates and double-stranded templates were treated with either dimethyl sulfate (DMS) or N-methyl-N'-nitro-N-nitrosoguanidine and used for DNA synthesis in vitro. Methylation inhibits the ability of the molecules to serve as templates. When either E. coli DNA polymerase I or AMV reverse transcriptase were used as polymerases, DNA synthesis terminated one nucleotide 3' to the site of adenine residues in the template. Heating of the templates resulted in the appearance of additional termination bands one nucleotide before the site of G's in the template. We assume that methylated A's but not methylated G's are blocks to in vitro DNA synthesis and that heating converts a portion of the sites of methylated G to AP sites which are blocks to synthesis.

Removal of O6-methylguanine from DNA of normal and xeroderma pigmentosum-derived lymphoblastoid lines

The ability to excise (repair) UV-induced pyrimidine dimers in Escherichia coli is not related to its ability to remove N-methyl-N'-nitro-N-nitrosoguanidine (MNNG)-induced O6-methylguanine (O6-MeG) from DNA. It was therefore surprising that certain xeroderma pigmentosum cell lines, deficient in dimer excision, were also unable to remove O6-MeG. We find that removal of O6-MeG occurs rapidly with a half life of less than 1 h. Two cell types can be distinguished: mex+, which remove O6-MeG residues produced by incubation with 0.5 microgram ml-1 MNNG, and mex- cells, which are unable to remove the adduct. Xeroderma pigmentosum-derived lymphoblastoid lines of complementation groups A, C or D may be either mex+ or mex-. The biochemical mechanism for the removal of O6-MeG in human cells is distinct from the excision of adducts produced by compounds such as N-acetoxy-N-2-acetylaminofluorene (AAAF) or by UV irradiation but it is not clear whether the distinction between mex+ and mex- lines is genetic or epigenetic.

The role of DNA polymerase in base substitution mutagenesis on non-instructional templates

In vitro DNA synthesis on phi X174 or M13 templates with non-instructional lesions such as UV dimers or AP (apurinic/apyrimidinic) sites terminates one base before the site of the lesion when synthesis is catalyzed by T4 DNA polymerase or E. coli polymerase I. E. Coli polymerase I also produces termination bands at the site of AP lesions. Substitution of Mn2+ for Mg2+ and increasing the concentration of dNTP's results in elongation of the newly synthesized strand opposite the site of the lesion and beyond. Purine deoxynucleoside triphosphates are utilized for insertion opposite lesions to a greater extent than are pyrimidine deoxynucleoside triphosphates. Deoxy ATP is used almost exclusively for elongation opposite AP sites with pol I-Klenow fragment in the presence of Mg2+. We suppose that these results illustrate the previously observed greater affinity of polymerases under template-free conditions for purine nucleotides. We also suppose that the results can be used to account for mutagenic base selection on noninstructional DNA templates. If purines are preferentially selected by polymerases, then treatments which inactivate pyrimidines will lead to an excess of transitions whereas inactivation of purines will produce more transversions. Data in the literature support this hypothesis.

Exploring Patterns of Awareness and Use of HIV Pre-Exposure Prophylaxis Among Young Men Who Have Sex with Men

Pre-exposure prophylaxis (PrEP) has shown promise as a safe and effective HIV prevention strategy, but there is limited research on awareness and use among young men who have sex with men (YMSM). Using baseline data from the "Keep It Up! 2.0" randomized control trial, we examined differences in PrEP awareness and use among racially diverse YMSM (N = 759; mean age = 24.2 years). Participants were recruited from study sites in Atlanta, Chicago, and New York City, as well as through national advertising on social media applications. While 67.5 % of participants reported awareness of PrEP, 8.7 % indicated using the medication. Awareness, but not use, varied by demographic variables. PrEP-users had twice as many condomless anal sex partners (ERR = 2.05) and more condomless anal sex acts (ERR = 1.60) than non-users. Future research should aim to improve PrEP awareness and uptake among YMSM and address condom use.

Guidelines for counselling in infertility: outline version

The Guidelines for Counselling in Infertility describe the purpose, objectives, typical issues and communication skills involved in providing psychosocial care to individuals using fertility services. The Guidelines are presented in six sections. The first section describes how infertility consultations differ from other medical consultations in obstetrics and gynaecology, whereas the second section addresses fundamental issues in counselling, such as what is counselling in infertility, who should counsel and who is likely to need counselling. Section 3 focuses on how to integrate patient-centred care and counselling into routine medical treatment and section 4 highlights some of the special situations which can provoke the need for counselling (e.g. facing the end of treatment, sexual problems). Section 5 deals exclusively with third party reproduction and the psychosocial implications of gamete donation, surrogacy and adoption for heterosexual and gay couples and single women without partners. The final section of the Guidelines is concerned with psychosocial services that can be used to supplement counselling services in fertility clinics: written psychosocial information, telephone counselling, self-help groups and professionally facilitated group work. This paper summarizes the different sections of the Guidelines and describes how to obtain the complete text of the Guidelines for Counselling in Infertility.

Differential efficacy of group and individual/couple psychotherapy with infertile patients

BACKGROUND

The diagnosis of infertility and concurrent medical treatment may inflict an array of negative emotional symptoms in infertile persons. Evidence for the positive effects of psychotherapy on negative affect and also possible influence on conception rates has been discussed in several studies.

METHOD

Meta-analyses were conducted in order to evaluate the efficacy of group and individual/couple therapies on (i) the reduction of negative emotional symptoms, and (ii) the possible promotion of pregnancy.

RESULTS

Group and individual/couple psychotherapy led to a decrease in feelings of anxiety. Upon termination of psychotherapy, a reduction of depressive symptoms in patients was greater after 6 months. Psychotherapy accompanying IVF treatment yielded similar conception success rates to psychological interventions administered to patients not in specific medical care.

CONCLUSION

Results are suggestive of positive effects of psychotherapy for infertile patients. However, these results must be viewed with caution due to methodological and informational bias within the studies analysed.

The effects of blinding on acceptance of research papers by peer review

OBJECTIVE

To study whether reviewers aware of author identity are biased in favor of authors with more previous publications.

DESIGN

Randomized controlled trial.

SETTING

Editorial office of the Journal of Developmental and Behavioral Pediatrics.

PARTICIPANTS

Two "blinded" and two "nonblinded" reviewers assigned to 57 consecutive manuscripts submitted between September 1991 and March 1992.

OUTCOME MEASURES

Spearman rank correlation coefficients were used to compare the sum of rating scores of 1 to 5 (1, accept; 5, reject) given by the two blinded reviewers, the two nonblinded reviewers, and the editors to the number of articles published previously by the first and senior authors (as determined from requested curricula vitae). Blinded reviewers were sent a questionnaire asking whether they could determine the identity of the authors, how they knew, and whether they thought binding changed the quality or difficulty of their review.

RESULTS

The Wilcoxon Sign Rank Test disclosed no differences between blinded and nonblinded scores. The number of previous articles by the senior author was significantly correlated (P < .01) with blinded scores (r = -.45) and editors' decisions (r = -.45), but not with nonblinded scores; the number of articles by the first author was correlated (P < .05) with editors' decisions (r = -.35) but not with blinded or nonblinded scores. Fifty (46%) of 108 blinded reviewers correctly guessed the identity of the authors, mostly from self-references and knowledge of the work; 86% believed blinding did not change the quality of their review, and 73% believed it did not change the difficulty of performing a review.

CONCLUSIONS

Blinded reviewers and editors in this study, but not nonblinded reviewers, gave better scores to authors with more previous articles. These results suggest that blinded reviewers may provide more unbiased reviews and that nonblinded reviewers may be affected by various types of bias.

Voluntary weight loss: systematic review of early phase body composition changes

Weight loss follows when adult humans enter a phase of negative energy balance brought about by reducing energy intake and/or increasing energy expenditure. The weight loss period is usually viewed as a continuous process, ending when energy equilibrium is achieved at a lower weight or with death following depletion of fuel stores. However, growing evidence supports the expanded view that induction of negative energy balance leads to well-defined physiological effects characterized by three discrete phases (I-III). At present there are no comprehensive reviews of the 'early' phase of weight loss, a gap highlighted by recent interest in rapidly testing new treatments with short-term protocols. Herein we show from earlier reports and with new data that weight loss during phase I is: mathematically quantifiable with a t(1/2) < 1-week and 4- to 6-week duration; includes well-defined rapidly evolving body composition and energy expenditure changes; and is moderated by multiple factors including subject sex and activity level, nutrients ingested at baseline and during the negative energy balance period, and hormone and pharmacologic treatments. Our in depth review collectively characterizes phase I as a distinct weight loss period while revealing important knowledge gaps that can be filled with appropriately designed future studies.

Computer-based three-dimensional visualization of developmental gene expression

A broad understanding of the relationship between gene activation, pattern formation and morphogenesis will require adequate tools for three-dimensional and, perhaps four-dimensional, representation and analysis of molecular developmental processes. We present a novel, computer-based method for the 3D visualization of embryonic gene expression and morphological structures from serial sections. The information from these automatically aligned 3D reconstructions exceeds that from single-section and whole-mount visualizations of in situ hybridizations. In addition, these 3D models of gene-expression patterns can become a central component of a future developmental database designed for the collection and presentation of digitized, morphological and gene-expression data. This work is accompanied by a web site (http://www.univie.ac.at/GeneEMAC).

The measurement of chemically-induced DNA repair synthesis in human cells by BND-cellulose chromatography

Repair synthesis in human cells in tissue culture can be readily separated from semi-conservative DNA synthesis with the aid of a benzoylated naphthoylated DEAE cellulose (BND-cellulose) column. Cells are incubated with a radioactive DNA precursor during treatment with a repair-inducing agent. An inhibitor of semi-conservative DNA synthesis (hydroxyurea) is added to slow the progression of the DNA growing point. The cells are lysed and after treatment with ribonuclease and pronase the lysates are sheared and passed through a BND-cellulose column. Native DNA is eluted with I M NaCl. Any increase in radioactivity in the native DNA is due to repair synthesis and the specific repair activity (nucleotides inserted per mug of DNA) can be determined from radioactivity and absorbancy measurements. Repair can also be measured in the region of the DNA growing point by fractionation of the material eluted from BND-cellulose with 50% formamide. Repair was not detected in N-acetoxy-2-acetylaminofluorene (AAAF)-treated lymphoblasts derived from an individual with xeroderma pigmentosum although methyl methanesulfonate (MMS)-induced repair was observed in these cells.

Repair of alkylation damage: stability of methyl groups in Bacillus subtilis treated with methyl methanesulfonate

Bacillus subtilis was not inactivated and was able to replicate even though approximately 3 x 10(4) methyl groups added by methyl methanesulfonate (MMS) were bound to the deoxyribonucleic acid (DNA) of each organism. No significant loss of methyl groups from the DNA occurred for several generations upon incubation of methylated wild-type or MMS-sensitive cells. Single-strand breaks were not observed in the DNA from cells treated at this low MMS dose. Higher doses of MMS resulted in significant killing of both wild-type and MMS-sensitive strains, and the DNA extracted from such treated cells sedimented more slowly than control DNA through alkaline sucrose gradients, indicating the presence of breaks or apurinic sites (or both). These breaks were repaired upon incubation of wild-type but not of MMS-sensitive strains. Repair of damage induced by alkylating agents is probably the repair of breaks which occur as a consequence of high levels of alkylation.

Doping, drugs and drug abuse among adolescents in the State of Thuringia (Germany): prevalence, knowledge and attitudes

Goal-directed measures to prevent doping and drug abuse in sports requires empirical data. In this connection, a cross-sectional analysis was carried out in 2004. The purpose of the study, on the one hand, was to register reliable data of the current situation in Thuringia, and, on the other hand it was to give information on possible interventional steps with scientific support. Within three months, 2319 adolescents from 16 Thuringian schools (5 regular schools, 4 secondary schools, 3 sport schools and 4 vocational schools) were surveyed. Three hundred and forty-six (15.1 %) students out of 2287 students (26 students without a statement) indicated use of prohibited substances from the WADA list in the previous year: 16 (0.7 %) anabolic-androgenic steroids (AAS), 10 (0.4 %) growth hormones, 56 (2.4 %) stimulants, 305 (13.2 %) cannabis, 2 (0.1 %) diuretics, 52 (2.2 %) cocaine/heroin and 6 (0.3 %) erythropoeitin. Moreover, nonathletes (N = 490) reported a substance use that was approximately 5.0 % higher than that of recreational athletes (N = 1254) and nearly three times higher than that of competitive athletes (497). All three groups (nonathletes, recreational athletes and competitive athletes) performed poorly on a knowledge test regarding doping in general with an average below 60 % in each case. Another main aspect of the study was to determine factors influencing substance use in sports. Besides the doping specific knowledge (beta = 0.06, p < 0.05), age contributed (beta = 0.09, p < 0.05), as well as anti-doping attitude (beta = -0.34, p < 0.05), to the resulting variance. Gender, however, played no role. The findings of the study point towards the need for improvement of specific knowledge of doping among students and that their attitude towards doping must be altered. The goal in this case is to test the effectiveness of appropriate scientific intervention.

Focal adhesion kinase governs cardiac concentric hypertrophic growth by activating the AKT and mTOR pathways

The heart responds to sustained overload by hypertrophic growth in which the myocytes distinctly thicken or elongate on increases in systolic or diastolic stress. Though potentially adaptive, hypertrophy itself may predispose to cardiac dysfunction in pathological settings. The mechanisms underlying the diverse morphology and outcomes of hypertrophy are uncertain. Here we used a focal adhesion kinase (FAK) cardiac-specific transgenic mice model (FAK-Tg) to explore the function of this non-receptor tyrosine kinase on the regulation of myocyte growth. FAK-Tg mice displayed a phenocopy of concentric cardiac hypertrophy, reflecting the relative thickening of the individual myocytes. Moreover, FAK-Tg mice showed structural, functional and molecular features of a compensated hypertrophic growth, and preserved responses to chronic pressure overload. Mechanistically, FAK overexpression resulted in enhanced myocardial FAK activity, which was proven by treatment with a selective FAK inhibitor to be required for the cardiac hypertrophy in this model. Our results indicate that upregulation of FAK does not affect the activity of Src/ERK1/2 pathway, but stimulated signaling by a cascade that encompasses PI3K, AKT, mTOR, S6K and rpS6. Moreover, inhibition of the mTOR complex by rapamycin extinguished the cardiac hypertrophy of the transgenic FAK mice. These findings uncover a unique role for FAK in regulating the signaling mechanisms that governs the selective myocyte growth in width, likely controlling the activity of PI3K/AKT/mTOR pathway, and suggest that FAK activation could be important for the adaptive response to increases in cardiac afterload. This article is part of a Special Issue entitled "Local Signaling in Myocytes".

Geographic health information systems: a platform to support the 'triple aim'

Despite the rapid growth of electronic health data, most data systems do not connect individual patient records to data sets from outside the health care delivery system. These isolated data systems cannot support efforts to recognize or address how the physical and environmental context of each patient influences health choices and health outcomes. In this article we describe how a geographic health information system in Durham, North Carolina, links health system and social and environmental data via shared geography to provide a multidimensional understanding of individual and community health status and vulnerabilities. Geographic health information systems can be useful in supporting the Institute for Healthcare Improvement's Triple Aim Initiative to improve the experience of care, improve the health of populations, and reduce per capita costs of health care. A geographic health information system can also provide a comprehensive information base for community health assessment and intervention for accountable care that includes the entire population of a geographic area.