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

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

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

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

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest

BACKGROUND

Concern about the use of epinephrine as a treatment for out-of-hospital cardiac arrest led the International Liaison Committee on Resuscitation to call for a placebo-controlled trial to determine whether the use of epinephrine is safe and effective in such patients.

METHODS

In a randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest in the United Kingdom, paramedics at five National Health Service ambulance services administered either parenteral epinephrine (4015 patients) or saline placebo (3999 patients), along with standard care. The primary outcome was the rate of survival at 30 days. Secondary outcomes included the rate of survival until hospital discharge with a favorable neurologic outcome, as indicated by a score of 3 or less on the modified Rankin scale (which ranges from 0 [no symptoms] to 6 [death]).

RESULTS

At 30 days, 130 patients (3.2%) in the epinephrine group and 94 (2.4%) in the placebo group were alive (unadjusted odds ratio for survival, 1.39; 95% confidence interval [CI], 1.06 to 1.82; P=0.02). There was no evidence of a significant difference in the proportion of patients who survived until hospital discharge with a favorable neurologic outcome (87 of 4007 patients [2.2%] vs. 74 of 3994 patients [1.9%]; unadjusted odds ratio, 1.18; 95% CI, 0.86 to 1.61). At the time of hospital discharge, severe neurologic impairment (a score of 4 or 5 on the modified Rankin scale) had occurred in more of the survivors in the epinephrine group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90 patients [17.8%]).

CONCLUSIONS

In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group. (Funded by the U.K. National Institute for Health Research and others; Current Controlled Trials number, ISRCTN73485024 .).

Out-of-hospital cardiac arrest across the World: First report from the International Liaison Committee on Resuscitation (ILCOR)

BACKGROUND

Since development of the Utstein style recommendations for the uniform reporting of cardiac arrest, increasing numbers of national and regional out-of-hospital cardiac arrest (OHCA) registries have been established worldwide. The International Liaison Committee on Resuscitation (ILCOR) created the Research and Registries Working Group and aimed to systematically report data collected from these registries.

METHODS

We conducted two surveys of voluntarily participating national and regional registries. The first survey aimed to identify which core elements of the current Utstein style for OHCA were collected by each registry. The second survey collected descriptive summary data from each registry. We chose the data collected for the second survey based on the availability of core elements identified by the first survey.

RESULTS

Seven national and four regional registries were included in the first survey and nine national and seven regional registries in the second survey. The estimated annual incidence of emergency medical services (EMS)-treated OHCA was 30.0-97.1 individuals per 100,000 population. The combined data showed the median age varied from 64 to 79 years and more than half were male in all 16 registries. The provision of bystander cardiopulmonary resuscitation (CPR) and bystander automated external defibrillator (AED) use was 19.1-79.0% in all registries and 2.0-37.4% among 11 registries, respectively. Survival to hospital discharge or 30-day survival after EMS-treated OHCA was 3.1-20.4% across all registries. Favorable neurological outcome at hospital discharge or 30 days after EMS-treated OHCA was 2.8-18.2%. Survival to hospital discharge or 30-day survival after bystander-witnessed shockable OHCA ranged from 11.7% to 47.4% and favorable neurological outcome from 9.9% to 33.3%.

CONCLUSION

This report from ILCOR describes data on systems of care and outcomes following OHCA from nine national and seven regional registries across the world. We found variation in reported survival outcomes and other core elements of the current Utstein style recommendations for OHCA across nations and regions.

Exercise alone reduces insulin resistance in obese children independently of changes in body composition

CONTEXT

The number of obese children with insulin resistance and type 2 diabetes is increasing, but the best management strategy is not clear.

OBJECTIVE

The objective of this study was to assess the effect of a structured 8-wk exercise training program on insulin resistance and changes in body composition in obese children.

DESIGN

The study was 8 wk of structured supervised exercise intervention with outcome measures before and after the exercise period.

SUBJECTS

Fourteen obese children (12.70 +/- 2.32 yr; eight male, six female) with high fasting insulin levels were enrolled into the study.

INTERVENTION

INTERVENTION consisted of 8 wk of supervised circuit-based exercise training, composed of three fully supervised 1-h sessions per week.

OUTCOME MEASURES

Outcome measures were assessed pretraining program and posttraining program and included insulin sensitivity (euglycemic-hyperinsulinemic clamp studies), fasting insulin and glucose levels, body composition using dual energy x-ray absorptiometry scan, lipid profile, and liver function tests.

RESULTS

Insulin sensitivity improved significantly after 8 wk of training (M(lbm) 8.20 +/- 3.44 to 10.03 +/- 4.33 mg/kg.min, P < 0.05). Submaximal exercise heart rate responses were significantly lower following the training (P < 0.05), indicating an improvement in cardiorespiratory fitness. Dual energy x-ray absorptiometry scans revealed no differences in lean body mass or abdominal fat mass.

CONCLUSION

An 8-wk exercise training program increases insulin sensitivity in obese children, and this improvement occurred in the presence of increased cardiorespiratory fitness but is independent of measurable changes in body composition.

Communication of social support in computer-mediated groups for people with disabilities

This study documented the types and extent of social support messages exchanged by persons with disabilities who participated in a computer-based support group. A modified version of Cutrona & Suhr's (1992) social support category system was used to code 1,472 support messages. The largest percentage of these messages offered emotional and informational support, whereas network support and tangible assistance were least frequently offered. It appeared that many of the support messages directly redressed limitations and challenges associated with disability-related mobility, socialization, and self-care. Results are discussed in terms of the generalizability of existing category systems for coding support to this mediated context, the relative importance of different types of support in the communication of support group members, and the unique features of social support in mediated environments. The implications of this study for social support researchers, persons with disabilities, and human services professionals are also discussed.

Regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest in Australia and New Zealand: Results from the Aus-ROC Epistry

INTRODUCTION

The aim of this study was to investigate regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest (OHCA) in Australia and New Zealand.

METHODS

This was a population-based cohort study of OHCA using data from the Aus-ROC Australian and New Zealand OHCA Epistry over the period of 01 January 2015-31 December 2015. Seven ambulance services contributed data to the Epistry with a capture population of 19.8 million people. All OHCA attended by ambulance, regardless of aetiology or patient age, were included.

RESULTS

In 2015, there were 19,722 OHCA cases recorded in the Aus-ROC Epistry with an overall crude incidence of 102.5 cases per 100,000 population (range: 51.0-107.7 per 100,000 population). Of all OHCA cases attended by EMS (excluding EMS-witnessed cases), bystander CPR was performed in 41% of cases (range: 36%-50%). Resuscitation was attempted (by EMS) in 48% of cases (range: 40%-68%). The crude incidence for attempted resuscitation cases was 47.6 per 100,000 population (range: 34.7-54.1 per 100,000 population). Of cases with attempted resuscitation, 28% survived the event (range: 21%-36%) and 12% survived to hospital discharge or 30 days (range: 9%-17%; data provided by five ambulance services).

CONCLUSION

In the first results of the Aus-ROC Australian and New Zealand OHCA Epistry, significant regional variation in the incidence, characteristics and outcomes was observed. Understanding the system-level and public health drivers of this variation will assist in optimisation of the chain of survival provided to OHCA patients with the aim of improving outcomes.

An exploration of helping processes in an online self-help group focusing on issues of disability

This article reviews the growing use of online self-help and mutual aid groups and explores the helping mechanisms and content of an online self-help group for issues related to disability. Messages were downloaded from the group and coded by raters into helping categories to examine the extent to which therapeutic processes were found. The categories included both task and socioemotional-related functions. The study found that the group provided many of the processes used in face-to-face self-help and mutual aid groups, with an emphasis on mutual problem solving, information sharing, expression of feelings, catharsis, and mutual support and empathy. Implications for social work and health care providers and the need for further research are discussed.

Induction of Therapeutic Hypothermia During Out-of-Hospital Cardiac Arrest Using a Rapid Infusion of Cold Saline: The RINSE Trial (Rapid Infusion of Cold Normal Saline)

BACKGROUND

Patients successfully resuscitated by paramedics from out-of-hospital cardiac arrest often have severe neurologic injury. Laboratory and observational clinical reports have suggested that induction of therapeutic hypothermia during cardiopulmonary resuscitation (CPR) may improve neurologic outcomes. One technique for induction of mild therapeutic hypothermia during CPR is a rapid infusion of large-volume cold crystalloid fluid.

METHODS

In this multicenter, randomized, controlled trial we assigned adults with out-of-hospital cardiac arrest undergoing CPR to either a rapid intravenous infusion of up to 2 L of cold saline or standard care. The primary outcome measure was survival at hospital discharge; secondary end points included return of a spontaneous circulation. The trial was closed early (at 48% recruitment target) due to changes in temperature management at major receiving hospitals.

RESULTS

A total of 1198 patients were assigned to either therapeutic hypothermia during CPR (618 patients) or standard prehospital care (580 patients). Patients allocated to therapeutic hypothermia received a mean (SD) of 1193 (647) mL cold saline. For patients with an initial shockable cardiac rhythm, there was a decrease in the rate of return of a spontaneous circulation in patients who received cold saline compared with standard care (41.2% compared with 50.6%, P=0.03). Overall 10.2% of patients allocated to therapeutic hypothermia during CPR were alive at hospital discharge compared with 11.4% who received standard care (P=0.71).

CONCLUSIONS

In adults with out-of-hospital cardiac arrest, induction of mild therapeutic hypothermia using a rapid infusion of large-volume, intravenous cold saline during CPR may decrease the rate of return of a spontaneous circulation in patients with an initial shockable rhythm and produced no trend toward improved outcomes at hospital discharge.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01173393.

Erectile dysfunction as a predictor for subsequent atherosclerotic cardiovascular events: findings from a linked-data study

INTRODUCTION

In spite of the mounting interest in the nexus between erectile dysfunction (ED) and cardiovascular (CV) diseases, there is little published information on the role of ED as a predictor for subsequent CV events.

AIM

This study aimed to investigate the role of ED as a predictor for atherosclerotic CV events subsequent to the manifestation of ED. Method. The investigation involved the retrospective study of data on a cohort of men with ED linked to hospital morbidity data and death registrations. By using the linked data, the incidence rates of atherosclerotic CV events subsequent to the manifestation of ED were estimated in men with ED and no atherosclerotic CV disease reported prior to the manifestation of ED. The risk of subsequent atherosclerotic CV events in men with ED was assessed by comparing these incidence rates with those in the general male population.

MAIN OUTCOME MEASURE

Standardized incidence rate ratio (SIRR), comparing the incidence of atherosclerotic CV events subsequent to the manifestation of ED in a cohort of 1,660 men with ED to the incidence in the general male population.

RESULTS

On the basis of hospital admissions and death registrations, men with ED had a statistically significantly higher incidence of atherosclerotic CV events (SIRR 2.2; 95% confidence interval 1.9, 2.4). There were significantly increased incidence rate ratios in all age groups younger than 70 years, with a statistically highly significant downward trend with increase of age (P < 0.0001) across these age groups. Younger age at first manifestation of ED, cigarette smoking, presence of comorbidities and socioeconomic disadvantage were all associated with higher hazard ratios for subsequent atherosclerotic CV events.

CONCLUSIONS

The findings show that ED is not only significantly associated with but is also strongly predictive of subsequent atherosclerotic CV events. This is even more striking when ED presents at a younger age.

Cardiopulmonary resuscitation quality and patient survival outcome in cardiac arrest: A systematic review and meta-analysis

AIM

To conduct a systematic review and meta-analysis to determine whether cardiopulmonary resuscitation (CPR) quality, as indicated by parameters such as chest compression depth, compression rate and compression fraction, is associated with patient survival from cardiac arrest.

METHODS

Five databases were searched (MEDLINE, Embase, CINAHL, Scopus and Cochrane) as well as the grey literature (MedNar). To satisfy inclusion criteria, studies had to document human cases of in- or out-of hospital cardiac arrest where CPR quality had been recorded using an automated device and linked to patient survival. Where indicated (I(2)<75%), meta-analysis was undertaken to examine the relationship between individual CPR quality parameters and either survival to hospital discharge (STHD) or return of spontaneous circulation (ROSC).

RESULTS

Database searching yielded 8,842 unique citations, resulting in the inclusion of 22 relevant articles. Thirteen were included in the meta-analysis. Chest compression depth was significantly associated with STHD (mean difference (MD) between survivors and non-survivors 2.59 mm, 95% CI: 0.71, 4.47); and with ROSC (MD 0.99 mm, 95% CI: 0.04, 1.93). Within the range of approximately 100-120 compressions per minute (cpm), compression rate was significantly associated with STHD; survivors demonstrated a lower mean compression rate than non-survivors (MD -1.17 cpm, 95% CI: -2.21, -0.14). Compression fraction could not be examined by meta-analysis due to high heterogeneity, however a higher fraction appeared to be associated with survival in cases with a shockable initial rhythm.

CONCLUSIONS

Chest compression depth and rate were associated with survival outcomes. More studies with consistent reporting of data are required for other quality parameters.

Three-year trends in out-of-hospital cardiac arrest across the world: second report from the International Liaison Committee on Resuscitation (ILCOR)

BACKGROUND

The International Liaison Committee on Resuscitation (ILCOR) Research and Registries Working Group previously reported data on systems of care and outcomes of out-of-hospital cardiac arrest (OHCA) in 2015 from 16 national and regional registries. To describe the temporal trends with updated data on OHCA, we report the characteristics of OHCA from 2015 through 2017.

METHODS

We invited national and regional population-based OHCA registries for voluntary participation and included emergency medical services (EMS)-treated OHCA. We collected descriptive summary data of core elements of the latest Utstein style recommendation during 2016 and 2017 at each registry. For registries that participated in the previous 2015 report, we also extracted the 2015 data.

RESULTS

Eleven national registries in North America, Europe, Asia, and Oceania, and 4 regional registries in Europe were included in this report. Across registries, the estimated annual incidence of EMS-treated OHCA was 30.0-97.1 individuals per 100,000 population in 2015, 36.4-97.3 in 2016, and 40.8-100.2 in 2017. The provision of bystander cardiopulmonary resuscitation (CPR) varied from 37.2% to 79.0% in 2015, from 2.9% to 78.4% in 2016, and from 4.1% to 80.3% in 2017. Survival to hospital discharge or 30-day survival for EMS-treated OHCA ranged from 5.2% to 15.7% in 2015, from 6.2% to 15.8% in 2016, and from 4.6% to 16.4% in 2017.

CONCLUSION

We observed an upward temporal trend in provision of bystander CPR in most registries. Although some registries showed favourable temporal trends in survival, less than half of registries in our study demonstrated such a trend.

Does exposure to immunosuppressive therapy increase the 10 year malignancy and mortality risks in rheumatoid arthritis? A matched cohort study

Rheumatoid arthritis (RA) is associated with increased mortality and an increased risk of neoplasms of the immune system (NIM). To establish whether immunosuppressive therapy alters these risks, a matched cohort study was conducted. The exposed cohort were 259 RA patients, resident in the UK, who first received immunosuppressive drugs (mainly azathioprine, cyclophosphamide and chlorambucil) between 1979 and 1982. The unexposed cohort were 259 patients matched for age, sex and disease, resident in the USA, who had never received immunosuppressives. Both cohorts had no prior reported malignancies and were followed for 10 yr. There was a small increase in mortality in the exposed compared to the unexposed cohort. Most of the excess deaths were due to malignancy. The relative risk (RR) of developing malignancy [1.5 (95% CI 0.9-2.3)] was lower than the RR of dying from malignancy [4.2 (95% CI 1.7-10.0)]. The RR of developing a NIM in the immunosuppressive-exposed group was 7.0 (95% CI 0.9-56.5). These results may be explained in part by differences in cancer registration and death rates between the UK and the USA. Nevertheless, the results suggest that exposure to immunosuppressive therapy increases the 10 yr malignancy risk in RA, but not mortality from other causes.

International variation in survival after out-of-hospital cardiac arrest: A validation study of the Utstein template

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.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Trends from 1996 to 2007 in incidence and mortality outcomes of heart failure after acute myocardial infarction: a population-based study of 20,812 patients with first acute myocardial infarction in Western Australia

Background

Advances in treatment for acute myocardial infarction (AMI) are likely to have had a beneficial impact on the incidence of and deaths attributable to heart failure (HF) complicating AMI, although limited data are available to support this contention.

Methods and Results

Western Australian linked administrative health data were used to identify 20 812 consecutive patients, aged 40 to 84 years, without prior HF hospitalized with an index (first) AMI between 1996 and 2007. We assessed the temporal incidence of and adjusted odds ratio/hazard ratio for death associated with HF concurrent with AMI admission and within 1 year after discharge. Concurrent HF comprised 75% of incident HF cases. Between the periods 1996–1998 and 2005–2007, the prevalence of HF after AMI declined from 28.1% to 16.5%, with an adjusted odds ratio of 0.50 (95% CI, 0.44 to 0.55). The crude 28‐day case‐fatality rate for patients with concurrent HF declined marginally from 20.5% to 15.9% (P<0.05) compared with those without concurrent HF, in whom the case‐fatality rate declined from 11.0% to 4.8% (P<0.001). Concurrent HF was associated with a multivariate‐adjusted odds ratio of 2.2 for 28‐day mortality and a hazard ratio of 2.2 for 1‐year mortality in 28‐day survivors. Occurrence of HF within 90 days of the index AMI was associated with an adjusted hazard ratio of 2.7 for 1‐year mortality in 90‐day survivors.

Conclusions

Despite encouraging declines in the incidence of HF complicating AMI, it remains a common problem with high mortality. Increased attention to these high‐risk patients is needed given the lack of improvement in their long‐term prognosis.

Cardiac troponin I in pre-eclampsia and gestational hypertension

OBJECTIVE

To investigate serum cardiac troponin I, a sensitive marker of cardiac myocyte damage, in normal pregnancy and pregnancies complicated by hypertension with and without significant proteinuria.

DESIGN

Prospective cross sectional study.

SETTING

University hospital delivery suite.

SAMPLE

Serum samples obtained from women in normal pregnancy and in pregnancies complicated by hypertension with and without significant proteinuria.

METHOD

Women with hypertension in pregnancy (at least two readings of systolic blood pressure > 140 mmHg and diastolic blood pressure > 90 mmHg) (n = 26) and normotensive women (n = 43) were included in the study. Serum cardiac troponin I was measured using Beckman Access immunoassay.

MAIN OUTCOME MEASURE

Serum cardiac troponin I level in the pregnancies complicated by hypertension (with and without significant proteinuria) compared with the levels measured in normotensive women.

RESULTS

The median serum cardiac troponin I level in pregnancies complicated by hypertension was 0.118 ng/mL (n = 26) which was significantly greater than that measured in samples obtained from normotensive women in pregnancy (0.03 ng/mL; n = 43) (P < 0.0001). There were higher median serum cardiac troponin I levels in hypertensive women with significant proteinuria (0.155 ng/mL; n = 6), compared with those without proteinuria (0.089 ng/mL; n = 20; P = 0.03).

CONCLUSION

Serum cardiac troponin I is elevated in women with hypertensive disorders of pregnancy indicating some degree of cardiac myofibrillary damage in these disorders.

Heart failure: incidence, case fatality, and hospitalization rates in Western Australia between 1990 and 2005

BACKGROUND

We examined trends in incidence of first-ever (index) hospitalization for heart failure (HF), hospitalization rates, and 30-day and 1-year all-cause mortality subsequent to index hospitalization for HF.

METHODS AND RESULTS

The Western Australia Hospital Morbidity Database was used to identify a retrospective population-based cohort with an index hospitalization for HF in Western Australia between 1990 and 2005. Risk-adjusted temporal trends in mortality were examined with the use of multivariable logistic regression models. Baseline period for comparison was 1990-1993. The cohort (n=19 342; mean age, 74.2+/-13.2 years; 51.3% men) was followed until death or end of 2006. During the period of 1990-2005, age-standardized rates (per 100,000) of index hospitalization for HF as a principal diagnosis decreased from 191.0 to 103.2 in men, with an annual decrease of 3.5%, and from 130.5 to 75.1 in women, with an annual decrease of 3.1%. Risk-adjusted odds ratio of death at 30 days decreased to 0.73 (95% CI, 0.65 to 0.81) based on nonelective admissions. Risk-adjusted odds ratio of 1-year mortality also decreased during the study period in both genders and across all age groups. The total number of HF hospitalizations increased, with nonelective admissions increasing by 14.9% (P for trend, <0.0001) during this period. However, age-standardized rates of nonelective HF hospitalizations decreased during the same period.

CONCLUSIONS

During the 16-year period studied, the incidence of index hospitalization for HF in Western Australia decreased steadily in both genders. However, hospitalizations for HF as a measure of health service use increased, despite decreasing rates, partly because of an aging population and improved HF survival.

Variation in risk and mortality of acute kidney injury in critically ill patients: a multicenter study

BACKGROUND

Despite standardized definitions of acute kidney injury (AKI), there is wide variation in the reported rates of AKI and hospital mortality for patients with AKI. Variation could be due to actual differences in disease incidence, clinical course, or a function of data ascertainment and application of diagnostic criteria. Using standard criteria may help determine and compare the risk and outcomes of AKI across centers.

METHODS

In this cohort study of critically ill patients admitted to the intensive care units at six hospitals in four countries, we used KDIGO criteria to define AKI. The main outcomes were the occurrence of AKI and hospital mortality.

RESULTS

Of the 15,132 critically ill patients, 32% developed AKI based on serum creatinine criteria. After adjusting for differences in age, sex, and severity of illness, the odds ratio for AKI continued to vary across centers (odds ratio (OR), 2.57-6.04, p < 0.001). The overall, crude hospital mortality of patients with AKI was 27%, which also varied across centers after adjusting for KDIGO stage, differences in age, sex, and severity of illness (OR, 1.13-2.20, p < 0.001). The severity of AKI was associated with incremental mortality risk across centers.

CONCLUSIONS

In this study, the absolute and severity-adjusted rates of AKI and hospital mortality rates for AKI varied across centers. Future studies should examine whether variation in the risk of AKI among centers is due to differences in clinical practice or process of care or residual confounding due to unmeasured factors.

A randomised crossover trial of patient controlled intranasal fentanyl and oral morphine for procedural wound care in adult patients with burns

This study sought to compare the analgesic efficacy and safety of patient controlled intra-nasal (PCIN) fentanyl with oral morphine for procedural wound care in burns patients. A randomised double-blind placebo controlled, two period, two-treatment crossover trial was conducted within the Burns Unit of a major teaching hospital in Perth, Western Australia. Patients requiring identical wound care procedures on two consecutive mornings (and not prescribed intravenous analgesia) were randomised to receive either PCIN fentanyl with oral placebo or oral morphine with intranasal placebo on 1 day, followed by the alternate active drug on the following day. Twenty-six patients (22 males), aged between 18 and 69 years (35.5 +/- 12.4 years), with total body surface burns (TBSA) range 1-25% (6.9 +/- 4.5), indicated their level of pain on a 10 point (0-10) numeric scale at various time periods before, during and after the procedure. A mean total dose of 1.48 +/- 0.57 microg/kg of PCIN fentanyl and 0.35 +/- 0.12 mg/kg of oral morphine was administered. No statistically significant difference was found between the pain scores recorded for patients during the procedure with PCIN fentanyl compared to that with oral morphine (mean difference = -0.75, 95% CI = -1.97 to 0.47, P = 0.22). Two patients experienced hypotension during the procedure--both had received active oral morphine. No patients experienced respiratory depression or a significant drop in oxygen saturation. There were four episodes (in three patients) where 'rescue analgesia' for severe pain was required--two episodes involving oral morphine and two involving PCIN fentanyl. It was concluded that PCIN fentanyl is similar in efficacy and safety to oral morphine for relief of procedural wound care pain in burns patients.