Prehospital Tranexamic Acid for Severe Trauma.

BACKGROUND: Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and suspected trauma-induced coagulopathy who are being treated in advanced trauma systems is uncertain. METHODS: We randomly assigned adults with major trauma who were at risk for trauma-induced coagulopathy to receive tranexamic acid (administered intravenously as a bolus dose of 1 g before hospital admission, followed by a 1-g infusion over a period of 8 hours after arrival at the hospital) or matched placebo. The primary outcome was survival with a favorable functional outcome at 6 months after injury, as assessed with the use of the Glasgow Outcome Scale-Extended (GOS-E). Levels on the GOS-E range from 1 (death) to 8 ("upper good recovery" [no injury-related problems]). We defined survival with a favorable functional outcome as a GOS-E level of 5 ("lower moderate disability") or higher. Secondary outcomes included death from any cause within 28 days and within 6 months after injury. RESULTS: A total of 1310 patients were recruited by 15 emergency medical services in Australia, New Zealand, and Germany. Of these patients, 661 were assigned to receive tranexamic acid, and 646 were assigned to receive placebo; the trial-group assignment was unknown for 3 patients. Survival with a favorable functional outcome at 6 months occurred in 307 of 572 patients (53.7%) in the tranexamic acid group and in 299 of 559 (53.5%) in the placebo group (risk ratio, 1.00; 95% confidence interval [CI], 0.90 to 1.12; P = 0.95). At 28 days after injury, 113 of 653 patients (17.3%) in the tranexamic acid group and 139 of 637 (21.8%) in the placebo group had died (risk ratio, 0.79; 95% CI, 0.63 to 0.99). By 6 months, 123 of 648 patients (19.0%) in the tranexamic acid group and 144 of 629 (22.9%) in the placebo group had died (risk ratio, 0.83; 95% CI, 0.67 to 1.03). The number of serious adverse events, including vascular occlusive events, did not differ meaningfully between the groups. CONCLUSIONS: Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo. (Funded by the Australian National Health and Medical Research Council and others; PATCH-Trauma ClinicalTrials.gov number, NCT02187120.).

Effect of Lower vs Higher Oxygen Saturation Targets on Survival to Hospital Discharge Among Patients Resuscitated After Out-of-Hospital Cardiac Arrest: The EXACT Randomized Clinical Trial.

Importance: The administration of a high fraction of oxygen following return of spontaneous circulation in out-of-hospital cardiac arrest may increase reperfusion brain injury. Objective: To determine whether targeting a lower oxygen saturation in the early phase of postresuscitation care for out-of-hospital cardiac arrest improves survival at hospital discharge. Design, Setting, and Participants: This multicenter, parallel-group, randomized clinical trial included unconscious adults with return of spontaneous circulation and a peripheral oxygen saturation (Spo2) of at least 95% while receiving 100% oxygen. The trial was conducted in 2 emergency medical services and 15 hospitals in Victoria and South Australia, Australia, between December 11, 2017, and August 11, 2020, with data collection from ambulance and hospital medical records (final follow-up date, August 25, 2021). The trial enrolled 428 of a planned 1416 patients. Interventions: Patients were randomized by paramedics to receive oxygen titration to achieve an oxygen saturation of either 90% to 94% (intervention; n = 216) or 98% to 100% (standard care; n = 212) until arrival in the intensive care unit. Main Outcomes and Measures: The primary outcome was survival to hospital discharge. There were 9 secondary outcomes collected, including hypoxic episodes (Spo2 <90%) and prespecified serious adverse events, which included hypoxia with rearrest. Results: The trial was stopped early due to the COVID-19 pandemic. Of the 428 patients who were randomized, 425 were included in the primary analysis (median age, 65.5 years; 100 [23.5%] women) and all completed the trial. Overall, 82 of 214 patients (38.3%) in the intervention group survived to hospital discharge compared with 101 of 211 (47.9%) in the standard care group (difference, -9.6% [95% CI, -18.9% to -0.2%]; unadjusted odds ratio, 0.68 [95% CI, 0.46-1.00]; P = .05). Of the 9 prespecified secondary outcomes collected during hospital stay, 8 showed no significant difference. A hypoxic episode prior to intensive care was observed in 31.3% (n = 67) of participants in the intervention group and 16.1% (n = 34) in the standard care group (difference, 15.2% [95% CI, 7.2%-23.1%]; OR, 2.37 [95% CI, 1.49-3.79]; P < .001). Conclusions and Relevance: Among patients achieving return of spontaneous circulation after out-of-hospital cardiac arrest, targeting an oxygen saturation of 90% to 94%, compared with 98% to 100%, until admission to the intensive care unit did not significantly improve survival to hospital discharge. Although the trial is limited by early termination due to the COVID-19 pandemic, the findings do not support use of an oxygen saturation target of 90% to 94% in the out-of-hospital setting after resuscitation from cardiac arrest. Trial Registration: ClinicalTrials.gov Identifier: NCT03138005.

Outcomes of patients with refractory out-of-hospital cardiac arrest transported to an ECMO centre compared with transport to non-ECMO centres.

Objective: To compare the outcomes of patients with refractory out-of-hospital cardiac arrest (OHCA) transported to a hospital that provides extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) with patients transported to hospitals without ECPR capability. Design, setting: Retrospective review of patient care records in a pre-hospital and hospital setting. Participants: Adult patients with OHCA who left the scene and arrived with cardiopulmonary resuscitation in progress at 16 hospitals in Melbourne, Australia, between January 2016 and December 2019. Intervention: For selected patients transported to the ECPR centre, initiation of ECMO. Main outcome measures: Survival to hospital discharge and 12-month quality of life. Results: There were 223 eligible patients during the study period. Of 49 patients transported to the ECPR centre, 23 were commenced on ECMO. Of these, survival to hospital with good neurological recovery (Cerebral Performance Category [CPC] score 1/2) occurred in 4/23 patients. Four other patients developed return of spontaneous circulation in the ECPR centre before cannulation of whom one survived, giving overall good functional outcome at 12 months survival of 5/49 (10.2%). There were 174 patients transported to the 15 non-ECPR centres and 3/174 (2%) had good functional outcome at 12 months. After adjustment for baseline differences, the odds ratio for good neurological outcome after transport to an ECPR centre compared with a non-ECPR centre was 4.63 (95% CI, 0.97-22.11; P = 0.055). Conclusion: The survival rate of patients with refractory OHCA transported to an ECPR centre remains low. Outcomes in larger cities might be improved with shorter scene times and additional ECPR centres that would provide for earlier initiation of ECMO.

Management of Pain in the United States-A Brief History and Implications for the Opioid Epidemic.

Pain management in the United States reflects attitudes to those in pain. Increased numbers of disabled veterans in the 1940s to 1960s led to an increased focus on pain and its treatment. The view of the person in pain has moved back and forth between a physiological construct to an individual with pain where perception may be related to social, emotional, and cultural factors. Conceptually, pain has both a medical basis and a political context, moving between, for example, objective evidence of disability due to pain and subjective concerns of malingering. In the 20th century, pain management became predominately pharmacologic. Perceptions of undertreatment led to increased use of opioids, at first for those with cancer-related pain and then later for noncancer pain without the multidimensional care that was intended. The increased use was related to exaggerated claims in the medical literature and by the pharmaceutical industry, of a lack of addiction in the setting of noncancer pain for these medications-a claim that was subsequently found to be false and deliberatively deceptive; an epidemic of opioid prescribing began in the 1990s. An alarming rise in deaths due to opioids has led to several efforts to decrease use, both in patients with noncancer conditions and in those with cancer and survivors of cancer.

Retrieval of Adult Patients on Extracorporeal Membrane Oxygenation by an Intensive Care Physician Model.

The optimal staffing model during the inter-hospital transfer of patients on extracorporeal membrane oxygenation (ECMO) is not known. We report the complications and outcomes of patients who were commenced on ECMO at a referring hospital by intensive care physicians and compare these findings with patients who had ECMO established at an ECMO center in Australia. This was a single center, retrospective observational study based on a prospectively collected ECMO database from Melbourne, Australia. Patients with severe cardiac and/or respiratory failure failing conventional supportive treatment between 2007-2013 were placed on ECMO via a physician-led model of ECMO retrieval, including two intensivists in a four person team, using percutaneous ECMO cannulation. Patients (198) underwent ECMO over the study period, of which 31% were retrieved. Veno-venous (VV)-ECMO and veno-arterial (VA)-ECMO accounted for 27 and 73% respectively. The VA-ECMO patients had more intra-transport interventions compared with VV-ECMO transported patients, but none resulting in serious morbidity or death. There was no overall difference in survival at 6 months between retrieved and ECMO center patients: VV-ECMO (75 vs. 70%, P = 0.690) versus VA-ECMO (70 vs. 68%, P = 1.000). An intensive care physician-led team was able to safely place all critically ill patients on ECMO and retrieve them to an ECMO center. This may be an appropriate staffing model for ECMO retrieval.

Integrating Palliative and Oncology Care for Patients with Advanced Cancer: A Quality Improvement Intervention.

BACKGROUND: Practice guidelines recommend palliative care for patients with advanced cancer, but gaps in access and quality of care persist. OBJECTIVE: To increase goals-of-care (GOC) communication for hospitalized patients with Stage IV cancer. METHODS: An interdisciplinary team designed a quality improvement intervention to enhance oncology palliative care, including training in communication skills and triggers for palliative care consults. SETTING/SUBJECTS: All adult inpatients with Stage IV cancer and unplanned admission at an 804-bed hospital affiliated with a National Cancer Institute (NCI) Comprehensive Cancer Center. MEASUREMENTS: The primary quality measure was the percentage of patients with Stage IV cancer who had a GOC discussion during hospitalization; secondary measures included screening for pain, dyspnea, spiritual needs, and outcomes of intensive care, hospice, and 30-day readmission. RESULTS: In the 11-month study period, n = 330, Stage IV cancer patients were hospitalized. Comparing the first three months with the final three months, rates of GOC discussion increased from 29% to 48% (p = 0.013), and specialty palliative care consultation increased from 18% to 33%, (p = 0.026). Rates of symptom screening, intensive care unit transfer, hospice, and 30-day re-admission did not change overall. However, patients with specialty palliative care more frequently had pain screening (91% vs. 81%, p = 0.020), spiritual assessment (48% vs. 10%, p < 0.001), and hospice referral (39% vs. 9%, p < 0.001), and they were less likely to be re-admitted within 30 days (12% vs. 21%, p = 0.059). DISCUSSION: Interdisciplinary quality improvement was effective to increase GOC discussions and palliative care consults for patients with Stage IV cancer.

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.

A Paramedic-staffed Helicopter Emergency Medical Service's Response to Winch Missions in Victoria, Australia.

Winching emergency medical care providers from a helicopter to the scene enables treatment of patients in otherwise inaccessible locations, but is not without risks. The objective of this study was to define characteristics of winch missions undertaken by Intensive Care Flight Paramedics (ICFP) in Victoria, Australia with a focus on extraction methods and clinical care delivered at the scene. A retrospective data analysis was performed to identify all winch missions between November 2010 and March 2014. Demographic data, winch characteristics, physiological parameters, and interventions undertaken on scene by the ICFP were extracted. Out of 5,003 missions in the study period, 125 were identified as winch operations. Winter missions were significantly less frequent than those of any other season. Patients were predominantly male (78.4%) and had a mean age of 38 years (±17.6). A total of 109 (87.2%) patients were identified as experiencing trauma with a mean Revised Trauma Score of 7.5288, and isolated limb fractures were the most frequently encountered injury. Falls and vehicle-related trauma were the most common mechanisms of injury. The total median scene duration was 49 minutes (IQR 23-91). Sixty-three patients (50.4%) were extracted using a stretcher, 45 (36.0%) using a hypothermic strop, and 6 (4.8%) via normal rescue strop. Eleven patients (8.8%) were not winched to the helicopter. Vascular access (38.4%), analgesia (44.0%), and anti-emetic administration (28.8%) were the most frequent clinical interventions. Forty-nine patients (39.2%) did not receive any clinical intervention prior to winch extraction. Winch operations in Victoria, Australia consisted predominantly of patients with minor to moderate traumatic injuries. A significant proportion of patients did not require any clinical treatment prior to winching, and among those who did, analgesia was the most frequent intervention. Advanced medical procedures were rarely required prior to winch extraction.

Interventions to treat malignant pleural effusions.

Malignant pleural effusions (MPEs) are common complications that occur with advanced stages of cancer. In general, they indicate a poor prognosis and greatly affect quality of life (QOL). The treatment goal of MPEs is to provide relief of symptoms. The standard treatment for MPEs is talc pleurodesis; however, indwelling pleural catheters have become more frequently used. This article focuses on current management strategies for MPEs and assesses their influence on QOL.At a GlanceSymptoms of malignant pleural effusions (MPEs), which involve the accumulation of fluid in the pleural space, include dyspnea, shortness of breath, chest pain, and other issues that decrease functional status.Treatment for MPEs should be palliative, achieving immediate symptom relief and improved quality of life.The optimal treatment strategy for MPEs should have minimal side effects, require minimal or no hospitalization, and have low rates of recurrence.

Conducting an antidepressant clinical trial in oncology: challenges and strategies to address them.

OBJECTIVE: The aim of this report is to discuss the design of an antidepressant clinical trial and discuss the challenges and potential solutions to these challenges to successful recruitment of oncology patients for psychopharmacology trials. METHOD: We utilize meeting minutes and investigator discussions to identify the modifiable and nonmodifiable variables that affected successful subject recruitment for this study. RESULTS: No subjects were enrolled in our placebo-controlled antidepressant trial. After study modification to remove the placebo arm, we enrolled 21 subjects with depression and cancer. We identified the following recruitment difficulties during the study: diagnostic ambiguity in patients with depression and cancer, lowered subject retention in a medically ill population, patient reluctance to enroll in placebo-controlled studies and lack of a standardized referral processes for antidepressant studies in oncology at our institution. CONCLUSION: Our experience provides guidance on specific factors that future clinicians and researchers can consider when implementing psychopharmacologic trials in the medically ill.

Population density predicts outcome from out-of-hospital cardiac arrest in Victoria, Australia.

OBJECTIVE: To examine the impact of population density on incidence and outcome of out-of-hospital cardiac arrest (OHCA). DESIGN, SETTING AND PARTICIPANTS: Data were extracted from the Victorian Ambulance Cardiac Arrest Registry for all adult OHCA cases of presumed cardiac aetiology attended by the emergency medical service (EMS) between 1 January 2003 and 31 December 2011. Cases were allocated into one of five population density groups according to their statistical local area: very low density (≤ 10 people/km(2)), low density (11-200 people/km(2)), medium density (201-1000 people/km(2)), high density (1001-3000 people/km(2)), and very high density (> 3000 people/km(2)). MAIN OUTCOME MEASURES: Survival to hospital and survival to hospital discharge. RESULTS: The EMS attended 27 705 adult presumed cardiac OHCA cases across 204 Victorian regions. In 12 007 of these (43.3%), resuscitation was attempted by the EMS. Incidence was lower and arrest characteristics were consistently less favourable for lower population density groups. Survival outcomes, including return of spontaneous circulation, survival to hospital and survival to hospital discharge, were significantly poorer in less densely populated groups (P < 0.001 for all comparisons). When compared with very low density populations, the risk-adjusted odds ratios of surviving to hospital discharge were: low density, 1.88 (95% CI, 1.15-3.07); medium density, 2.49 (95% CI, 1.55-4.02); high density, 3.47 (95% CI, 2.20-5.48) and very high density, 4.32 (95% CI, 2.67-6.99). CONCLUSION: Population density is independently associated with survival after OHCA, and significant variation in the incidence and characteristics of these events are observed across the state.

A pilot study to evaluate symptom-oriented selection of antidepressants in patients with cancer.

BACKGROUND: Major depressive disorder (MDD) is a common and debilitating illness in patients with cancer. However, the optimal treatment of depression in these patients remains uncertain, with limited evidence to support the use of pharmacologic therapy. We conducted a pilot study to evaluate the feasibility of an antidepressant clinical trial in the oncology population and the process of symptom-oriented selection of antidepressants (citalopram or mirtazapine) in patients with cancer and MDD. METHODS: This was a single center, two-arm, nonrandomized, open-label, nine-week pilot study of mirtazapine or citalopram in cancer patients with MDD. The primary endpoint was the feasibility to recruit and to retain patients. Secondary outcomes included changes in Patient Health Questionnaire-9 (PHQ-9) (depression), Functional Assessment of Cancer Therapy-General (FACT-G) (quality of life), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue) (fatigue), and Pittsburgh Sleep Quality Index (PSQI) (sleep). We conducted descriptive statistics and responder analyses. RESULTS: Of 21 patients, 18 (86%) successfully completed the study. An average of 2.8 subjects were enrolled per month. Mean scores on the PHQ-9 improved overall by 6.4 points (95% confidence interval [CI] 3.6-9.2). Additionally, mean FACT-G, FACIT-Fatigue, and PSQI scores improved in both study arms. CONCLUSION: Conducting antidepressant clinical trials is challenging in the oncology population. We approached but did not meet our feasibility goals. Depression and quality of life (QOL) scores improved with both mirtazapine and citalopram, but evidence-based pharmacologic treatments for depression in cancer patients are needed.

Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilising the precordial thump.

BACKGROUND: Few studies have described the value of the precordial thump (PT) as first-line treatment of monitored out-of-hospital cardiac arrest (OHCA) from ventricular fibrillation and pulseless ventricular tachycardia (VF/VT). METHODS: Patient data was extracted from the Victorian Ambulance Cardiac Arrest Registry (VACAR) for all OHCA witnessed by paramedics between 2003 and 2011. Adult patients who suffered a monitored VF/VT of presumed cardiac aetiology were included. Cases were excluded if the arrest occurred after arrival at hospital, or a 'do not resuscitate' directive was documented. Patients were assigned into two groups according to the use of the PT or defibrillation as first-line treatment. The study outcomes were: impact of first shock/thump on return of spontaneous circulation (ROSC), overall ROSC, and survival to hospital discharge. RESULTS: A total of 434 cases met the eligibility criteria, of which first-line treatment involved a PT in 103 (23.7%) and immediate defibrillation in 325 (74.8%) cases. Patient characteristics did not differ significantly between groups. Seventeen patients (16.5%) observed a PT-induced rhythm change, including five cases of ROSC and 10 rhythm deteriorations. Immediate defibrillation resulted in significantly higher levels of immediate ROSC (57.8% vs. 4.9%, p<0.0001), without excess rhythm deteriorations (12.3% vs. 9.7%, p=0.48). Of the five successful PT attempts, three required defibrillation following re-arrest. Overall ROSC and survival to hospital discharge did not differ significantly between groups. CONCLUSION: The PT used as first-line treatment of monitored VF/VT rarely results in ROSC, and is more often associated with rhythm deterioration.

A two-cohort phase I study of weekly oxaliplatin and gemcitabine, then oxaliplatin, gemcitabine, and erlotinib during radiotherapy for unresectable pancreatic carcinoma.

OBJECTIVES: Gemcitabine is a potent radiosensitizer. When combined with standard radiotherapy (XRT) the gemcitabine dose must be reduced to about 10% of its conventional dose. Oxaliplatin and erlotinib also have radiosensitizing properties. Oxaliplatin and gemcitabine have demonstrated synergy in vitro. We aimed to determine the maximum tolerated dose of oxaliplatin and gemcitabine with concurrent XRT, then oxaliplatin, gemcitaibine, and erlotinib with XRT in the treatment of locally advanced and low-volume metastatic pancreatic or biliary cancer. METHODS: A modified 3+3 dose-escalation design was used for testing 4 dose levels of oxaliplatin and gemcitabine given once weekly for a maximum of 6 weeks with daily XRT in fractions of 1.8 Gy to a total dose of 50.4 Gy. Dose-limiting toxicity (DLT) was defined as any grade 4 toxicity or grade 3 toxicity resulting in a treatment delay of >1 week. In addition, dose reduction in 2 of the 3 patients in a given cohort was counted as a DLT in dose escalation-deescalation rule in the modified 3+3 design. RESULTS: Eighteen patients were enrolled, all with pancreatic cancer. Grade 4 transaminitis in a patient in cohort 3 resulted in cohort expansion. Cohort 4, the highest planned dose cohort, had no DLTs. The recommended phase II dose is oxaliplatin 50 mg/m(2)/wk with gemcitabine 200 mg/m(2)/wk and 50.4 Gy XRT. The most prevalent grade 3 toxicities were nausea (22%), elevated transaminases (17%), leucopenia (17%), and hyperglycemia (17%). Median progression-free survival was 7.1 months (95% confidence interval, 4.6-11.1 mo) and median overall survival was 10.8 months (95% confidence interval, 7.1-16.7 mo). The addition of erlotinib was poorly tolerated at the first planned dose level, but full study of the combination was hindered by early closure of the study. CONCLUSIONS: Weekly oxaliplatin 50 mg/m/wk combined with gemcitabine 200 mg/m/wk and XRT for pancreatic cancer has acceptable toxicity and interesting activity.

Paediatric out-of-hospital cardiac arrests in Melbourne, Australia: improved reporting by adding coronial data to a cardiac arrest registry.

AIM: We describe improved reporting of paediatric out-of-hospital cardiac arrest (OHCA) by adding coronial findings to a cardiac arrest registry. METHODS: Non-traumatic OHCA occurring in paediatric patients aged less than 16 years were identified using the Victorian Ambulance Cardiac Arrest Registry and available coronial findings reviewed. RESULTS: Between the years 2001 and 2009, emergency medical services (EMS) attended 26 974 non-traumatic OHCA of which 390 (1.4%) occurred in children less than 16 years of age. We successfully linked 301 patients with the coronial registry; excluding patients discharged alive from hospital (n=22) and patients with terminal illness (n=16), this represents 86% of OHCA attended by the ambulance. Agreement between the paramedic cause of OHCA and the coronial cause of death was 66.5% (κ 0.16) for presumed cardiac, 74.4% (κ 0.43) for sudden infant death syndrome (SIDS), 81.1% (κ 0.17) for respiratory, 92.7% (κ 0.18) for neurological and 98.3% (κ 0.27) for drug overdose precipitants to OHCA. Undiagnosed congenital heart disease was a rare cause of OHCA (n=3, 1%). Intentional injury was found on autopsy in 13 cases; six cases were clinically thought to be SIDS and two cases presumed cardiac. Co-sleeping was found in 35 cases (39%) of SIDS. CONCLUSIONS: This study highlights the limitations associated with ascribing the cause of OHCA on the basis of clinical details. Improved reporting is possible by linkage with coronial data. Such robust data inform EMS service providers but also the wider healthcare system where preventive, diagnostic and treatment strategies can be maximised.

Measuring palliative care quality for seriously ill hospitalized patients.

OBJECTIVE: Hospice and palliative care providers need ways to measure and improve care processes. We tested feasibility, usability, reliability, and validity of Prepare, Embrace, Attend, Communicate, Empower (PEACE) quality measures for palliative care. METHODS: Trained research nurses abstracted data from medical records to generate quality measures for a random sample of 460 seriously ill patients without, and 102 patients with, specialty palliative care (SPC) services. RESULTS: Patient age ranged from 16 to 99 years, 50% were women, and 24% were African American. Of 34 PEACE quality measures, 17 were feasible for hospital palliative care. Inter-rater reliability was high (κ>0.80) for all but two quality measures. Face validity was endorsed by clinical service leaders, and construct validity was established by higher scores for patients receiving SPC. Comprehensive palliative care assessment was completed for only 10% of seriously ill hospitalized patients, compared with 56% of patients with SPC (p<0.001). Patients with moderate or severe pain were more likely to have a clinical assessment with SPC (67% versus 42%, p=0.002). Patients with SPC more often received attention for their emotional and spiritual needs (64% versus 40%, p<0.001) and documentation of preferences for life-sustaining treatments (91% versus 59%, p>0.001). Usability was endorsed by service leaders, who initiated two practice improvement projects. CONCLUSION: PEACE quality measures are feasible and reliable, and may be useful to examine and improve the quality of palliative care for seriously ill hospitalized patients as well as for patients in hospice. Research is needed to test measures for actionability and responsiveness to intervention.

Improved time to progression for transarterial chemoembolization compared with transarterial embolization for patients with unresectable hepatocellular carcinoma.

BACKGROUND: Embolizing branches of the hepatic artery lengthens survival for patients with unresectable hepatocellular carcinoma (HCC), but the benefit of combining chemotherapy with the embolizing particles remains controversial. METHODS: A retrospective review was undertaken of sequential patients with advanced HCC undergoing embolization in the past 10 years at 2 neighboring institutions and with 2 years of follow-up data. TACE was generally performed with doxorubicin plus mitomycin C. RESULTS: One hundred twenty-four patients were included; 77 received TACE and 47 received TAE. On multivariable analysis stratified by institution, type of embolization and CLIP score significantly predicted PFS and time to progression (TTP), whereas CLIP score and AFP independently predicted overall survival (OS). TACE significantly prolonged PFS and TTP (P = .0004 and P = .001, respectively), but not OS (P = .83). CONCLUSIONS: The addition of chemotherapy to TAE prolongs PFS and TTP. Future efforts should focus on adjunctive therapies after the embolization to increase survival.