The nationwide impact of COVID-19 on life support courses. A retrospective evaluation by Resuscitation Council UK.

Aim: To determine the impact of the COVID-19 pandemic on Resuscitation Council UK Advanced Life Support (ALS) and Immediate Life Support (ILS) course numbers and outcomes. Methods: We conducted a before-after study using course data from the Resuscitation Council UK Learning Management System between January 2018 and December 2021, using 23 March 2020 as the cut-off between pre- and post-pandemic periods. Demographics and outcomes were analysed using chi-squared tests and regression models. Results: There were 90,265 ALS participants (51,464 pre-; 38,801 post-) and 368,140 ILS participants (225,628 pre-; 142,512 post-). There was a sharp decline in participants on ALS/ILS courses due to COVID-19. ALS participant numbers rebounded to exceed pre-pandemic levels, whereas ILS numbers recovered to a lesser degree with increased uptake of e-learning versions. Mean ALS course participants reduced from 20.0 to 14.8 post-pandemic (P < 0.001).Post-pandemic there were small but statistically significant decreases in ALS Cardiac Arrest Simulation Test pass rates (from 82.1 % to 80.1 % (OR = 0.90, 95 % CI = 0.86-0.94, P < 0.001)), ALS MCQ score (from 86.6 % to 86.0 % (mean difference = -0.35, 95 % CI -0.44 to -0.26, P < 0.001)), and overall ALS course results (from 95.2 %to 94.7 %, OR = 0.92, CI = 0.85-0.99, P = 0.023). ILS course outcomes were similar post-pandemic (from 99.4 % to 99.4 %, P = 0.037). Conclusion: COVID-19 caused a sharp decline in the number of participants on ALS/ILS courses and an accelerated uptake of e-learning versions, with the average ALS course size reducing significantly. The small reduction in performance on ALS courses requires further research to clarify the contributing factors.

Feedback in advanced life support: A quality improvement initiative.

AIM: To identify participant, course characteristics and centre factors associated with participant satisfaction and ALS outcomes. METHODS: 17,690 participants enrolled on ALS courses between 1st December 2017 and 30th November 2018. Participant, course and centre characteristics were explored in relation to course learning outcomes and participant experience. Learning outcomes were assessed through a post-course MCQ score and technical and non-technical skills through a cardiac arrest simulation test (CAS-Test). Successful completion of knowledge and skill-based assessments led to overall course success. Participant feedback was collected on a post-course questionnaire. Multivariable analyses identified variables associated with course outcomes and feedback. Adjusted funnel plots compared inter-course centre outcomes. RESULTS: Mean post-course MCQ score was 86.7% (SD = 6.7). First attempt CAS-Test pass rate was 82.6% and overall course pass rate 94.4%. Participant characteristics explained the majority of variation between course centres. Characteristics associated with knowledge, skill and course outcomes were age, prior experience, pre-course MCQ score, course type, ethnicity, place of work, profession and seniority. Feedback scores were predicted by course type, pre-course MCQ, ethnicity, profession and seniority. CONCLUSION: This is the first study to identify variables associated with both ALS feedback scores and assessment outcomes. It has demonstrated that both course outcomes and participant experience are similar across a large number of course centres. Identifying the demographic traits of participants who may struggle with ALS, may enable bespoke support from an earlier stage. Analysis of feedback scores and outcomes enables ongoing appraisal and targeted improvement of the Resuscitation Council UK ALS course.

KRAS Status is Associated with Metabolic Parameters in Metastatic Colorectal Cancer According to Primary Tumour Location.

Colorectal cancer (CRC) is characterized by complex interplay between macroenvironmental factors and tumour microenvironment, leading to variable outcomes in CRC patients. To date, there is still a need to identify macroenvironment/microenvironment factors that could define subgroup of patients that would benefit from specific anti-cancer treatment in order to improve patient selection for individualized targeted-based therapy. Aim of this study was to evaluate associations between metabolic parameters and KRAS status in metastatic CRC (mCRC) according to a new tumour site classification. Retrospective data were extracted from a total of 201 patients diagnosed with mCRC between 2012 and 2017 extracted from an established CRC database at our tertiary institute. Clinical-pathological data, including age, gender, BMI, hypertension, diabetes, pre-CRC diagnosis serum lipid levels and KRAS status were recorded. Categorical characteristics were compared using chi-squared test. Continuous characteristics were compared using Mann-Whitney U test. Log rank test was used to compare hazards for survival. In all comparisons, a two-sided P value <0.05 was considered statistically significant. Out of 201 patients, 170 patients with complete serum lipid profile were included in the analysis. In recto-sigmoid cancers there was a statistically significant association between high cholesterol:high-density lipoprotein (chol:HDL) ratio and KRAS mutation (OR 2.69, 95% CI 1.1-6.4, p = 0,02). In non recto-sigmoid cancers, high cholesterol was associated with KRAS WT (OR 0.39, CI 0.15-0.97, p = 0.04). In 22 patients with KRAS mutated recto-sigmoid cancer stage IV at diagnosis normal chol:HDL ratio was associated with a trend to better survival (p = 0.06). High chol:HDL ratio was significantly associated with KRAS mutated metastatic recto-sigmoid cancers. A subgroup of mCRC patients with KRAS mutated recto-sigmoid cancer may benefit from optimal lipid lowering treatment.

Multimodal analysis of the effects of dexamethasone on high-altitude cerebral oedema: protocol for a pilot study.

BACKGROUND: Acute mountain sickness (AMS) is a cluster of symptoms that commonly occur in those ascending to high altitudes. Symptoms can include headaches, nausea, insomnia and fatigue. Exposure to high altitude can also lead to high-altitude cerebral oedema (HACE), which is a potential cause of death whilst mountaineering. Generally, AMS precedes the development of HACE. Historical studies have demonstrated the effectiveness of regular dexamethasone administration in reducing the symptoms of AMS. However, the mechanism by which dexamethasone works to reduce symptoms AMS remains poorly understood. Further studies, simulating altitude using hypoxic tents, have characterised the effect of prolonged exposure to normobaric hypoxia on cerebral oedema and blood flow using MRI. This randomised trial assesses the effect of dexamethasone on hypoxia-induced cerebral oedema in healthy adult volunteers. METHODS/DESIGN: D4H is a double-blind placebo-controlled randomised trial assessing the effect of dexamethasone on hypoxia-induced cerebral oedema. In total, 20 volunteers were randomised in pairs to receive either 8.25 mg dexamethasone or normal saline placebo intravenously after 8 h of hypoxia with an FiO2 of 12%. Serial MRI images of the brain and spinal cord were obtained at hours 0, 7, 11, 22 and 26 of the study along with serum and urinary markers to correlate with the severity of cerebral oedema and the effect of the intervention. DISCUSSION: MRI has been used to identify changes in cerebral vasculature in the development of AMS and HACE. Dexamethasone is effective at reducing the symptoms of AMS; however, the mechanism of this effect is unknown. If this study demonstrates a clear objective benefit of dexamethasone in this setting, future studies may be able to demonstrate that dexamethasone is an effective therapy for oedema associated with brain and spinal cord ischaemia beyond AMS. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03341676 . Registered on 14 November 2017.

e-Learning in Advanced Life Support-What factors influence assessment outcome?

AIM: To establish variables which are associated with favourable Advanced Life Support (ALS) course assessment outcomes, maximising learning effect. METHOD: Between 1 January 2013 and 30 June 2014, 8218 individuals participated in a Resuscitation Council (UK) e-learning Advanced Life Support (e-ALS) course. Participants completed 5-8h of online e-learning prior to attending a one day face-to-face course. e-Learning access data were collected through the Learning Management System (LMS). All participants were assessed by a multiple choice questionnaire (MCQ) before and after the face-to-face aspect alongside a practical cardiac arrest simulation (CAS-Test). Participant demographics and assessment outcomes were analysed. RESULTS: The mean post e-learning MCQ score was 83.7 (SD 7.3) and the mean post-course MCQ score was 87.7 (SD 7.9). The first attempt CAS-Test pass rate was 84.6% and overall pass rate 96.6%. Participants with previous ALS experience, ILS experience, or who were a core member of the resuscitation team performed better in the post-course MCQ, CAS-Test and overall assessment. Median time spent on the e-learning was 5.2h (IQR 3.7-7.1). There was a large range in the degree of access to e-learning content. Increased time spent accessing e-learning had no effect on the overall result (OR 0.98, P=0.367) on simulated learning outcome. CONCLUSION: Clinical experience through membership of cardiac arrest teams and previous ILS or ALS training were independent predictors of performance on the ALS course whilst time spent accessing e-learning materials did not affect course outcomes. This supports the blended approach to e-ALS which allows participants to tailor their e-learning experience to their specific needs.

Assessment of the structures at risk during wrist arthroscopy: a cadaveric study and systematic review.

UNLABELLED: We assessed the proximity of neurological structures to arthroscopic portals in a cadaveric study and through a systematic review. Arthroscopy was performed on ten cadaveric wrists. Subsequently the specimens were dissected to isolate the superficial branch of the radial nerve, the dorsal branch of the ulnar nerve, the posterior interosseous nerve and the extensor tendons. We measured the distances from the nerves to common portals. For the systematic review Pubmed and EMBASE were searched on the 31 May 2014 for cadaveric studies reporting the proximity of neurological structures to any arthroscopic wrist portal. In the cadaveric study, partial injuries were seen to six extensor tendons and one posterior interosseous nerve; it was assumed this was due to creation of the portals. Seven published studies were included in the systematic review. The dorsal sensory branch of the ulnar nerve was found to be at risk by performing the 6 Ulnar, 6 Radial and ulnar midcarpal portals, the sensory branch of the radial nerve by the 1-2 and 3-4 portals and the posterior interosseous nerve by the 3-4 and 4-5 portals. LEVEL OF EVIDENCE: V.

Current practice of rapid sequence induction of anaesthesia in the UK - a national survey.

BACKGROUND: The 'classical' technique of rapid sequence induction (RSI) of anaesthesia was described in 1970. With the introduction of new drugs and equipment in recent years, a wide variation in this technique has been used. The role of cricoid pressure is controversial because of the lack of scientific evidence. Moreover, gentle mask ventilation has been recommended in situations such as obesity and critically ill patients, to prevent hypoxaemia during the apnoeic period. In identifying multiple techniques, we conducted a national postal survey to establish the current practice of RSI in the UK. METHODS: A survey consisting of 17 questions was created and posted to 255 National Health Service (NHS) hospitals in the UK. We included two copies of the questionnaire in each envelope; one to be completed by the airway lead (consultant anaesthetist with responsibility of overseeing the standard of airway training and implementing national airway guidelines and recommendations within their institution) and the other by a trainee in the same department. The difference in responses from consultants and trainees were assessed using the χ(2) test and the Fisher's exact test. RESULTS: In total we received 272 responses (response rate 53%) of which 266 (58% from consultants and 42% from trainees) were analysed. A majority of the respondents (68%) pre-oxygenated by monitoring end-tidal oxygen concentration and 76% of the respondents use 20-25° head up tilt for all RSIs. Propofol is the most commonly used induction agent (64% of all respondents). Opioid has been used by 80% of respondents and only 18% of respondents use suxamethonium for all patients and others choose rocuronium or suxamethonium based on clinical situation. Although 92% of anaesthetists use cricoid pressure, 83% of them never objectively measure the force used. During the apnoeic period 17% of the respondents use gentle mask ventilation. CONCLUSIONS: Our survey demonstrated a persistent variation in the practice of RSI amongst the anaesthetists in the UK. The 'classical' technique of RSI is now seldom used. Therefore there is a clear need for developing consistent guidelines for the practice of RSI.

Evidence of increased blood pressure and hypertension risk among people living with HIV on antiretroviral therapy: a systematic review with meta-analysis.

Owing to antiretroviral drug-induced endothelial dysfunction, HIV-infected patients on antiretroviral therapy (ART) may have elevated blood pressure. We conducted a systematic review and meta-analysis to estimate the effects of ART on blood pressure levels and hypertension risk among HIV-infected populations worldwide. We sought articles that compared the mean blood pressure measurements and hypertension prevalence between HIV-infected adults naive and exposed to ART. Thirty-nine studies comprising 44 903 participants met the inclusion criteria. Overall, systolic (mean difference (MD) 4.52 mm Hg, 95% confidence interval (CI) 2.65-6.39, I(2)=68.1%, 19 studies) and diastolic blood pressure levels (MD 3.17 mm Hg, 95% CI 1.71-4.64, I(2)=72.5%, 16 studies) were significantly higher among ART-exposed patients compared with treatment-naive patients. Similarly, the risk of hypertension was significantly higher among ART-exposed patients, such that among 28 908 ART-exposed patients, 4195 (14.5%) had hypertension compared with 950 of 9086 (10.5%) in those who were treatment-naive (odds ratio 1.68, 95% CI 1.35-2.10, I(2)=81.5%, 32 studies). In summary, exposure to ART is significantly associated with increased systolic and diastolic blood pressure levels, and increased risk of hypertension, regardless of study-level sociodemographic differences. This meta-analysis supports the need for population-based strategies to reduce the risk of high blood pressure among people living with HIV on ART.

Effectiveness and cost-effectiveness of a universal parenting skills programme in deprived communities: multicentre randomised controlled trial.

OBJECTIVE: To evaluate the effectiveness and cost utility of a universally provided early years parenting programme. DESIGN: Multicentre randomised controlled trial with cost-effectiveness analysis. SETTING: Early years centres in four deprived areas of South Wales. PARTICIPANTS: Families with children aged between 2 and 4 years. 286 families were recruited and randomly allocated to the intervention or waiting list control. INTERVENTION: The Family Links Nurturing Programme (FLNP), a 10-week course with weekly 2 h facilitated group sessions. MAIN OUTCOME MEASURES: Negative and supportive parenting, child and parental well-being and costs assessed before the intervention, following the course (3 months) and at 9 months using standardised measures. RESULTS: There were no significant differences in primary or secondary outcomes between trial arms at 3 or 9 months. With '+' indicating improvement, difference in change in negative parenting score at 9 months was +0.90 (95%CI -1.90 to 3.69); in supportive parenting, +0.17 (95%CI -0.61 to 0.94); and 12 of the 17 secondary outcomes showed a non-significant positive effect in the FLNP arm. Based on changes in parental well-being (SF-12), the cost per quality-adjusted life year (QALY) gained was estimated to be £34 913 (range 21 485-46 578) over 5 years and £18 954 (range 11 664-25 287) over 10 years. Probability of cost per QALY gained below £30 000 was 47% at 5 years and 57% at 10 years. Attendance was low: 34% of intervention families attended no sessions (n=48); only 47% completed the course (n=68). Also, 19% of control families attended a parenting programme before 9-month follow-up. CONCLUSIONS: Our trial has not found evidence of clinical or cost utility for the FLNP in a universal setting. However, low levels of exposure and contamination mean that uncertainty remains. TRIAL REGISTRATION: The trial is registered with Current Controlled Trials ISRCTN13919732.