Towards individualised treatment of out-of-hospital cardiac arrest patients: an update on technical innovations in the prehospital chain of survival.

Out-of-hospital cardiac arrest (OHCA) is a major healthcare problem, with approximately 200 weekly cases in the Netherlands. Its critical, time-dependent nature makes it a unique medical situation, of which outcomes strongly rely on infrastructural factors and on-scene care by emergency medical services (EMS). Survival to hospital discharge is poor, although it has substantially improved, to roughly 25% over the last years. Recognised key factors, such as bystander resuscitation and automated external defibrillator use at the scene, have been markedly optimised with the introduction of technological innovations. In an era with ubiquitous smartphone use, the Dutch digital text message alert platform HartslagNu ( www.hartslagnu.nl ) increasingly contributes to timely care for OHCA victims. Guidelines emphasise the role of cardiac arrest recognition and early high-quality bystander resuscitation, which calls for education and improved registration at HartslagNu. As for EMS care, new technological developments with future potential are the selective use of mechanical chest compression devices and extracorporeal life support. As a future innovation, 'smart' defibrillators are under investigation, guiding resuscitative interventions based on ventricular fibrillation waveform characteristics. Taken together, optimisation of available prehospital technologies is crucial to further improve OHCA outcomes, with particular focus on more available trained volunteers in the first phase and additional research on advanced EMS care in the second phase.

An unexpected finding late after repair of coarctation of the aorta.

We describe a late complication in a 75-year-old man 50 years after repair of a coarctation of the aorta (CoA). Two years after an aortic valve replacement, mitral valve repair and radiofrequency MAZE the patient presented with dyspnoea and right-sided heart failure, based on a large pseudoaneurysm of the descending aorta, compressing the main bronchus and possibly temporarily the pulmonary arterial system. After sealing the aneurysm with an endovascular stent the patient recovered uneventfully. Recommendations are made for follow-up in patients after repair of CoA. (Neth Heart J 2008;16:260-3.).

[Sudden death at young age and the importance of molecular-pathologic investigation]. / Plotseling overlijden op jonge leeftijd en het belang van moleculair-pathologisch onderzoek.

The autopsy of a 16-year-old boy who had died suddenly revealed hypertrophic cardiomyopathy (HCM). Molecular genetic investigation revealed mutations in the MYBPC3 gene. His surviving family members could then be examined and reassured that they did not carry the mutation. An 18-year-old boy who died suddenly turned out to have known HCM. No further investigations were done and no tissue was saved. Genetic investigation of his immediate family was impossible due to the lack of a known mutation in the family. Periodic examination in clinically unaffected family members was therefore advised. Sudden cardiac death at young age is not infrequently the first symptom of an inherited cardiac disease. Because these diseases usually inherit as an autosomal dominant trait, first-degree family members have a 50% chance of carrying the same genetic defect. Besides clinical cardiologic examination of the remaining family members, post-mortem molecular genetic investigation can be of value in reaching a diagnosis and in determining the subsequent therapeutic options for immediate relatives.

[Obstacles to the routine discussion with hospital patients of possible cardiopulmonary resuscitation]. / Belemmeringen om in ziekenhuizen eventuele reanimatie altijd met patiënten te bespreken.

Nowadays, cardiopulmonary resuscitation is not routinely discussed with all hospital patients, even though it should be for a number of reasons. First of all, every patient may suffer cardiac arrest, and the overall outcome of a subsequent attempt at resuscitation is difficult to predict. Besides, patients who do not wish to be resuscitated often do not tell that to the physician of their own accord. Patients should therefore be more actively informed and encouraged to express their own preferences. The routine discussion of possible resuscitation gives physicians the opportunity to discuss, determine and delimit the extent of the intended medical procedure. In the literature, communication problems in three different areas can be identified as a cause of the present situation. These are--for both physician and patient--inability, lack of insight and unwillingness to discuss resuscitation. Physicians should be aware of the identified communication problems and deal with them in a professional manner. An understanding of these problems forms the basis for a broader implementation of resuscitation discussions in hospitals.

Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation Study (ARRESUST).

The objective of this study was to analyze the functioning of the first two links of the chain of survival: 'access' and 'basic cardiopulmonary resuscitation (CPR)'. In a prospective study, all bystander witnessed circulatory arrests resuscitated by emergency medical service (EMS) personnel, were recorded consecutively. Univariate differences in survival were calculated for various witnesses, the performance of basic CPR, the quality of CPR, the performers of CPR and the delays. A logistic regression model for survival was developed from all potential predictors of these first two links. From the 922 included patients, 93 survived to hospital discharge. In 21% of the cases, the witness did not immediately call 112, but first called others, resulting in a longer delay and a lower survival. Family members were frequent witnesses of the arrest (44%), but seldom started basic CPR (11%). Survival, when basic CPR performers were untrained and had no previous experience, was similar to that when no basic CPR was performed (6%). Not performing basic CPR, delay in basic CPR, the interval between basic CPR and EMS arrival, and being both untrained and inexperienced in basic CPR were independent predictors for survival. Basic CPR performed by persons trained a long time ago did not appear to have a negative influence on outcome, nor did basic CPR limited to chest compressions alone. The mere reporting that basic CPR has been performed does not describe adequately the actual value of basic CPR. The interval from collapse to initiation of basic CPR, and the training and experience of the performer must be taken into account. Policy makers for basic CPR training should focus on partners of the patients, who are most likely witness of an arrest.

Survival models for out-of-hospital cardiopulmonary resuscitation from the perspectives of the bystander, the first responder, and the paramedic.

Survival from out-of-hospital resuscitation depends on the strength of each component of the chain of survival. We studied, on the scene, witnessed, nontraumatic resuscitations of patients older than 17 years. The influence of the chain of survival and potential predictors on survival was analyzed by logistic regression modeling. From 1030 patients, 139 survived to hospital discharge. Three prediction models of survival were developed from the perspective of the different contributors active in out-of-hospital resuscitation: model I, bystanders; model II, first responders; and model III, paramedics. Predictors for survival (with odds ratio) were: in model I (bystanders): emergency medical service (EMS) witnessed arrest (0.50), delay to basic cardiopulmonary resuscitation (CPR) (0.74/min) and delay to EMS arrival (0.87/min); in model II (first responders): initial recorded heart rhythm (0.02 for nonshockable rhythm), delay to basic CPR (0.71/min and 0.87/min for shockable and nonshockable rhythms) and to defibrillation (0.89/min), and in model III (paramedics): need for advanced CPR (4.74 for advanced CPR not-needed), initial recorded heart rhythm (0.05 for nonshockable rhythm), and delay to basic CPR (0.77/min and 0.72/min for shockable and nonshockable rhythms), to defibrillation and to advanced CPR for shockable rhythms (0.85/min), and to advanced CPR for nonshockable rhythm (0.85/min). The area under the receiver-operator characteristic curve for model I was 0.763, for model II was 0.848, and for model III was 0.896. Of survivors, 50% had restoration of circulation without need for advanced CPR. Three survival models for witnessed nontraumatic out-of-hospital resuscitation based on the information known by bystanders, first responders and paramedics explained survival with increasing precision. Early defibrillation can restore circulation without the need for advanced CPR. When advanced CPR is needed, its delay leads to a markedly reduced survival.

Out-of-hospital cardiac arrests in Amsterdam and its surrounding areas: results from the Amsterdam resuscitation study (ARREST) in 'Utstein' style.

The purpose of this study was to describe the chain of survival in Amsterdam and its surroundings and to suggest areas for improvement. To ensure accurate data, collection was made by research personnel during the resuscitation, according to the Utstein recommendations. Between June 1, 1995 and August 1, 1997 all consecutive cardiac arrests were registered. Patient characteristics, resuscitation characteristics and time intervals were analyzed in relation to survival. From the 1046 arrests with a cardiac etiology and where resuscitation was attempted, 918 cases were not witnessed by EMS personnel. The analysis focussed on these 918 patients of whom 686 (75%) died during resuscitation, 148 (16%) died during hospital admission and 84 patients (9%) survived to hospital discharge. Patient and resuscitation characteristics associated with survival were: age, VF as initial rhythm, witnessed arrest and bystander CPR. EMS arrival time was significantly shorter for survivors (median 9 min) compared to non-survivors (median 11 min). In 151 cases the police was also alerted and arrived 5 min (median) earlier than EMS personnel. Using the OPC/CPC good functional health was observed in 50% of the survivors and moderate performance in 29%. All links in the chain of survival must be strengthened, but equipping the police with semi-automatic defibrillators may be the most useful intervention to improve survival.

Localization of pepsinogen (A and C) and cellular differentiation of pepsinogen-synthesizing cells in the human gastric mucosa.

The localization of pepsinogens (PG A and PG C) was studied intracellularly in human gastric biopsies embedded in Lowicryl K4M, using affinity-purified antibodies and protein A-gold. The homogeneous secretory granules of the chief cells contained both PG A and PG C, as was proved by serial sections. Identical reaction was also seen in the core of the biphasic mucous neck cell granules, whereas the mantle did not label. The rough endoplasmic reticulum (RER) and Golgi complex of the chief cells and mucous neck cells contained ample label. Transitional cells identified by the presence of granules of both chief cells and mucous neck cells were recognized. This type of mucous neck cell is thought to transform into a chief cell. However, an increase of RER that could explain an increase of the pepsinogen production was not observed. A mixture of these granules was also found in cells morphologically characterized as young parietal cells, suggesting a common precursor for these three cell types. These observations make the transformation from mucous neck to chief cells questionable. Antral gland cells contained only PG C, as was shown in serial section, too.