Chest compression duration influences outcome between integrated load-distributing band and manual CPR during cardiac arrest.

BACKGROUND: The Circulation Improving Resuscitation Care (CIRC) Trial found equivalent survival in adult out-of-hospital cardiac arrest (OHCA) patients who received integrated load-distributing band CPR (iA-CPR) compared to manual CPR (M-CPR). We hypothesized that as chest compression duration increased, iA-CPR provided a survival benefit when compared to M-CPR. METHODS: A pre-planned secondary analysis of OHCA of presumed cardiac etiology from the randomized CIRC trial. Chest compressions duration was defined as the total number of minutes spent on compressions during resuscitation and identified from transthoracic impedance and accelerometer data recorded by the EMS defibrillator. Logistic regression was used to model the interaction between treatment and duration of chest compressions and was covariate-adjusted for trial site, patient age, witnessed arrest, and initial shockable rhythm. Primary outcome was survival to hospital discharge. RESULTS: We enrolled 4231 subjects and of those, 2012 iA-CPR and 2002 M-CPR had complete outcome and duration of chest compressions data. While covariate-adjusted odds ratio for survival to hospital discharge was 1.86 in favor of iA-CPR (95% CI 1.16-3.0), there was an interaction between duration and study arm. When this was factored into the multivariate equation, the odds ratio for survival to hospital discharge showed a significant benefit for iA-CPR vs. M-CPR for chest compression duration greater than 16.5 min. CONCLUSION: After adjusting for compression duration and duration-treatment interaction, iA-CPR showed a significant benefit for survival to hospital discharge vs. M-CPR in patients with OHCA if chest compression duration was longer than 16.5 min.

Shock decision algorithm for use during load distributing band cardiopulmonary resuscitation.

AIM: Chest compressions delivered by a load distributing band (LDB) induce artefacts in the electrocardiogram. These artefacts alter shock decisions in defibrillators. The aim of this study was to demonstrate the first reliable shock decision algorithm during LDB compressions. METHODS: The study dataset comprised 5813 electrocardiogram segments from 896 cardiac arrest patients during LDB compressions. Electrocardiogram segments were annotated by consensus as shockable (1154, 303 patients) or nonshockable (4659, 841 patients). Segments during asystole were used to characterize the LDB artefact and to compare its characteristics to those of manual artefacts from other datasets. LDB artefacts were removed using adaptive filters. A machine learning algorithm was designed for the shock decision after filtering, and its performance was compared to that of a commercial defibrillator's algorithm. RESULTS: Median (90% confidence interval) compression frequencies were lower and more stable for the LDB than for the manual artefact, 80 min-1 (79.9-82.9) vs. 104.4 min-1 (48.5-114.0). The amplitude and waveform regularity (Pearson's correlation coefficient) were larger for the LDB artefact, with 5.5 mV (0.8-23.4) vs. 0.5 mV (0.1-2.2) (p < 0.001) and 0.99 (0.78-1.0) vs. 0.88 (0.55-0.98) (p < 0.001). The shock decision accuracy was significantly higher for the machine learning algorithm than for the defibrillator algorithm, with sensitivity/specificity pairs of 92.1/96.8% (machine learning) vs. 91.4/87.1% (defibrillator) (p < 0.001). CONCLUSION: Compared to other cardiopulmonary resuscitation artefacts, removing the LDB artefact was challenging due to larger amplitudes and lower compression frequencies. The machine learning algorithm achieved clinically reliable shock decisions during LDB compressions.

Cost-effectiveness of antenatal screening for neonatal alloimmune thrombocytopenia.

OBJECTIVES: To estimate the costs and health consequences of three different screening strategies for neonatal alloimmune thrombocytopenia (NAIT). DESIGN: Cost-utility analysis on the basis of a decision tree that incorporates the relevant strategies and outcomes. SETTING: Three health regions in Norway encompassing a 2.78 million population. POPULATION: Pregnant women (n = 100,448) screened for human platelet antigen (HPA) 1a and anti-HPA 1a antibodies, and their babies. METHOD: Decision tree analysis. In three branches of the decision tree, pregnant women entered a programme while in one no screening was performed. The three different screening strategies included all HPA 1a negative women, only HPA 1a negative, HLA DRB3*0101 positive women or only HPA 1a negative women with high level of anti-HPA 1a antibodies. Included women underwent ultrasound examination and elective caesarean section 2-4 weeks before term. Severely thrombocytopenic newborn were transfused immediately with compatible platelets. MAIN OUTCOME MEASUREMENTS: Quality-adjusted life years (QALYs) and costs. RESULTS: Compared with no screening, a programme of screening and subsequent treatment would generate between 210 and 230 additional QALYs among 100,000 pregnant women, and at the same time, reduce health care costs by approximately 1.7 million euros. The sensitivity analyses indicate that screening is cost effective or even cost saving within a wide range of probabilities and costs. CONCLUSION: Our calculations indicate that it is possible to establish an antenatal screening programme for NAIT that is cost effective.

Treatment costs in Hodgkin's disease: a cost-utility analysis.

The aim of this study was to estimate costs of treatment for Hodgkin's disease (HD) and the outcome in health in terms of quality-adjusted life-years (QALYs), and compare these to a constructed nontreatment alternative. All 55 patients treated for HD at the oncological unit of the University Hospital of Tromsø between 1985 and 1993 were included. The total treatment costs (medication, hospital stay, hospital hotel stay, radiotherapy, travelling, loss in production, i.e. work) were retrospectively estimated for all patients. In December 1994, the 49 survivors were sent a EuroQol questionnaire recording quality of life: 42 responded. The mean quality of life score was 0.78 on a 0-1 scale, and the mean total cost of treatment was pounds 12512. The total treatment costs were significantly higher in patients with advanced clinical stages of the disease (P = 0.0006), B-symptoms (fever, sweats, weight loss) (P = 0.0027) and relapse (P < 0.0001). The costs of one QALY (with production gains included and using a 10% discount rate) were estimated at pounds 1651. When excluding production gains and using a 5% discount rate, the figures became pounds 1327. This makes HD one of the most cost-effective malignancies to treat.

A note on eliciting distributive preferences for health.

While in theory the strength of preferences for equity in health can be expressed in an 'inequality aversion parameter', in practice, analysts would have to obtain them from people's choices. We are faced with a number of methodological problems when turning to this type of empirical research. This note investigates which types of preference could explain the choices people make when responding to equity-efficiency questions of this kind. Respondents may be heavily influenced by concerns that are not related to their equity preferences, something which may lead them to choose distributions that are not consistent with models on the equity-efficiency trade-off. Specifically, a threshold effect is identified, which could explain why some people would rather prefer to concentrate than to diffuse health gains. The second aim of this note is to offer some lessons from a survey which was designed for eliciting people's distributive preferences for health gains.

On what basis should health be discounted?

The discount rate to be applied in health care programmes should be based on the time preference rate for health, and this same rate should be applied to costs as well. Due to the limited tradeability of health, when eliciting its time preference rate, the intertemporal choices must be framed in such a way as to resemble as closely as possible those facing health planners and decision makers.

Theories of justice and their implications for priority setting in health care.

The paper aims to show how three theories of distributive justice; utilitarianism, egalitarianism and maximum, can provide a clearer understanding of the normative basis of different priority setting regimes in the health service. The paper starts with a brief presentation of the theories, followed by their prescriptions for distribution, as illustrated with their respective preferred points on a utility possibility frontier. After this general discussion, attention is shifted from utils to health. The paper discusses how the recent Norwegian guidelines for priority setting can be understood in the light of the theories.

Agency in health care with an endogenous budget constraint.

In this paper a doctor acts as a perfect agent for a group of patients in an environment where the health service is funded by a group of contributors. The contributor group donates resources to the health sector in accordance with its split preferences about the health care services which they would like for themselves and those which they would like for others. We show that the size of the health budget is endogenous and depends on the choices made by the doctor. The focus is on the division of the budget between health enhancing and non-health enhancing health care.

Equity in health: the importance of different health streams.

This paper develops a conceptual framework in which preferences about the distribution of future health gains depend on differences in four 'health streams'. These are as follows: (1) the amount of health to be gained; (2) the no-treatment profiles; (3) the amount of health experienced thus far: and (4) the amount of health gained previously as a result of public health interventions. This classification puts the well-established concerns for severity (stream 2) and age weights (stream 3) into a more complete analytical framework. Stream 4 has not been discussed to date and the paper suggests some moral arguments about the distributive relevance of this stream of health.

Production gains from health care: what should be included in cost-effectiveness analyses?

Recent literature has been concerned with the correct measurement of the 'indirect costs and benefits' of health care as well as the issue of including these items in economic evaluations. This article considers the question of which 'indirect benefits' to include in cost effectiveness analysis and cost utility analysis. Within the context of a collectively financed health scheme the relevant issues include not only the size of the net resource costs of providing health care but also which costs and benefits the society is prepared to consider in its assessment of health services. The strong preference for 'equal access for equal need' implies that some production gains may have to be disregarded in the social welfare function. We introduce the notion of socially relevant and socially irrelevant production gains. The analysis suggests that the magnitude of the socially relevant part of the production gains may vary between countries as it depends, first, upon differences in patients' potential contributions to the rest of society (tax rates), and second, the strength of preferences for equity.

Helicopters, hearts and hips: using willingness to pay to set priorities for public sector health care programmes.

The paper reports from a study that asked 150 interviewees their willingness to pay (WTP) in increased earmarked taxation for three different health care programmes: a helicopter ambulance service, more heart operations and more hip replacements. Reasons behind the stated WTP were asked for. Ordinary least squares regression analyses were used to analyse factors associated with WTP for each of the three programmes, and factors associated with the relative WTP for one programme compared with the total of the three. Comparisons were made of WTP for these programmes and the health outcome in terms of quality adjusted life years.

Breast reconstruction following radical mastectomy, using custom designed implants.

Procedures are described for total breast reconstruction in patients who have undergone radical and modified radical mastectomies. The reconstruction includes restoration of the contour of the breast, including the nipple-areola complex and filling the defect from loss of the pectoral muscles. The reconstructions have been done in 37 patients with good results, and several are illustrated.

Association of time preference for health with age and disease severity.

This study assessed the relationship between time preference for health and age and disease severity. An implicit time preference for health was inferred in 59 patients with chronic obstructive pulmonary disease (COPD) using the time tradeoff method with 10-year and 30-year perspectives. The preference rate was calculated by solving the resulting nonlinear equation, solvable for 50 patients.Among the resulting rates, 4 were negative, 8 zero, and 38 positive. The time preference rate ranged from -10.8% to 75.0%, with a median of 6.6%, and a mean of 11.5%. In correlation analysis, the implicit time preference rate was associated with age;however, there was little association with markers of disease severity. In multivariate analysis, only age was a significant predictor of time preference rate after controlling for the other variables in the model.

Blood pressure measurement in childhood and adolescence. International recommendations and normal limits of blood pressure.

BLOOD PRESSURE MEASUREMENTS IN CHILDREN SHOULD BE BASED ON THE FOLLOWING RULES: 1. Resting period prior to readings should be about 5-10 minutes. In children under 5 years of age, lying position should be used. In older children sitting position is most suitable. 2. Either flush method or ultrasound technique should be used in newborn. Auscultatory blood pressure is suitable in other children. 3. Width of cuff should be based on circumference of the arm, and not on arm-length: (width = 120% of diameter = 40% of circumference, i.e., 3, 6, 9, 12, or 15 cm). Length of cuff-bladder = circumference or more. 4. Diastolic blood pressure should be read at muffling of Korotkoff sounds (phase IV). 5. Although some agreement exists between different studies, it is obvious, that definition of "normal blood pressure" in children is dependent on the methodological factors involved in the measurement of blood pressure.

The relationship between early development and psychosexual behaviors in adolescent females.

The relationship between early sexual maturation and the psychosexual behaviors of dating and sexual intercourse was investigated using a national sample of adolescent females aged 15 to 19. Among both black and nonblack subjects, early-maturing girls were more likely to have experienced earlier dating and coital onset than were their later-maturing peers. Blacks experienced menarche and first intercourse at earlier ages, yet dating onset at later ages. Early menarche was also associated with marriage at an early age for nonblacks, but not for blacks. These racial differences were explained in terms of diverse socialization patterns or cultural expectations. For both blacks and nonblacks, those with earlier coital experience were found to have had menarche and dating onset at earlier ages.

PIP: The relationship between early sexual maturation and the psychosexual behaviors of dating and sexual intercourse was investigated using a national sample of US adolescent females aged 15-19. The purpose of the study was to clarify the relationship between sexual maturation, dating onset, and premarital intercourse. It was hypothesized that a positive correlation exist between the age of menarche, age of dating onset, and age of 1st intercourse for both black and nonblack subjects. Also, it was hypothesized that those who have 1st intercourse at an early age will, when compared with those who have 1st intercourse at a moderate or later age, have experienced menarche and dating onset at earlier ages. The sample was divided into 2 racial categories: 581 blacks, and 1253 nonblacks. The variables studied included age at menarche, age began dating, ever had intercourse, and age at 1st intercourse. Statistical analysis was conducted on the data. For both blacks and nonblacks, the most commonly reported ages at menarche were 12 and 13. Among both black and nonblack subjects, early-maturing girls were more likely to have experienced earlier dating and coital onset than were their later- maturing peers. Blacks experienced menarche and 1st intercourse at an earlier age (black' mode=15 and nonblacks' mode=16), yet dating onset at later ages (blacks' mode=16 and nonblacks' mode=15). Early menarche was also associated with marriage at an early age for nonblacks, but not for blacks. These racial differences were explained in terms of diverse socialization patterns or cultural expectations. These differences include the differing interpretation of the ritual of dating and the more liberal attitudes existing concerning births outside marriage in the black culture. For both blacks and nonblacks, those with earlier coital experience were found to have had menarche and dating onset at earlier ages. There was a tendency for the majority of adolescent females to have complied with societal norms and engaged in psychosexual behaviors by the end of their teen years. Also, the results of this study suggest that early-maturing girl are prone to earlier psychosexual behaviors. Therefore, it is suggested that menarche be a target age for stressing sex education.

Adolescent sexuality and public policy.

In recent decades, various attempts have been made to determine the level of sexual activity among adolescents. This information has been used in the planning and evaluation of sex-related programs. However, there is a flaw in using only the initial estimates of the behavior--that a sexually active person is defined as one who has had sexual intercourse. This narrow definition distorts the perception of adolescent sexual behavior. Sexual activity can more accurately be designated by focusing on the actual frequency with which teenagers have sex. In this research report, adolescents were considered sexually active if they had had sex within the last four weeks. Using this definition, adolescents were found to be substantially less sexually active than has been previously reported. This finding was then used to look at various policy decisions in the areas of sex education, family planning, and sexually transmitted disease prevention.

PIP: This analysis of national surveys of teenage sexual behavior in the US provides a more useful and precise estimate of teenage sexual activity for policy and program decisions. Data were taken from the 1979 National Survey of Men (NSYM), and Women (NSYW), and the 1982 National Survey of Family Growth (NSFG). Analysis was based on 1) the % of unmarried respondents who were sexually experienced and the % who were sexually active, and 2) the % sexually experienced who were sexually active. The distinction between sexual activity vs. experience shows considerable differences; i.e., for women 15-19 in 1979, 46% were sexually experienced but only 26% were sexually active at the time of the survey. Further delineation is made for never, seldom, monthly, and currently active by race. Black women 15-19 in 1982 were shown to be no more sexually active than white women. However, from the NSYM black males followed the traditional pattern of higher sexual activity, with 68.2% for blacks vs. 60.1% for whites. The data dispute the typical image of rampant sexual portrayed by the popular press. The public policy response to this epidemic was to adopt a family planning (FP) approach to teenage pregnancy prevention. Reduced adolescent pregnancy rates as a measure of program effectiveness have not been shown, and program effectiveness must be based on other measures. Sex education also has had limited success in reducing adolescent pregnancy. The suggestion is that access to accurate information, student liking, parental support, and knowledge acquisition are more reasonable criteria for demonstrating success of sex education programs. Abstinence programs help reduce the risks of teenage pregnancy by emphasizing skills in decision making and resisting pressures to be sexually involved. The example is given of an Atlanta-based program, Postponing Sexual Involvement, which reported that 84% resisted becoming sexually involved after completion of the program. Other abstinence programs show promise and are an inexpensive alternative to FP, albeit evaluations are needed. Contraceptive approaches are appropriate for the already sexually active population.

The effects of family structure on the sexual behavior of adolescents.

The effects of two family structures, single- and two-parent homes, on adolescent sexual behavior were studied. The variables of race, age, and gender were controlled. The analysis compared the age at first intercourse, frequency of intercourse in the last four weeks, and virgin/nonvirgin status of adolescents from black single-parent families, white single-parent families, black two-parent families, and white two-parent families. For males, the two-parent family was related to less sexual activity and older age at first intercourse. For females, the two-parent family was not as important as race in influencing sexual behavior. The white females from two-parent families were more likely to be virgins, but once having had sexual intercourse, tended to have a higher level of sexual activity than did black females from two-parent homes.

PIP: The hypotheses in this study of adolescent sexual behavior are that the effects of single-parent homes will be greater for white males, that males in single-parent families would differ more from males in intact families than the corresponding females, and that traditional 2-parent families may be related to less adolescent sexual behavior. Data were available from the 1979 National Survey of Young Men and the 1979 National Survey of Young Women on never-married persons 17-19 years (609 males and 892 females). There were 150 black males and 184 black females living with 1 parent, 80 white males and 184 females living with 1 parent, 107 black males and 184 females living with 2 parents, and 272 white males and 418 females living with 2 parents. Family types were grouped based on what woman raised you and what man raised you and for how long between birth and 12 years for males and 10 years for females. Dependent variables were sexual experience and frequency of sexual intercourse within the month. The results were that the race/family variable was significantly related to sexual experience for males and females. When gender and race are controlled for, persons from 1-parent families were more likely to have had sexual intercourse than from 2- parent families, i.e., for black males (84.7% vs. 72.0%), white males (73.8% vs. 64.7%), black females (84.8% vs. 76.1%), and white females (65.1% vs. 50.0%). Blacks were more likely than whites to have had sexual intercourse when gender and family structure are controlled for. The data do not support the hypothesis that males are more influenced by family structure, or that white males are more influenced than black males. The analysis of variance showed a significant race/family effect (F=3.81, df=3/974, p.01) and a significant family/race by gender interaction (F=2.63, df=6/974, p.05). Blacks had a lower frequency of sexual activity than whites, as well as persons from 2-parent families that from 1-parent families. Race was the most important influence females, and family structure among males, especially white males. Sexually experienced black females had less sexual intercourse than white females, regardless of family structure. Regardless of race, 1- parent females had the same frequency of intercourse as 2-parent females. Black males and whit males had similar patterns of intercourse, but any males from 2-parent families had sex less frequently than from 1-parent families. Sexual involvement was influenced by family structure. Frequency of intercourse and initiation of intercourse clearly distinguish adolescent sexual behavior by race. It is important how sexual activity is measured.

The effects of three abstinence sex education programs on student attitudes toward sexual activity.

The effects of three abstinence sex education programs on student attitudes toward sexual activity were studied. The programs were administered to 7th- and 10th-grade students in three school districts in the State of Utah. All students were administered a pre- and posttest survey to determine attitude change. The independent variables were program, grade level, gender, and pre/posttest. The dependent variable was the combined and averaged response to 12 questions taken from the survey. There was a four-way interaction between the independent variables. The Sex Respect program produced the most positive attitude change.

PIP: Abstinence programs in 14 Utah junior and high schools were evaluated during the 1988-89 school year. The 3 programs under review were the Sex Respect Program and the Teen Aid Program in suburban districts and the Values and Choices Program in a rural area. The population represented the sociodemographic and economic structure of Utah. It was predicted that there would be a positive change between pre- and posttest scores and an increase in abstinence values, and that older students would be more resistant to change. A 105-item instrument was developed by the Institute for Research and Evaluation. The questions used pertaining to attitudes toward premarital sex are provided. A single-scale score was derived from the 13 items for the dependent variable. Independent variables were program, grade level, gender, and test. A factor analysis was performed on the measure of attitudes toward premarital sex and only 1 item had a reliability correlation lower than .66; it was discarded. The remaining items were reanalyzed and yielded a Cronbach's alpha coefficient of .938 for raw variables. In the 4-way analysis of variance with the 12-item averaged scale score, test, program, and grade level, all effects were significant and interactive. The pattern of change from pre- to posttest varied with gender, grade level, and program. The amount of attitude change between males and females was similar, but females scored higher in all 3 programs on the pre- and posttest and were more positive about abstinence. Younger students were similar to older students except for the Teen Aid Program which showed an increase from pre- to post test. More change occurred in the Sex Respect Program and the least in the Values and Choices Program. Junior high students did not increase the pre- and posttest scores in the Teen Aid Program. The Sex Respect Program may have contributed to more change because it used the student's vernacular and had better visual aids. The 1st hypothesis was substantiated; the 2nd, on older student's resistance to change, was not supported. In fact the Teen Aid Program was more effective for high school students. In fact the Teen Aid Program was more effective for high school students. Attitude toward sexual behavior was correlated with actual sexual behavior as indicated with the Pearson coefficient of -.548. This association needs to be explored further to ascertain if the changed attitudes will indeed change behavior.

[Estrogen/gestagen induced hypertension. A follow-up study on treatment and subsequent occurrence of hypertension]. / Ostrogen/gestagen-induceret hypertension. Et opfølgningsstudium med henblik på behandling og senere forekomst af forhøjet blodtryk.

PIP: Between 1976-83, 126 cases of suspected estrogen/progestogen hormone-induced hypertension were reported. Probability was established in 86 of the cases. 84 cases were linked to oral contraceptives (OCs). In 72 patients, blood pressure returned to normal levels after withdrawal of the OCs although temporary antihypertensive treatment was necessary in 23 cases. 14 patients remained hypertensive and 18 women were subsequently re-exposed to hormones with the consequent rise in blood pressure for 4 patients. Of the 72 women whose blood pressure returned to normal levels, follow-up data were available for 55 of them; among them, hypertension was then discovered in 14 (25%). Women with previous increases in blood pressure during OC administration required regular blood pressure control. (author's modified)^ieng