Out-of-Hospital Cardiac Arrest Resuscitation Systems of Care: A Scientific Statement From the American Heart Association.

The American Heart Association previously recommended implementation of cardiac resuscitation systems of care that consist of interconnected community, emergency medical services, and hospital efforts to measure and improve the process of care and outcome for patients with cardiac arrest. In addition, the American Heart Association proposed a national process to develop and implement evidence-based guidelines for cardiac resuscitation systems of care. Significant experience has been gained with implementing these systems, and new evidence has accumulated. This update describes recent advances in the science of cardiac resuscitation systems and evidence of their effectiveness, as well as recent progress in dissemination and implementation throughout the United States. Emphasis is placed on evidence published since the original recommendations (ie, including and since 2010).

Extended Water-Level Drawdowns in Dammed Rivers Enhance Fish Habitat: Environmental Pool Management in the Upper Mississippi River.

Environmental Pool Management (EPM) can improve ecosystem function in rivers by restoring aspects of the natural flow regime lost to dam construction. EPM recreates summer baseflow conditions and promotes the growth of terrestrial vegetation which is inundated in the fall, thereby improving habitat heterogeneity for many aquatic taxa. A three-year experiment was conducted wherein terrestrial floodplain areas were dewatered through EPM water-level reductions and the resulting terrestrial vegetation was (1) allowed to remain or (2) removed in paired plots in Mississippi River pool 25. Fish assemblage and abundance were quantified in paired plots after inundation. Abundances of many fish species were greater in vegetated plots, especially for species that utilize vegetation during portions of their life history. Fish assemblages varied more between plot types when the magnitude of EPM water-level drawdowns was greater, which produced greater vegetation growth. Young-of-year individuals, especially from small, early maturing species and/or species reliant on vegetation for refuge, feeding, or life history, utilized vegetated plots more than devegetated plots. Vegetation growth produced under EPM was heavily used by river fishes, including young-of-year individuals, which may ultimately positively influence recruitment. Increased habitat heterogeneity may mitigate some of the negative impacts of dam construction and water-level regulation on river fishes. Annual variability in vegetation responses that occurs under EPM enhances natural environmental variability which could ultimately contribute to increased fish diversity. Low-cost programs like EPM can be implemented as a part of adaptive management plans to help maintain biodiversity and ecosystem health in anthropogenically altered rivers.

Status Cataplecticus Following Abrupt Withdrawal of Clomipramine

Presentation This is a case of a 31 year old gentleman who suffered an attack of status cataplecticus following abrupt withdrawal of clomipramine. Diagnosis Clomipramine was temporarily discontinued in order to confirm a suspected diagnosis of narcolepsy using Multiple Sleep Latency Testing. This precipitated an episode of status cataplecticus which resolved with re-introduction of therapy. A diagnosis of narcolepsy was later confirmed with undetectable levels of hypocretin/orexin in the CSF. Treatment Re-introduction of clomipramine led to resolution of status cataplecticus. The patient now remains stable with regards to his cataplexy on clomipramine 30mg. Discussion There have been a total of 4 case reports of status cataplecticus following withdrawal of antidepressant therapy. In all cases, reintroduction of anti-cataplectic therapy led to resolution of attacks. The abrupt discontinuation of an SSRI is believed to precipitate cataplexy attacks due to reduction in noradrenergic tone.

Regional Systems of Care Demonstration Project: American Heart Association Mission: Lifeline STEMI Systems Accelerator.

BACKGROUND: Up to 50% of patients fail to meet ST-segment-elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact-to-device time of <90 minutes for patients directly presenting to percutaneous coronary intervention-capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans. METHODS: We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. RESULTS: Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact-to-device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%-48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001). CONCLUSIONS: This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact-to-device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals.

Electrocardiographic diagnosis of ST segment elevation myocardial infarction: An evaluation of three automated interpretation algorithms.

OBJECTIVE: To assess the validity of three different computerized electrocardiogram (ECG) interpretation algorithms in correctly identifying STEMI patients in the prehospital environment who require emergent cardiac intervention. METHODS: This retrospective study validated three diagnostic algorithms (AG) against the presence of a culprit coronary artery upon cardiac catheterization. Two patient groups were enrolled in this study: those with verified prehospital ST-elevation myocardial infarction (STEMI) activation (cases) and those with a prehospital impression of chest pain due to ACS (controls). RESULTS: There were 500 records analyzed resulting in a case group with 151 patients and a control group with 349 patients. Sensitivities differed between AGs (AG1=0.69 vs AG2=0.68 vs AG3=0.62), with statistical differences in sensitivity found when comparing AG1 to AG3 and AG1 to AG2. Specificities also differed between AGs (AG1=0.89 vs AG2=0.91 vs AG3=0.95), with AG1 and AG2 significantly less specific than AG3. CONCLUSIONS: STEMI diagnostic algorithms vary in regards to their validity in identifying patients with culprit artery lesions. This suggests that systems could apply more sensitive or specific algorithms depending on the needs in their community.

Pushing the Envelope on STEMI Response.

New findings from the Mission: Lifeline STEMI Systems Accelerator program suggest that a regionalized approach to ST-segment elevation myocardial infarctions (STEMI) can cut time-to-treatment for patients modestly, thereby improving the prospects for better outcomes. The approach encourages hospitals, emergency medical services (EMS) and cardiologists in a region to work together to optimize treatment and efficiency so that patients in need of percutaneous coronary intervention (PCI) receive this care more expeditiously. The research included 484 hospitals, 1,253 EMS agencies, and nearly 24,000 patients in 16 regions across the United States. The goal was to increase the number of STEMI patients who receive PCI bed time parameters. Overall, the percentage of STEMI patients receiving PCI in accordance with guidelines improved from 50% to 55% during the study period. Key to the Mission: Lifeline approach is a focus on starting the clock ticking on time-to-treatment at first medical contact (FMC) as opposed to the hospital door, but this requires coordination with EMS and other hospitals. Some observers question whether a push for regionalization is worth the effort, considering the modest results thus far.

Successful use of intra-arrest thrombolysis for electrical storm due to acute myocardial infarction.

Acute vascular thrombotic disease, including acute myocardial infarction and pulmonary embolism, accounts for 70% of sudden outpatient cardiac arrest. The role of intra-arrest thrombolytic administration aimed at reversing the underlying cause of cardiac arrest remains an area of debate with recent guidelines advising against routine use. We present a case of prolonged refractory ventricular fibrillation electrical storm in a patient who demonstrated intra-arrest electrocardiographic and sonographic markers confirming acute myocardial infarction. Return of spontaneous circulation was rapidly achieved after rescue intra-arrest bolus thrombolysis.Highlights of this case are discussed in the context of the current evidence for thrombolytic therapy in cardiac arrest with specific attention to the issue of patient selection.

The impact of a statewide pre-hospital STEMI strategy to bypass hospitals without percutaneous coronary intervention capability on treatment times.

BACKGROUND: The ultimate treatment goal for ST-segment elevation myocardial infarction (STEMI) is rapid reperfusion via primary percutaneous intervention (PCI). North Carolina has adopted a statewide STEMI referral strategy that advises paramedics to bypass local hospitals and transport STEMI patients directly to a PCI-capable hospital, even if a non-PCI-capable hospital is closer. METHODS AND RESULTS: We assessed the adherence of emergency medical services to this STEMI protocol, as well as subsequent associations with patient treatment times and outcomes by linking data from the Acute Coronary Treatment and Intervention Outcomes Network Registry(®)-Get With the Guidelines(™) and a statewide emergency medical services data system from June 2008 to September 2010 for all patients with STEMI. Patients were divided into those (1) transported directly to a PCI hospital, thereby bypassing a closer non-PCI hospital and (2) first taken to a closer non-PCI center and later transferred to a PCI hospital. Among 6010 patients with STEMI, 1288 were eligible and included in our study cohort. Of these, 826 (64%) were transported directly to a PCI facility, whereas 462 (36%) were first taken to a non-PCI hospital and later transferred. In a multivariable model, increase in differential driving time and cardiac arrest were associated with a lesser likelihood of being taken directly to a PCI center, whereas a history of PCI was associated with a higher likelihood of being taken directly to a PCI center. Patients sent directly to a PCI center were more likely to have times between first medical contact and PCI within guideline recommendations. CONCLUSIONS: We found that patients who were sent directly to a PCI center had significantly shorter time to reperfusion.

Rates of cardiac catheterization cancelation for ST-segment elevation myocardial infarction after activation by emergency medical services or emergency physicians: results from the North Carolina Catheterization Laboratory Activation Registry.

BACKGROUND: For patients with an acute ST-segment elevation myocardial infarction, cardiac catheterization laboratory (CCL) activation by emergency medical technicians or emergency physicians has been shown to substantially reduce treatment times. One drawback to this approach involves overtriage, whereby CCL staffs are activated for patients who ultimately do not require emergent coronary angiography or for patients who undergo angiography but are not found to have coronary artery occlusion. METHODS AND RESULTS: We examined CCL activation at 14 primary angioplasty hospitals to determine the course of management, including the rate of inappropriate activation. Among 3973 activations (29% by emergency medical technicians, 71% by emergency physicians) between December 2008 and December 2009, appropriate CCL activations occurred for 3377 patients (85%), with 2598 patients (76.9% of appropriate activations) receiving primary percutaneous coronary intervention. Reasons for inappropriate activations (596 patients; 15%) included ECG reinterpretations (427 patients; 72%) or the fact that the patient was not a CCL candidate (169 patients; 28%). The rate of cancellation because of reinterpretation of emergency medical technicians' ECG (6% of all activations) was more common than for cancellation because of reinterpretation of emergency physicians' ECG (4.6%). CONCLUSIONS: This represents the first report of the rates of CCL cancellation for ST-segment elevation myocardial infarction system activation by emergency medical technicians and emergency physicians in a large group of hospitals organized within a statewide program. The high rate of coronary intervention and relatively low rate of inappropriate activation suggest that systematic CCL activation by emergency personnel on a broad scale is feasible and accurate, and these rates set a benchmark for ST-segment elevation myocardial infarction systems.

Expansion of a regional ST-segment-elevation myocardial infarction system to an entire state.

BACKGROUND: Despite national guidelines calling for timely coronary artery reperfusion, treatment is often delayed, particularly for patients requiring interhospital transfer. METHODS AND RESULTS: One hundred nineteen North Carolina hospitals developed coordinated plans to rapidly treat patients with ST-segment-elevation myocardial infarction according to presentation: walk-in, ambulance, or hospital transfer. A total of 6841 patients with ST-segment-elevation myocardial infarction (3907 directly presenting to 21 percutaneous coronary intervention hospitals, 2933 transferred from 98 non-percutaneous coronary intervention hospitals) were treated between July 2008 and December 2009 (age, 59 years; 30% women; 19% uninsured; chest pain duration, 91 minutes; shock, 9.2%). The rate of patients not receiving reperfusion fell from 5.4% to 4.0% (P=0.04). Treatment times for hospital transfer patients substantially improved. First-hospital-door-to-device time for hospitals that adopted a "transfer for percutaneous coronary intervention" reperfusion strategy fell from 117 to 103 minutes (P=0.0008), whereas times at hospitals with a mixed strategy of transfer or fibrinolysis fell from 195 to 138 minutes (P=0.002). Median door-to-device times for patients presenting directly to PCI hospitals fell from 64 to 59 minutes (P<0.001). Emergency medical services-transported patients were most likely to reach door-to-device goals, with 91% treated within 90 minutes and 52% being treated with 60 minutes. Patients treated within guideline goals had a mortality of 2.2% compared with 5.7% for those exceeding guideline recommendations (P<0.001). CONCLUSION: Through extension of regional coordination to an entire state, rapid diagnosis and treatment of ST-segment-elevation myocardial infarction has become an established standard of care independently of healthcare setting or geographic location.

Prehospital system delay in ST-segment elevation myocardial infarction care: a novel linkage of emergency medicine services and in hospital registry data.

BACKGROUND: Emergency medical services (EMS) are critical in the treatment of ST-segment elevation myocardial infarction (STEMI). Prehospital system delays are an important target for improving timely STEMI care, yet few limited data are available. METHODS: Using a deterministic approach, we merged EMS data from the North Carolina Pre-hospital Medical Information System (PreMIS) with data from the Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments-Emergency Response (RACE-ER) Project. Our sample included all patients with STEMI from June 2008 to October 2010 who arrived by EMS and who had primary percutaneous coronary intervention (PCI). Prehospital system delays were compared using both RACE-ER and PreMIS to examine agreement between the 2 data sources. RESULTS: Overall, 8,680 patients with STEMI in RACE-ER arrived at a PCI hospital by EMS; 21 RACE-ER hospitals and 178 corresponding EMS agencies across the state were represented. Of these, 6,010 (69%) patients were successfully linked with PreMIS. Linked and notlinked patients were similar. Overall, 2,696 patients were treated with PCI only and were taken directly to a PCI-capable hospital by EMS; 1,750 were transferred from a non-PCI facility. For those being transported directly to a PCI center, 53% reached the 90-minute target guideline goal. For those transferred from a non-PCI facility, 24% reached the 120-minute target goal for primary PCI. CONCLUSIONS: We successfully linked prehospital EMS data with in hospital clinical data. With this linked STEMI cohort, less than half of patients reach goals set by guidelines. Such a data source could be used for future research and quality improvement interventions.

Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association.

The management of low-risk patients presenting to emergency departments is a common and challenging clinical problem entailing 8 million emergency department visits annually. Although a majority of these patients do not have a life-threatening condition, the clinician must distinguish between those who require urgent treatment of a serious problem and those with more benign entities who do not require admission. Inadvertent discharge of patients with acute coronary syndrome from the emergency department is associated with increased mortality and liability, whereas inappropriate admission of patients without serious disease is neither indicated nor cost-effective. Clinical judgment and basic clinical tools (history, physical examination, and electrocardiogram) remain primary in meeting this challenge and affording early identification of low-risk patients with chest pain. Additionally, established and newer diagnostic methods have extended clinicians' diagnostic capacity in this setting. Low-risk patients presenting with chest pain are increasingly managed in chest pain units in which accelerated diagnostic protocols are performed, comprising serial electrocardiograms and cardiac injury markers to exclude acute coronary syndrome. Patients with negative findings usually complete the accelerated diagnostic protocol with a confirmatory test to exclude ischemia. This is typically an exercise treadmill test or a cardiac imaging study if the exercise treadmill test is not applicable. Rest myocardial perfusion imaging has assumed an important role in this setting. Computed tomography coronary angiography has also shown promise in this setting. A negative accelerated diagnostic protocol evaluation allows discharge, whereas patients with positive findings are admitted. This approach has been found to be safe, accurate, and cost-effective in low-risk patients presenting with chest pain.

Urinary excretion of foreign antigens and RNA following primary and secondary injections of antigens.

Two soluble antigens, BSA and KLH labeled with sulfanilate-(35)S, when injected intravenously into normal animals, were excreted in the urine to over 70% in 24 hr. Over the next 6 days, 25% more was excreted after which time only a trace could be detected. Much of the antigen remaining from the primary injection appeared in the urine following a secondary injection of the unlabeled protein carrier at 7 days after primary injection. The antigen material found in the urine was quite heterogeneous with respect to physical properties and much of it was associated with RNA material as shown by chromatographic analyses. The main difference between the labeled material released following the primary and secondary injection was the higher degree of association of antigen material with nucleotide material after secondary injection as compared with primary injection. Further study is needed to distinguish qualitative from quantitative changes of the components, antigen and nucleic acid, and also the nature of their association. Possible similarities were found for the RNA-antigen material released from tissue after secondary injection of unlabeled antigen, and the material that was isolated previously from liver.

Competition of haptens.

Groups of rabbits were injected with either bovine serum albumin, sheep red cell stroma, or keyhole limpet hemocyanin to which 2,4-dinitrophenyl and/or p-azophenyl arsonate groups had been coupled. Groups of animals received either doubly coupled antigen or an equivalent mixture of singly coupled antigens. Materials were injected intravenously as a solution or subcutaneously and intramuscularly in complete Freund's adjuvant. The presence of dinitrophenyl groups on the immunizing antigen could suppress, partially or completely, the antibody response to p-azophenyl arsonate when this hapten was located on the same molecule. Suppression was dependent on the ratio of haptenic groups on the molecule, appeared to be greatly affected by the method of immunization, and could be demonstrated in all three antigen systems. Partial suppression was manifested in decreased frequency and delayed appearance of the response as well as decreased maximal antibody titers. These findings appear irreconcilable with the possibility of direct clonal selection of antibody-producing cells by unprocessed antigen.

Encapsulating peritoneal sclerosis: experience of a tertiary referral center.

AIM: Encapsulating peritoneal sclerosis (EPS) is arguably the most serious complication of chronic peritoneal dialysis (PD) therapy with extremely high mortality rates. We aimed to establish the rates of EPS and factors associated with its development in a single center. METHODS: We retrospectively reviewed the records of all our PD patients from 1 January 1989 until 31 December 2008. All suspected cases were confirmed at laparotomy. Multifactorial models adjusted for potentially confounding variables such as age and sex. RESULTS: Eleven cases of EPS were identified giving a prevalence rate of 1.98%. Median duration on PD was substantially longer in affected versus unaffected patients (42.5 months versus 13.8 months; p = 0.0002). EPS patients had experienced a mean of 3.54 previous cases of peritonitis (1 infection per year versus 0.71 per year in unaffected patients; p = 0.075). Six patients died (54.5%) due to intra-abdominal sepsis including all five who presented with small bowel obstruction. Three patients had an omentectomy and adhesiolysis performed with a successful outcome. CONCLUSION: Our study reinforces the link between duration on PD and EPS. While mortality was high in our cohort, emerging surgical techniques demonstrate a favorable outcome that can be achieved even in severely affected cases.

Cardiovascular disease in obstructive sleep apnoea syndrome: the role of intermittent hypoxia and inflammation.

There is increasing evidence that intermittent hypoxia plays a role in the development of cardiovascular risk in obstructive sleep apnoea syndrome (OSAS) through the activation of inflammatory pathways. The development of translational models of intermittent hypoxia has allowed investigation of its role in the activation of inflammatory mechanisms and promotion of cardiovascular disease in OSAS. There are noticeable differences in the response to intermittent hypoxia between body tissues but the hypoxia-sensitive transcription factors hypoxia-inducible factor-1 and nuclear factor-kappaB appear to play a key role in mediating the inflammatory and cardiovascular consequences of OSAS. Expanding our understanding of these pathways, the cross-talk between them and the activation of inflammatory mechanisms by intermittent hypoxia in OSAS will provide new avenues of therapeutic opportunity for the disease.

Detection of circulating metallothionein in rats injected with zinc or cadmium.

Circulating metallothionein was measured by radioimmunoassay over a 13-day period in male Sprague-Dawley rats that received a sequence of three intraperitoneal injections (at 3-day intervals) of either 5 milligrams of zinc or 0.8 milligrams of cadmium per kilogram of body weight. These amounts of zinc and cadmium produced metallothionein concentrations in the range of 2 to 5 nanograms per milliliter of serum (zinc) and 2 to 15 nanograms per milliliter of serum (cadmium). In control rats given saline injections over the same period the metallothionein concentration ranged from 1 to 3 nanograms per milliliter of serum.