[How I treat ... out-of-hospital cardiac arrest. The role of the emergency medical dispatcher]. / Comment je traite ... l'arrêt cardio-respiratoire extrahospitalier: la fenêtre du centraliste 112.

Sudden cardiac arrest is an event associated with a very low survival rate. The latter is inversely proportional to the duration of the cardiovascular arrest. The chain of survival concept is a sequence of 4 events to be carried out as fast as possible with a view to ensure the patient's survival. This sequence consists of early access to and activation of the emergency medical system, early initiation of basic cardiopulmonary resuscitation, early defibrillation and early specialized care. The number of potential witnesses trained in Basic Life Support (BLS) does not guarantee an adequate basic resuscitation before the arrival of medical aid. In order to optimize the management of victims and callers, the concept of dispatching-assisted cardiopulmonary resuscitation based on a structured protocol has been implemented. The implementation of this plan to improve the quality of call handling required training and assessment of impacts on beneficiaries. The research datashow a reduction of the duration of cardiac arrest, an increase in resuscitation initiated by a witness, an improved survival rate, and a decreased stress and unanimous approval of dispatchers. Currently, the process is being improved and sustained.

The 2010 British Association of Stroke Physicians Survey of interventional treatments for stroke in the United Kingdom.

INTRODUCTION: The UK National Stroke Strategy (Department of Health 2007) states that patients should have access to a stroke service with neurointerventional capacity. This survey was conducted by the Clinical Standards Committee of the British Association of Stroke Physicians to get a snapshot of the availability of interventional treatments for stroke in the United Kingdom. METHODS: Questionnaires covering availability of endovascular treatments for stroke, e.g. intra-arterial thrombolysis and mechanical thrombectomy, were emailed to all British Association of Stroke Physicians members in October 2010. Where more than one response was received from the same hospital, the data were only entered once. If there was a discrepancy between different respondents for the same hospital, details were cross-checked with the respondents to ensure accuracy. RESULTS: Responses were received from 58 hospitals in England, Scotland, Wales, and Northern Ireland. Intra-arterial thrombolysis and/or mechanical thrombectomy were available in 23 hospitals. Of these, three had not performed any procedures in 2010. Twenty centres had conducted a mean (range) of eight (2-20) procedures during the 10-month period. Thirty-five hospitals were not offering endovascular treatments. Sixteen of these were not referring patients to centres which could provide interventional treatments. Hospitals offering endovascular treatments had a mean (range) of 5.2 (2-12) stroke physicians, 2.3 (0-4) interventional neuroradiologists, and 3.6 (0-9) noninterventional neuroradiologists. Only two hospitals providing interventions had four or more interventional neuroradiologists. CONCLUSIONS: Only a small number of hospitals in the United Kingdom provide interventional treatments for stroke. Almost 50% of hospitals not providing interventions had no processes in place for referral to providers.

Impact of initial intervention on long-term neurological recovey after cardiac arrest: data from the Luxembourg "North Pole" cohort.

BACKGROUND: Prognosis after cardiac arrest is variable and difficult to predict. Early prognostic markers would facilitate the care of these patients. AIMS: Therefore, we evaluated the impact of initial interventions after resuscitation on neurological outcome at 6 months. MATERIAL AND METHODS: We conducted a retrospective analysis of the patient charts from consecutive cardiac arrest patients admitted to our intensive care unit and treated with induced hypothermia. RESULTS: Over a 3-year period, 90 patients were included in our study. Sixty-four percent of the patients had bystander cardio-pulmonary resuscitation. An automated external defibrillator (AED) was used in 19% of the patients and the mean time to first defibrillation was 11 +/- 8.9 minutes. Patients being resuscitated and defibrillated by bystanders did better than those who had CPR only and far better than those patients in whom no rescue measures where attempted at all (73% vs. 56% vs. 32% for good neurological outcome, respectively, p= 0.03). Witnessed cardiac arrest was more frequent in patients with a good outcome than in those who collapsed without a witness (91% vs 75%, p = 0.03). In 76% of the patients with good outcome, CPR was performed whereas only 52% benefited from these measures in the bad outcome group (p = 0.01). Although the use of an AED was not significantly different between good and bad outcome groups (26% vs. 11%, p = 0.06), time to first defibrillation was significantly lower in patients with good outcome (8.7 +/- 6.3 vs. 13.3 +/- 11.3 minutes, p = 0.05). In the 17 patients in whom an AED was used, 12 (71%) recovered without major sequelae whereas in the 73 cases where no AED was used, only 34 (47%) had a good outcome (p = 0.06). At 6 months follow-up, 46 (51%) survivors had a good outcome (cerebral performance category 1-2), 5 (6%) survived with severe neurological sequelae or stayed in coma and 39 (43%) died. CONCLUSIONS: Our local data confirm that early interventions have a major impact on survival of cardiac arrest patients. Efforts should concentrate on delivering rapid and high quality CPR as well as early defibrillation by AED's to every patient in cardiac arrest. Besides large scale Basic life support training, the introduction of dispatcher assisted CPR and the implementation and use of public AED's could considerably help to improve outcome in these patients.

Age-associated changes in detrusor sensory function in women with lower urinary tract symptoms.

This study examined changes in bladder sensation which occur with age in women. 1381 women (age range 20-95 years, mean 54.9) with symptoms of lower urinary tract dysfunction underwent urodynamic study. The bladder capacity at which they first became aware of the desire to void was taken as a quantitative measure of bladder sensation. Maximum bladder capacity fell in the eighth and ninth decades (H = 95.84, df = 7, P = 0.00), but by contrast bladder capacity at first desire to void rose progressively in association with age, both in the group as a whole (H = 17.13, df = 7, P = 0.017) and in a subgroup with detrusor instability (n = 952, H = 15.42, df = 7, P = 0.032). This rise in capacity points to a decrease in bladder sensation in association with age. This is not due to neurological disease, anti-muscarinic drugs or oestrogens, as the median capacity at first desire to void of these three subgroups did not differ significantly from that of the group as a whole.

Oxybutynin with bladder retraining for detrusor instability in elderly people: a randomized controlled trial.

The aim of this study was to examine the efficacy of oxybutynin plus bladder training in the treatment of detrusor instability in frail elderly patients living independently in the community. It was a randomized, double-blind, placebo-controlled parallel-group trial of oxybutynin in 57 elderly patients (mean age 82.2, SD 6.06), with frequency and incontinence due to detrusor instability. After a 2-week run-in period patients received a bladder training and drug or placebo for the next 6 weeks. Outcome measures were changes in frequency and incontinence, recorded throughout on diary charts, and subjective evaluation of symptoms ('better'/'not better', and using a four-point scale 'cure' to 'no change'). Oxybutynin was superior to placebo in reducing daytime frequency [95% confidence interval (CI) of difference in change in frequencies totalled over 14 days was -27.0, -6.0; p = 0.003] and in producing subjective benefit (at day 29 only), when 24/28 (86%) patients on oxybutynin described benefit compared with 16/29 (55%) on placebo (p = 0.02). There was no difference between the groups in reduction of incontinent episodes. The median dose of oxybutynin titrated for therapeutic effect was 5 mg/day, and for placebo 10 mg/day (CI of difference 0.001, 5.001; p = 0.05). Side-effects reported were of similar frequency (50%) in the two groups. We conclude that oxybutynin with bladder training is superior to bladder training alone in reducing frequency due to detrusor instability in very elderly people living at home.

Study to assess quality of life (morale and happiness) in two continuing care facilities - a comparative study in the UK and The Netherlands.

The elderly in a nursing home in Nijmegen are less disabled and have higher morale and happiness scores than the elderly in a continuing care facility in London. These scores, however, do not correlate with physical or mental disabilities within each group. In Nijmegen, religion (practising and importance of) is associated with high happiness scores in the elderly, whereas use of sedatives lead to reduced happiness or low morale in both groups of elderly.

On-site modular management training for junior doctors.

A structured, modular management training programme has been developed to introduce junior doctors to basic management skills and concepts, successfully improving the efficiency of the organization.

[Digoxin poisoning in patients of 2 geriatric departments in London: prevalence and mortality]. / Digoxine-intoxicatie bij patiënten van twee Londense geriatrische afdelingen: prevalentie en mortalitiet.

Digoxin is a toxic drug with a narrow therapeutic index that is mostly used by the elderly. Although it is accepted that toxicity of digoxin occurs more frequently in elderly than in younger patients, there is dispute about its prevalence and associated mortality. A study was therefore set up to, on the one hand, find the prevalence and associated mortality of digoxin toxicity in patients admitted onto two geriatric wards in London and, on the other hand, to study the relationship between serum digoxin level and age, serum urea, serum potassium and serum calcium in geriatric patients with digoxin toxicity. Over a period of three years 1438 patients (age 75-93) were admitted of whom 452 (31%) were on digoxin. Thirty-five patients (7.7%) were diagnosed as having digoxin toxicity. Eight patients (22.9%) with digoxin toxicity died during admission. Mortality was higher although not statistically significant for the patients with toxicity than for the patients who were on digoxin without toxicity. The fatal outcome was not predicted by age, serum urea, serum potassium or serum calcium. The serum digoxin level of the eight patients who died was lower than the level of those (n = 23) who survived. Four patients (11%) had a normal serum digoxin level and clinical features of digoxin toxicity that disappeared on stopping digoxin. A hypothesis is put foreward to explain the weak association between serum digoxin level and digoxin toxicity in geriatric patients.

Complement activation and spleen function in erythema multiforme associated with herpes simplex virus reactivation.

Plasma C3d concentrations were measured in patients with erythema multiforme (EM) complicating herpes labialis. C3d levels were raised during cold sores but not during EM. Heat damaged red cell clearance was prolonged during EM. These observations support the concept that immune complexes disseminate herpes simplex virus (HSV) antigens to skin before the onset of EM.