Does real-time objective feedback and competition improve performance and quality in manikin CPR training--a prospective observational study from several European EMS.

BACKGROUND: Previous studies have reported that the quality of cardiopulmonary resuscitation (CPR) is important for patient survival. Real time objective feedback during manikin training has been shown to improve CPR performance. Objective measurement could facilitate competition and help motivate participants to improve their CPR performance. The aims of this study were to investigate whether real time objective feedback on manikins helps improve CPR performance and whether competition between separate European Emergency Medical Services (EMS) and between participants at each EMS helps motivation to train. METHODS: Ten European EMS took part in the study and was carried out in two stages. At Stage 1, each EMS provided 20 pre-hospital professionals. A questionnaire was completed and standardised assessment scenarios were performed for adult and infant out of hospital cardiac arrest (OHCA). CPR performance was objectively measured and recorded but no feedback given. Between Stage 1 and 2, each EMS was given access to manikins for 6 months and instructed on how to use with objective real-time CPR feedback available. Stage 2 was undertaken and was a repeat of Stage 1 with a questionnaire with additional questions relating to usefulness of feedback and the competition nature of the study (using a 10 point Likert score). The EMS that improved the most from Stage 1 to Stage 2 was declared the winner. An independent samples Student t-test was used to analyse the objective CPR metrics with the significance level taken as p < 0.05. RESULTS: Overall mean Improvement of CPR performance from Stage 1 to Stage 2 was significant. The improvement was greater for the infant assessment. The participants thought the real-time feedback very useful (mean score of 8.5) and very easy to use (mean score of 8.2). Competition between EMS organisations recorded a mean score of 5.8 and competition between participants recorded a mean score of 6.0. CONCLUSIONS: The results suggest that the use of real time objective feedback can significantly help improve CPR performance. Competition, especially between participants, appeared to encourage staff to practice and this study suggests that competition might have a useful role to help motivate staff to perform CPR training.

Psycho-organic symptoms as early manifestation of adult onset POMT1-related limb girdle muscular dystrophy.

We report two siblings of Croatian consanguineous healthy parents with a novel homozygous missense mutation in the POMT1 gene, presenting with intellectual disability and psychotic, in particular hallucinatory symptoms and abnormal brain MRIs, preceding classical symptoms of limb-girdle muscular dystrophy by several years. Weakness became apparent in early adulthood and both siblings remained ambulant into the 3rd and 4th decade of life. The muscle biopsy showed reduced α-dystroglycan compatible with the POMT1 defect. This case report extends the phenotypic spectrum of POMT1 associated muscular dystrophies to the adult onset limb girdle muscular dystrophies with psycho-organic deficits.

Daily omeprazole surpasses intermittent dosing in preventing relapse of oesophagitis: a US multi-centre double-blind study.

INTRODUCTION: Relapse of erosive oesophagitis occurs in almost all patients if treatment is stopped after initial healing. AIM: To assess the potential of different therapeutic regimens of omeprazole to prevent relapse of erosive reflux oesophagitis after initial healing with omeprazole. PATIENTS AND METHODS: Patients whose active erosive reflux oesophagitis (grade > or = 2) had healed (grade 0 or 1) after 4-8 weeks of open-label omeprazole 40 mg daily (phase I) were eligible to join a multi-centre, 6-month double-blind, placebo-controlled maintenance study (phase II), which included endoscopy, symptom assessments, serum gastrin measurements, and gastric fundic biopsies. During phase I, endoscopy was performed at weeks 0, 4, and 8. At the end of phase I, 429 of 472 patients (91%) were healed, and there were significant reductions in heartburn, dysphagia and acid regurgitation. Of the 429 patients who healed, 406 joined phase II and were randomized to one of three groups: 20 mg omeprazole daily (n = 138), 20 mg omeprazole for 3 consecutive days each week (n = 137), or placebo (n = 131). During phase II, endoscopy was performed at months 1, 3, and 6 or at symptomatic relapse. RESULTS: The percentages of patients still in endoscopic remission at 6 months were 11% for placebo, 34% for omeprazole 3-days-a-week, and 70% for omeprazole daily. Both omeprazole regimens were superior to placebo in preventing recurrence of symptoms (P < 0.001); however, omeprazole 20 mg daily was superior to omeprazole 20 mg 3-days-a-week (P < 0.001). Compared to baseline, omeprazole therapy resulted in no significant differences among treatment groups in the distribution of gastric endocrine cells. CONCLUSIONS: These results show that after healing of erosive oesophagitis with 4-8 weeks of omeprazole, relapse of oesophagitis and recurrence of reflux symptoms can be prevented in 70% of patients with a maintenance regimen of 20 mg daily, but that intermittent dosing comprising 3 consecutive days each week significantly compromises efficacy.

[Sudden deafness and increased toxoplasmosis IgM titer]. / Hörsturz und erhöhter IgM-Titer für Toxoplasmose.

BACKGROUND: Prenatal damage of the inner ear due to infection with toxoplasma gondii is documented. Nevertheless, there are only a few references about postnatal acquired toxoplasmosis as a cause of inner ear damage. PATIENTS: We report about a nine-year-old boy who suffered from unilateral hearing loss and tinnitus. RESULTS: Examinations did not show any other sign of a possible cause of hearing loss except for a very high toxoplasmosis titer of 1:102400. Besides our usual therapy regime for acute hearing loss, we treated the patient with pyrimethamine and sulphadiazine. Antibody titer decreased but the sensorineural hearing loss did not change substantially. Fortunately the patient lost the tinnitus. CONCLUSIONS: Acute Toxoplasmosis should be considered in the diagnostic process of sudden hearing loss, at least if there are appropriate clues in the medical history.

Evaluation of a subsidy program to increase bicycle helmet use by children of low-income families.

OBJECTIVE: We have previously shown that an educational program was not effective in increasing bicycle helmet use in children of low-income families. The objective of this study was to evaluate a combined educational and helmet subsidy program in the same population, while controlling for secular trends. The secondary objective was to complete a third year of surveying children's bicycle helmet use throughout the study community. DESIGN: A prospective, controlled, before-and-after study. SUBJECTS: Bicycling children 5 to 14 years of age from areas of low average family income. SETTING: A defined geographic community within a large urban Canadian city. INTERVENTION: In April 1992, students in three schools located in the area of lowest average family income were offered $10 helmets and an educational program; three other low-income areas served as control areas. MAIN OUTCOME MEASURE: Helmet use was determined by direct observation of more than 1800 bicycling children. RESULTS: Nine hundred ten helmets were sold to a school population of 1415 (64%). Reported helmet ownership increased from 10% to 47%. However, observed helmet use in the low-income intervention area was no different from the rate in the three low-income control areas (18% versus 19%). There was no difference in the trend in helmet use during the period of 1990 through 1992 in the intervention area (4% to 18%) compared with the control areas (3% to 19%). Helmet use rates from all income areas have increased from 3.4% in 1990, to 16% in 1991, to 28% in 1992. In 1992, helmet use in the high-income areas was 48% and in the low-income areas was 20%. CONCLUSIONS: There has been a trend toward increasing helmet use in all income areas during the 3-year period. Despite encouraging helmet sales and increases in reported helmet ownership, the results of the observational study do not support the efficacy of a helmet subsidy program in increasing helmet use in children residing in areas of low average family income. Strategies to increase helmet use in children of low average family income remain a priority.

Evaluation of a promotional strategy to increase bicycle helmet use by children.

Bicycle-related head injuries are an important cause of death and disability, despite the availability of helmets. The objective of this study was to evaluate the effectiveness of a school-based bicycle helmet promotion program in increasing helmet use by children while controlling for secular trends. Two high-income and two low-income schools in an urban Canadian community were selected to receive a bicycle helmet promotion intervention, with the remaining 18 schools serving as controls. Approximately 1800 observations of bicycling children were made at randomly selected observational sites 2 to 5 months after the intervention to assess changes in behavior. Helmet use at all observation sites tripled from 3.4% (1990, preintervention) to 16% (1991, postintervention). In the high-income intervention area, observed helmet use rose dramatically from 4% to 36% in contrast to the more modest increase in the high-income control area from 4% to 15%. In the low-income intervention area, there was a modest increase from 1% to 7%, but it did not differ from the increase in the low-income control area from 3% to 13%. The program was highly successful in children of high-income families but not in children of low-income families. Developing strategies for low-income families remains a priority.

A prospective crossover trial of direct current electrotherapy in symptomatic hemorrhoidal disease.

Many new modalities have been developed to treat symptomatic hemorrhoidal disease. In order to determine whether direct current electrotherapy therapy is effective, a prospective, crossover study was done. Sixteen patients referred for treatment of symptomatic hemorrhoids underwent a 16-week treatment protocol. Patients were randomized to receive either medical therapy with a sham therapy, or medical therapy with active direct current electrotherapy at 4-week intervals. All patients were instructed in medical therapy including sitz baths, hydrocortisone suppositories, topical preparations, and a high fiber diet with an educational booklet. Patients who did not respond to initial therapy were crossed over at 8 weeks, receiving alternate therapy twice. Improvement in symptoms, or lack thereof, was not statistically different between the two treatment groups. Comparisons of the internal sphincter pressure, external sphincter pressure, maximum squeeze pressure, and rectal sensitivity to balloon insufflation (volume) were not statistically different before, during, or after any treatment modality (p = 0.46, 0.60, 0.33). The size and grade of hemorrhoids on entry into the study had no bearing on the outcome. In a prospective crossover trial, no difference could be found between standard medical therapy and direct current electrotherapy in the treatment of symptomatic-hemorrhoidal disease.

Prospective randomized comparison of esophageal variceal sclerotherapy agents: sodium tetradecyl sulfate versus sodium morrhuate.

We designed a prospective randomized study to evaluate differences in efficacy and complication rate between the two most commonly used sclerosing agents, sodium tetradecyl sulfate (STD) and sodium morrhuate (MOR). Of 41 patients with acute index variceal bleeding initially evaluated, 21 were randomized to receive 0.75% STD and 20 to receive 1.6% MOR diluted with 50% dextrose. Overall mortality for the STD group was 38% and that for the MOR group was 25% (NS). Control of acute bleeding was achieved in 86% of the STD patients and 90% of the MOR patients (NS). Overall, obliteration was achieved in only 33% of the STD group and 25% of the MOR group; but in those patients who remained in the study over 3 months, obliteration was achieved in 87 and 83%, respectively (NS). There was a trend toward higher rebleeding in the STD group compared with the MOR group (81% vs. 51%) (p = 0.078), but there was no significant difference between the STD and MOR patients with regard to transfusion requirements (8.4 units/patient vs. 8.7 units/patient), ulceration (53% vs. 40%), or stricture formation (9.5% vs. 0.0%). The results of this study suggest that STD and MOR are clinically equivalent sclerosing solutions, and that bias favoring use of one agent over the other may be unfounded.

Necrotizing fasciitis associated with porphyria cutanea tarda.

A case is presented of a 31-year-old white woman with necrotizing fasciitis. She had had a previous diagnosis of porphyria cutanea tarda that was manifested in part by bullous lesions on her forearms and hands. A soft tissue infection developed in her left hand and forearm in an area of bullous disease. After a delay of 8 days the diagnosis of necrotizing fasciitis was made. She recovered following surgical debridement, extensive fasciotomy, broad-spectrum antibiotic coverage, and hyperbaric oxygen therapy.