Drone-Facilitated Real-Time Video-Guided Feedback Helps to Improve the Quality of Lay Bystander Basic Life Support. A Randomized Controlled Simulation Trial.

OBJECTIVES: Telephone instructions are commonly used to improve cardiopulmonary resuscitation (CPR) by lay bystanders. This usually implies an audio but no visual connection between the provider and the emergency medical telecommunicator. We aimed to investigate whether video-guided feedback via a camera drone enhances the quality of CPR. METHODS: We conducted a randomized controlled simulation trial. Lay rescuers performed 8 min of CPR on an objective feedback manikin. Participants were randomized to receive telephone instructions with (intervention group) or without (control group) a drone providing a visual connection with the telecommunicator after a 2-min run-in phase. Performed work (total compression depth minus total lean depth) was the primary outcome. Secondary outcomes were the proportion of effective chest compressions, average compression depth, subjective physical strain measured every 2 min, and dexterity in the nine-hole peg test after the scenario. Outcomes were compared using the t- and Mann Whitney-U tests. A two-sided p-value of <0.05 was considered significant. RESULTS: We included 27 individuals (14 (52%) female, mean age 41 ± 14 years). Performed work was greater in the intervention than in the control group (41.3 ± 7.0 vs. 33.9 ± 10.9 m; absolute difference 7.5, 95% CI 1.4 to 14.8; p = 0.046), with higher average compression depth (49 ± 7 vs. 40 ± 13 mm; p = 0.041), and higher proportions of adequate chest compressions (43 (IQR 14-60) vs. 3 (0-29) %; p = 0.041). We did not find any significant differences regarding the remaining secondary outcomes. CONCLUSION: Video-guided feedback via drones might be a helpful tool to enhance the quality of telephone-assisted CPR in lay bystanders.

Vertical locomotion improves horizontal locomotion: effects of climbing on gait and other mobility aspects in Parkinson's disease. A secondary analysis from a randomized controlled trial.

BACKGROUND: In the Climb Up! Head Up! trial, we showed that sport climbing reduces bradykinesia, tremor, and rigidity in mildly to moderately affected participants with Parkinson's disease. This secondary analysis aimed to evaluate the effects of sport climbing on gait and functional mobility in this cohort. METHODS: Climb Up! Head Up! was a 1:1 randomized controlled trial. Forty-eight PD participants (Hoehn and Yahr stage 2-3) either participated in a 12-week, 90-min-per-week sport climbing course (intervention group) or were engaged in regular unsupervised physical activity (control group). Relevant outcome measures for this analysis were extracted from six inertial measurement units placed on the extremities, chest, and lower back, that were worn during supervised gait and functional mobility assessments before and after the intervention. Assessments included normal and fast walking, dual-tasking walking, Timed Up and Go test, Instrumented Stand and Walk test, and Five Times Sit to Stand test. RESULTS: Compared to baseline, climbing improved gait speed during normal walking by 0.09 m/s (p = 0.005) and during fast walking by 0.1 m/s. Climbing also reduced the time spent in the stance phase during fast walking by 0.03 s. Climbing improved the walking speed in the 7-m- Timed Up and Go test by 0.1 m/s (p < 0.001) and the turning speed by 0.39 s (p = 0.052), the speed in the Instrumented Stand and Walk test by 0.1 m/s (p < 0.001), and the speed in the Five Times Sit to Stand test by 2.5 s (p = 0.014). There was no effect of sport climbing on gait speed or gait variables during dual-task walking. CONCLUSIONS: Sport climbing improves gait speed during normal and fast walking, as well as functional mobility in people with Parkinson's disease. Trial registration This study was registered within the U.S. National Library of Medicine (No: NCT04569981, date of registration September 30th, 2020).

Efficacy and Safety of Methoxyflurane for Treatment of Acute Traumatic Pain by EMTs during Alpine Rescue Operations: The "PainDrop" Trial.

Background: Treatment of acute traumatic pain is a core task for mountain rescue services. Intravenous access, however, is often difficult, and the vast majority of missions are carried out without a physician at the scene. The spectrum of analgesics available for use by non-physician personnel is limited. Inhaled analgesics, such as methoxyflurane, might prove useful, but currently no data exist on their application by non-physicians in the alpine setting.Methods: This prospective observational alpine field study was conducted over a period of 15 months. Patients suffering traumatic injuries with moderate to severe pain (pain score ≥ 5) after downhill bike accidents in the Tyrol mountains (1,362 m to 2,666 m above sea level) were enrolled. Teams of four mountain rescue service members, one of them a trained EMT, treated the patients with 3 ml of methoxyflurane by inhaler. We measured efficacy as reduction in pain from baseline to 15 minutes after treatment on a numerical rating scale. Safety was assessed by change in vital signs or occurrence of side-effects. Sample-size calculations were based on the efficacy outcome and yielded a need for 20 patients at a power of 0.8.Results: From June 29, 2020 to September 30, 2021, a total of 20 patients (two females; mean age 37 years) were included. The mean initial pain score was 7.2 (SD 1.0) points. After 15 minutes, pain was significantly reduced by a mean of 2.9 (SD 1.4) points. No major adverse events or relevant changes in vital signs were observed.Conclusion: The use of methoxyflurane by EMTs during alpine rescue operations in our study proved to be safe and efficient. We observed no reduction in the efficacy of the inhaler device at moderate altitude.

Climb up! Head up! Climbing improves posture in Parkinson's disease. A secondary analysis from a randomized controlled trial.

OBJECTIVE: To investigate the effect of sport climbing on a biomechanical marker of axial posture in patients with Parkinson's disease, as well as its association with age, body mass index and health-related quality-of-life outcome measures. DESIGN: Pre-planned secondary analysis of our randomized controlled, semi-blind trial (unblinded patients, blinded assessors) comparing sport climbing to unsupervised exercise. SETTING: Single-centre study conducted at the Department of Neurology of the Medical University of Vienna, Austria. PARTICIPANTS: Forty-eight Parkinson's disease patients (aged 64 ± 8 years, Hoehn & Yahr stage 2-3) were included. INTERVENTION: Sport climbers (n = 24) followed a 12-week, 90 min/week supervised top-rope sport climbing course in an indoor climbing gym. The unsupervised training group (n = 24) independently followed the 'European Physiotherapy Guidelines for Parkinson's Disease' and World Health Organization recommendations for an active lifestyle for 12 weeks. MAIN MEASURES: Posture was assessed with the horizontal distance of the seventh cervical vertebra to the wall at baseline and after the intervention. RESULTS: Participating in the sport climbing group significantly predicted the biomechanical marker of axial posture (P = 0.044). The improvement in the biomechanical marker did not affect the quality of life, depression, fatigue, physical activity or fear of falling. Participants in the sport climbing group showed a significantly decreased horizontal distance of the seventh cervical vertebra to the wall after the intervention (-1.7 cm (95%CI [-2.6, -0.8]). In the unsupervised training group, no difference was found (-0.5 cm; 95%CI -1.3, 0.2]). CONCLUSIONS: We conclude that sport climbing improves a biomechanical marker of axial posture in Parkinson's disease.

Neutrophils prevent rectal bleeding in ulcerative colitis by peptidyl-arginine deiminase-4-dependent immunothrombosis.

OBJECTIVE: Bleeding ulcers and erosions are hallmarks of active ulcerative colitis (UC). However, the mechanisms controlling bleeding and mucosal haemostasis remain elusive. DESIGN: We used high-resolution endoscopy and colon tissue samples of active UC (n = 36) as well as experimental models of physical and chemical mucosal damage in mice deficient for peptidyl-arginine deiminase-4 (PAD4), gnotobiotic mice and controls. We employed endoscopy, histochemistry, live-cell microscopy and flow cytometry to study eroded mucosal surfaces during mucosal haemostasis. RESULTS: Erosions and ulcerations in UC were covered by fresh blood, haematin or fibrin visible by endoscopy. Fibrin layers rather than fresh blood or haematin on erosions were inversely correlated with rectal bleeding in UC. Fibrin layers contained ample amounts of neutrophils coaggregated with neutrophil extracellular traps (NETs) with detectable activity of PAD. Transcriptome analyses showed significantly elevated PAD4 expression in active UC. In experimentally inflicted wounds, we found that neutrophils underwent NET formation in a PAD4-dependent manner hours after formation of primary blood clots, and remodelled clots to immunothrombi containing citrullinated histones, even in the absence of microbiota. PAD4-deficient mice experienced an exacerbated course of dextrane sodium sulfate-induced colitis with markedly increased rectal bleeding (96 % vs 10 %) as compared with controls. PAD4-deficient mice failed to remodel blood clots on mucosal wounds eliciting impaired healing. Thus, NET-associated immunothrombi are protective in acute colitis, while insufficient immunothrombosis is associated with rectal bleeding. CONCLUSION: Our findings uncover that neutrophils induce secondary immunothrombosis by PAD4-dependent mechanisms. Insufficient immunothrombosis may favour rectal bleeding in UC.

Prehospital triage optimization of patients with large vessel occlusion by Austrian Prehospital Stroke Scale.

OBJECTIVES: The Austrian Prehospital Stroke Scale (APSS) score was developed to predict large vessel occlusion (LVO) and improve prehospital transportation triage. Its accuracy has been previously analyzed retrospectively. We now aimed to investigate the accuracy, as well as the impact of the implementation of a triage strategy using this score on treatment times and outcome in a prospective study. MATHERIAL & METHODS: Prospective diagnostic test accuracy and before-after interventional study. EMS prospectively evaluated APSS in patients suspected of stroke. Accuracy was compared with other LVO scores. Patients with APSS ≥4 points were brought directly to the comprehensive stroke center. Treatment time frames, neurological, and radiological outcome before and after the APSS implementation were compared. RESULTS: A total of 307 patients with suspected stroke were included from October 2018 to February 2020. Treatable LVO was present in 79 (26%). Sensitivity of APSS to detect those was 90%, specificity 79%, positive predictive value 66%, negative predictive value 95%, and area under the curve 0.87 (95% CI 0.83-0.91). This was similar to in-hospital NIHSS (AUC 0.89 95% CI 0.89-0.92, p = .06) and superior to CPSS (AUC 0.83 95% CI 0.78-0.87, p = .01). Implementation of APSS triage increased direct transportation rate for LVO patients (21% before vs. 52% after; p < .001) with a significant time benefit (alert to groin puncture time benefit: 51 min (95% CI 28-74; p < .001). Neurological and radiological outcome did not differ significantly. CONCLUSIONS: Austrian Prehospital Stroke Scale triage showed an accuracy comparable with in-hospital NIHSS, and lead to a significant optimization of prehospital workflows in patients with potential LVO.

Design and Derivation of the Austrian Prehospital Stroke Scale (APSS) to Predict Severe Stroke with Large Vessel Occlusion.

Objectives: Prediction of large vessel occlusion (LVO) is highly relevant for accurate prehospital transportation triage. The Austrian Prehospital Stroke Scale (APSS) score for LVO prediction was developed using critical synthesis of previously published LVO-scores. The aim of this study was to investigate the accuracy of the APSS and compare it to other LVO-scores. Methods: APSS consists of 5 items: "facial palsy," "motor arm," "language," "motor leg" and "gaze deviation." The score ranges from 0 to 9 points. Data from 741 consecutive stroke patients with acute vessel imaging admitted to an independent comprehensive stroke center was used to test the predictive performance of the APSS in context of other LVO-scores (CPSS, FAST-ED, G-FAST, sNIHSS-EMS and RACE). Results: In the prediction of treatable LVO the APSS showed the highest area under the curve (0.834) with significant difference to CPSS (p = 0.010) and G-FAST (p = 0.006) and showed highest sensitivity (69%) as compared to other LVO scores. Specificity (85%), positive predictive value (75%), negative predictive value (81%) and accuracy (79%) were comparable to other LVO scores. Receiver operating curve analysis revealed an optimal cutoff for LVO prediction at APSS equal to 4 points. Conclusions: The easy assessable 5-item APSS score tended to outperform other LVO scores. Real-life prospective evaluation in prehospital setting is ongoing.

Short- and intermediate-term effects of a hospital-integrated walk-in clinic on emergency department-visits and case mix.

BACKGROUND AND IMPORTANCE: Emergency department (ED) admissions have been rising over the last decades, especially in countries without any effective gate-keeping functions. Integration of walk-in clinics into the hospital might reduce ED-visits. Over a longer period, however, the additional service of a walk-in clinic might attract even more patients, nullifying an initial decrease in patients for the ED. OBJECTIVES, DESIGN, SETTINGS AND PARTICIPANTS: This study aimed to determine short- and intermediate-term changes after the implementation of a hospital-integrated walk-in clinic. This is an observational study using routinely-collected health data. Study setting was the ED of a large tertiary care hospital in Austria, a country with universal health care and no regulations regarding level of care. OUTCOMES MEASURE AND ANALYSIS: ED-visits were compared between before (2015) and after (2017 and 2018) establishment of a hospital-integrated walk-in clinic. MAIN RESULTS: Total ED-visits decreased from 87,624 in 2015 to 67,479 in 2017, and 67,871 in 2018 (p < 0.001), mainly due to a decrease in non-urgent (ESI 4 & 5) cases (45,715 (54.1%) in 2015; 33,142 (51.3%) in 2017; 30,846 (47.5%) in 2018; short term OR non-urgent vs. urgent: 0.89 (95% CI 0.88-0.91); intermediate term OR urgent vs. non-urgent: 0.76 (95% CI 0.78-0.75)). A total of 2611 (13%) (2017) and 1714 (8.5%) (2018) patients were referred back to the ED. CONCLUSIONS: After the introduction of the walk-in clinic, ED-visits declined significantly. This remained stable over a two-year period. Reduction in ED-visits was mainly due to low-acuity patients not requiring admission to the hospital.

Extreme weather conditions as a gender-specific risk factor for acute myocardial infarction.

BACKGROUND: Acute coronary syndrome is a disease with high prevalence and high mortality. Exposure to heat or cold increases the risks of myocardial infarction significantly. Gender-specific effects of this have not yet been examined. Our goal was to determine whether extreme weather conditions, which become more and more frequent, are gender-specific risk factors for myocardial infarction, in order to help provide faster diagnosis and revascularization therapy for patients. METHODS: We analysed the incidence of ST-elevation myocardial infarction (STEMI) in a large urban area over a 65-months period in a cohort study. A day was the unit of analysis. Incidence rate ratios (IRR) with Poisson regression models were calculated. All patients with STEMI on Saturdays and Sundays were included. Gender, high or low perceived temperatures (PT), a function of temperature, wind speed and humidity, and meteorological cold and heat warnings by the Austrian Central Institute for Meteorology and Geodynamics (ZAMG) were considered as risk factors. RESULTS: During the 562 days of the study period, a total of 1109 patients with STEMI (803; 72% men, mean age 61;14 years) were included. The gender difference between men and women was much more pronounced on cold (0 °C) days (85% of patients male; 1.8 per day) than on hot (20 °C) days (71% male; 1.4 per day) or days without extreme temperatures (72% male; 1.4 per day). We found significant interaction between gender and cold days (IRR of the interaction term 2.3 (95% CI 1.2-4.6), p = 0.02). No gender-specific effect was observed on warm days (IRR for interaction 0.9 (95% CI 0.6-1.3), p = 0.3). CONCLUSION: Low perceived temperature pronouncedly increases the already elevated risk for STEMI in males. Whether this effect is based on gender alone, or on one of the cardiovascular risk factors which are more common in men, is up to further study.

Impact of more conservative European Society of Cardiology guidelines on the management of patients with acute chest pain.

OBJECTIVE: Early diagnosis or rule-out of acute coronary syndrome (ACS) is a key competence of emergency medicine. Changes in the NSTE-ACS guidelines of the European Society of Cardiology (ESC) in 2015 and 2020 both warranted a henceforth more conservative approach regarding high-sensitivity troponin t (hsTnt) testing. We aimed to assess the impact of more conservative guidelines on the frequency of early rule-out and prolonged observation with repeated hsTnt testing at a high-volume tertiary care emergency department. PATIENTS AND METHODS: We conducted a pre- and post-changeover analysis 3 months before and 3 months after transition from less (hsTnt cut-off 30 ng/L, 3-hour rule-out) to more conservative (hsTnt cut-off 14 ng/L, 1-hour rule-out) guidelines in 2015, comparing proportions of patients requiring repeated testing. RESULTS: We included 5442 cases of symptoms suspicious of acute cardiac origin (3451 before, 1991 after, 2370 (44%) female, age 55 (SD 19) years). The proportion of patients fulfilling early-rule out criteria decreased from 68% (2348 patients) before to 60% (1195 patients) with the 2015 guidelines (P < .01). Those requiring repeated testing significantly (P < .01) increased from 22% (743 patients) to 25% (494 patients). Positive results in repeated testing significantly (P = .02) decreased from 43% (320 patients) to 37% (181 patients). Invasive diagnostics were performed in 91 patients (2.6%) before and in 75 patients (3.8%) after (P = .02) the guideline revision. CONCLUSION: The implementation of the more conservative 2015 ESC guidelines led to a minor rise in prolonged observations because of an increase in negative repeated testing and to an increase in invasive procedures.

Generalisability of randomised trials evaluating perioperative ß-blocker therapy in noncardiac surgery.

BACKGROUND: The limited applicability of evidence from RCTs in real-word practice is considered a potential bottleneck for evidence-based practice but rarely systematically assessed. Using our failure to recruit patients into a perioperative beta-blocker trial, we set out to analyse the restrictiveness and generalisability of trial eligibility criteria in a real-world cohort. METHODS: We prospectively included adult patients (≥18 yr) scheduled for elective noncardiac surgery at an academic tertiary care facility who were screened for inclusion in a planned perioperative beta-blocker RCT, which was terminated owing to recruitment failure. The primary outcome was the proportion of screened patients who matched the eligibility criteria of 36 published RCTs included in a large Cochrane meta-analysis on perioperative beta-blocker therapy. The pragmatic/explanatory level of each RCT was assessed using the PRagmatic-Explanatory Continuum Indicator Summary 2 (PRECIS-2) score, which ranges from 9 points (indicating a very explanatory study) to 45 points (indicating a very pragmatic study). RESULTS: A total of 2241 patients (54% female, n=1215; 52 [standard deviation, 20] yr) were included for the assessment of trial eligibility between October 2015 and January 2016. Only a small proportion of patients matched the inclusion and exclusion criteria for each of the 36 RCTs, ranging from 53% to 0%. The average proportion of patients who did match the eligibility criteria of all 36 RCTs was 6.5% (n=145; 95% confidence interval, 6.3-6.6). A higher PRECIS-2 score was associated with a higher proportion of matching patients (P<0.001). CONCLUSIONS: Trial eligibility criteria in perioperative beta-blocker therapy trials are overly restrictive and not generalisable to a real-world surgical population. CLINICAL TRIAL REGISTRATION: EudraCT#: 2015-002366-23.

Laryngeal Tube Practice in a Metropolitan Ambulance Service: A Five-year Retrospective Observational Study (2009-2013).

Background: The endotracheal tube (ETT) is considered the gold standard in emergency airway management, although supraglottic airway devices, especially the laryngeal tube (LT), have recently gained in importance. Although regarded as an emergency device in case of failure of endotracheal intubation in most systems, we investigated the dynamics of the use of the LT in a metropolitan ambulance service without any regulations on the choice of airway device. Methods: A retrospective, observational study on all patients from the Municipal Ambulance Service, Vienna in need of advanced airway management over a 5-year period. Differences between years were compared; influencing factors for the use of the LT were analyzed using multivariable logistic regression. Results: In total 5,175 patients (mean age 62 ± 20 years, 36.6% female) underwent advanced airway management. Of these, 15.6% received the LT. LT use increased from 20 out of 1,001 (2.0%) in 2009 to 292 of 1,085 (26.9%) in 2013 (p < 0.001). The increase between each consecutive year was also significant. Paramedics more frequently inserted the LT than physicians (RR 1.80 (95%CI 1.48-2.16); p < 0.001). Female patients received a LT less frequently (RR 0.84 (95%CI 0.72-0.97), p = 0.013). There was no difference regarding airway device due to underlying causes requiring airway management and no relationship to the NACA-score. Conclusion: In a European EMS system of physician and paramedic response, the proportion of airway managed by LT over ETT rose considerably over five years. Although the ET is still the gold standard, the LT is gaining in importance for EMS physicians and paramedics.

Early identification of patients with chest pain at very low risk of acute myocardial infarction using clinical information and ECG only.

BACKGROUND: A considerable proportion of patients with angina-like symptoms in an emergency department have very low pretest probability for acute myocardial infarction (AMI). Numerous algorithms exist for the exclusion of AMI, usually including laboratory tests. We aimed to investigate whether patients with very low risk can safely be identified by ECG and clinical information without biomarker testing, contributing to saving time and costs. METHODS: Prospective diagnostic test accuracy study. We included all consecutive patients presenting with angina at the department of emergency medicine of a tertiary care hospital during a 1-year period. Using clinical information without biomarker testing and ECG, the "Mini-GRACE score," based on the well-established GRACE-score without using laboratory parameters was calculated. In a cohort design we compared the index test Mini-GRACE to AMI as reference standard in the final diagnosis using standard measures of diagnostic test accuracy. RESULTS: We included 2755 patients (44% female, age 44 ± 17 years). AMI was diagnosed in 103 (4%) patients, among those 44% with STEMI. Overall 2562 patients (93%) had a negative "Mini-GRACE," four (0.2%) of these patients had myocardial infarction, and this results in a sensitivity of 96.1% (95% CI 90.4%-98.9%), specificity 96.5% (95.7%-97.1%), positive predictive value 51.3% (46.3%-56.3%) and negative predictive value 99.8% (99.6%-99.9%). Model performance according to C statistic (0.90) and Brier score (0.0045) was excellent. In rule-out patients 30-day mortality was 0.3% and 1-year mortality was 0.8%. CONCLUSIONS: Patients with very low risk of AMI can be identified with high certainty using clinical information without biomarker testing and ECG. Cardiac biomarkers might be avoided in such cases, potentially leading to a significant cost reduction.

Risk stratification in acute coronary syndrome: Evaluation of the GRACE and CRUSADE scores in the setting of a tertiary care centre.

OBJECTIVE: Risk assessment plays a decisive role in the management of acute coronary syndrome (ACS). The GRACE and the CRUSADE scores are among the most frequently used risk assessment tools. We aimed to compare the performance of the GRACE and CRUSADE risk scores to predict in-hospital mortality and major bleeding in a contemporary ACS population at a high-volume academic hospital. METHODS: All patients treated for ACS from January 1, 2006 to December 31, 2015 at a tertiary care centre were prospectively enrolled. We calculated GRACE and CRUSADE risk scores. We compared the discrimination capacity of both scores for in-hospital mortality and major bleeding. RESULTS: In total 4087 patients (1151 [28.2%] female; age 62 ± 14 years) were included. Among these 2218 (54.3%) were diagnosed with ST-elevation myocardial infarction, 113 (2.8%) died in hospital and major bleeding occurred in 65 (1.6%). Discrimination capacity for in-hospital mortality of the GRACE score was superior to the CRUSADE score (receiver operator characteristic area under the curve (AUC) 0.91 (95% CI 0.89-0.93) vs 0.83 (95% CI 0.80-0.86); P < .01). Performance for major bleeding differed but was poor for both scores (AUC 0.71 [0.65-0.76] for GRACE vs 0.61 [0.55-0.68] for CRUSADE; P < .01). CONCLUSION: The GRACE score appears to be superior over CRUSADE to predict in-hospital mortality. Major bleeding is rare in the era of primary PCI and performance of both scores for this outcome was poor.

Airway physical examination tests for detection of difficult airway management in apparently normal adult patients.

BACKGROUND: The unanticipated difficult airway is a potentially life-threatening event during anaesthesia or acute conditions. An unsuccessfully managed upper airway is associated with serious morbidity and mortality. Several bedside screening tests are used in clinical practice to identify those at high risk of difficult airway. Their accuracy and benefit however, remains unclear. OBJECTIVES: The objective of this review was to characterize and compare the diagnostic accuracy of the Mallampati classification and other commonly used airway examination tests for assessing the physical status of the airway in adult patients with no apparent anatomical airway abnormalities. We performed this individually for each of the four descriptors of the difficult airway: difficult face mask ventilation, difficult laryngoscopy, difficult tracheal intubation, and failed intubation. SEARCH METHODS: We searched major electronic databases including CENTRAL, MEDLINE, Embase, ISI Web of Science, CINAHL, as well as regional, subject specific, and dissertation and theses databases from inception to 16 December 2016, without language restrictions. In addition, we searched the Science Citation Index and checked the references of all the relevant studies. We also handsearched selected journals, conference proceedings, and relevant guidelines. We updated this search in March 2018, but we have not yet incorporated these results. SELECTION CRITERIA: We considered full-text diagnostic test accuracy studies of any individual index test, or a combination of tests, against a reference standard. Participants were adults without obvious airway abnormalities, who were having laryngoscopy performed with a standard laryngoscope and the trachea intubated with a standard tracheal tube. Index tests included the Mallampati test, modified Mallampati test, Wilson risk score, thyromental distance, sternomental distance, mouth opening test, upper lip bite test, or any combination of these. The target condition was difficult airway, with one of the following reference standards: difficult face mask ventilation, difficult laryngoscopy, difficult tracheal intubation, and failed intubation. DATA COLLECTION AND ANALYSIS: We performed screening and selection of the studies, data extraction and assessment of methodological quality (using QUADAS-2) independently and in duplicate. We designed a Microsoft Access database for data collection and used Review Manager 5 and R for data analysis. For each index test and each reference standard, we assessed sensitivity and specificity. We produced forest plots and summary receiver operating characteristic (ROC) plots to summarize the data. Where possible, we performed meta-analyses to calculate pooled estimates and compare test accuracy indirectly using bivariate models. We investigated heterogeneity and performed sensitivity analyses. MAIN RESULTS: We included 133 (127 cohort type and 6 case-control) studies involving 844,206 participants. We evaluated a total of seven different prespecified index tests in the 133 studies, as well as 69 non-prespecified, and 32 combinations. For the prespecified index tests, we found six studies for the Mallampati test, 105 for the modified Mallampati test, six for the Wilson risk score, 52 for thyromental distance, 18 for sternomental distance, 34 for the mouth opening test, and 30 for the upper lip bite test. Difficult face mask ventilation was the reference standard in seven studies, difficult laryngoscopy in 92 studies, difficult tracheal intubation in 50 studies, and failed intubation in two studies. Across all studies, we judged the risk of bias to be variable for the different domains; we mostly observed low risk of bias for patient selection, flow and timing, and unclear risk of bias for reference standard and index test. Applicability concerns were generally low for all domains. For difficult laryngoscopy, the summary sensitivity ranged from 0.22 (95% confidence interval (CI) 0.13 to 0.33; mouth opening test) to 0.67 (95% CI 0.45 to 0.83; upper lip bite test) and the summary specificity ranged from 0.80 (95% CI 0.74 to 0.85; modified Mallampati test) to 0.95 (95% CI 0.88 to 0.98; Wilson risk score). The upper lip bite test for diagnosing difficult laryngoscopy provided the highest sensitivity compared to the other tests (P < 0.001). For difficult tracheal intubation, summary sensitivity ranged from 0.24 (95% CI 0.12 to 0.43; thyromental distance) to 0.51 (95% CI 0.40 to 0.61; modified Mallampati test) and the summary specificity ranged from 0.87 (95% CI 0.82 to 0.91; modified Mallampati test) to 0.93 (0.87 to 0.96; mouth opening test). The modified Mallampati test had the highest sensitivity for diagnosing difficult tracheal intubation compared to the other tests (P < 0.001). For difficult face mask ventilation, we could only estimate summary sensitivity (0.17, 95% CI 0.06 to 0.39) and specificity (0.90, 95% CI 0.81 to 0.95) for the modified Mallampati test. AUTHORS' CONCLUSIONS: Bedside airway examination tests, for assessing the physical status of the airway in adults with no apparent anatomical airway abnormalities, are designed as screening tests. Screening tests are expected to have high sensitivities. We found that all investigated index tests had relatively low sensitivities with high variability. In contrast, specificities were consistently and markedly higher than sensitivities across all tests. The standard bedside airway examination tests should be interpreted with caution, as they do not appear to be good screening tests. Among the tests we examined, the upper lip bite test showed the most favourable diagnostic test accuracy properties. Given the paucity of available data, future research is needed to develop tests with high sensitivities to make them useful, and to consider their use for screening difficult face mask ventilation and failed intubation. The 27 studies in 'Studies awaiting classification' may alter the conclusions of the review, once we have assessed them.

Acute carbon monoxide poisoning treatment by non-invasive CPAP-ventilation, and by reservoir face mask: Two simultaneous cases.

Carbon monoxide (CO) is a leading cause of morbidity and mortality. Treatment focuses on the rapid elimination of CO and management of hypoxia. Oxygen is the cornerstone of therapy, and usually applied via a reservoir face mask. Hyperbaric oxygen therapy eliminates CO faster, but requires extensive equipment and expertise. Non-invasive continuous positive airway pressure (CPAP) ventilation using a tight mask provides a higher inspired fraction of oxygen (FiO2) compared to a reservoir face mask, and increases gas exchange. As this modality is widely available, it might represent a supplemental approach to current treatment of CO poisoning. We present two simultaneous cases of a married couple of 31- and 34-year-old patients, who concurrently suffered CO intoxication due to a faulty gas heater in their apartment. Both reported similar symptoms of headache and weakness, and carboxyhemoglobin (COHb)-levels at admission were 21% in both patients. One patient was treated by non-invasive CPAP-ventilation support with a FiO2 of 100%, whereas the other was treated by conventional oxygen inhalation. In the patient treated by CPAP, COHb-levels fell quickly to 6% within one hour, and reached 3% after 90 min, whereas it took six hours to reach the same levels in the patient with conventional treatment. This vividly illustrates the potential of CPAP therapy as an alternative to conventional oxygen inhalation in the treatment of CO poisoning.

Harms of off-label erythropoiesis-stimulating agents for critically ill people.

BACKGROUND: Anaemia is a common problem experienced by critically-ill people. Treatment with erythropoiesis-stimulating agents (ESAs) has been used as a pharmacologic strategy when the blunted response of endogenous erythropoietin has been reported in critically-ill people. The use of ESAs becomes more important where adverse clinical outcomes of transfusing blood products is a limitation. However, this indication for ESAs is not licensed by regulatory authorities and is called off-label use. Recent studies concern the harm of ESAs in a critical care setting. OBJECTIVES: To focus on harms in assessing the effects of erythropoiesis-stimulating agents (ESAs), alone or in combination, compared with placebo, no treatment or a different active treatment regimen when administered off-label to critically-ill people. SEARCH METHODS: We conducted a systematic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO via OvidSP, CINAHL, all evidence-based medicine (EBM) reviews including IPA and SCI-Expanded, Conference Proceedings Citation Index- Science, BIOSIS Previews and TOXLINE up to February 2017. We also searched trials registries, checked reference lists of relevant studies and tracked their citations by using SciVerse Scopus. SELECTION CRITERIA: We considered randomized controlled trials (RCTs) and controlled observational studies, which compared scheduled systemic administration of ESAs versus other effective interventions, placebo or no treatment in critically-ill people. DATA COLLECTION AND ANALYSIS: Two review authors independently screened and evaluated the eligibility of retrieved records, extracted data and assessed the risks of bias and quality of the included studies. We resolved differences in opinion by consensus or by involving a third review author. We assessed the evidence using GRADE and created a 'Summary of findings' table. We used fixed-effect or random-effects models, depending on the heterogeneity between studies. We fitted three-level hierarchical Bayesian models to calculate overall treatment effect estimates. MAIN RESULTS: Of the 27,865 records identified, 39 clinical trials and 14 observational studies, including a total of 945,240 participants, were eligible for inclusion. Five studies are awaiting classification. Overall, we found 114 adverse events in 33 studies (30 RCTs and three observational studies), and mortality was reported in 41 studies (32 RCTs and nine observational studies). Most studies were at low to moderate risk of bias for harms outcomes. However, overall harm assessment and reporting were of moderate to low quality in the RCTs, and of low quality in the observational studies. We downgraded the GRADE quality of evidence for venous thromboembolism and mortality to very low and low, respectively, because of risk of bias, high inconsistency, imprecision and limitations of study design.It is unclear whether there is an increase in the risk of any adverse events (Bayesian risk ratio (RR) 1.05, 95% confidence interval (CI) 0.93 to 1.21; 3099 participants; 9 studies; low-quality evidence) or venous thromboembolism (Bayesian RR 1.04, 95% CI 0.70 to 1.41; 18,917 participants; 18 studies; very low-quality evidence).There was a decreased risk of mortality with off-label use of ESAs in critically-ill people (Bayesian RR 0.76, 95% CI 0.61 to 0.92; 930,470 participants; 34 studies; low-quality evidence). AUTHORS' CONCLUSIONS: Low quality of evidence suggests that off-label use of ESAs may reduce mortality in a critical care setting. There was a lack of high-quality evidence about the harm of ESAs in critically-ill people. The information for biosimilar ESAs is less conclusive. Most studies neither evaluated ESAs' harm as a primary outcome nor predefined adverse events. Any further studies of ESA should address the quality of evaluating, recording and reporting of adverse events.

Different Mortality Time Points in Critical Care Trials: Current Practice and Influence on Effect Estimates in Meta-Analyses.

OBJECTIVE: Mortality is frequently used as an outcome in critical care trials, being a patient-orientated variable and robust against information/selection bias. Mortality frequency, however, should be measured at a defined time point of follow-up. Practice of meta-analysis shows that follow-up times of trials in critical care medicine differ substantially. This may have substantial implications on potential pooling of effect estimates. We aimed to describe the current practice of mortality follow-up time definitions in a representative sample of published critical care randomized controlled trials and to analyze the influence of different follow-up times on subsequently pooled effect estimates. DATA SOURCES: Cochrane CENTRAL, EMBASE, MEDLINE, PASCAL Biomed, and PsycINFO. STUDY SELECTION: Databases were searched for critical care randomized controlled trials published after 2000. A random sample of 50% was drawn for further review. DATA EXTRACTION: Study characteristics were extracted, as well as the number and time points of mortality ascertainment. Additional data were extracted from Kaplan-Meier plots, as available. DATA SYNTHESIS: Meta-regression and multilevel mixed-effects linear regression were used to analyze the influence of follow-up time (independent variable) on deviation of pooled risk ratios from study baseline (dependent variable). From 9,246 retrieved references, we included 106 studies representing 63,713 participants. Among these, 45 studies (43%) reported more than one time point, with 24 different time points at all, only three (28, 30, and 90 d) being reported in more than 10% of studies. Limiting meta-analyses to only one predefined time point would reduce the number of eligible studies by at least 60%. No influence of time points on meta-analytic summary effect estimates was found. CONCLUSIONS: In a large sample of critical care randomized controlled trials, numerous different mortality time points are reported. Mortality time points did not influence pooled point estimates of the effects. Consequently, it seems possible to pool effect estimates, which in turn will increase the precision of these effect estimates.