Remote Ischemic Conditioning for Acute Stroke: The RESIST Randomized Clinical Trial.

Importance: Despite some promising preclinical and clinical data, it remains uncertain whether remote ischemic conditioning (RIC) with transient cycles of limb ischemia and reperfusion is an effective treatment for acute stroke. Objective: To evaluate the effect of RIC when initiated in the prehospital setting and continued in the hospital on functional outcome in patients with acute stroke. Design, Setting, and Participants: This was a randomized clinical trial conducted at 4 stroke centers in Denmark that included 1500 patients with prehospital stroke symptoms for less than 4 hours (enrolled March 16, 2018, to November 11, 2022; final follow-up, February 3, 2023). Intervention: The intervention was delivered using an inflatable cuff on 1 upper extremity (RIC cuff pressure, ≤200 mm Hg [n = 749] and sham cuff pressure, 20 mm Hg [n = 751]). Each treatment application consisted of 5 cycles of 5 minutes of cuff inflation followed by 5 minutes of cuff deflation. Treatment was started in the ambulance and repeated at least once in the hospital and then twice daily for 7 days among a subset of participants. Main Outcomes and Measures: The primary end point was improvement in functional outcome measured as a shift across the modified Rankin Scale (mRS) score (range, 0 [no symptoms] to 6 [death]) at 90 days in the target population with a final diagnosis of ischemic or hemorrhagic stroke. Results: Among 1500 patients who were randomized (median age, 71 years; 591 women [41%]), 1433 (96%) completed the trial. Of these, 149 patients (10%) were diagnosed with transient ischemic attack and 382 (27%) with a stroke mimic. In the remaining 902 patients with a target diagnosis of stroke (737 [82%] with ischemic stroke and 165 [18%] with intracerebral hemorrhage), 436 underwent RIC and 466 sham treatment. The median mRS score at 90 days was 2 (IQR, 1-3) in the RIC group and 1 (IQR, 1-3) in the sham group. RIC treatment was not significantly associated with improved functional outcome at 90 days (odds ratio [OR], 0.95; 95% CI, 0.75 to 1.20, P = .67; absolute difference in median mRS score, -1; -1.7 to -0.25). In all randomized patients, there were no significant differences in the number of serious adverse events: 169 patients (23.7%) in the RIC group with 1 or more serious adverse events vs 175 patients (24.3%) in the sham group (OR, 0.97; 95% CI, 0.85 to 1.11; P = .68). Upper extremity pain during treatment and/or skin petechia occurred in 54 (7.2%) in the RIC group and 11 (1.5%) in the sham group. Conclusions and Relevance: RIC initiated in the prehospital setting and continued in the hospital did not significantly improve functional outcome at 90 days in patients with acute stroke. Trial Registration: ClinicalTrials.gov Identifier: NCT03481777.

PrehospitaL Ultrasound in Undifferentiated DyspnEa (PreLUDE): a prospective, clinical, observational study.

BACKGROUND: Diagnostic uncertainty in patients with dyspnea is associated with worse outcomes. We hypothesized that prehospital point-of-care ultrasound (POCUS) can improve diagnostic accuracy. METHODS: Prospective observational study of adult patients suffering dyspnea. Prehospital critical care physicians registered a suspected diagnosis based on clinical examination alone, performed POCUS of the heart and lungs, and finally registered suspected diagnoses based on their clinical examination supplemented with POCUS. Pre- and post-POCUS diagnoses were compared to endpoint committee adjudicated diagnoses. The primary outcome was improved sensitivity for diagnosing acute heart failure. Secondary outcomes included other diagnostic accuracy measures in relation to acute heart failure and other causes of dyspnea. RESULTS: In total, 214 patients were included. The diagnosis of acute heart failure was suspected in 64/214 (30%) of patients before POCUS and 64/214 (30%) patients after POCUS, but POCUS led to reclassification in 53/214 (25%) patients. The endpoint committee adjudicated the diagnosis of acute heart failure in 87/214 (41%) patients. The sensitivity for the diagnosis of acute heart failure was 58% (95% CI 46%-69%) before POCUS compared to 65% (95% CI 53%-75%) after POCUS (p = 0.12). ROC AUC for the diagnosis acute heart failure was 0.72 (95% CI 0.66-0.78) before POCUS compared to 0.79 (0.73-0.84) after POCUS (p < 0.001). ROC AUC for the diagnosis acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) or asthma was 0.87 (0.82-0.91) before POCUS and 0.93 (0.88-0.97) after POCUS (p < 0.001). A POCUS finding of any of severely reduced left ventricular function, bilateral B-lines or bilateral pleural effusion demonstrated the highest sensitivity for acute heart failure at 88% (95% CI 79%-94%), whereas the combination of all of these three findings yielded the highest specificity at 99% (95% CI 95%-100%). CONCLUSION: Supplementary prehospital POCUS leads to an improvement of diagnostic accuracy of both heart failure and AE-COPD/-asthma overall described by ROC AUC, but the increase in sensitivity for the diagnoses of acute heart failure did not reach statistical significance. Tailored use of POCUS findings optimizes diagnostic accuracy for rule-out and rule-in of acute heart failure. TRIAL REGISTRATION: Registered in Clinical Trials, 05.04.2019 (identifier: NCT03905460) https://clinicaltrials.gov/ct2/show/study/NCT03905460?term=NCT03905460&cond=Dyspnea&cntry=DK&draw=2&rank=1 .

The National Danish Cardiac Arrest Registry for Out-of-Hospital Cardiac Arrest - A Registry in Transformation.

Aim of the Database: The aim of the Danish Cardiac Arrest Registry is to monitor the quality of prehospital cardiac arrest treatment, evaluate initiatives regarding prehospital treatment of cardiac arrest, and facilitate research. Study Population: All patients with prehospital cardiac arrest in Denmark treated by the emergency medical services in whom resuscitation or defibrillation has been attempted. Main Variables: The Danish Cardiac Arrest Register records descriptive and qualitative variables as outlined in the "Utstein" template for reporting out-of-hospital-cardiac arrest. Main variables include whether the case was witnessed, whether the cardiac arrest was electrocardiographically monitored, the timing of cardiopulmonary resuscitation, and the timing of the first analysis of the cardiac rhythm. The outcome measures are the status of the patient at handover to the hospital, return of spontaneous circulation, and 30-day survival after event. Database Status: The Danish Cardiac Arrest Registry was established in June 2001, and all Danish emergency medical services are reporting to the database. Conclusion: The Danish Cardiac Arrest Registry is among the oldest Danish national clinical registries, with a high quality of clinical data and coverage. This registry provides the prerequisite for all research on out-of-hospital cardiac arrest research in Denmark and is essential for monitoring and improving the quality of care for patients suffering from out-of-hospital cardiac arrest.

[Life-threatening Pneumocystis pneumonia in a previously healthy pregnant woman].

Pneumocystis pneumonia (PCP) is one of the most common infections in patients with HIV. Pneumocystis jirovecii rarely gives rise to symptoms in immunocompetent individuals. PCP has been reported in individuals with immunosuppression. We report a case of life-threatening PCP in an otherwise healthy pregnant woman. Pregnant patients should be considered to be relatively immunosuppressed, and more opportunistic infections should be included in differential diagnosis considerations.

[Propofol-induced pancreatitis after surgery for thyroid carcinoma].

Propofol is a hypnotic agent for induction and maintainance of general anaesthesia and it is used for sedation of critically ill intensive care patients. As a rare adverse effect propofol can cause acute pancreatitis. We report a case of post-operative pancreatitis in an otherwise healthy 62-year-old male who was anaesthezised with propofol during an otherwise uncomplicated surgery for thyroid carcinoma. Other common causes could be excluded. Since this is a possible lethal complication in post-operative patients, medical doctors should be aware of this adverse effect.

[Necrotising fasciitis in a patient infected by Streptococcus pneumoniae]. / Nekrotiserende fasciitis hos en patient med pneumokokbakteriæmi.

A 71 year-old male with interscapular pain was admitted on suspicion of an acute aortic dissection. The diagnosis was not supported by echocardiography or computed tomography (CT). Physical examination showed an erythematous area of the skin with crepitation between the scapulae, and the CT showed subcutaneous emphysema of the entire back region. Necrotising fasciitis was diagnosed and despite aggressive supportive therapy the patient died within hours. Blood cultures were positive for Streptococcus pneumoniae and this case adds to the list of reports of necrotising fasciitis related to pneumococci.

[Use of skills among ambulance crews assessed by ambulance on-line record-keeping system]. / Kompetenceanvendelse hos ambulancebehandlere vurderet med ny elektronisk ambulancejournal.

INTRODUCTION: To fulfil the increasing requirements for documentation and quality assurance, amPHI, an ambulance on-line record-keeping system has been developed. We present the data from the pilot study to access how often ambulance crews use their skills. MATERIALS AND METHODS: As a pilot study amPHI was installed and tested in an emergency ambulance for 21 months. Data was entered using a computer with touch-enabled screen. Communication between the ambulance and the hospital was established through a special secured network based on the GSM mobile telephone network. RESULTS: The ambulance was dispatched for 830 high-priority services and amPHI was used in 674 cases (81%) during the pilot study. A total of 26 out of 31 skills were used less than ten times a year per EMT (Emergency Medical Technician). Three of these skills--mask-ventilation, CPR (Cardio Pulmonary Resuscitation) and suction are technically difficult and require routine. CONCLUSION: The initial treatment is of prime importance for the outcome of the patient. It is therefore necessary to ensure that the ambulance crew is able to maintain their skills. In this connection amPHI can be very useful. Important and sometimes life-saving skills such as mask-ventilation, CPR and suction were used to a very limited extent. It is of great importance for the EMT to keep up these skills in another way. The ambulance crews are satisfied with the amPHI system and find it easy to use.