The barriers to interprofessional care for cancer cachexia among Japanese healthcare providers: A nationwide survey.

BACKGROUND: Cancer cachexia is a severe complication of advanced malignancy, with few therapeutic options. To promote interprofessional care for cancer cachexia, healthcare providers' needs should be addressed in detail. This pre-planned subgroup analysis of the Global Educational Needs Evaluation: a systemic interprofessional study in cancer cachexia (GENESIS-CC) survey aimed to identify barriers to interprofessional care of cancer cachexia in Japan. METHODS: A nationwide survey was electronically conducted for healthcare providers in oncological or general healthcare facilities from January to March 2021 in Japan. The Japanese Regional Advisory Board developed a barrier scoring system with 33 from the 58 original survey items to quantify six domains of barriers: (1) lack of confidence, (2) lack of knowledge, (3) barriers in personal practice, (4) barriers in perception, (5) barriers in team practice and (6) barriers in education. The largest possible barrier score was set at 100 points. We compared the scores by profession. RESULTS: A total of 1227 valid responses were obtained from 302 (24.6%) physicians, 252 (20.5%) pharmacists, 236 (19.2%) nurses, 218 (17.8%) dietitians, 193 (15.7%) rehabilitation therapists and 26 (2.0%) other professionals. Overall, 460 (37.5%) were not very or at all confident about cancer cachexia care, 791 (84.1%) agreed or strongly agreed that care was influenced by reimbursement availability and 774 (81.9%) did not have cancer cachexia as a mandatory curriculum. The largest mean barrier score (± standard deviation) was 63.7 ± 31.3 for education, followed by 55.6 ± 21.8 for team practice, 43.7 ± 32.5 for knowledge, 42.8 ± 17.7 for perception and 36.5 ± 16.7 for personal practice. There were statistically significant interprofessional differences in all domains (P < 0.05), especially for pharmacists and nurses with the highest or second highest scores in most domains. CONCLUSIONS: There is a need to improve the educational system and team practices of cancer cachexia for most Japanese healthcare providers, especially pharmacists and nurses. Our study suggests the need to reform the mandatory educational curriculum and reimbursement system on cancer cachexia to promote interprofessional care for cancer cachexia in Japan.

A Bayesian Analysis of a Cognitive-Behavioral Therapy Intervention for High-Risk People on Probation.

This analysis employs a Bayesian framework to estimate the impact of a Cognitive-Behavioral Therapy (CBT) intervention on the recidivism of high-risk people under community supervision. The study relies on the reanalysis of experimental datal using a Bayesian logistic regression model. In doing so, new estimates of programmatic impact were produced using weakly informative Cauchy priors and the Hamiltonian Monte Carlo method. The Bayesian analysis indicated that CBT reduced the prevalence of new charges for total, non-violent, property, and drug crimes. However, the effectiveness of the CBT program varied meaningfully depending on the participant's age. The probability of the successful reduction of drug offenses was high only for younger individuals (<26 years old), while there was an impact on property offenses only for older individuals (>26 years old). In general, the probability of the successful reduction of new charges was higher for the older group of people on probation. Generally, this study demonstrates that Bayesian analysis can complement the more commonplace Null Hypothesis Significance Test (NHST) analysis in experimental research by providing practically useful probability information. Additionally, the specific findings of the reestimation support the principles of risk-needs responsivity and risk-stratified community supervision and align with related findings, though important differences emerge. In this case, the Bayesian estimations suggest that the effect of the intervention may vary for different types of crime depending on the age of the participants. This is informative for the development of evidence-based correctional policy and effective community supervision programming.

Transforming medical education in Liberia through an international community of inquiry.

A critical component of building capacity in Liberia's physician workforce involves strengthening the country's only medical school, A.M. Dogliotti School of Medicine. Beginning in 2015, senior health sector stakeholders in Liberia invited faculty and staff from U.S. academic institutions and non-governmental organizations to partner with them on improving undergraduate medical education in Liberia. Over the subsequent six years, the members of this partnership came together through an iterative, mutual-learning process and created what William Torbert et al describe as a "community of inquiry," in which practitioners and researchers pair action and inquiry toward evidence-informed practice and organizational transformation. Incorporating faculty, practitioners, and students from Liberia and the U.S., the community of inquiry consistently focused on following the vision, goals, and priorities of leadership in Liberia, irrespective of funding source or institutional affiliation. The work of the community of inquiry has incorporated multiple mixed methods assessments, stakeholder discussions, strategic planning, and collaborative self-reflection, resulting in transformation of medical education in Liberia. We suggest that the community of inquiry approach reported here can serve as a model for others seeking to form sustainable global health partnerships focused on organizational transformation.

Identification and management of cancer cachexia in patients: Assessment of healthcare providers' knowledge and practice gaps.

BACKGROUND: Cancer cachexia negatively impacts patient outcomes, quality of life and survival. Identification and management of cancer cachexia remains challenging to healthcare professionals (HCPs). The aim of this assessment was to identify current gaps in HCPs' knowledge and practice for identifying and managing adults with cancer-related cachexia. Results may guide development of new educational programmes to close identified gaps and improve outcomes of cancer patients. METHODS: An international assessment was conducted using a mixed-methods approach including focus group interviews with subject matter experts and an electronic survey of practising HCP. The assessment was led by the Society on Sarcopenia, Cachexia and Wasting Disorders (SCWD) and was supported by in-country collaborating organizations. RESULTS: A quantitative survey of 58 multiple-choice questions was completed by physicians, nurses dietitians and other oncology HCP (N = 2375). Of all respondents, 23.7% lacked confidence in their ability to provide care for patients with cancer cachexia. Patients with gastrointestinal, head and neck, pulmonary cancers and leukaemia/lymphoma were reported as those at highest risk for cachexia. Only 29.1% of respondents recognized a key criterion of cancer cachexia as >5% weight loss from baseline, but many (14.4%) did not utilize a standardized definition of cancer cachexia. Despite this, most clinicians (>84%) were able to identify causes of weight loss-reduced oral intake, progressive disease, side effects of therapy and disease-related inflammation. Of all respondents, 52.7% indicated newly diagnosed patients with cancer should be screened for weight loss. In practice, 61.9% reported that patient weight was systematically tracked over time, but only 1125 (47.4%) reported they weigh their cancer patients at each visit. Treatment of cachexia focused on increasing the patient's nutritional intake by oral nutritional supplements (64.2%), energy and protein fortified foods (60.3%) and counselling by a dietitian (57.1%). Whereas many respondents (37.3%) considered cachexia inevitable, most (79.2%) believed that an interprofessional team approach could improve care and that use of standardized tools is critical. CONCLUSIONS: Findings from this international assessment highlight the challenges associated with the care of patients with cancer cachexia, opportunities for interventions to improve patient outcomes and areas of variance in care that would benefit from further analysis.

Current State and Future Opportunities for Continuing Medical Education in Japan.

Globally, CPD systems vary widely. In Japan, the Japanese Medical Association (JMA) is responsible for identifying content and developing education for its speciality practice physicians. The JMA was concerned about persistent low levels of participation in its CME activities and wanted to better understand the root causes. The analysis would provide an opportunity to restructure its programme informed by the needs of its practising clinicians. The JMA engaged a global education provider to conduct an independent analysis of its CME programme. Using a mixed-methods approach, the education provider conducted an on-line survey (N = 338) and held two in-person focus groups (N = 24) to better understand the perspectives of physicians in speciality practice. The on-line survey was sent to over 7,000 practising physicians throughout Japan. Respondents reflected a variety of medical and surgical specialities and length in clinical practice. They described factors that influenced or were barriers to participation in JMA-sponsored education. Respondents also suggested changes to the current model of CME in Japan and expressed an ongoing commitment to life-long learning and achieving the goals set forth in Japan's vision for health care in 2035: Leading the World Through Health. Globally, medical associations are challenged with developing education that meets the needs of a diverse physician workforce. Improved understanding of the perspectives of its physician members and implementation of collaborations with speciality societies may be one strategy to improve quality and address healthcare population needs. Lessons learned from this analysis may help other medical associations with similar challenges.

Ventricular Fibrillation Waveform Analysis During Chest Compressions to Predict Survival From Cardiac Arrest.

BACKGROUND: Quantitative measures of the ventricular fibrillation (VF) ECG waveform can assess myocardial physiology and predict cardiac arrest outcomes, making these measures a candidate to help guide resuscitation. Chest compressions are typically paused for waveform measure calculation because compressions cause ECG artifact. However, such pauses contradict resuscitation guideline recommendations to minimize cardiopulmonary resuscitation interruptions. We evaluated a comprehensive group of VF measures with and without ongoing compressions to determine their performance under both conditions for predicting functionally-intact survival, the study's primary outcome. METHODS: Five-second VF ECG segments were collected with and without chest compressions before 2755 defibrillation shocks from 1151 out-of-hospital cardiac arrest patients. Twenty-four individual measures and 3 combination measures were implemented. Measures were optimized to predict functionally-intact survival (Cerebral Performance Category score ≤2) using 460 training cases, and their performance evaluated using 691 independent test cases. RESULTS: Measures predicted functionally-intact survival on test data with an area under the receiver operating characteristic curve ranging from 0.56 to 0.75 (median, 0.73) without chest compressions and from 0.53 to 0.75 (median, 0.69) with compressions ( P<0.001 for difference). Of all measures evaluated, the support vector machine model ranked highest both without chest compressions (area under the receiver operating characteristic curve, 0.75; 95% CI, 0.73-0.78) and with compressions (area under the receiver operating characteristic curve, 0.75; 95% CI, 0.72-0.78; P=0.75 for difference). CONCLUSIONS: VF waveform measures predict functionally-intact survival when calculated during chest compressions, but prognostic performance is generally reduced compared with compression-free analysis. However, support vector machine models exhibited similar performance with and without compressions while also achieving the highest area under the receiver operating characteristic curve. Such machine learning models may, therefore, offer means to guide resuscitation during uninterrupted cardiopulmonary resuscitation.

A conceptual framework for planning and assessing learning in continuing education activities designed for clinicians in one profession and/or clinical teams.

PURPOSE: The purpose of this article is to provide a more actionable description of the components of the outcomes framework published in 2009. METHODS: Synthesis of recent research in the learning sciences. RESULTS: The authors propose a conceptual framework to be used planning learning activities and assessing learning in CPD. CONCLUSIONS: CPD practitioners will have a more explicit approach to help clinicians provide the very best care to their patients.

An interactive faculty development workshop designed to improve knowledge, skills (competence), attitudes, and practice in interprofessional continuing education.

PURPOSE: Interprofessional continuing education (IPCE) health care educators must plan activities as members of interprofessional teams and deliver activities to an interprofessional audience. Evidence in the literature suggests they are not well prepared to meet this challenge. This paper reviews one strategy to improve the knowledge, skills, attitudes, and practices of IPCE educators. METHODS: Seven faculty development workshops were conducted within the USA, Europe, Asia, and the Middle East. Approximately 250 learners participated in the workshops in total, with 107 in an IRB-approved research study. RESULTS: From the research cohorts demonstrated improved knowledge and skills over a 12-month period. Knowledge and skills scores increased most significantly from baseline to 3 months and remained above baseline at 6-12 months. The workshop was not an effective strategy to improve attitudes towards IPCE, though attitude scores were already high prior to participating. CONCLUSIONS: All participants actively engaged in the workshops. There were no observed differences in engagement by geographic region, gender, age, or profession. Participants stated they were better able to understand the roles of other team members; perspectives of patients, families, and caregivers; and their own roles on clinical teams. Participants described gaining a new appreciation for the complexity of designing IPCE.

Rhythm profiles and survival after out-of-hospital ventricular fibrillation cardiac arrest.

OBJECTIVE: Treatment: protocols for cardiac arrest rely upon rhythm analyses performed at two-minute intervals, neglecting possible rhythm changes during the intervening period of CPR. Our objective was to describe rhythm profiles (patterns of rhythm transitions during two-minute CPR cycles) following attempted defibrillation and to assess their relationship to survival. METHODS: The study included out-of-hospital cardiac arrest cases presenting with ventricular fibrillation from 2011 to 2015. The rhythm sequence was annotated during two-minute CPR cycles after the first and second shocks of each case, and the rhythm profile of each sequence was classified. We calculated absolute survival differences among rhythm profiles with the same rhythm at the two-minute check. RESULTS: Of 569 rhythm sequences after the first shock, 46% included a rhythm transition. Overall survival was 47%, and survival proportion varied by rhythm at the two-minute check: ventricular fibrillation (46%), organized (58%) and asystole (20%). Survival was similar between profiles which ended with an organized rhythm at the two-minute check. Likewise, survival was similar between profiles with asystole at the two-minute check. However, in patients with ventricular fibrillation at the two-minute check, survival was twice as high in those with a transient organized rhythm (69%) compared to constant ventricular fibrillation (32%) or transient asystole (28%). CONCLUSION: Rhythm transitions are common after attempted defibrillation. Among patients with ventricular fibrillation at the subsequent two-minute check, transient organized rhythm during the preceding two-minute CPR cycle was associated with favorable survival, suggesting distinct physiologies that could serve as the basis for different treatment strategies.

Ventricular fibrillation waveform measures combined with prior shock outcome predict defibrillation success during cardiopulmonary resuscitation.

AIM: Amplitude Spectrum Area (AMSA) and Median Slope (MS) are ventricular fibrillation (VF) waveform measures that predict defibrillation shock success. Cardiopulmonary resuscitation (CPR) obscures electrocardiograms and must be paused for analysis. Studies suggest waveform measures better predict subsequent shock success when combined with prior shock success. We determined whether this relationship applies during CPR. METHODS: AMSA and MS were calculated from 5-second pre-shock segments with and without CPR, and compared to logistic models combining each measure with prior return of organized rhythm (ROR). RESULTS: VF segments from 692 patients were analyzed during CPR before 1372 shocks and without CPR before 1283 shocks. Combining waveform measures with prior ROR increased areas under receiver operating characteristic curves for AMSA/MS with CPR (0.66/0.68 to 0.73/0.74, p<0.001) and without CPR (0.71/0.72 to 0.76/0.76, p<0.001). CONCLUSIONS: Prior ROR improves prediction of shock success during CPR, and may enable waveform measure calculation without chest compression pauses.

Short ECG segments predict defibrillation outcome using quantitative waveform measures.

AIM: Quantitative waveform measures of the ventricular fibrillation (VF) electrocardiogram (ECG) predict defibrillation outcome. Calculation requires an ECG epoch without chest compression artifact. However, pauses in CPR can adversely affect survival. Thus the potential use of waveform measures is limited by the need to pause CPR. We sought to characterize the relationship between the length of the CPR-free epoch and the ability to predict outcome. METHODS: We conducted a retrospective investigation using the CPR-free ECG prior to first shock among out-of-hospital VF cardiac arrest patients in a large metropolitan region (n=442). Amplitude Spectrum Area (AMSA) and Median Slope (MS) were calculated using ECG epochs ranging from 5s to 0.2s. The relative ability of the measures to predict return of organized rhythm (ROR) and neurologically-intact survival was evaluated at different epoch lengths by calculating the area under the receiver operating characteristic curve (AUC) using the 5-s epoch as the referent group. RESULTS: Compared to the 5-s epoch, AMSA performance declined significantly only after reducing epoch length to 0.2s for ROR (AUC 0.77-0.74, p=0.03) and with epochs of ≤0.6s for neurologically-intact survival (AUC 0.72-0.70, p=0.04). MS performance declined significantly with epochs of ≤0.8s for ROR (AUC 0.78-0.77, p=0.04) and with epochs ≤1.6s for neurologically-intact survival (AUC 0.72-0.71, p=0.04). CONCLUSION: Waveform measures predict defibrillation outcome using very brief ECG epochs, a quality that may enable their use in current resuscitation algorithms designed to limit CPR interruption.

An accurate method for real-time chest compression detection from the impedance signal.

OBJECTIVE: Real-time feedback improves CPR performance. Chest compression data may be obtained from an accelerometer/force sensor, but the impedance signal would serve as a less costly, universally available alternative. The objective is to assess the performance of a method which detects the presence/absence of chest compressions and derives CPR quality metrics from the impedance signal in real-time at 1s intervals without any latency period. METHODS: Defibrillator recordings from cardiac arrest cases were divided into derivation (N=119) and validation (N=105) datasets. With the force signal as reference, the presence/absence of chest compressions in the impedance signal was manually annotated (reference standard). The method classified the impedance signal at 1s intervals as Chest Compressions Present, Chest Compressions Absent or Indeterminate. Accuracy, sensitivity and specificity for chest compression detection were calculated for each case. Differences between method and reference standard chest compression fractions and rates were calculated on a minute-to-minute basis. RESULTS: In the validation set, median accuracy was 0.99 (IQR 0.98, 0.99) with 2% of 1s intervals classified as Indeterminate. Median sensitivity and specificity were 0.99 (IQR 0.98, 1.0) and 0.98 (IQR 0.95, 1.0), respectively. Median chest compression fraction error was 0.00 (IQR -0.01, 0.00), and median chest compression rate error was 1.8 (IQR 0.6, 3.3) compressions per minute. CONCLUSION: A real-time method detected chest compressions from the impedance signal with high sensitivity and specificity and accurately estimated chest compression fraction and rate. Future investigation should evaluate whether an impedance-based guidance system can provide an acceptable alternative to an accelerometer-based system.

Adaptive rhythm sequencing: A method for dynamic rhythm classification during CPR.

OBJECTIVE: The accuracy of methods that classify the cardiac rhythm despite CPR artifact could potentially be improved by utilizing continuous ECG data. Our objective is to compare three approaches which use identical ECG features and differ only in their degree of temporal integration: (1) static classification, which analyzes 4-s ECG frames in isolation; (2) "best-of-three averaging," which takes the average of three consecutive static classifications successively; and (3) "adaptive rhythm sequencing," which uses hidden Markov models to model ECG segments as rhythm sequences. METHODS: Defibrillator recordings from 95 out-of-hospital cardiac arrests were divided into training and test sets. Each method classified the rhythm as asystole, organized rhythm or shockable rhythm throughout the recordings. Classifications were compared to the gold standard of physician review. The primary outcome was accuracy during CPR, which was estimated using a generalized linear mixed-effects model. RESULTS: In the training set, accuracies during CPR were 0.89 (95% CI 0.85, 0.92), 0.92 (95% CI 0.89, 0.94) and 0.97 (95% CI 0.95, 0.98) for the static, best-of-three averaging and adaptive rhythm sequencing methods, respectively. The corresponding results in the test set were 0.92 (95% CI 0.86, 0.96), 0.94 (95% CI 0.89, 0.97), and 0.97 (95% CI 0.94, 0.99). Of the dynamic methods, only adaptive rhythm sequencing was significantly more accurate than static classification in the training (p < 0.001) and test (p = 0.03) sets. CONCLUSION: In a continuous monitoring setting, adaptive rhythm sequencing was significantly more accurate than static rhythm classification during CPR.

Moving from data collection to application: a systematic literature review of surgical capacity assessments and their applications.

BACKGROUND: Over the past decade, assessments of surgical capacity in low- and middle-income countries (LMICs) have contributed to our understanding of barriers to the delivery of surgical services in a number of countries. It is yet unclear, however, how the findings of these assessments have been applied and built upon within the published literature. METHODS: A systematic literature review of surgical capacity assessments in LMICs was performed to evaluate current levels of understanding of global surgical capacity and to identify areas for future study. A reverse snowballing method was then used to follow-up citations of the identified studies to assess how this research has been applied and built upon in the literature. RESULTS: Twenty-one papers reporting the findings of surgical capacity assessments conducted in 17 different LMICs in South Asia, East Asia and Pacific, Latin America and the Caribbean, and sub-Saharan Africa were identified. These studies documented substantial deficits in human resources, infrastructure, equipment, and supplies. Only seven additional papers were identified which applied or built upon the studies. Among these, capacity assessment findings were most commonly used to develop novel tools and intervention strategies, but they were also used as baseline measurements against which updated capacity assessments were compared. CONCLUSIONS: While the global surgery community has made tremendous progress in establishing baseline values of surgical capacity in LMICs around the world, further work is necessary to build upon and apply the foundational knowledge established through these efforts. Capacity assessment data should be coordinated and used in ongoing research efforts to monitor and evaluate progress in global surgery and to develop targeted intervention strategies. Intervention strategy development may also be further incorporated into the evaluation process itself.

Outcomes by rescue shock number during the metabolic phase of porcine ventricular fibrillation resuscitation.

BACKGROUND: Optimal resuscitation duration before the first rescue shock (RS) to maximize the probability of success after prolonged ventricular fibrillation (VF) cardiac arrest remains unknown. The purpose of this study was to determine the occurrence of return of spontaneous circulation (ROSC) and survival by RS attempt after 12 minutes of untreated VF. METHODS: This was a secondary analysis of prospectively collected data from an institutional animal care and use committee-approved protocol. Fifty-three swine (30-35 kg) were instrumented under anesthesia. Ventricular fibrillation was electrically induced. After 12 minutes of untreated VF, cardiopulmonary resuscitation (CPR) was initiated (and continued as necessary (prn)) and a standard dose of epinephrine (0.01 mg/kg) was given (and repeated every 3 (q3) minutes prn). The first RS was delivered after 3 minutes of CPR (and q3 minutes thereafter prn). Each failed RS was followed (in series) by vasopressin (0.57 mg/kg), amiodarone (4.3 mg/kg), and sodium bicarbonate (1 mEq/kg) prn. Resuscitation continued until ROSC or 20-minute elapsed time. The primary outcomes were ROSC and 20-minute survival. Data were analyzed using descriptive statistics. RESULTS: After 3 minutes of resuscitation, 1 animal (1.9% [95% confidence interval {CI, 0.3-10.0]) achieved ROSC on RS1 and survived. After 6 minutes of resuscitation, 17 animals (32.1% [95% CI, 21.1-45.5]) achieved ROSC on RS2 and 15 (28.3% [95% CI, 18.0-41.6]) survived. Twelve additional animals had ROSC and survival with continued resuscitation. In 23 animals, ROSC was never achieved and efforts were terminated per protocol. CONCLUSION: Our data suggest that during the metabolic phase of VF, 3 minutes of CPR and 1 standard dose of epinephrine may be insufficient to achieve ROSC on the first RS attempt. A longer duration of CPR and/or additional vasopressors may increase the likelihood of successful defibrillation.

Towards the automated analysis and database development of defibrillator data from cardiac arrest.

BACKGROUND: During resuscitation of cardiac arrest victims a variety of information in electronic format is recorded as part of the documentation of the patient care contact and in order to be provided for case review for quality improvement. Such review requires considerable effort and resources. There is also the problem of interobserver effects. OBJECTIVE: We show that it is possible to efficiently analyze resuscitation episodes automatically using a minimal set of the available information. METHODS AND RESULTS: A minimal set of variables is defined which describe therapeutic events (compression sequences and defibrillations) and corresponding patient response events (annotated rhythm transitions). From this a state sequence representation of the resuscitation episode is constructed and an algorithm is developed for reasoning with this representation and extract review variables automatically. As a case study, the method is applied to the data abstraction process used in the King County EMS. The automatically generated variables are compared to the original ones with accuracies ≥ 90% for 18 variables and ≥ 85% for the remaining four variables. CONCLUSIONS: It is possible to use the information present in the CPR process data recorded by the AED along with rhythm and chest compression annotations to automate the episode review.

Course of quantitative ventricular fibrillation waveform measure and outcome following out-of-hospital cardiac arrest.

BACKGROUND: Quantitative measures of the ventricular fibrillation waveform at the outset of resuscitation are associated with survival. However, little is known about the course of these measures during resuscitation and how this course is related to outcome. OBJECTIVE: The purpose of this study was to determine how waveform measures change over the course of resuscitation and whether these changes might be used to guide resuscitation. METHODS: We evaluated 390 persons treated by emergency providers following out-of-hospital ventricular fibrillation arrest. We assessed the ventricular fibrillation waveform using the amplitude spectrum area (AMSA) from the defibrillator's continuous electrocardiogram measured before each of the first three shocks. We used logistic regression to evaluate the relationship of AMSA and the change in AMSA with favorable neurologic survival as determined by the Cerebral Performance Category at hospital discharge 1-2. RESULTS: Of the 390 patients who received an initial shock, 273 required a second shock and 210 required a third shock. The mean (standard deviation) for AMSA was 9.64 (0.52) for the 873 total shock cycles. AMSA1 measured before the first shock was strongly associated with favorable neurologic survival (odds ratio [OR] 3.40, 95% confidence interval [CI] [2.48, 4.66] for 1 SD change). We observed a similar relationship for second-shock AMSA2 (OR 3.53, 95% CI [2.42, 5.14]) and third-shock AMSA3 (OR 3.10, 95% CI [2.03, 4.73]). The median change in AMSA was 0.24 for ΔAMSA1₋2 and 0.21 for ΔAMSA2₋3. A positive median change in AMSA between shocks was associated with favorable neurologic survival (OR 1.44, 95% CI [1.16, 1.80] for ΔAMSA1₋2 and OR 1.31, 95% CI [1.01, 1.71] for ΔAMSA2₋3). CONCLUSION: Given their prognostic and dynamic qualities, quantitative waveform measures may provide an effective real-time strategy to guide individual treatment and improve survival.

Developing an interprofessional continuing education symposium for health care educators in Qatar.

An international interprofessional continuing education symposium was developed and implemented by a global faculty team in Qatar in March 2014. This symposium was undertaken as part of the country's goal of improving the quality of health care. After an extensive planning process, health care educators engaged in multiple types of learning experiences to enrich their knowledge and skills. Evaluation data support the value of this experience.

Beta-blockade causes a reduction in the frequency spectrum of VF but improves resuscitation outcome: A potential limitation of quantitative waveform measures.

INTRODUCTION: Methods to identify appropriate treatments for the various stages of ventricular fibrillation (VF) involve differentiating groups of subjects who will respond to defibrillation with return of spontaneous circulation (ROSC) and those who require other therapies (e.g., CPR, drugs) prior to defibrillation. The use of quantitative waveform measures (QWM) which measure the frequency and fractal dimension of the VF electrocardiogram have shown success in predicting response to defibrillatory shock in animal models. Patients in cardiac arrest are often taking medications affecting adrenergic activity such as the beta blocker metoprolol and the combined alpha and beta blocker, labetalol. How this exposure might alter the QWM and ROSC rates is not known. HYOTHESIS: We sought to determine how pretreatment with adrenergic agents alters two QWM measures, the amplitude spectrum area (AMSA) and the detrended fluctuation analysis (DFA). We also examined how these medications alter the probability of ROSC after shock. METHODS: A swine model of ischemically induced VF cardiac arrest was used in which metoprolol and labetalol were administered prior to VF onset. 30 swine were randomly assigned to three groups of 10; control, metoprolol and labetalol. They were anesthetized, intubated and given the appropriate study drug. A balloon catheter was placed in the LAD coronary artery and inflated until VF occurred. ECG was recorded at 1000Hz for 7min of untreated VF. Closed chest compressions were then begun and after 1min a 200J shock was delivered. Resuscitation was continued with repeat defibrillation shocks as indicated for 15min or until ROSC was achieved (defined: systolic BP>60 for 10min). The Fourier frequency spectra, AMSA and DFA measures from VF onset to 7min were calculated using custom MATLAB routines. The QWM were compared over the electrical and circulatory phases of VF using generalized estimating equations. The rates of ROSC in the three groups were compared using relative risk measures. RESULTS: All 10 control animals fibrillated after coronary occlusion, 8 metoprolol and 7 labetalol animals fibrillated. The frequency spectrum in metoprolol treated animals demonstrated a reduction in mean frequencies from 1 to 3min (electrical phase) and from 3 to 7min (circulatory phase). Labetalol produced an even greater reduction in frequencies in these intervals. The decline in AMSA was similar in all three groups over the first 3min. From 3 to 7min the metoprolol group was significantly lower than the control group (p<0.001) and the labetalol group was lower still (p<0.001). The DFA demonstrated little difference between the control and metoprolol groups, but showed a linear increase over 7min in the labetalol group (p<0.001 vs compared to control and metoprolol groups). ROSC was noted in 2/10 in the control group, 7/8 in metoprolol group and 2/7 in the labetalol group. The frequentist analysis of ROSC showed a relative risk (RR) of ROSC of 4.4 when comparing control to metoprolol animals and 1.4 comparing control to labetalol animals. DISCUSSION: Metoprolol results in a reduction in frequencies in the Fourier spectrum of VF as compared with controls. There is a further decrease in frequencies with labetalol. The AMSA reflects this reduction in frequencies with lower AMSA values from 3 to 7min of VF. The DFA demonstrates consistent changes with labetalol treated animals over the 7min, but the metoprolol treated animals do not differ from the controls. The marked improvement in ROSC seen with metoprolol (RR 4.4) is unexpected and is not seen in labetalol treated animals. Adrenergic blockade prior to VF induction affects quantitative measures of the VF waveform and may limit the ability of such measures to predict downtime or defibrillation outcome.