Comparison of C-MAC ® conventional blade, D-Blade ™ , and Macintosh laryngoscopes for endotracheal intubation in patients with simulated immobilization using manual in-line stabilization: A randomized trial.

BACKGROUND: A difficult airway is anticipated with cervical spine injuries (CSIs) as immobilization techniques such as manual in-line stabilization (MILS) are used, which distort the oro-pharyngeal-laryngeal axis. Video laryngoscopes (VLs) make difficult airway management easy, as they do not require axis alignment. The present study aimed to compare the total time taken by Macintosh laryngoscope (ML), conventional blade, and D-blade ™ of C-MAC ® VL in simulated CSI scenarios using MILS. METHODS: Ninety patients were randomly allocated into three groups: Group M (ML), Group C (conventional blade of C-MAC ® ), and Group D (D-blade ™ of C-MAC ® ) with MILS applied before intubation. Primary outcome was the total time taken for successful intubation, while secondary outcomes were to assess Cormack-Lehane (CL) grade, number of attempts, hemodynamic response, and associated complications. RESULTS: Total time for intubation in Group C was 23.40 ± 7.06 sec compared to 35.27 ± 6.53 and 47.27 ± 2.53 sec in groups D and M, respectively ( P < 0.001). CL-grade I was observed in 15/30 (50%) in Group M, 25/30 (83.3%) in Group C, and 29/30 (96.7%) in Group D. Group M reported 7/30 (23.3%) failed intubations, while none were observed in other groups. Hemodynamic parameters were significantly higher at 3 and 5 min in Group M. Postoperative sore throat was recorded in 12/30 (40%) in Group M compared to 3/30 (10%) in groups C and D each ( P value 0.037). CONCLUSION: C-MAC ® VL requires less time for intubation, provides better glottic view, and has higher success, with better attenuation of hemodynamic response and fewer complications compared to ML.

Individual patient data analysis of tidal volumes used in three large randomized control trials involving patients with acute respiratory distress syndrome.

BACKGROUND.: The acute respiratory distress syndrome (ARDS) is a condition with a high mortality and morbidity. Mechanical ventilation prevents immediate mortality but may further damage patients' lungs. Low tidal volume lung-protective strategies have been shown to increase survival by reducing this iatrogenic damage. Current guidelines recommend tidal volumes of 6-8 ml kg -1 of predicted body weight. We used data from three large randomized controlled trials of treatments for ARDS to determine compliance with these recommendations. METHODS.: We used the tidal volume recorded at randomization for all patients in the OSCAR, HARP-2, and BALTI-2 studies. In addition, we used the ventilation data for control arm patients in OSCAR and all patients in HARP-2 at days 1 and 7 after randomization. RESULTS.: The three trials enrolled 1660 patients, with tidal volume data available at least at one time point in 1412 patients. Compliance with the 6-8 ml kg -1 recommendation for tidal volume ranged from 20 to 39% of patients across all time points in all three trials. CONCLUSION.: Poor compliance with the guidelines for tidal volume in patients with ARDS has been demonstrated before in case series, but not in clinical trials where the patient population is specifically selected against standard ARDS diagnostic criteria and the investigators were encouraged to use low tidal volumes. This study may indicate a need to improve implementation and compliance with protective lung ventilation.

Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN).

BACKGROUND: Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury. METHODS: A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes. DISCUSSION: The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia. TRIAL REGISTRATION: ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474.

Sugar or salt ("SOS"): A protocol for a UK multicentre randomised trial of mannitol and hypertonic saline in severe traumatic brain injury and intracranial hypertension.

Hyperosmolar solutions are widely used to treat raised intracranial pressure following severe traumatic brain injury. Although mannitol has historically been the most frequently administered, hypertonic saline solutions are increasingly being used. However, definitive evidence regarding their comparative effectiveness is lacking. The Sugar or Salt Trial is a UK randomised, allocation concealed open label multicentre pragmatic trial designed to determine the clinical and cost-effectiveness of hypertonic saline compared with mannitol in the management of patients with severe traumatic brain injury. Patients requiring intensive care unit admission and intracranial pressure monitoring post-traumatic brain injury will be allocated at random to receive equi-osmolar boluses of either mannitol or hypertonic saline following failure of routine first-line measures to control intracranial pressure. The primary outcome for the study will be the Extended Glasgow Outcome Scale assessed at six months after randomisation. Results will inform current clinical practice in the routine use of hyperosmolar therapy as well as assess the impact of potential side effects. Pre-planned longer term clinical and cost effectiveness analyses will further inform the use of these treatments.

Group treatments for sensitive health care problems: a randomised controlled trial of group versus individual physiotherapy sessions for female urinary incontinence.

BACKGROUND: The aim was to compare effectiveness of group versus individual sessions of physiotherapy in terms of symptoms, quality of life, and costs, and to investigate the effect of patient preference on uptake and outcome of treatment. METHODS: A pragmatic, multi-centre randomised controlled trial in five British National Health Service physiotherapy departments. 174 women with stress and/or urge incontinence were randomised to receive treatment from a physiotherapist delivered in a group or individual setting over three weekly sessions. Outcome were measured as Symptom Severity Index; Incontinence-related Quality of Life questionnaire; National Health Service costs, and out of pocket expenses. RESULTS: The majority of women expressed no preference (55%) or preference for individual treatment (36%). Treatment attendance was good, with similar attendance with both service delivery models. Overall, there were no statistically significant differences in symptom severity or quality of life outcomes between the models. Over 85% of women reported a subjective benefit of treatment, with a slightly higher rating in the individual compared with the group setting. When all health care costs were considered, average cost per patient was lower for group sessions (Mean cost difference 52.91 pounds 95%, confidence interval ( 25.82 pounds- 80.00 pounds)). CONCLUSION: Indications are that whilst some women may have an initial preference for individual treatment, there are no substantial differences in the symptom, quality of life outcomes or non-attendance. Because of the significant difference in mean cost, group treatment is recommended. TRIAL REGISTRATION NUMBER: ISRCTN 16772662.

Successful implantation and immediate activation of Vagus Nerve Stimulation (VNS) during pregnancy in a patient with intractable epilepsy: A case illustration and review of the literature.

While Vagus Nerve Stimulation (VNS) is proven to be a safe and effective adjunctive therapy in the general population with medically intractable seizures, little is published about its implantation during pregnancy. Here we illustrate the case of a 21year old primigravid woman with medically refractory seizures who underwent safe and successful VNS implantation and immediate activation of the device in her 32nd week of pregnancy, resulting in dramatically improved seizure control and subsequent delivery of a healthy baby.

Post-admission outcomes of participants in the PARAMEDIC trial: A cluster randomised trial of mechanical or manual chest compressions.

BACKGROUND: The PARAMEDIC cluster randomised trial evaluated the LUCAS mechanical chest compression device, and did not find evidence that use of mechanical chest compression led to an improvement in survival at 30 days. This paper reports patient outcomes from admission to hospital to 12 months after randomisation. METHODS: Information about hospital length of stay and intensive care management was obtained through linkage with Hospital Episode Statistics and the Intensive Care National Audit and Research Centre. Patients surviving to hospital discharge were approached to complete questionnaires (SF-12v2, EQ-5D, MMSE, HADS and PTSD-CL) at 90days and 12 months. The study is registered with Current Controlled Trials, number ISRCTN08233942. RESULTS: 377 patients in the LUCAS arm and 658 patients in the manual chest compression were admitted to hospital. Hospital and intensive care length of stay were similar. Long term follow-up assessments were limited by poor response rates (53.7% at 3 months and 55.6% at 12 months). Follow-up rates were lower in those with worse neurological function. Among respondents, long term health related quality of life outcomes and emotional well-being was similar between groups. Cognitive function, measured by MMSE, was marginally lower in the LUCAS arm mean 26.9 (SD 3.7) compared to control mean 28.0 (SD 2.3), adjusted mean difference -1.5 (95% CI -2.6 to -0.4). CONCLUSION: There were no clinically important differences identified in outcomes at long term follow-up between those allocated to the mechanical chest compression compared to those receiving manual chest compression.

Characteristics of patients who are not resuscitated in out of hospital cardiac arrests and opportunities to improve community response to cardiac arrest.

AIM: This study explores why resuscitation is withheld when emergency medical staff arrive at the scene of a cardiac arrest and identifies modifiable factors associated with this decision. METHODS: This is a secondary analysis of unselected patients who sustained an out of hospital cardiac arrest attended by ambulance vehicles participating in a randomized controlled trial of a mechanical chest compression device (PARAMEDIC trial). Patients were categorized as 'non-resuscitation' patients if there was a do-not-attempt-cardiopulmonary-resuscitation (DNACPR) order, signs unequivocally associated with death or resuscitation was deemed futile (15min had elapsed since collapse with no bystander-CPR and asystole recorded on EMS arrival). RESULTS: Emergency Medical Services attended 11,451 cardiac arrests. Resuscitation was attempted or continued by Emergency Medical Service staff in 4805 (42%) of cases. Resuscitation was withheld in 6646 cases (58%). 711 (6.2%) had a do not attempt resuscitation decision, 4439 (38.8%) had signs unequivocally associated with death and in 1496 cases (13.1%) CPR was considered futile. Those where resuscitation was withheld due to futility were characterised by low bystander CPR rates (7.2%) and by being female. CONCLUSIONS: Resuscitation was withheld by ambulance staff in over one in ten (13.1%) victims of out of hospital cardiac arrest on the basis of futility. These cases were associated with a very low rate of bystander CPR. Future studies should explore strengthening the 'Chain of Survival' to increase the community bystander CPR response and evaluate the effect on the numbers of survivors from out of hospital cardiac arrest.

Hematuria-loin pain syndrome: its existence as a discrete clinicopathological entity cannot be supported.

OBJECTIVE: To (a) review existing literature and current concepts on Hematuria-Loin Pain Syndrome (HLPS) and (b) to describe seven cases of this syndrome. PATIENTS AND SETTING: Seven HLPS patients seen over a period of 8 years by the pain and nephrology services of the Toronto Hospital, Toronto, Ontario, Canada. METHODS AND RESULTS: Retrospective analysis was performed. All patients were remarkable for the variability of clinical presentation, pain characteristics, and dissociation of pain and hematuria occurrence. Routine renal investigations revealed different benign kidney pathologies in 5 of 7 patients. All patients, however, displayed variable combinations of personality factors, drug seeking behaviour, psychopathology, and presence of significant psychosocial stressors. Four cases were managed conservatively with antidepressants, anxiolytics, and supportive counseling and did very well despite persistent hematuria in two. CONCLUSIONS: HLPS does not constitute a distinct clinicopathological entity. In a minority of cases only underlying kidney pathology is related to pain, and in many cases psychosocial stressors and underlying psychopathology may play a significant role in the reported disabling pain. A concerted medical/psychological approach is advocated.

Randomised controlled double blind study of role of recombinant erythropoietin in the prevention of chronic lung disease.

AIM: To evaluate the role of recombinant human erythropoietin (R-HuEpo) in reducing iron infusion, which may exacerbate free radical damage, leading to chronic lung disease. METHODS: A multicentre, randomised, placebo controlled, double blind study was carried out in four neonatal intensive care units in Yorkshire. Infants were randomly allocated and received either R-HuEpo (480 U/kg/wk) or placebo by twice weekly subcutaneous injection. The primary outcome measure was the number of days on respiratory support and a secondary outcome the number of blood transfusions required. RESULTS: Forty two very low birthweight (VLBW) infants were randomly allocated. There was little difference in the need for respiratory support one month after randomisation, but subsequently there was a trend towards a reduction in the proportion requiring respiratory support in the R-HuEpo group (difference at three months -0.50, 95% confidence interval -1.00, 0.17). During stay in hospital, the median number of blood transfusions was lower for infants in the R-HuEpo group (difference in medians -2, 95% CI -4, 0). The study was stopped early because of failure to recruit babies at the expected rate. CONCLUSIONS: R-HuEpo seems to reduce the number of days in oxygen for ill VLBW infants. These data could be used to construct a larger multicentre study to evaluate this effect further.

A review of ordinal regression models applied on health-related quality of life assessments.

There has been increasing emphasis in medical research on the design and analysis of quality of life scales. Many quality of life scales are ordinal and statistical methods such as ordinal regression models have been reviewed on a number of occasions. However, when such models are applied, the way the data have been generated is often overlooked. In this paper we illustrate the use of ordinal regression models, in particular the proportional odds model, the partial proportional odds model and the stereotype model in the MRC Cognitive Function and Ageing Study (MRC CFAS). The partial proportional odds and the stereotype models are often under-utilized, perhaps due to the lack of available software. However, in this paper, analysis based on these models has been carried out using the popular statistical software package SAS and macros devised in SAS. Furthermore, bootstrapping techniques have been applied to obtain valid estimates of the standard errors of the parameters in the stereotype model. Strikingly different results were obtained using the different ordinal regression models. We conclude that the way the data have been generated is particularly important for the analysis of quality of life assessments. Different methods of generating scores yield data with different properties. It is now possible to fit a variety of ordinal regression models and so select the appropriate one that correctly models the data.

The role of objective personality inventories in suicide risk assessment: an evaluation and proposal.

Objective personality assessment instruments offer a comparatively underutilized source of clinical data in attempts to evaluate and predict risk for suicide. In contrast to focal suicide risk measures, global personality inventories may be useful in identification of long-standing styles that predispose persons to eventual suicidal behavior. This article reviews the empirical literature regarding the efficacy of established personality inventories in predicting suicidality. The authors offer several recommendations for future research with these measures and conclude that such objective personality instruments offer only marginal utility as sources of clinical information in comprehensive suicide risk evaluations. Personality inventories may offer greatest utility in long-term assessment of suicide risk.

Dengue haemorrhagic fever and the dengue shock syndrome in India.

The clinical spectrum of dengue fever ranges from asymptomatic infection through severe haemorrhage and sudden fatal shock. Increased capillary permeability is the diagnostic feature of dengue haemorrhagic fever (DHF). The pathophysiology of DHF/dengue shock syndrome (DSS) is related to sequential infection with different serotypes of the virus, variations in virus virulence, interaction of the virus with environmental or host factors and a combination of various risk factors. Infection due to low virulence strains is assumed to be the reason for the infrequent incidence of serious dengue disease in India. Since all four serotypes of the dengue virus have been implicated in various outbreaks in this country and several outbreaks of DHF/DSS have been recorded since the first report in 1963, further epidemics of the disease are likely. The situation is aggravated by the recent emergence of DHF/DSS in Sri Lanka. In view of the potential of this disease to spread, effective preventive and control measures should be a priority.

Salient personality characteristics among Navy divers.

This study evaluated the personality characteristics of U.S. Navy divers. Seventy-two active duty Navy divers completed the Million Index of Personality Styles. The sample strongly showed the traits of Enhancing. Modifying, Individuating, Thinking, and Controlling. The results are discussed in terms of adaptation to the environmental demands of military diving. Suggestions for further research are offered.

Contraceptive knowledge, contraceptive use, and self-esteem among Navy personnel.

This study evaluated the sexual knowledge (including contraceptive and reproductive knowledge), contraceptive use, and self-esteem among a sample of 158 male and female United States Navy sailors assigned to Navy ships. In spite of the fact that men and women viewed themselves as relatively knowledgeable with respect to contraception, results showed substantial knowledge deficits. Women demonstrated significantly greater sexual knowledge than men, and contraceptive/ reproductive knowledge was highly correlated with self-reported use of contraceptives. Finally, self-esteem was highly correlated with sexual knowledge and certain contraceptive use behaviors.

PIP: Current US Navy policy mandates the transfer of female sailors who become pregnant to land-based units. No previous study has evaluated issues related to unintended pregnancy among men and women assigned to Navy ships. In this study, 158 personnel (89 men and 69 women) assigned to 3 mixed-gender Navy ships volunteered to complete a demographic questionnaire, Coopersmith Self-Esteem Inventory, Contraceptive Behavior Scale, and Sexual Knowledge Scale (SKS). Ages ranged from 17 to 44 years, with a mean of 24.43 years for women and 26.02 years for men. 40% of males and 72% of females reported having had formal contraceptive education within the previous 2 years. On a scale from 1 (no knowledge) to 5 (very knowledgeable), mean self-reported contraceptive knowledge scores were 4.56 for women and 4.33 for men. However, SKS scores contradicted these self-assessments. Out of a maximum possible score of 32.0, the mean total SKS score was 21.22 among women and 17.29 among men. Current consistent contraceptive use was reported by 44% of females and 38% of males. Sexual knowledge was significantly predictive of more frequent and consistent contraceptive use, during both initial and subsequent sexual experiences. Self-esteem scores, comparable for men and women, were significantly positively correlated with contraceptive and reproductive knowledge scores but less clearly linked to actual contraceptive use. These findings suggest that competence-centered sex education represents an important strategy for decreasing rates of unplanned pregnancy among Navy personnel.

Personality characteristics of successful Navy submarine personnel.

This study evaluated the personality characteristics of senior enlisted and occupationally successful Navy submarine personnel. One hundred subjects completed the Schedule for Nonadaptive and Adaptive Personality (SNAP). Results indicated that the traits of detachment, propriety, and workaholism were most descriptive of the sample. Thirty-seven percent met SNAP criteria for a personality disorder, typically antisocial, obsessive-compulsive, or avoidant. The results are discussed in terms of adaptation to environmental demands aboard submarines. Suggestions for further research are offered.

Mentoring experiences among Navy midshipmen.

Previous research suggests that mentor relationships are facilitative of career success, career satisfaction, and retention in organizations. Yet, little research has been done to explore the prevalence or function of mentor relationships in military populations. In this study, preliminary data were collected regarding the prevalence of mentor relationship experiences among 576 third year midshipmen at the U.S. Naval Academy. Only 40% of respondents had ever experienced a mentor relationship. Most mentors were senior military personnel, and 87% were male. Most relationships were mutually initiated, and they tended to last for several years. Although both career and psychosocial mentor functions were present in these relationships, psychosocial functions were most notable and most highly correlated with positive appraisals of mentor relationships. Midshipmen viewed mentoring as extremely important and rated their own mentor relationships as extremely positive. Implications for further research on mentoring are discussed.

Personality characteristics of future military leaders.

Relatively little is known about the personality characteristics of military personnel, particularly those who are most successful in military careers. This study evaluated the personality characteristics of 530 third-year midshipmen at the U.S. Naval Academy. Participants completed the Hogan Personality Inventory and a demographic questionnaire. Class ranking data were also obtained as an indicator of success at the Naval Academy. The results indicated that compared with national norms, midshipmen scored somewhat higher on scales of ambition, sociability, intellectance, and school success and lower on scales of adjustment, likability, and prudence. Ambition, prudence, intellectance, and school success were each significantly positively correlated with class standing. The implications of these findings for understanding personality correlates of success in military leadership are discussed.

Pilot study of suicide risk factors among personnel in the United States Marine Corps (Pacific Forces).

Risk factors for suicide among active-duty members of the United States Marine Corps were investigated. Three groups were suicide attempters (n = 172), completers (n = 22), and a nonpsychiatric comparison group (n = 384). A series of multiple regression and discriminant analyses were conducted to assess whether any of 137 selected risk-factors differentiated the suicidal group from the comparison group. The following factors differentiated suicide attempters and completers from the comparison group and were associated with increased suicide risk: History of Abuse, Neglect, or Rejection, Lower Performance Evaluation, Symptoms of Depression, No History of Gambling Behavior, Younger Age, History of Alcohol Abuse, and Hopelessness. A discriminant analysis using these seven variables resulted in a 77% accuracy rate. When evaluating variables that could be obtained by a review of military records alone, three variables differentiated the attempters and completers from the comparison group, Lower Performance Evaluation, Younger Age, and a History of Military or Legal Problems. These variables correctly classified 73% of the sample. Implications for suicide-risk assessment for individuals in the Marine Corps are provided.

Effects of locus of control, occupational stress, and psychological distress on job satisfaction among nurses.

This study evaluated the effects of locus of control, occupational stress, and psychological symptom distress on reported job satisfaction in a sample of 34 practicing nurses. As predicted, greater work-related stress and higher psychological symptom distress were significantly negatively correlated with job satisfaction. External locus of control was also negatively associated with job satisfaction.