Randomized feasibility trial of remote ischemic conditioning to enhance resuscitation (RICE).

RATIONALE: Restoration of blood flow after out-of-hospital cardiac arrest (OHCA) is associated with inflammation that causes cellular injury. The extent of this reperfusion injury (RI) is associated with the duration of ischemia and adequacy of resuscitation. Remote ischemic conditioning (RIC) consists of repeated application of non-lethal ischemia then reperfusion to a limb distal to the heart by inflating a blood pressure (BP) cuff. Trials in animal models in cardiac arrest and in humans with acute infarction show RIC reduces RI. OBJECTIVE: We sought to demonstrate the feasibility and safety of RIC in patients resuscitated from OHCA and transported to hospital. METHODS: This study was conducted under exception from informed consent (EFIC) for emergency research. Eligible subjects were randomized with masked allocation to control (standard care) versus intervention (standard care and RIC). Included were adults with non-traumatic OHCA. The primary outcome was attrition, the proportion of patients enrolled and not on allocated therapy for the study duration. Key secondary outcomes were survival to discharge, neurologic status at discharge, hospital-free survival, and adverse events. Results were summarized descriptively as recommended for pilot studies. RESULTS: N = 30 patients were enrolled (n = 14 control, n = 16 intervention). Mean age of enrolled patients was 52.5 ± 16.2 years. Eight (27%) were female gender and 7 (23%) had a shockable first recorded rhythm. 100% of enrolled patients completed their allocated study intervention (i.e., 0% attrition). The RIC group had 7 (44%) survival to discharge and median Rankin score of 6 (IQR 1, 6) at discharge as compared to the standard care group which had 6 (43%) survival to discharge and median Rankin score of 6 (IQR 1.5, 6) at discharge. A single patient (6%) in the intervention group had transient occlusion of their upper extremity intravenous line, which immediately resolved on repositioning of the blood pressure cuff. CONCLUSION: Application of RIC to patients resuscitated from CA and transported to an ED is feasible and safe. An adequately powered trial is required to assess whether RIC is effective at decreasing morbidity and mortality after CA.

Instilling Hope and Resiliency: A Narrative Photo-Taking Intervention During an Intercultural Exchange Involving 9/11 Survivors in Post 3/11 Japan.

On March 11, 2011 ("3/11"), a magnitude 9.0 earthquake in Northeastern Japan triggered a tsunami and nuclear power plant meltdown that killed 16,000 people and displaced more than 470,000 people. Since 2012, a group of volunteer docents from the September 11th Families Association in New York City has traveled throughout Northeastern Japan and held organized meetings where 9/11 and 3/11 survivors share their experiences and stories of trauma as part of an intercultural exchange to promote posttraumatic recovery. We sought to elucidate whether participating 9/11 docents developed a sense of increased resiliency by participating in this international outreach. This study employed photo-taking as well as framing questions, which were developed by 9/11 docents from the August 2016 trip. These questions guided photo-taking and resulting photographs informed discussion in individual and group sharing sessions. This process helped identify codes that guided analysis. Participants acquired a deeper appreciation of their own ability to overcome adversity and experienced a gratifying desire to help 3/11 survivors better cope with their experiences. This narrative photo-taking and group sharing experience demonstrates that a cross-cultural exchange between survivors of different disasters can instill feelings of resilience among participants. It additionally provides early evidence of the efficacy of such an exchange in benefitting disaster survivors in the long term.

Investigating a Quantitative Measure of Student Self-authorship for Undergraduate Medical Education.

CONSTRUCT: In this study, the authors investigated the validity of a quantitative measure of self-authorship among medical students. Self-authorship is a cognitive-structural theory incorporating the ability to define one's beliefs, identity, and social relations to operate in a complex, ambiguous environment. BACKGROUND: Competency-based medical education (CBME) provides learners with the opportunity to self-direct their education at an appropriate pace to develop and exhibit required behaviors while incorporating functioning relationships with supervisors and trainers. Students must develop skills to adjust and succeed in this educational climate. Self-authorship is a theoretical lens that is relevant to identifying the development of the skills necessary to succeed in a CBME curriculum. Understanding the level of attained self-authorship by medical students can provide important information about which professional characteristics are more prevalent among those who are more self-authored and about how students succeed in medical school. Although there are calls in the extant literature for the application of self-authorship in medical education, there is no quantitative measure to assess its development among medical students. APPROACH: The authors developed a survey to measure self-authorship, including a free text question regarding the thought process around a hypothetical ethical situation during training. Data were collected in 2014 and 2015 from undergraduate medical students and analyzed using factor analysis and qualitative analysis of the free text. Validity evidence was sought regarding content, internal structure, and relationships to other variables. RESULTS: Analysis supports the use of a 22-item instrument to assess 3 constructs of self-authorship: asserting independence and autonomy, knowledge processing, and sense of self in ethical situations. Content analysis of text responses supported the ability of the instrument to separate development, or a lack thereof, of self-authorship. CONCLUSIONS: The authors identified an instrument that measures multidimensional, higher-order characteristics that intersect with self-authorship. This instrument can be useful at a macro level for curricular and student assessment of self-authorship. Development of these characteristics can help foster success in a CBME environment and support curricular efforts in this regard. Understanding a student's level of self-authorship can help identify areas for support as well as allow for comparisons of different student characteristics.