Extranodal marginal zone lymphoma of the larynx: A case report and scoping review.

BACKGROUND: This scoping review aims to review cases of extranodal marginal zone lymphoma (MZL) of the larynx to establish best management practices for this rare clinical entity. METHODS: In this paper, we report a case of laryngeal MZL, in accordance with CARE guidelines. We then performed a scoping review according to PRISMA-ScR criteria of published cases of MZL involving the larynx. The following data were collected for each case: age, sex, size, location(s) involved, stage, treatment, follow-up, and recurrence duration. RESULTS: Sixty-six patients with laryngeal MZL, first reported in 1990, were identified. Characterized by its low-grade histological appearance and indolent course, laryngeal MZL is generally confined to the larynx and has an excellent prognosis with radiation used as first-line therapy. CONCLUSIONS: It is imperative for clinicians to consider lymphoma in the differential diagnosis of a laryngeal tumor from any subsite, as certain pathologies may carry high risks of metastasis.

Patient Engagement with Conversational Agents in Health Applications 2016-2022: A Systematic Review and Meta-Analysis.

Clinicians and patients seeking electronic health applications face challenges in selecting effective solutions due to a high market failure rate. Conversational agent applications ("chatbots") show promise in increasing healthcare user engagement by creating bonds between the applications and users. It is unclear if chatbots improve patient adherence or if past trends to include chatbots in electronic health applications were due to technology hype dynamics and competitive pressure to innovate. We conducted a systematic literature review using Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology on health chatbot randomized control trials. The goal of this review was to identify if user engagement indicators are published in eHealth chatbot studies. A meta-analysis examined patient clinical trial retention of chatbot apps. The results showed no chatbot arm patient retention effect. The small number of studies suggests a need for ongoing eHealth chatbot research, especially given the claims regarding their effectiveness made outside the scientific literatures.

Granular Cell Tumors of the Larynx: A Systematic Review.

OBJECTIVE: Granular cell tumor of the larynx is an uncommon, typically benign lesion that may be confused for a malignant neoplasm based on histopathology. This review examines cases of granular cell tumor of the larynx in adults to highlight key distinctions in diagnosis/management and demonstrate how misclassification may lead to unnecessary escalations in therapy. DATA SOURCES AND METHODS: A systematic search of PubMed, Ovid, and EBSCO Search Hosts was completed in December 2021. The search yielded 501 articles with 87 full-text articles included in the review. Primary search terms included granular cell, tumor, larynx, and adult. Primary endpoints were patient presentation, primary management, pathological features, and disease course. RESULTS: A systematic review of 87 articles identified 200 patients with granular cell tumors (GCTs) of the larynx. Of the 200 patients, 50.3% were males and 49.7% were females. Of these, 54.0% were reported as white patients, and 46.0% were reported as black patients. The most common presenting symptoms were dysphonia (85.9%) and stridor/dyspnea (14.1%). On examination, the lesions were most commonly polypoid/nodular and firm. Pseudoepitheliomatous hyperplasia (PEH) was identified in 33.5% of cases, and 2% of cases were malignant. GCTs were misdiagnosed as other malignant lesions in 11% of cases. In benign cases, 13.5% of patients underwent additional surgeries beyond simple excision/laryngofissure, including laryngectomy and neck dissection. Less than 2% of lesions reoccurred. CONCLUSION: Granular cell tumors of the larynx are typically benign lesions that may be misdiagnosed with unnecessary escalation of treatment. However, most lesions resolve via primary surgical excision. Laryngoscope, 134:1523-1530, 2024.

Evaluation and Management of Inflammatory Reactions to Vocal Fold Injection Laryngoplasty with Hyaluronic Acid.

OBJECTIVES: Inflammatory reaction to vocal fold injection laryngoplasty with hyaluronic acid (HA) is a rare condition whose optimal management is not established. In this study, we aim to review the presentation of these reactions and outline an approach for evaluation and management. METHODS: We performed a retrospective review of all patients at our institution who underwent vocal fold injection augmentation with HA during the period extending from August 2018 until October 2022. We then identified patients with postinjection inflammatory reaction and reviewed demographic data, indication for injection, amount of HA injected, setting of procedure, and symptoms. The types of complication, management plan, onset, and time to complete resolution were also recorded. A comprehensive literature search for similar complications was conducted for comparative analysis. Once the available data were aggregated with our institutional experience, we developed an algorithmic approach to manage this condition. RESULTS: We identified 83 patients (124 vocal folds) who underwent vocal fold injection laryngoplasty with HA over a 4-year period. Four patients (4.8%) had a postprocedure inflammatory reaction (5.6% of all vocal folds). Of the four patients, three presented with dyspnea and stridor, while one presented with dysphonia, with onset of symptoms ranging from 24 to 48 hour postinjection. All patients were treated with corticosteroids. For comparative analysis, we identified 24 patients from the literature with reported inflammatory reactions to HA. CONCLUSION: We suggest an algorithmic approach to managing laryngeal inflammation following HA injection. Familiarity with treatment for this rare complication is essential to avoid significant morbidity and achieve optimal outcomes.

Task-related and task-unrelated thoughts in runners and equestrians: Measurement issues in evaluations of thought content.

Much of the thought content and mind-wandering literature examines self-reported thought content's relationship with performance criteria in limited ways. Furthermore, retrospective reports about thought content may be influenced by the quality of one's performance. We explored these method issues in a cross-sectional study of individuals competing in a trail race and an equestrian event. Our results demonstrated that self-reports of thought content differed based on the performance context: whereas runners' task-related and task-unrelated thoughts were negatively correlated, equestrians' thought content showed no relationship. Moreover, equestrians in general reported fewer task-related and task-unrelated thoughts than runners. Finally, objective performance predicted task-unrelated thought (but not task-related thought) among runners, and an exploratory mediation test suggested the effect was partially mediated by performance awareness. We discuss the applied implications of this research for human performance practitioners.

The real-time and carry-over effects of injustice on performance and service quality in a ridesharing driver scenario.

The nature of gig work and its growth have important implications for organizational justice theory. Aspects of gig work, including the transactional compensation arrangement, strict algorithmic rating system, and power asymmetry between drivers and customers, have implications for understanding how dimensions of distributive, informational, and interpersonal injustice manifest and impact job performance in the gig context. An understanding of this topic can inform justice theory more broadly and help explain inconsistent findings in the literature. Here, we report the results of two studies examining the unique effects of these respective dimensions of injustice on emotions and, ultimately, the driving performance and service quality in a ridesharing service context. In Study 1, we modeled the passenger-driver interaction of the ridesharing context using a driving simulator in a laboratory setting to differentiate the real-time and carry-over effects of specific dimensions of injustice. The results from 99 participants showed that perceptions of interpersonal injustice increased anger and unhappiness during the ride, in turn impairing driving and service performance. Antecedent-focused emotion regulation strategies (ERS) reduced felt unhappiness. Moreover, unexpectedly, perceived distributive injustice as caused by the customer rating had opposite (direct versus indirect) effects on service performance in the subsequent ride. Study 2 was an online simulation vignette scenario with 294 participants. The results replicated the findings of Study 1 and revealed two moderators of the unexpected distributive justice-performance relationship. Supplementary Information: The online version contains supplementary material available at 10.1007/s12144-022-04215-3.

Efficacy of Office-Based Intralesional Steroid Injections in the Management of Subglottic Stenosis: A Systematic Review.

OBJECTIVE: To determine the efficacy of office-based intralesional steroid injections (ILSI) as a management therapy for adult subglottic stenosis (SGS). DATA SOURCES: A systematic review was completed using PubMed and Science Direct for office-based management of SGS due to various etiologies. REVIEW METHODS: The primary end point measured was a change in surgery free interval (SFI) between endoscopic procedures due to office-based serial ILSI. The secondary end point was to determine what percentage of patients did not require further operative intervention for SGS maintenance therapy after changing management to office-based serial ILSI. RESULTS: We identified 187 abstracts, 4 of which were included in the analysis. The total number of participants was 55. The mean age was 50.4, and 78.1% were women. The etiologies were as follows: idiopathic (58.2%), postintubation/tracheotomy (29.1%), and autoimmune (12.7%). The SFI was reported in 3 of the 4 studies. The reported mean pre-ILSI SFI was 362.9 days and the post-ILSI SFI was 582.2 days. The secondary outcome was reported in 3 of the 4 studies. Forty-one of the 55 patients (74.5%) did not require further operative intervention during the duration of the study. CONCLUSION: This review explored office-based ILSI as a potential treatment option for patients with SGS. The limited data presented found ILSI significantly lengthened SFI, potentially reducing surgical burden. In addition, ILSI was found to be safe with few reported side effects.

Influence of Simulation-based Training on Reflective Practice.

BACKGROUND: Simulation-based training (SBT) is often evaluated based on the transfer of specific knowledge and skills. In contrast, the degree to which reflective practice is inculcated by SBT is rarely considered. Because reflection is a pillar of adult learning theories, we sought to examine the degree to which participation in SBT was associated with increased reflective practice. METHOD: Eighty one healthcare professionals completed a survey which included the number of SBTs they participated in during the past two years, content- and administrative-related features of those SBTs, and a key aspect of reflective practice (i.e., self-appraisal). RESULTS: The number of SBTs healthcare professionals participated in during the past two years was positively associated with reflective self-appraisal. This relationship was not moderated by the inclusion of reflection components in SBTs nor by the voluntary/mandatory nature of participation in SBTs. Furthermore, the facilitator was ranked as the most important feature of the overall learning experience in SBTs. Also, no significant differences were found between the number of technical skills-based and non-technical skills-based SBTs. CONCLUSION: These findings demonstrate the importance (of evaluating) SBTs for facilitating reflective learning mindsets that healthcare practitioners can apply beyond the specific skills trained by SBTs.

Hacking teamwork in health care: Addressing adverse effects of ad hoc team composition in critical care medicine.

BACKGROUND: The continued need for improved teamwork in all areas of health care is widely recognized. The present article reports on the application of a hackathon to the teamwork problems specifically associated with ad hoc team formation in rapid response teams. PURPOSES: Hackathons-problem-solving events pioneered in computer science-are on the rise in health care management. The focus of these events tends to be on medical technologies, however, with calls for improvements in management practices as general recommendations. The hackathon reported here contributes to health care management practice by addressing improvements in teamwork as the focal problem. METHODOLOGY: The hackathon event took place over 2.5 days in conjunction with an academic conference focused on group research. Three teams comprised of practicing healthcare professionals, academic researchers and students developed solutions to problems of ad hoc team formation in rapid response teams. FINDINGS: The event fulfilled several goals. The teams produced three distinct, yet complementary solutions that were backed by both field-based experience and solid research evidence. The event provided the opportunity for two-way translation of research and practice through direct collaboration among key stakeholders. The hackathon produced long term effects through establishing or strengthening collaborations, dissemination of the ideas through presentations, workshops, and publications, and changes in participantsâ work practices. PRACTICE IMPLICATION: The event demonstrated that hackathons, classically focused on technology, can also offer a spur to innovation around organizational processes. The article provides advice for organizing other hackathons focused on similar topics. The solutions offered by the participants in the event yields the clear insight that multipronged solutions for emergency-oriented teamwork are needed. The hackathon highlighted the scaled of collaboration and effort needed to tackle the many complexities in health care that impact outcomes for providers, patients, and health organizations.

The Impact of Surgical Team Familiarity on Length of Procedure and Length of Stay: Inconsistent Relationships Across Procedures, Team Members, and Sites.

BACKGROUND: Team familiarity has been shown to be important for operative efficiency and number of complications, but it is unclear for which types of operations and for which team members familiarity matters the most. The objective of this study is to further our understanding of familiarity in the OR by quantifying the relative importance of familiarity among all possible core team dyads, and defining the impact of team level familiarity on outcomes. MATERIALS AND METHODS: Using a retrospective chart and administrative data review, five years of data from two health systems (14 hospitals) and across two procedures, (knee arthroplasty and lumbar laminectomy) were included. Multilevel modeling approach and a dominance analysis were conducted. RESULTS: For each previous surgery that any two members of the core surgical team had participated in together, the length of surgery decreased significantly. The familiarity of the scrub and the surgeon was the most significant relationship for knee arthroplasty across the two hospitals, and laminectomies at one hospital. CONCLUSIONS: The relationship between familiarity of the surgical team and surgical efficiency may be more complex than previously articulated. Familiarity may be more important for certain types of procedures. The familiarity of certain dyads may be more important for certain types of procedures.

"Worse than I anticipated" or "This isn't so bad"?: The impact of affective forecasting accuracy on self-reported task performance.

Various motivational theories emphasize that desired emotional outcomes guide behavioral choices. Although motivational theory and research has emphasized that behavior is affected by desired emotional outcomes, little research has focused on the impact of anticipated feelings about engaging in behavior. The current research seeks to partly fill that void. Specifically, we borrow from affective forecasting research in suggesting that forecasts about engaging in performance-relevant behaviors can be more or less accurate. Furthermore, we suggest that the degree of accuracy has implications for self-reported task performance. To examine these ideas, we conducted two studies in which individuals made affective predictions about engaging in tasks and then later reported how they actually felt during task engagement. We also assessed their self-reported task performance. In Study 1, 214 workers provided affective forecasts about upcoming work tasks, and in Study 2, 185 students made forecasts about studying for an exam. Results based on polynomial regression were largely consistent across the studies. The accuracy of the forecasts did not conform to the pattern of affective forecasting accuracy typically found outside the performance domain. Furthermore, anticipated and experienced affect jointly predicted self-reported task performance in a consistent manner. Collectively, these findings suggest that taking into account anticipated affect, and its relationship with later experienced affect, provides a more comprehensive account of affect's role in task performance.

Respiratory Laryngeal Dystonia: Characterization and Diagnosis of a Rare Neurogenic Disorder.

OBJECTIVES/HYPOTHESIS: Respiratory laryngeal dystonia (RLD) is poorly understood and rarely reported in the literature. Patients have atypical laryngeal movement resulting in airway obstruction. This motion is neurogenic in nature, is constant while awake, nonepisodic, and non-trigger dependent. Given its rarity, it is often misdiagnosed for inducible laryngeal obstruction; however, it is refractory to medical and behavioral management. Although this condition has been addressed in the literature, this report is the largest case series characterizing presenting symptomology, multimodal treatment outcomes, and longitudinal course of these patients, and proposes a set of diagnostic criteria to aid in clinical identification of RLD patients. Our objectives were to characterize RLD clinically and offer diagnostic guidelines to clinicians. STUDY DESIGN: A prospective case series with a retrospective analysis at a tertiary referral center. METHODS: A review of clinical records and videostroboscopic analysis of 16 patients treated for respiratory laryngeal dystonia from October 2005 to October 2018 was performed. RESULTS: Sixteen patients with respiratory laryngeal dystonia were included. The common features of this group were persistent, nonepisodic dyspnea and stridor with laryngoscopic evidence of paradoxical vocal fold motion. Our patients had no structural neurologic abnormalities. These patients typically failed respiratory retraining therapy and medical management of laryngeal irritants. In our series, 100% of patients underwent respiratory retraining therapy, 68.8% received laryngeal botulinum toxin injection, and 31.3% required tracheostomy. CONCLUSIONS: RLD is a rare and challenging condition. The disorder can be severely disabling, and treatment options appear limited. A multidisciplinary approach may be helpful. Some patients responded to laryngeal botulinum injection and medical management, whereas others required tracheostomy for symptom control. Laryngoscope, 2020.

Development of a Measure of Informal Workplace Social Interactions.

A measure of informal, non-task-related workplace social interactions that captures both the frequency of interactions and the positive affect that can accompany such interactions was developed and validated. In two samples of employees (N = 188 and N = 315, respectively), the factor structure, reliability, and incremental predictive validity of the newly developed measure were evaluated. Results support the anticipated two-factor structure, demonstrate strong psychometric properties, and reveal that the new measure explains additional variance in employee outcomes (job satisfaction and job-related positive affect). This newly developed, 16-item scale provides a psychometrically sound measure for researchers and organizations to use in assessing, and potentially improving, two dimensions of workplace social interactions.

Just how miserable is work? A meta-analysis comparing work and non-work affect.

Although we spend much of our waking hours working, the emotional experience of work, versus non-work, remains unclear. While the large literature on work stress suggests that work generally is aversive, some seminal theory and findings portray working as salubrious and perhaps as an escape from home life. Here, we examine the subjective experience of work (versus non-work) by conducting a quantitative review of 59 primary studies that assessed affect on working days. Meta-analyses of within-day studies indicated that there was no difference in positive affect (PA) between work versus non-work domains. Negative affect (NA) was higher for work than non-work, although the magnitude of difference was small (i.e., .22 SD, an effect size comparable to that of the difference in NA between different leisure activities like watching TV versus playing board games). Moderator analyses revealed that PA was relatively higher at work and NA relatively lower when affect was measured using "real-time" measurement (e.g., Experience Sampling Methodology) versus measured using the Day Reconstruction Method (i.e., real-time reports reveal a more favorable view of work as compared to recall/DRM reports). Additional findings from moderator analyses included significant differences in main effect sizes as a function of the specific affect, and, for PA, as a function of the age of the sample and the time of day when the non-work measurements were taken. Results for the other possible moderators including job complexity and affect intensity were not statistically significant.

Pressure induced tissue resection in the larynx: A preliminary canine study.

OBJECTIVES: The application of laser (light amplification by stimulated emission of radiation) energy in the larynx relies on thermal injury. The impact of this injury on adjacent tissue can be undesirable. Attempts have been made to limit the extent and range of injury to adjacent tissue. The O-Pel Surgical System (Precise Light Surgical, Inc., Campbell, CA), a new technology, utilizes kinetic energy through Pressure Induced Tissue Resection (PITR) (Precise Light Surgical, Inc.) to cut tissue, theoretically eliminating injury to adjacent tissue. The purpose of this study was to evaluate the PSL in canine vocal folds. METHODS: Four dogs underwent PITR incisions (4 mJ pulses at 200 Hz) on their vocal folds, through mucosa into the muscle. The animals were sacrificed at days 0, 3, 7, and 21 days postsurgery. The larynges were harvested and histology was performed with hematoxylin and eosin, Masson trichrome, and Verhoeff-van Gieson. RESULTS: At day 0, focal denudation of the epithelium and coagulation necrosis in the lamina propria and adjacent connective tissue are noted. On days 3 and 7, an inflammatory infiltrate of neutrophils is seen within the lamina propria and surrounding connective tissue with minimal edema and early deposition of collagen. At day 21, the mucosa is completely regenerated with the area of previous PITR into the muscle replaced with thick bundles of collagen. CONCLUSION: The unique PITR characteristics offer a potentially unique cutting technology for laryngeal microsurgery. The current canine study suggests appropriate and rapid healing. With refinements of the tip size of the probe and adjustment of energy, PITR will likely be an appropriate alternate to traditional lasers in laryngeal surgery. LEVEL OF EVIDENCE: NA. Laryngoscope, 129:2557-2562, 2019.

A brief peer gatekeeper suicide prevention training: Results of an open pilot trial.

OBJECTIVE: The purpose of the present study was to test a 1-hour peer suicide gatekeeper training for students from the broad college community in the context of an open pilot trial. METHOD: Two-hundred and thirty-one college students were recruited university-wide, Mage  = 20.7, 65.4% female, and completed a peer suicide prevention gatekeeping training program. Assessments were completed at pre-training and post-training as well as 3-month follow-up. RESULTS: This brief peer suicide gatekeeper training program was associated with increases in suicide prevention knowledge. It was also associated with an increase in the number of students who identified suicidal youth and made mental health referrals, as well as total number of referrals made, over the course of three months. Females reported greater improvement in suicide prevention skills and knowledge post-training than males. CONCLUSIONS: Offering peer suicide gatekeeper training to students from the general college population may hold promise in suicide prevention efforts.

Trauma resuscitation: can team behaviours in the prearrival period predict resuscitation performance?

Background: Optimising team performance is critical in paediatric trauma resuscitation. Previous studies in aviation and surgery link performance to behaviours in the prearrival period. Objective: To determine if patterns of human behaviour in the prearrival period of a simulated trauma resuscitation is predictive of resuscitation performance. Design: Twelve volunteer trauma teams performed in four simulation scenarios in a paediatric hospital. The scenarios were video recorded, transcribed and analysed in 10-second intervals. Variation in the amount of utterances per team member in the prearrival period was compared with team performance and implicit coordination during the resuscitation. Key results: Coders analysed 18 962 s of video. They coded 5204 team member utterances into one of eight communication behaviour categories. Inter-rater reliability was excellent (an average of 83.1% across all four scenarios). The average number of communications occurring during the prearrival period was 18.84 utterances, with a range of 2-42 and a SD of 9.55. The average length of this period was almost 2 minutes (mean =117.30 s, SD=39.20). Lower variance in team member communication during the prearrival better was associated with better implicit coordination (p=0.011) but not team performance (p=0.054) during the resuscitation. Conclusion: Patterns of communication in the prearrival trauma resuscitation period predicted implicit coordination and a trend towards significance for team performance which suggests further studies in such patterns are warranted.

An examination of two positive organizational interventions: For whom do these interventions work?

Owing to the importance of employee psychological well-being for a variety of work- and non-work-related outcomes, practitioners and scholars have begun to broaden the scope of workplace well-being interventions by incorporating principles from positive psychology. Among such positive interventions, gratitude exercises have arguably emerged as the "gold standard" practice, with much research pointing to their effectiveness. However, existing workplace interventions lack a true (i.e., no intervention) control group, and effects have been observed for some-but not all-outcomes tested. Therefore, the purpose of this brief report was to conduct a concise but methodologically rigorous evaluation of the effectiveness of 2 positive psychology workplace interventions in improving employee affect, and to examine potential moderators of intervention effectiveness. Ninety-two employees in a large social services agency were assigned to (a) a gratitude intervention, (b) an intervention in which participants alternated between the gratitude activity and one involving increasing social connectedness, or (c) a wait list control condition, for 1 month. Neither intervention produced a main effect on any of the 3 affective outcomes measured. However, agreeableness, conscientiousness, and job tenure were significant moderators of intervention effectiveness. We discuss the implications of these preliminary results in an effort to advance the literature on workplace positive psychology interventions. (PsycINFO Database Record

Reducing nurses' stress: A randomized controlled trial of a web-based stress management program for nurses.

BACKGROUND: Nursing is a notoriously high-stress occupation - emotionally taxing and physically draining, with a high incidence of burnout. In addition to the damaging effects of stress on nurses' health and well being, stress is also a major contributor to attrition and widespread shortages in the nursing profession. Although there exist promising in-person interventions for addressing the problem of stress among nurses, the experience of our group across multiple projects in hospitals has indicated that the schedules and workloads of nurses can pose problems for implementing in-person interventions, and that web-based interventions might be ideally suited to addressing the high levels of stress among nurses. PURPOSE: The purpose of this study was to evaluate the effectiveness of the web-based BREATHE: Stress Management for Nurses program. METHODS: The randomized controlled trial was conducted with 104 nurses in five hospitals in Virginia and one hospital in New York. The primary outcome measure was perceived nursing-related stress. Secondary measures included symptoms of distress, coping, work limitations, job satisfaction, use of substances to relieve stress, alcohol consumption, and understanding depression and anxiety. RESULTS: Program group participants experienced significantly greater reductions than the control group on the full Nursing Stress Scale, and six of the seven subscales. No other significant results were found. Moderator analysis found that nurses with greater experience benefitted more. CONCLUSION: Using a web-based program holds tremendous promise for providing nurses with the tools they need to address nursing related stress.

Cardiac resuscitation events: one eyewitness is not enough.

OBJECTIVE: To determine the accuracy of paper cardiopulmonary resuscitation records. DESIGN: Case series. SETTING: Twenty-six-bed video-monitored pediatric cardiac ICU. PATIENTS: All patients who had a resuscitation event with available video and electronically stored vital sign and waveform data from May 2012 to February 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 41 cardiopulmonary resuscitation events during the study period. Fifteen had complete and valid data from the paper cardiopulmonary resuscitation forms, the retrieved monitor data, and the continuous bedside video monitoring. These 15 events occurred in 12 individual patients, and there was 100% agreement of data in the documentation of interventions in place (ventilation, arterial catheter, pulse oximetry, and vascular access) and in the presence of a witness at the onset of the arrest. All events were witnessed. Of the 15 events, video and monitor review revealed that 14 used waveform and numeric capnometry to confirm endotracheal tube/tracheostomy placement, but this section was only completed on the paper cardiopulmonary resuscitation record in three of the 14 cases. All records showed no discrepancies in the time of return of spontaneous circulation. The video and monitor review revealed delay in initiating cardiopulmonary resuscitation (mode, 2 min; two cases ≥ 7 min) and shockable rhythms (ventricular arrhythmia) in two cases. A sign of pulseless state was discovered in seven cases classified on the paper record as "always with a pulse." Those include sudden loss of consciousness, flat arterial line tracing, and abrupt drop in the partial pressure of exhaled carbon dioxide tracing (< 10 mm Hg). CONCLUSIONS: Eyewitness accounts of cardiopulmonary resuscitation are often inaccurate and incomplete. Review of information from video and electronically stored vital sign and waveform data provides more accurate information than review of paper-based cardiopulmonary resuscitation records and may provide the insight necessary to improving cardiopulmonary resuscitation.