CaRdiac Arrest Survival Score (CRASS) - A tool to predict good neurological outcome after out-of-hospital cardiac arrest.

AIM: The aim of this study was to develop a score to predict the outcome for patients brought to hospital following out-of-hospital cardiac arrest (OHCA). METHODS: All patients recorded in the German Resuscitation Registry (GRR) who suffered OHCA 2010-2017, who had ROSC or ongoing CPR at hospital admission were included. The study population was divided into development (2010-2016: 7985) and validation dataset (2017: 1806). Binary logistic regression analysis was used to derive the score. The probability of hospital discharge with good neurological outcome was defined as 1/(1 + e-X), where X is the weighted sum of independent variables. RESULTS: The following variables were found to have a significant positive (+) or negative (-) impact: age 61-70 years (-0·5), 71-80 (-0·9), 81-90 (-1·3) and > = 91 (-2·3); initial PEA (-0·9) and asystole (-1·4); presumable trauma (-1·1); mechanical CPR (-0·3); application of adrenalin > 0 - < 2 mg (-1·1), 2 - <4 mg (-1·6), 4 - < 6 mg (-2·1), 6 - < 8 mg (-2·5) and > = 8 mg (-2·8); pre emergency status without previous disease (+0·5) or minor disease (+0·2); location at nursing home (-0·6), working place/school (+0·7), doctor's office (+0·7) and public place (+0·3); application of amiodarone (+0·4); hospital admission with ongoing CPR (-1·9) or normotension (+0·4); witnessed arrest (+0·6); time from collapse until start CPR 2 - < 10 min (-0·3) and > = 10 min (-0·5); duration of CPR <5 min (+0·6). The AUC in the development dataset was 0·88 (95% CI 0·87-0·89) and in the validation dataset 0·88 (95% CI 0·86-0·90). CONCLUSION: The CaRdiac Arrest Survival Score (CRASS) represents a tool for calculating the probability of survival with good neurological function for patients brought to hospital following OHCA.

Ultrastructural and optogenetic dissection of V1 corticotectal terminal synaptic properties.

The superior colliculus (SC) is a major site of sensorimotor integration in which sensory inputs are processed to initiate appropriate motor responses. Projections from the primary visual cortex (V1) to the SC have been shown to exert a substantial influence on visually induced behavior, including "freezing." However, it is unclear how V1 corticotectal terminals affect SC circuits to mediate these effects. To investigate this, we used anatomical and optogenetic techniques to examine the synaptic properties of V1 corticotectal terminals. Electron microscopy revealed that V1 corticotectal terminals labeled by anterograde transport primarily synapse (93%) on dendrites that do not contain gamma aminobutyric acid (GABA). This preference was confirmed using optogenetic techniques to photoactivate V1 corticotectal terminals in slices of the SC maintained in vitro. In a mouse line in which GABAergic SC interneurons express green fluorescent protein (GFP), few GFP-labeled cells (11%) responded to activation of corticotectal terminals. In contrast, 67% of non-GABAergic cells responded to activation of V1 corticotectal terminals. Biocytin-labeling of recorded neurons revealed that wide-field vertical (WFV) and non-WFV cells were activated by V1 corticotectal inputs. However, WFV cells were activated in the most uniform manner; 85% of these cells responded with excitatory postsynaptic potentials (EPSPs) that maintained stable amplitudes when activated with light trains at 1-20 Hz. In contrast, in the majority of non-WFV cells, the amplitude of evoked EPSPs varied across trials. Our results suggest that V1 corticotectal projections may initiate freezing behavior via uniform activation of the WFV cells, which project to the pulvinar nucleus.

When is a bystander not a bystander any more? A European survey.

OBJECTIVE: There is international variation in the rates of bystander cardiopulmonary resuscitation (CPR). 'Bystander CPR' is defined in the Utstein definitions, however, differences in interpretation may contribute to the variation reported. The aim of this cross-sectional survey was to understand how the term 'bystander CPR' is interpreted in Emergency Medical Service (EMS) across Europe, and to contribute to a better definition of 'bystander' for future reference. METHODS: During analysis of the EuReCa ONE study, uncertainty about the definition of a 'bystander' emerged. Sixty scenarios were developed, addressing the interpretation of 'bystander CPR'. An electronic version of the survey was sent to 27 EuReCa National Coordinators, who distributed it to EMS representatives in their countries. Results were descriptively analysed. RESULTS: 362 questionnaires were received from 23 countries. In scenarios where a layperson arrived on scene by chance and provided CPR, up to 95% of the participants agreed that 'bystander CPR' had been performed. In scenarios that included community response systems, firefighters and/or police personnel, the percentage of agreement that 'bystander CPR' had been performed ranged widely from 16% to 91%. Even in scenarios that explicitly matched examples provided in the Utstein template there was disagreement on the definition. CONCLUSION: In this survey, the interpretation of 'bystander CPR' varied, particularly when community response systems including laypersons, firefighters, and/or police personnel were involved. It is suggested that the definition of 'bystander CPR' should be revised to reflect changes in treatment of OHCA, and that CPR before arrival of EMS is more accurately described.

Urban and rural differences in out-of-hospital cardiac arrest in Ireland.

BACKGROUND: More than a third of Ireland's population lives in a rural area, defined as the population residing in all areas outside clusters of 1500 or more inhabitants. This presents a challenge for the provision of effective pre-hospital resuscitation services. In 2012, Ireland became one of three European countries with nationwide Out-of-Hospital Cardiac Arrest (OHCA) register coverage. An OHCA register provides an ability to monitor quality and equity of access to life-saving services in Irish communities. AIM: To use the first year of national OHCAR data to assess differences in the occurrence, incidence and outcomes of OHCA where resuscitation is attempted and the incident is attended by statutory Emergency Medical Services between rural and urban settings. METHODS: The geographical coordinates of incident locations were identified and co-ordinates were then classified as 'urban' or 'rural' according to the Irish Central Statistics Office (CSO) definition. RESULTS: 1798 OHCA incidents were recorded which were attended by statutory Emergency Medical Services (EMS) and where resuscitation was attempted. There was a higher percentage of male patients in rural settings (71% vs. 65%; p = 0.009) but the incidence of male patients did not differ significantly between urban and rural settings (26 vs. 25 males/100,000 population/year p = 0.353). A higher proportion of rural patients received bystander cardiopulmonary resuscitation (B-CPR) 70% vs. 55% (p ≤ 0.001), and had defibrillation attempted before statutory EMS arrival (7% vs. 4% (p = 0.019), respectively). Urban patients were more likely to receive a statutory EMS response in 8 min or less (33% vs. 9%; p ≤ 0.001). Urban patients were also more likely to be discharged alive from hospital (6% vs. 3%; p = 0.006) (incidence 2.5 vs. 1.1/100,000 population/year; p ≤ 0.001). Multivariable analysis of survival showed that the main variable of interest i.e. urban vs. rural setting was also independently associated with discharge from hospital alive (OR 3.23 (95% CI 1.43-7.31)). CONCLUSION: There are significant disparities in the incidence of resuscitation attempts in urban and rural areas. There are challenges in the provision of services and subsequent outcomes from OHCA that occur outside of urban areas requiring novel and innovative solutions. An integrated community response system is necessary to improve metrics around OHCA response and outcomes in rural areas.

A double-edged sword: review of the interplay between physical health and mental health.

It is widely acknowledged that there is interplay between physical and mental health, with causality in both directions. A common theme across countries is the uncertainty surrounding who should act as gatekeeper for physical health matters in psychiatry. Much of the metabolic monitoring is carried out by psychiatrists who often feel ill equipped to treat medical problems such as abnormal cholesterol or disturbances of glucose metabolism. However many patients do not attend primary care on a regular basis and may not be likely to follow through on referral to primary care. This review aims to examine the interplay between co-morbid physical and mental health conditions, identify the physical health conditions particularly associated with severe affective and psychotic illness and briefly discuss interventions and recommendations in this area. As people with severe mental illness die 10-20 years younger than their peers, with much of this premature mortality due to cardiovascular disease, this topic is emerging as one of great importance amongst clinicians and policymakers internationally.

The risk of neurovascular injury in minimally invasive plate osteosynthesis (MIPO) when using a distal tibia anterolateral plate: a cadaver study.

PURPOSE OF THE STUDY: Percutaneous plating of the distal tibia via a limited incision is an accepted technique of osteosynthesis for extra-articular and simple intra-articular distal tibia fractures. The aim of this study was to analyze structures that are at risk during this approach. MATERIAL AND METHODS: Thirteen unpaired adult lower limbs were used for this study. Thirteen, 15-hole LCP anterolateral distal tibial plates were percutaneously inserted according to the recommended technique. Dissection was performed to examine the relation of the superficial and deep peroneal nerves and anterior tibial artery relative to the plate. RESULTS: The superficial peroneal nerve was found to cross the vertical limb of the LCP plate at a mean distance of 63 mm (screw hole five) but with a wide range of 21 to 105 mm. The neurovascular bundle (deep peroneal nerve and anterior tibial artery) crossed the plate at a mean of 76 mm (screw hole six) but also with a wide range of 38 to 138 mm. The zone of danger of the neurovascular structures ranges from 21 to 138 mm from the tibial plafond. In one specimen, a significant branch of the deep peroneal nerve was found to be entrapped under the plate. CONCLUSION: Caution is advised when using anterolateral minimally invasive technique for plate insertion and screw placement in the distal tibia due to great variability in the neurovascular structures that course distally in the lower leg and cross the ankle.

Candida tropicalis: diagnostic dilemmas for an unusual prosthetic hip infection.

Infection is the third commonest cause of total hip arthroplasty failure. Infections of the hip with Candida species are extremely rare with only a few reports in the literature. A case of a 76-year-old female subject is presented illustrating both the difficulty in initial diagnosis and the challenges faced in hip reconstruction.

Impaction femoral allografting at revision hip arthroplasty: uncemented versus cemented technique using a Freeman femoral component.

We report the long-term results of revision total hip replacement using femoral impaction allografting with both uncemented and cemented Freeman femoral components. A standard design of component was used in both groups, with additional proximal hydroxyapatite coating in the uncemented group. A total of 33 hips in 30 patients received an uncemented component and 31 hips in 30 patients a cemented component. The mean follow-up was 9.8 years (2 to 17) in the uncemented group and 6.2 years (1 to 11) in the cemented group. Revision procedures (for all causes) were required in four patients (four hips) in the uncemented group and in five patients (five hips) in the cemented group. Harris hip scores improved significantly in both groups and were maintained independently of the extent of any migration of the femoral component within the graft or graft-cement mantle.

Bilateral hip fractures associated with transient osteoporosis of pregnancy.

A case of transient osteoporosis of pregnancy complicated by bilateral neck of femur fractures is reported. We discuss the condition and review the literature, provide information to aid in the diagnostic dilemma clinicians may face when considering imaging techniques and the potential for foetal harm during radiation exposure. We discuss management strategies in such patients.

Acute spinal epidural haematoma causing cord compression after chiropractic neck manipulation: an under-recognised serious hazard?

Spinal manipulative therapy performed by chiropractors is increasingly common in the United Kingdom. Spinal epidural haematoma is a rare complication of such physical therapy but when identified represents a neurological emergency. We describe the case of a 64 year-old man who presented with a dense hemiplegia due to a spinal epidural haematoma following cervical spine manipulation performed for acute neck pain. The clinical features and surgical management of the case are discussed and we stress the importance of recognition of chiropractic manipulation as a potential cause of neurological sequelae and discuss the potential pitfalls of such therapy as it becomes more widespread.

A trickle-down model of organizational justice: relating employees' and customers' perceptions of and reactions to fairness.

This study developed and tested a trickle-down model of organizational justice that hypothesized that employees' perceptions of fairness should affect their attitudes toward the organization, subsequently influencing their behaviors toward customers. In turn, customers should interpret these behaviors as signals of fair treatment, causing them to react positively to both the employee and the organization. The model was tested on a sample of 187 instructors and their students. The results revealed that instructors who perceived high distributive and procedural justice reported higher organizational commitment. In turn, their students reported higher levels of instructor effort, prosocial behaviors, and fairness, as well as more positive reactions to the instructor. Overall, the results imply that fair treatment of employees has important organizational consequences because of customers' attitudes and future intentions toward key service employees.