Medically Managed Type A Thoracic Intramural Hematoma and Penetrating Aortic Ulcer.

Intramural hematoma (IMH) and a penetrating aortic ulcer (PAU) are included in a larger category of disorders termed acute aortic syndromes. These disorders typically involve the thoracic aorta, abdominal aorta, or both, and often require emergent evaluation and treatment. Both IMH and PAU, much like aortic dissection, are classified using the Stanford and DeBakey systems to indicate the aortic area involved, with Stanford type A (DeBakey type I and II) necessitating surgical intervention, and Stanford type B sufficing with medical management of blood pressure. While IMH and PAU share many characteristics of aortic dissection in terms of diagnosis and initial management, there is much controversy surrounding ultimate treatment. In this report, we describe a case of a Stanford type A IMH with associated PAU that was managed medically with a good outcome.

Optimal Scene Time to Achieve Favorable Outcomes in Out-of-hospital Cardiac Arrest: How Long Is Too Long?

Background Despite advances in resuscitation science and public health, out-of-hospital cardiac arrest (OOHCA) cases have an average survival rate of only 12% nationwide, compared to 24.8% of cases occurring in hospital. Many factors, including resuscitation interventions, contribute to positive patient outcomes and have, therefore, been studied in attempts to optimize emergency medical services (EMS) protocols to achieve higher rates of return of spontaneous circulation (ROSC) in the field. However, no consensus has been met regarding the appropriate amount of time for EMS to spend on scene. Aim A favorable outcome is defined as patients that achieved the combination of ROSC and a final disposition of "ongoing resuscitation in the emergency department (ED)." The primary purpose of this preliminary study was to determine the scene time interval (STI) in which American urban EMS systems achieved the highest rates of favorable outcomes in non-traumatic OOHCAs. Methods All EMS-related data, including demographics, presenting rhythm, airway management, chemical interventions, and ROSC were recorded using a standardized EMS charting system by the highest-ranking EMS provider on the ambulance. The reports were retrospectively collected and analyzed. Conclusion Our data suggest that the optimal 20-minute STI for OOHCA patients in an urban EMS system is between 41 and 60 minutes. Interestingly, the 10-minute interval within the 41-60 minute cohort that provided the highest rate of ROSC was between 41 and 50 minutes. Generally, the longer the STI, the greater the percentage of favorable outcomes up to the 50-minute mark. Once past 50 minutes, a phenomenon of diminishing return was observed and the rates of favorable outcomes sharply declined. This suggests a possible "sweet spot" that may exist regarding the optimal scene time in a cardiac arrest encounter. Significant differences between the average number of interventions per patient were found, however, many confounding factors and the limited data set make the results difficult to generalize.

Gender Disparities in Out-of-hospital Cardiac Arrests.

Background Despite advances in resuscitation science and public health, out-of-hospital cardiac arrest (OOHCA) has an average survival rate of only 12% nationwide, compared to 24.8% of patients who suffer from cardiac arrest while in hospital. Additionally, gender is an important element of human health, and there is a clear pattern for gender-specific survivability in cardiac arrest. This study examined differences in presentations, treatment, management, and outcomes. Aim The primary focus of this study was to shed light on differences in presentations, treatments, and outcomes between men and women suffering from an out-of-hospital cardiac arrest and the accompanying contributing factors. Methods All emergency medical services-related data, including age, date, initial rhythm, chemical interventions (i.e., epinephrine, dextrose), blood glucose levels, defibrillations, endotracheal tube (ETT) attempts, final airway management, achievement of return of spontaneous circulation (ROSC), and the conclusion of the case up to the emergency department, were recorded using a standardized emergency medical services (EMS) charting record by the highest-ranking EMS provider on the ambulance. The reports were retrospectively collected and analyzed. Conclusion The study examined demographics, treatments rendered, and outcomes in OOHCA cases that occurred in a major United States (US) city in 2016. Several significant differences in care were noted between men and women. In general, women received less respiratory, chemical, and electrical interventions than men; however, statistically significant differences were only observed in the number of attempts of endotracheal intubations, number of doses of epinephrine per encounter, and number of defibrillations per encounter. In spite of generally receiving less care, women appeared to respond more favorably to cardiac arrest interventions, as demonstrated by higher rates of ROSC. Despite this, women were also found to be eight years older at the time of arrest. Future studies are needed to determine causality in discrepancies between the genders in addition to investigating differences in treatment in other areas of the United States.

Prediction of body composition in elderly men over 75 years of age.

A comprehensive number of body composition predictions (involving weight, height, skinfold thicknesses, bioelectrical impedance and near-infrared interactance-NIRI) were evaluated against total body water (TBW from isotope dilution), in 23 randomly selected men over 75 years old, and dual-energy X-ray absorptiometry (DXA), in 15 volunteers from this group. Comparisons were made between anthropometric and impedance methods for estimating limb muscle mass (obtained using DXA). Bias and 95% limits of agreement between measured TBW and DXA estimates were -2.1 kg and 3.1 kg, respectively (for fat, 5.4% and 6.1% body weight). Agreement between TBW predictions and reference measurements was remarkably variable, irrespective of whether TBW was predicted from TBW-specific equations or indirectly from estimates of fat or fat-free mass: for predictions using anthropometry, bias ranged from -4.7 kg to 1.6 kg and 95% limits of agreement from bias +/- 3.8 kg to +/- 5.0 kg; using impedance, bias was -8.8 kg to 3.2 kg and 95% limits of agreement were bias +/- 3.6 kg to +/- 7.8 kg; corresponding values for NIRI were -5.3 kg and +/- 5.4 kg. Although some non-age-specific equations appeared valid, age-specific equations generally predicted TBW better. Limb muscle mass (DXA) was predicted better using the segmental impedance method, from indices of limb muscle area (r = 0.76; SEE = 1.9 kg) and volume (r = 0.86; SEE = 1.6 kg), than by anthropometry alone (r = 0.61 and 0.71; SEE = 2.3 kg and 2.1 kg, respectively). In conclusion, some body composition predictions are unacceptable (at least for TBW) in older men, and care is recommended when selecting from these methods or equations. Also, the segmental impedance method is as good as, if not better than, anthropometry alone in predicting limb muscle mass (DXA) in older men.

Components of total energy expenditure in free-living elderly men (over 75 years of age): measurement, predictability and relationship to quality-of-life indices.

Current recommendations for energy requirements in the elderly are based on assumed levels of physical activity relative to BMR (1.5 x BMR). The main aim of the present study was to establish whether these recommendations might be applicable to a randomly-selected group of free-living elderly men (all over 75 years of age). BMR was measured by indirect calorimetry and total energy expenditure (TEE) by the doubly-labelled-water technique. Further aims included evaluating the applicability of a variety of BMR prediction equations and whether assessed quality of life reflected any measured indices of energy expenditure. The mean value for daily energy requirement was found to be 1.5 x BMR (89 J/kg per min) but with substantial inter-individual variation (sd 0.2 x BMR; 14 J/kg per min). The bias between measured TEE and TEE estimated (1.5 x BMR) from the various BMR predictions varied according to which equation was used (-10- + 8% of the mean) with substantial 95% limits of agreement (28-30% of the mean). TEE and physical activity plus thermogenesis (TEE-BMR) were positively related to activities of daily living, but no relationships were apparent between these and perceived quality of life. It is concluded that, despite considerable inter-individual variability, national recommendations for energy requirements of elderly people are applicable to this randomly-selected group of free-living men over 75 years of age but that substantial variation exists when attempts are made to estimate TEE from measurements or predictions of BMR.

Screening for HIV and hepatitis B virus in Los Angeles County prenatal clinics: a demonstration project.

A project designed to pilot voluntary screening for HIV antibody and hepatitis B virus antigen (HBsAg) in women using Los Angeles County Department of Health Services prenatal clinics is described. The purpose of the study was to demonstrate that HIV testing could be integrated into an existing prenatal health care system with minimal disruption. In an 8-month period, 9,069 women entered the project; 76% accepted HIV antibody testing. The rate of HIV antibody seropositivity was 144 per 100,000 (10 per 6,943), and the rate of HBsAg seropositivity was 253 per 100,000 (23 per 9,103). No difference in test acceptance rates was found using a sign-off versus a sign-on HIV antibody consent form although potential confounders were not controlled. Only five of the eight HIV antibody-positive women (63%) and eight of the 20 HBsAg-positive women (40%) who were interviewed reported behaviors considered high risk for HIV or HBsAg infection.