ILCOR's revised Covid-19 defibrillation recommendation requires a new approach to training.

In-hospital resuscitation practices have changed by necessity in the Covid-19 era, principally due to precautions intended to protect caregivers from infection. This has resulted in serious delays in resuscitation response.ILCOR has recently modified its guidelines to separate defibrillation from other interventions, recognizing that shock success is extremely time-dependent and that defibrillation poses relatively little risk of Covid-19 transmission. The new recommendation calls for sending one caregiver into the isolation room in order to initiate bedside monitoring and defibrillate if indicated, while the code team is donning their personal protective equipment. Implementing this change requires focused training in that specific role. This can be accomplished by intensively training a subset of clinical staff to assume the responsibility and act without hesitation when a code occurs.Focused defibrillation training promises to avoid compromising the care of patients experiencing tachyarrhythmic arrests in the setting of Covid-19. Such a training program might even result in better survival than before the pandemic for this subset of patients.

Automated external defibrillators in the hospital: A case of medical reversal.

Automated external defibrillators (AEDs) emerged in the 1980s as an important innovation in pre-hospital emergency cardiac care (ECC). In the years since, the American Heart Association (AHA) and the International Liaison Committee for Resuscitation (ILCOR) have promoted AED technology for use in hospitals as well, resulting in the widespread purchase and use of AED-capable defibrillators. In-hospital use of AEDs now appears to have decreased survival from cardiac arrests. This article will look at the use of AEDs in hospitals as a case of "medical reversal." Medical reversal occurs when an accepted, widely used treatment is found to be ineffective or even harmful. This article will discuss the issue of AEDs in the hospital using a conceptual framework provided by recent work on medical reversal. It will go on to consider the implications of the reversal for in-hospital resuscitation programs and emergency medicine more generally.

Factors influencing quality of sleep among non-mechanically ventilated patients in the Intensive Care Unit.

AIM: To investigate the self-reported quality of sleep of non-mechanically ventilated patients admitted to an ICU, and to identify barriers to sleep in this setting. METHOD: Patients admitted to the ICU of Frankston Hospital over a two month period who had spent at least one night in the ICU, and had not received mechanical ventilation were surveyed as they were discharged from the ICU. This survey required patients to rate the quality of their sleep in the ICU and at home immediately prior to hospitalisation on a 10cm visual analogue scale; and to identify perceived barriers to sleep in the ICU and at home prior to hospitalisation. RESULTS: 56 respondents were surveyed during the study period. Median age was 74 years (range=18-92 years); median ICU length of stay was 1 day (range=1-7 days). Overall, respondents rated their quality of sleep in ICU (median=4.9/10) as significantly worse than at home immediately prior to ICU admission (median=7.15/10; Z=-3.02, p<0.002); however 44% of respondents rated their quality of sleep in ICU as better, or no worse, than at home immediately prior to hospitalisation. Sub-group analysis revealed that among patients with reduced quality of sleep (<5/10) prior to hospitalisation, 71.4% rated their quality of sleep in ICU as better, or no worse, than at home prior to hospitalisation, with no significant difference between sleep quality ratings in ICU and at home (p=0.341). Respondents identified the following as barriers to sleep in the ICU: noise levels overnight (53.6%); discomfort (33.9%); pain (32.1%); being awoken for procedures (32%); being attached to medical devices (28.6%); stress/anxiety (26.8%); and light levels (23.2%). CONCLUSION: Pre-hospitalisation sleep quality appears to be an important influence on sleep in ICU. Many barriers to sleep in the ICU identified by respondents are potentially modifiable.

A Canadian study of the use of poly-L-lactic acid dermal implant for the treatment of hill and valley acne scarring.

BACKGROUND: Hill and valley scarring is 1 of 3 atrophic scar types that occur as a result of acne, becoming more apparent with facial skin aging. Treatment includes resurfacing techniques and the use of injectable fillers. Poly-L-lactic acid is an injectable collagen builder that has been used for the treatment of HIV-associated lipodystrophy and cosmetic enhancement. OBJECTIVE: To determine the degree of correction attainable with poly-L-lactic acid and safety findings for the treatment of hill and valley acne scarring. MATERIALS AND METHODS: Poly-L-lactic acid was injected over 3 to 4 serial treatments at 4-week intervals in 22 subjects in this single-arm, unblinded, open-label Phase II study. Efficacy was determined by physician, blinded evaluator, and subject assessment of scar improvement using Likert scales, comparing photographs taken by 3 camera systems at treatment visits 2 to 4 and follow-up to baseline. Subjects also assessed treatment satisfaction. RESULTS: Percentage of patients with much to excellent improvement using the most sensitive camera system (VISIA-CR) ranged from 45.5% to 68.2%. Subject treatment satisfaction scores increased by 44%. One patient experienced a palpable nonvisible nodule. No subjects discontinued treatment. CONCLUSION: Injectable poly-L-lactic acid facilitated improvement in hill and valley acne scarring and was well tolerated.

Environmental Justice and Health Effects of Urban Air Pollution.

PURPOSE: Minority communities often bear the burden of "hosting" pollution sources. This report assesses whether there are any health effects from living near such pollution sources and whether health effects of pollution vary by sex, ethnicity, or income. METHODS: The air pollution emissions from Hartford area, point sources are modeled and exposures are estimated for the residents who participated in a geographically-based health survey. The pollution intensities and other individual and neighborhood characteristics are used to predict an individual's reported respiratory problems. RESULTS: The results indicate that respiratory problems are correlated significantly with pollution levels, especially sulfur dioxide from the local trash-to-energy incinerator-the fifth largest one in the U.S. The effects of a given pollution level tend to be more serious for specific subgroups based upon sex, ethnicity, poverty, and age. CONCLUSION: Even when controlling for other factors, air pollution levels are significantly correlated with health problems, especially for Hispanics. This air pollution may contribute to health disparities.

Can a computerized format replace a paper form in PRO and HRQL evaluation? Psychometric testing of the computer-assisted LCSS instrument (eLCSS-QL).

PURPOSE: This trial assessed the ability to enhance health-related quality of life (HRQL) and patient-reported outcome (PRO) evaluation in trials and patient management using computer assistance with a handheld device, called a personal digital assistant. The study assessed ease of use and psychometric properties of this approach, comparing the Lung Cancer Symptom Scale (LCSS) paper form with the electronic (eLCSS-QL). Objectives were to: (1) measure completion times; (2) evaluate acceptability by patients, nurses, and physicians; (3) determine the correlation of the eLCSS-QL with the paper version; and (4) determine the feasibility of using a shorter visual analogue scale (VAS) in the electronic version. PATIENTS AND METHODS: Patients were entered at 12 COMET clinics. All had: (a) stage III or IV non-small cell lung cancer, (b) Karnofsky performance status (KPS) ≥ 60, (c) no prior chemotherapy, and (d) received initial courses of docetaxel + platinum. Of the 148 patients enrolled, characteristics were: men, 57 %; median, KPS 80 %; and median age, 67 years. Of these, 131 patients completed the evaluation form. RESULTS: The eLCSS-QL had excellent acceptance by patients, nurses, and physicians. Patients required 2.2 min (mean) to complete the eLCSS-QL. Reliability coefficients using Cronbach's alpha were high for the paper (0.84) and electronic (0.88) versions. The correlation coefficient between forms was high (0.92). The length of the VAS on the handheld pc (53 mm versus 100 mm on the paper format) resulted in nearly identical scores. CONCLUSIONS: The high acceptance rate by patients and professionals, the rapid completion time, ease of use, and strong psychometric properties confirm that the electronic LCSS (eLCSS-QL) is practical for use in trials and patient management. This study indicates that computer assistance helps overcome barriers associated with evaluating HRQL and PROs.

Management and adherence to VTE treatment guidelines in a national prospective cohort study in the Canadian outpatient setting. The Recovery Study.

Documenting patterns and outcomes of venous thromboembolism (VTE) management and degree of adherence by clinicians to treatment guidelines could help identify remediable gaps in patient care. Prospective, clinical practice-based data from Canadian outpatient settings on management of VTE, degree of adherence with treatment guidelines and frequency of recurrent VTE and bleeding during follow-up was obtained in a multicentre, prospective observational study. From 12 Canadian centres, we assessed 868 outpatients with acute symptomatic VTE who received the low-molecular-weight heparin (LMWH) enoxaparin alone or with vitamin K antagonists (VKA), at baseline and at six months (or at the end of treatment, whichever came first). Index VTE was limb deep venous thrombosis (DVT) in 583 (67.2%) patients, pulmonary embolism (PE) with or without DVT in 262 (30.2%) patients, and unusual site DVT in 23 (2.6%) patients. VTE was unprovoked in 399 (46.0%) patients, associated with cancer in 74 (8.5%) patients, transient risk factors in 327 (37.7%) patients and hormonal factors in 68 (7.8%) patients.With regard to guideline adherence, 58 (7.3%) patients received <5 days LMWH and 114 (14.5%) had overlap <1 day. Among patients with cancer-related VTE, 59.5% were prescribed LMWH monotherapy and 43.2% received such treatment for >3 months. Only 38.1% of patients with transient VTE risk factors had received thromboprophylaxis. Our study provides useful information on clinical presentation, management and related outcomes in Canadian outpatients with VTE. Our results suggest there may be important gaps in use of thromboprophylaxis to prevent VTE and use of LMWH monotherapy to treat cancer-related VTE.

Focused nurse-defibrillation training: a simple and cost-effective strategy to improve survival from in-hospital cardiac arrest.

Time to first defibrillation is widely accepted to correlate closely with survival and recovery of neurological function after cardiac arrest due to ventricular fibrillation or ventricular tachycardia. Focused training of a cadre of nurses to defibrillate on their own initiative may significantly decrease time to first defibrillation in cases of in-hospital cardiac arrest outside of critical care units. Such a program may be the best single strategy to improve in-hospital survival, simply and at reasonable cost.