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Study objective Termination of resuscitation in the field for out-of-hospital cardiac arrest can reduce unnecessary transport to hospital and associated road hazards and increase availability of emergency medical services (EMS) and emergency department resources for other patients. We compare the performance of 3 termination-of-resuscitation guidelines for basic life support–defibrillator (BLS) providers when applied to cardiac arrest patients in the Ontario Prehospital Advanced Life Support study. Methods This prospective cohort study involved all out-of-hospital cardiac arrest patients attended by BLS defibrillator providers in 21 Ontario urban or suburban communities. The data analyses were conducted secondarily on these prospectively collected data. Three termination-of-resuscitation guidelines (referred to as Marsden, Petrie, and Verbeek rules) were applied and contingency tables calculated to show the relationship between the rule and actual survival. Results From 1988 to 2003, 13,684 cardiac arrest patients were attended by BLS defibrillator providers. Six hundred thirty-six (4.7%) patients survived to hospital discharge. For the 3 termination-of-resuscitation rules, sensitivity was 99.8% (95% confidence interval [CI] 99.5% to 100.0%) (Petrie rules), 99.5% (95% CI 99.0% to 100.0%) (Verbeek rules), and 99.8% (95% CI 99.5% to 100.0%) (Marsden rules). Specificity was 9.9% (95% CI 9.4% to 10.4%) (Petrie rules), 52.9% (95% CI 52.1% to 53.8%) (Verbeek rules), and 19.4 % (95% CI 18.8% to 20.1%) (Marsden rules). Negative predictive value was 99.9% (95% CI 99.8% to 100.0%) (Petrie rules), 100.0% (95% CI 99.9% to 100.0%) (Verbeek rules), and 100.0% (95% CI 99.9% to 100.0%) (Marsden rules). These rules would have resulted in field termination of resuscitation in 9.4% (Petrie rules), 50.5% (Verbeek rules), and 18.5 % (Marsden rules) of cases. Termination of resuscitation was recommended for 1 patient (Petrie rules), 3 patients (Verbeek rules), and 1 patient (Marsden rules), who survived. Conclusion We found all 3 termination-of-resuscitation rules to have high sensitivity and negative predictive value. However, the specificity and transport rates varied greatly. The results of this study will be useful for EMS providers considering adoption of termination of resuscitation in BLS defibrillator systems for out-of-hospital cardiac arrest.

Introduccion y objetivos La practica clinica en la angina inestable (AI) no esta siempre basada en la major evidencia disponible. Las guias clinicas tienen el potencial de mejorar la calidad de la asistencia. Hasta el momento no hay ningun ensayo clinico aleatorizado para evaluar diversas estrategias de implantacion de guias en el sistema sanitario publico espanol. El objetivo de este articulo es comparar la efectividad de una estrategia multifactorial de implantacion de una guia clinica (sesiones formativas interactivas, procesos de consenso local) en la AI frente a una estrategia de diseminacion pasiva. Pacientes y metodo El estudio se realizo en 10 unidades de 3 hospitales universitarios de Sevilla. Participaron 153 especialistas (cardiologos, internistas) y sus pacientes admitidos por AI. La intervencion se realizo de enero a abril de 1998. La recogida retrospectiva de datos se hizo en julio de 1999, tanto para los episodios preintervencion como postintervencion atendidos desde enero a octubre de 1997 y de septiembre 1998 a junio de 1999, respectivamente. En cuanto al diseno, fue un ensayo clinico aleatorizado por grupos, antes-despues, pragmatico. Los desenlaces fueron: cumplimiento de las recomendaciones de una guia sobre la utilizacion de la angiografia coronaria, pruebas de estres y valoracion de fraccion de eyeccion. Resultados La estrategia multifactorial comparada con la pasiva se asocio con una mejoria absoluta en la adecuacion de uso de angiografia coronaria y de pruebas de estres del 11% (intervalo de confianza [IC] del 95%, 0,85-21,1; p = 0,03). Para la valoracion de la fraccion de eyeccion no se encontro asociacion: mejoria absoluta del 1,1% (IC del 95%, −15,9 a 18,1; p = 0,88). Conclusiones Nuestros resultados muestran que una intervencion combinada de sesiones formativas interactivas con procesos de consenso de local administrada a unidades asistenciales de facultativos puede mejorar la adecuacion de uso de la angiografia coronaria y de las pruebas de estres.

Objective To assess the validity of Cystatin-C (Cys-C) and beta trace protein (BTP) as clinical markers of glomerular filtration rate (GFR) in pregnant women. Design Prospective cross sectional study. Setting Obstetric unit of a tertiary care hospital. Population One hundred and thirty-seven normal pregnant women and 13 women postpartum. Methods Twenty-four hour creatinine clearance (CrCl), serum creatinine, Cys-C and BTP concentrations were measured on normal pregnant women in the first trimester (n= 5), second trimester (n= 68) and third trimester (n= 64) and in 13 women postpartum. Data are given as median (2.5th centile, 97.5th centile). Main outcome measures Serum concentrations of Cys-C and BTP compared with creatinine clearance and serum creatinine. Results The median serum creatinine throughout gestation was 53 μmol/L (39, 71), and median CrCl was 143 mL/minute (91 to 216). Postpartum, creatinine rose to 74 μmol/L (58, 86) and CrCl decreased to 104 mL/minute (71, 159). For Cys-C, the median concentration was 0.70 mg/L (0.46, 1.32), and 0.54 mg/L (0.36, 0.96) for BTP. Comparing the second and third trimesters, there was no significant difference between CrCl (median 145 vs 141 mL/minute) and BTP concentrations (median 0.51 vs 0.55 mg/L), while median Cys-C was significantly higher in the third trimester (0.61 vs 0.88 mg/L; P < 0.001). Unlike creatinine and BTP, Cys-C levels decreased to 0.72 mg/L (0.57, 0.95) postpartum. The only significant relationship of either of these markers to the standard used for GFR was between Cys-C and CrCl in the third trimester, and the correlation was weak (r= 0.27 for 1/Cys-C vs CrCl). Conclusion These data demonstrate that despite claims to the contrary, Cys-C is a poor marker of GFR during pregnancy. Similarly, BTP shows little promise.

SummaryPrevious studies suggest elevated factor VIII is a common, independent risk factor for venous thromboembolism (VTE); however, these studies included secondary and idiopathic VTE. We sought to explore the association between elevated factor VIII and VTE in Canadian patients with idiopathic thrombosis, and confirm the current upper factor VIII reference range was appropriate. We enrolled 300 consecutive patients with idiopathic VTE who were matched to friend controls by age, sex and ethnicity. Factor VIII levels were measured and compared between cases and controls. The optimal cut-off value to designate factor VIII levels as elevated was determined using a variety of methods. The optimal upper cut-off value for factor VIII levels was 270 IU/dl. In the logistic regression analysis, cases were more likely to have elevated factor VIII levels (OR:8.76), as were females (OR:1.93) and older subjects (OR:1.05). Factor VIII cutoffs for a 95% specificity by age were 238 IU/dl for subjects 70. Our findings confirm that elevated factor VIII is associated with an increased risk of idiopathic VTE. In our patients and matched controls, the current upper limit of normal (150 IU/dl) for factor VIII is not of clinical use. We propose that the upper limit be increased to 270 IU/dl or individual labs should establish their upper limit if they wish their assays to be discriminatory in patients with VTE. Age specific cut-offs may be clinically relevant.

Short-term modulation of distal tubule fluid nitric oxide in vivo by loop NaCl reabsorption. Background Intrarenal nitric oxide (NO) production and signaling effects are influenced by NaCl loading. To gain further insight into NO mechanisms we determined whether rat distal tubular fluid (DTF) [NO] and collected NO may acutely change when NaCl loop delivery is altered. Methods An NO microelectrode was used to measure real-time DTF [NO] and DT-collected NO. With proximal flow blocked (open system), 150mmol/L NaCl, with and without 10 −4 mol/L furosemide was perfused with measurement of loop [Cl] reabsorption. Using a closed system, DTF [NO] was also determined using several different loop perfusates. Results In the open system, perfusion with 40 nL/min of 150mmol/L NaCl to which 10 −4 mol/L furosemide was added, DT [NO] and DT-collected NO was approximately twice that measured with perfusion of 150mmol/L NaCl alone, while loop Cl reabsorption decreased by half. In the closed system, perfusion at 10 nL/min of 150mmol/L NaCl + furosemide 10 −4 mol/L also induced a significant rise in DTF [NO] and collected NO. Perfusion of 10 −3 mol/L S-methyl-L-thiocitrulline (SMTC) with 150mmol/L NaCl, induces a significant drop in DT [NO], but without a significant increase in collected NO. Furthermore, with addition of 10 −3 mol/L SMTC to the 150mmol/L NaCl + 10 −4 furosemide perfusate, the rise in DT [NO] was prevented. Analysis of covariance showed that flow changes within, or between all groups, had no significant additional effect. Conclusion In both open and closed loop perfusion systems, 10 −4 mol/L furosemide inhibition of NaCl transport stimulates net loop NO emission independent of flow; 10 −3 mol/L SMTC + 150mmol/L NaCl reduces DT [NO], but not DT-collected NO. Short-term net NO emission from the entire loop, as collected in distal tubule fluid, increases with inhibition of loop NaCl transport.

The purpose of this study is to examine the effects of age (≤65 years or >65 years) and androgen-deprivation therapy (ADT, presence or absence) as factors that may predict changes in body composition and fitness following a 24-week exercise program in prostate cancer patients. One hundred twenty-one men were randomly allocated to either: (1) aerobic exercise (AE), (2) resistance exercise (RE), or (3) usual care (UC). Body composition was assessed by DXA. Aerobic fitness was assessed through a maximal treadmill test. Muscular strength was assessed by leg extension and bench press using the eight-repetition maximum test. Responses were compared between younger (≤65 years) and older (>65 years) patients with or without ADT. There did not appear to be an interaction between age and ADT on body composition or fitness, nor were there any significant changes in body composition for participants ≤65 years. In participants aged >65 years, lean mass decreased in AE (p = 0.013) and UC (p = 0.006), but was preserved in RE. In participants receiving ADT, there was a decrease in lean mass in AE (p = 0.003) and UC (p

Background Point-of-care devices (POCDs) for monitoring long-term oral anticoagulation therapy (OAT) may be a useful alternative to laboratory-based international normalized ratio [INR] testing and clinical management. Purpose To determine clinical outcomes of the use of POCDs for OAT management by performing a meta-analysis. Previous meta-analyses on POCDs have serious limitations. Data sources PubMed, the Cochrane Library, DIALOG, MEDLINE, EMBASE, BIOSIS Previews and PASCAL databases. Study selection Randomized controlled trials of patients on long-term OAT, comparing anticoagulation monitoring by POCD with laboratory INR testing and clinical management. Data extraction 1) rates of major hemorrhage; 2) rates of major thromboembolic events; 3) percentage of time that the patient is maintained within the therapeutic range; 4) deaths. Outcomes were compared using a random-effects model. Summary measures of rates were determined. The quality of studies was assessed using the Jadad scale. Data synthesis Seventeen articles (16 studies) were included. Data analysis showed that POCD INR testing reduced the risk of major thromboembolic events (odds ratio [OR] = 0.51; 95% confidence interval [CI] 0.35–0.74), was associated with fewer deaths (OR = 0.58; 95% CI = 0.38–0.89), and resulted in better INR control compared with laboratory INR testing. No significant difference between the two management modalities with respect to odds ratios for major hemorrhage was found. Limitations Quality scores varied from 1 to 3 (out of a maximum of 5). Only 3 studies defined how thromboembolic events would be diagnosed, casting doubt on the accuracy of the reporting of thromboembolic events. The studies suggest that only 24% of patients are good candidates for self-testing and self-management. Compared with patients managed with laboratory-based monitoring, POCD patients underwent INR testing at a much higher frequency and received much more intensive education on OAT management. Conclusions The use of POCDs is safe and may be more effective than laboratory-based monitoring. However, most patients are not good candidates for self-testing and self-management. Patient education and frequency of testing may be the most important factors in successful PODC management. Definitive conclusions about the clinical benefits provided by self-testing and self-management require more rigorously designed trials.

To determine objective criteria for ultrasonography (US) appearance in the diagnosis of abnormal axillary lymph nodes (ALNs) and to assess retrospectively their accuracy in preoperative staging of patients with Breast Imaging Reporting and Data System (BI-RADS) Category 5 breast lesion.US-guided axillary fine-needle aspiration biopsy (FNAB) was performed for preoperative staging of BI-RADS Category 5 lesions in breast cancer patients seen at the Ottawa Regional Women's Breast Health Centre. Retrospectively, ALN morphology was classified into 3 categories based on US appearance: mass-like appearance, focal nodular cortical thickening (FNCT), and diffuse cortical thickening (DCT), the latter 2 with fatty hilum preservation and cortical thickening greater than 2 mm. Cytologic results from the FNAB were compared with axillary lymph node dissection (ALND) or sentinel lymph node procedure (SLNP), when available. Retrospective image-based classification was performed blind to pathology results and analyzed with Pearson's correlation coefficient, receiver operating characteristic (ROC) curves, and chi-square and Hosmer-Lemeshow tests against the cytologic ground truth.Eighty-six ALNs in 84 patients were sampled with an 18-gauge needle under US guidance. The number of passes per sample was related to adequate sampling of positive ALNs having mass-like morphology but not DCT or FNCT (p0.001). The most frequent morphologic presentation of the 86 ALNs was mass-like appearance of lymph nodes (45%), followed by DCT (35%) and FNCT (20%). Metastatic involvement was found in 34 (87%) of 39 ALNs that were mass-like, in 9 (53%) of 17 ALNs with FNCT, and in 9 (30%) of 30 ALNs with DCT. The kappa agreement between FNAB and ALND or SLNP was 0.64 for mass-like lymph nodes, 0.7 for lymph nodes with DCT, and 1.0 for FNCT. Overall sensitivity and specificity were 94% and 89%, respectively, with a positive predictive value of 97% and negative predictive value of 80%.Using a 2-mm threshold, FNCT and DCT warrant US-guided FNAB by an experienced radiologist as much as do mass-like lymph nodes. When biopsy is positive, axillary dissection can be performed and the sentinel node technique avoided.

To assess driving problems experienced by patients with rheumatoid arthritis (RA) and to examine the relationship between functional status and driving difficulty.Using the South Eastern Ontario Medical Organization (SEAMO) database, we identified 721 patients with RA from both urban and rural backgrounds. They completed a cross-sectional, self-administered mail survey that included the Health Assessment Questionnaire (HAQ-DI) and a co-morbidity questionnaire. We assessed the proportion of drivers versus non-drivers and patients who reported difficulty driving and who used vehicle adaptations.Survey response rate was 74% and 92.2% of the subjects were current drivers. Fifty percent of the current drivers reported a little difficulty, 6.8% reported quite a bit of difficulty, and 1.5% a great deal of difficulty driving. Major reasons given for why RA limited their driving were stiffness and pain. Frequent use of mobility aids (adjusted odds ratio, OR: 5.85), HAQ-DIor = 1 (adjusted OR: 3.40), and older age (adjusted OR: 1.04) were significant predictors of an individual with RA discontinuing driving. Higher levels of disability (HAQ-DI) were associated with a greater number of problems reported with driving and with curtailment of driving. A multivariate logistic regression determined that having a HAQ-DIor = 1 (adjusted OR: 4.3) and difficulties sitting in the vehicle (adjusted OR: 2.9) were associated with RA limiting driving.Over 50% of respondents reported some degree of difficulty driving due to their RA. Scores on HAQ-DIor = 1 were associated with difficulty driving. Further validation of our findings needs to be performed.

The authors have developed a CT protocol, CT duodeno-cholangiopancrealography (CDCP), which is performed during a single contrast-enhanced phase, proceeding cranially, allowing enhancement of the pancreas during its parenchymal phase followed by enhancement of the liver during its portal-venous phase. This retrospective pilot study evaluates CDCP compared with endoscopic retrograde cholangiopancreatography (ERCP) as a diagnostic tool for assessing the cause and level ol biliary obstruction. Forty-one patients with jaundice underwent CDCP and ERCP between October 2002 and May 2004. Pathologic confirmation was obtained in 31 of the 41 (76%) patients. The sensitivity, specificity, and kappa values of CDCP and ERCP compared with pathology were calculated for tumors and stones. Pathology-proven cases included 7 cases of stones, 23 tumors, and I other cause of obstruction. The overall level of agreement of diagnoses between CDCP and pathology was 29 of 31 (93.5%); that between CDCP and ERCP was 36 of 41 (88%). Comparing CDCP to pathology for tumors, (lie sensitivity was 100%, the specificity was 89%, and the kappa was 0.92 (95% CI 0.76 1.0). For stone detection, CDCP had a sensitivity of 86%, a specificity of 100%. and a kappa value of 0.90 (95% CI 0.72 1.0). For level of obstruction of the Common bile duct, comparing CDCP to ERCP, observations agreed in 31 of the 36 (86%) cases; for the pancreatic duct, observations agreed in 24 of the 25 (96%) cases. CDCP is a noninvasive diagnostic tool that can he used to assess the cause and level of obstruction. A blinded prospective study would he valuable to further assess the merits of CDCP.

INTRODUCTION AND OBJECTIVES. Clinical practice in unstable angina is not always based on best evidence. Guidelines have the potential to improve quality of health care. There are no randomised trials assessing implementation strategies in the public healthcare system of Spain yet.to compare the effectiveness of a multifaceted strategy (interactive educational meetings, local consensus process) for guideline implementation in unstable angina, with a passive dissemination strategy. Patients and method.10 wards from 3 university hospitals in Sevilla.153 specialists (cardiologists, internists) and their patients admitted for an unstable angina episode.a pragmatic, before and after cluster randomized controlled trial. Intervention was delivered from January to April 1998. Retrospective data collection took place in July 1999, of those pre and post-intervention episodes attended from January to October 1997 and from September 1998 to June 1999, respectively.compliance with the guideline recommendations for coronary angiography and stress testing, and ejection fraction assessment.The multifaceted strategy compared with the passive one, was associated with an absolute improvement in the appropriateness of use of coronary angiography and stress testing of 11% (95% CI, 0.85-21.1), P=.03. There was no association for the assessment of the ejection fraction: absolute improvement of 1.1% (95% CI, --15.9 to 18.1), P=.88.Our results show that a combination of interactive educational meetings and local consensus process delivered to wards of physicians may improve the appropriateness of use of coronary angiography and stress testing.

SummaryThe deletion/deletion (D/D) genotype of the angiotensin converting enzyme (ACE) has been purported to be a risk for postoperative thrombosis. This D/D genotype has not been evaluated as a risk factor for idiopathic venous thromboembolism (VTE).The primary objective of the present study was to determine whether the D/D genotype of ACE is independently associated with the occurrence of idiopathic venous thromboembolic disease.We prospectively enrolled consecutive patients with at least one objectively confirmed idiopathic VTE. Friends of cases were recruited as controls and matched to cases by sex, ethnicity, and age. Patients were tested for the ACE I/D polymorphism in addition to factor V Leiden, prothrombin G20210A, and factor VIII levels.Three hundred cases and 300 controls were enrolled; 97% were Caucasian. There were 148 females and 152 males in each group with a mean age of 56.21 years (SD=15.33). The ACE D/D genotype was present in 25.3% of cases and 32.4% of controls for an adjusted odds ratio of 0.66 (95% CI = 0.433 to 0.997). We can conclude that the ACE D/D genotype is protective against idiopathic venous thromboembolism.

Background Previous trials have evaluated the effects of aerobic training alone and of resistance training alone on glycemic control in type 2 diabetes, as assessed by hemoglobin A1c values. However, none could assess incremental effects of combined aerobic and resistance training compared with either type of exercise alone. Objective To determine the effects of aerobic training alone, resistance training alone, and combined exercise training on hemoglobin A1c values in patients with type 2 diabetes. Design Randomized, controlled trial. Setting 8 community-based facilities. Patients 251 adults age 39 to 70 years with type 2 diabetes. A negative result on a stress test or clearance by a cardiologist, and adherence to exercise during a 4-week run-in period, were required before randomization. Interventions Aerobic training, resistance training, or both types of exercise (combined exercise training). A sedentary control group was included. Exercise training was performed 3 times weekly for 22 weeks (weeks 5 to 26 of the study). Measurements The primary outcome was the change in hemoglobin A1c value at 6 months. Secondary outcomes were changes in body composition, plasma lipid values, and blood pressure. Results The absolute change in the hemoglobin A1c value in the combined exercise training group compared with the control group was -0.51 percentage point (95% CI, -0.87 to -0.14) in the aerobic training group and -0.38 percentage point (CI, -0.72 to -0.22) in the resistance training group. Combined exercise training resulted in an additional change in the hemoglobin A1c value of -0.46 percentage point (CI, -0.83 to -0.09) compared with aerobic training alone and -0.59 percentage point (CI, -0.95 to -0.23) compared with resistance training alone. Changes in blood pressure and lipid values did not statistically significantly differ among groups. Adverse events were more common in the exercise groups. Limitations The generalizability of the results to patients who are less adherent to exercise programs is uncertain. The participants were not blinded, and the total duration of exercise was greater in the combined exercise training group than in the aerobic and resistance training groups. Conclusion Either aerobic or resistance training alone improves glycemic control in type 2 diabetes, but the improvements are greatest with combined aerobic and resistance training. ClinicalTrials.gov registration number: NCT00195884.