Search

OBJECTIVE: Timely reperfusion therapy for ST-elevation myocardial infarction (STEMI) is an important determinant of outcome, yet targets for time to treatment are frequently unmet in North America. Prehospital strategies can reduce time to reperfusion. We sought to determine the extent to which emergency medical services (EMS) use these strategies in Canada. METHODS: We carried out a cross-sectional survey in 2007 of ground EMS operators in British Columbia, Alberta, Ontario, Quebec and Nova Scotia. We focused on the use of 4 prehospital strategies: 1) 12-lead electrocardiogram (ECG), 2) routine expedited emergency department (ED) transfer of STEMI patients (from a referring ED to a percutaneous coronary intervention [PCI] centre), 3) prehospital bypass (ambulance bypass of local EDs to transport patients directly to PCI centres) and 4) prehospital fibrinolysis. RESULTS: Ninety-seven ambulance operators were surveyed, representing 15 681 paramedics serving 97% of the combined provincial populations. Of the operators surveyed, 68% (95% confidence interval [CI] 59%-77%) had ambulances equipped with 12-lead ECGs, ranging from 40% in Quebec to 100% in Alberta and Nova Scotia. Overall, 47% (95% CI 46%-48%) of paramedics were trained in ECG acquisition and 40% (95% CI 39%-41%) were trained in ECG interpretation. Only 18% (95% CI 10%-25%) of operators had prehospital bypass protocols; 45% (95% CI 35%-55%) had protocols for expedited ED transfer. Prehospital fibrinolysis was available only in Alberta. All EMS operators in British Columbia, Alberta and Nova Scotia used at least 1 of the 4 prehospital strategies, and one-third of operators in Ontario and Quebec used 0 of 4. In major urban centres, at least 1 of the 3 prehospital strategies 12-lead ECG acquisition, bypass or expedited transfer was used, but there was considerable variation within and across provinces. CONCLUSION: The implementation of widely recommended prehospital STEMI strategies varies substantially across the 5 provinces studied, and relatively simple existing technologies, such as prehospital ECGs, are underused in many regions. Substantial improvements in prehospital services and better integration with hospital-based care will be necessary in many regions of Canada if optimal times to reperfusion, and associated outcomes, are to be achieved. [ABSTRACT FROM AUTHOR]

Objectives: Most studies of pre-hospital management of ST-elevation myocardial infarction (STEMI) have involved physicians accompanying the ambulance crew, or electrocardiogram (ECG) transmission to a physician at the base hospital. We sought to determine if Advanced Care Para-medics (ACPs) could accurately identify STEMI on the pre-hospital ECG and contribute to strategies that shorten time to reperfusion.Methods: A STEMI tool was developed to: 1) measure the accuracy of the ACPs at diagnosing STEMI; and 2) determine the potential time saved if ACPs were to independently administer thrombolytic therapy. Using registry data, we subsequently estimated the time saved by initiating thrombolytic therapy in the field compared with in-hospital administration by a physician.Results: Between August 2003 and July 2004, a correct diagnosis of STEMI on the pre-hospital ECG was confirmed in 63 patients. The performance of the ACPs in identifying STEMI on the ECG resulted in a sensitivity of 95% (95% confidence interval [CI] 86%-99%), a specificity of 96% (95% CI 94%-98%), a positive predictive value (PPV) of 82% (95% CI 71%-90%), and a negative predictive value (NPV) of 99% (95% CI 97%--100%). ACP performance for appropriately using thrombolytic therapy resulted in a sensitivity of 92% (95% CI 78%--98%), a specificity of 97% (95% CI 94%-98%), a PPV of 73% (95% CI 59%--85%) and an NPV of 99% (95% CI 97%-100%). We estimated that the median time saved by ACP administration of thrombolytic therapy would have been 44 minutes.Conclusions: ACPs can be trained to accurately interpret the pre-hospital ECG for the diagnosis of STEMI. These results are important for the design of regional integrated programs aimed at reducing delays to reperfusion. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the prevalence of popliteal aneurysms in men to enable the case for screening and elective surgery to be assessed. SETTING: Scott Research Unit, St Richards Hospital, Chichester. METHODS: The popliteal arteries of 1074 men aged between 65 and 80 were scanned with ultrasound, aneurysmal vessels >1.5 cm diameter were rescanned 5 years later to assess their rate of expansion. RESULTS: 11 of 1074 patients screened had a popliteal aneurysm between 15 and 26 mm, a prevalence of 1.0%. Five years later no increase in aneurysm size had occurred and no related complications were reported. CONCLUSION: In men the low prevalence and complication rate of popliteal aneurysms in conjunction with the effective treatment of acutely thrombosed aneurysms provides evidence for conservative management but against screening asymptomatic popliteal aneurysms. [ABSTRACT FROM AUTHOR]

Context: Blood flow restriction (BFR) is a rehabilitation tool which may introduce a constraint, similar to muscle fatigue, that challenge patients' sensorimotor system during balance exercises. The purpose of our study was to examine whether adding BFR to dynamic balance exercises produced a decrease in balance performance and an increase in ratings of perceived exertion and instability in individuals with chronic ankle instability (CAI) compared with dynamic balance exercises without BFR., Designs: Crossover design., Methods: Our sample included N = 25 young adults with a history of CAI. Participants completed 2 laboratory visits. At each visit, participants completed 4 sets (30×-15×-15×-15×) of dynamic balance exercises, performed similar to the modified star excursion balance test (SEBT), once with BFR and once with control (no BFR) conditions. We measured composite SEBT scores at baseline and during the final repetitions of each set of balance exercise (sets 1-4). We also measured ratings of perceived exertion and instability following each balance exercise set., Results: We observed no difference in composite SEBT scores between conditions at baseline; however, composite SEBT scores were significantly lower during all balance exercises sets 1 to 4 with the BFR condition compared with control. During the BFR condition, composite SEBT scores were significantly lower during all balance exercise sets compared with baseline. During the control condition, composite SEBT scores did not significantly change between baseline and each balance exercise set. Ratings of perceived exertion and instability scores were significantly greater in the BFR group compared with the control group during all balance exercise sets., Conclusions: Individuals with CAI demonstrated lower composite SEBT scores and greater perceived instability and exertion during dynamic balance exercise with BFR compared to without BFR. BFR introduced a novel muscle fatigue constraint during dynamic balance exercises in individuals with CAI. Additional research is needed to determine if adding BFR to balance training could improve clinical outcomes in CAI patients.

Background: Internal medicine (IM) residency is a notoriously challenging time generally characterized by long work hours and adjustment to new roles and responsibilities. The COVID-19 pandemic has led to multiple emergent adjustments in training schedules to accommodate increasing needs in patient care. The physician training period, in itself, has been consistently shown to be associated with vulnerability with respect to mental well-being. The impact of the COVID-19 pandemic on the experience of IM trainees is not well established., Objective: Characterize the impact of the COVID-19 pandemic on trainee clinical education, finances, and well-being., Methods: We developed a survey composed of 25 multiple choice questions, 6 of which had an optional short-answer component. The survey was distributed by the American College of Physicians (ACP) to 23,289 IM residents and subspecialty fellows. We received 1,128 complete surveys and an additional 269 partially completed surveys., Results: The majority of respondents reported a disruption in their clinical schedule (76%) and a decrease in both didactic conferences (71%) and protected time for education (56%). A majority of respondents (81%) reported an impact on their well-being with an increase in their level of burnout and 41% of respondents reported a decrease in level of direct supervision. Despite these changes, the majority of trainee respondents (78%) felt well prepared for clinical practice after graduation., Conclusions: These results outline the vulnerable position of internal medicine physicians in training. Preserving educational experiences, adequate supervision, and humane work hours are essential in protecting trainees from mental illness and burnout during global emergencies., (© 2023. The Author(s).)

Children born extremely preterm (EP) have poorer academic attainment than their term-born peers. There is a need to identify the specific cognitive mechanisms that are associated with poor academic attainment in preterm populations to inform the development of intervention strategies. A parallel mediation analysis was conducted with cross-sectional data from 152 EP children (< 27 weeks of gestation) and 120 term-born controls who were assessed at age 11. Mathematics and reading attainment was assessed using the Wechsler Individual Achievement Test 2nd Edition. Controlling for sex and socio-economic status we evaluated the following mediators: verbal working memory, visuospatial working memory, verbal processing speed, attention, and visuospatial processing. These were assessed using subtests from the standardized NEPSY-II test and Wechsler Intelligence Scale for Children-5th Edition. Verbal working memory, visuospatial working memory, visuospatial processing and verbal processing speed, but not attention, were significant independent mediators between EP birth and attainment in reading. No direct relationship between EP birth and reading attainment remained in the mediated model. All five neuropsychological variables mediated the relationship between EP birth and attainment in mathematics, but a direct effect of EP birth on mathematics remained in the mediated model. Together, all five neuropsychological abilities indirectly explained 44% of the variance in reading and 52% of the variance in mathematics. Visuospatial processing was the strongest mediator of both mathematics and reading. Components of executive function, especially visuospatial processing, are important predictors of academic attainment. Interventions to improve visuospatial skills could be trialed in EP populations.

There is emergent literature on the relationship between the development of sleep-wake cycles, sleep architecture, and sleep duration during the neonatal period on neurodevelopmental outcomes among children born preterm. There is also a growing literature on techniques to assess sleep staging in preterm neonates using either EEG methods or heart and respiration rate. Upon discharge from hospital, sleep in children born preterm has been assessed using parent report, actigraphy, and polysomnography. This review describes the ontogeny and measurement of sleep in the neonatal period, the current evidence on the impact of preterm birth on sleep both in the NICU and in childhood and adolescence, and the interaction between sleep, cognition, and social-emotional outcomes in this population.

Objectives: To determine growth outcomes at 11 years of age in children born <27 weeks of gestation in England in 2006 (EPICure2) and to compare growth from birth to 11 years of age for births<26 weeks with those in England in 1995 (EPICure)., Methods: 200 EPICure2 children assessed at 11 years alongside 143 term-born controls. Growth measures from birth to 11 years were compared for births<26 weeks between EPICure2 (n=112) and EPICure (n=176). Growth parameter z-scores were derived from 1990 UK standards., Results: Among EPICure2 children, mean z-scores for height and weight were close to the population standards (0.08 and 0.18 SD, respectively) but significantly below those of controls: difference in mean (Δ) z-scores for weight -0.42 SD (95% CI -0.68 to -0.17), for height -0.45 SD (-0.70 to -0.20) and for head circumference (HC) -1.05 SD (-1.35 to -0.75); mean body mass index (BMI) z-score in EPICure2 children was 0.18 SD, not significantly different from controls (0.43 SD, p=0.065). Compared with EPICure, EPICure2 children born <26 weeks at 11 years had higher z-scores for weight (Δ 0.72 (0.47, 0.96)), height (Δ 0.55 (0.29, 0.81)) and BMI (Δ 0.56 (0.24, 0.87)), which were not fully explained by perinatal/demographic differences between eras. Weight catch-up was greater from term-age to 2.5/3 years in EPICure2 than in EPICure (1.25 SD vs 0.53 SD; p<0.001). Poor HC growth was observed in EPICure2, unchanged from EPICure., Conclusions: Since 1995, childhood growth in weight, height and BMI have improved for births <26 weeks of gestation, but there was no improvement in head growth., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Aim: To determine whether children born extremely preterm are at increased risk for sleep disturbances and to explore relationships between extremely preterm birth, sleep and attention-deficit/hyperactivity disorder (ADHD) symptoms and emotional symptoms., Method: EPICure2 cohort study. Parents of 165 children born ≤26 weeks' gestation (53% male) and 121 children born at term (43% male) completed the Children's Sleep Habits Questionnaire, sleep disordered breathing subscale of the Pediatric Sleep Questionnaire, the emotional problems scale of the Strengths and Difficulties Questionnaire and the ADHD Rating Scale-5 at 11 years of age., Results: Extremely preterm children had greater habitual snoring (adjusted odds ratio 6.8; 95% confidence interval 2.3, 20.3), less frequently fell asleep within 20 minutes (Cohen's d 0.33), higher night wakings (d 0.44) and daytime sleepiness scores (d 0.40) than term-born children; there was no between-group difference in sleep duration scores. Among children without severe disability, night wakings scores partially mediated the relationship between preterm birth and inattention (additional 5% of variance explained), hyperactivity/impulsivity (13%) and emotional problems (9%). Snoring partially mediated the relationship between preterm birth, hyperactivity/impulsivity and inattention (additional 1-5% of variance)., Conclusion: Children born extremely preterm are at increased risk of disturbed sleep compared to term-born children. As night wakings partially mediated the relationship between preterm birth and ADHD symptoms and emotional problems, reducing sleep disturbance may improve sleep and reduce attention and emotional problems in this population., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: To determine whether improvements in school age outcomes had occurred between two cohorts of births at 22-25 weeks of gestation to women residents in England in 1995 and 2006., Design: Longitudinal national cohort studies., Setting: School-based or home-based assessments at 11 years of age., Participants: EPICure2 cohort of births at 22-26 weeks of gestation in England during 2006: a sample of 200 of 1031 survivors were evaluated; outcomes for 112 children born at 22-25 weeks of gestation were compared with those of 176 born in England during 1995 from the EPICure cohort. Classroom controls for each group acted as a reference population., Main Outcome Measures: Standardised measures of cognition and academic attainment were combined with parent report of other impairments to estimate overall neurodevelopmental status., Results: At 11 years in EPICure2, 18% had severe and 20% moderate impairments. Comparing births at 22-25 weeks in EPICure2 (n=112), 26% had severe and 21% moderate impairment compared with 18% and 32%, respectively, in EPICure. After adjustment, the OR of moderate or severe neurodevelopmental impairment in 2006 compared with 1995 was 0.76 (95% CI 0.45 to 1.31, p=0.32). IQ scores were similar in 1995 (mean 82.7, SD 18.4) and 2006 (81.4, SD 19.2), adjusted difference in mean z-scores 0.2 SD (95% CI -0.2 to 0.6), as were attainment test scores. The use of multiple imputation did not alter these findings., Conclusion: Improvements in care and survival between 1995 and 2006 are not paralleled by improved cognitive or educational outcomes or a reduced rate of neurodevelopmental impairment., Competing Interests: Competing interests: All authors declare no financial relationships with any organisations that might have an interest in the submitted work in the previous three years and no other relationships or activities that could appear to have influenced the submitted work. NM declares consultancy fees from Novartis in the past 3 years outside this study; the other authors have no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess whether adolescents born very preterm (VP; <32 weeks' gestation) have an excess of mathematics anxiety compared with their classmates born at term., Methods: This cohort study included 127 adolescents born VP (51% male, mean age 13.9 years, SD 0.7) and 95 term-born classmates (56% male, mean age 13.7 years, SD 0.7) who completed the Wechsler Individual Achievement Test Second UK Edition and the Mathematics Anxiety Scale-UK at the age of 11 to 15 years. Self-reported trait anxiety was assessed using a composite of 3 items from the Strengths and Difficulties Questionnaire., Results: Adolescents born VP had significantly poorer mathematics attainment than adolescents born at term (difference in means: -0.64 SD; 95% confidence interval -0.95 to -0.34). However, there were no between-group differences in self-reported mathematics anxiety or trait anxiety. There were significant moderate associations between mathematics anxiety and mathematics attainment for adolescents born VP (rho: -0.45) and at term (rho: -0.54), after controlling for trait anxiety., Conclusion: Adolescents born VP do not have heightened mathematics anxiety compared with their term-born classmates, despite poorer attainment in mathematics. Improving domain-general cognitive skills and scaffolding learning in the classroom may be more promising avenues for intervention than attempting to reduce mathematics anxiety., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Objectives: The objectives of the study were (1) to compare both actigraphy and questionnaire-assessed sleep quality and timing in children with Smith-Magenis syndrome (SMS) to a chronologically age-matched typically developing (TD) group and (2) to explore associations between age, nocturnal and diurnal sleep quality, and daytime behavior., Methods: Seven nights of actigraphy data were collected from 20 children with SMS (mean age 8.70; SD 2.70) and 20 TD children. Daily parent/teacher ratings of behavior and sleepiness were obtained. Mixed linear modeling was used to explore associations between total sleep time and daytime naps and behavior., Results: Sleep in children with SMS was characterized by shorter total sleep time (TST), extended night waking, shorter sleep onset, more daytime naps, and earlier morning waking compared to the TD group. Considerable inter-daily and inter-individual variability in sleep quality was found in the SMS group, so caution in generalizing results is required. An expected inverse association between age and TST was found in the TD group, but no significant association was found for the SMS group. No between-group differences in sleep hygiene practices were identified. A bidirectional negative association between TST and nap duration was found for the SMS group. In the SMS group, increased afternoon sleepiness was associated with increased irritability (p = .007) and overactivity (p = .005)., Conclusion: These findings evidence poor sleep quality in SMS and the need to implement evidence-based interventions in this population., (© Sleep Research Society 2019. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.)