Successful resuscitation after out-of-hospital cardiac arrest
Ann Emerg Med 2015; 65: 523-31
Although the survival rate after out-of-hospital cardiac arrest is increasing, the prognosis is still poor. It has been helped by wider availability of defibrillators, community responders and specialist cardiac centres with early revascularisation.
This study from Copenhagen looked at factors that influence survival and any temporal trends.
The factors that improve survival are obvious. A shockable rhythm increases survival chances fourfold, a witnessed arrest, 3.5 times, and a cardiac arrest in a public place, twofold. Other factors that help are bystander CPR, short time to hospital and younger age.
Factors that made no difference were comorbidity, sex or employment status.
Survival rates have increased by 1.6% each year, despite an increase in illness burden. Looking at how this paper might benefit patients outside hospital, the most obvious changeable factor to improve outcome is education – teaching CPR.
Criteria for infant dyschezia
Arch Dis Child 2015; 100: 533
Infant dyschezia is defined by the Rome III criteria of straining and crying for at least 10 minutes before successfully passing a soft stool in ?an infant under six months, in the ?absence of other health problems.
This functional GI disorder is thought to result from lack of co-ordination, leading to a build-up of GI pressure before relaxation of the pelvic floor allows defecation.
This prospective study looked at the outcomes for infants with dyschezia. There were 1,292 infants in the study. At one and three months, 3.9% and 0.9% of the infants respectively fulfilled the Rome III criteria, although 17.3% and 6.5% of parents reported pre-defecation symptoms.
At nine months, only 4.9% of the infants who fulfilled the Rome III criteria had symptoms of infantile functional constipation. Of those reported by the parents to have symptoms, this figure dropped to 0.3%.
The study shows that this is largely a self-limiting condition and confirms there is no role for laxatives in its management. The authors also suggest relaxing the criteria to fit more closely with parents’ experiences, and to allow clinicians to have a tool for explaining the condition and prognosis to parents.
Operating at night
Am J Surg 2015; 209: 633-9
With plans to make GPs work longer hours, this paper seems pertinent. This US study looked at a fairly narrow field – the standardised mortality rate (SMR) of trauma patients undergoing emergency exploratory laparotomy.
The researchers compared the SMR in operations started in what they called the ‘sleepy hours’ of midnight to 6am with the ‘awake hours’ or office hours of 7am to 5pm.
They found no difference in SMR between the two times and put this down to the heightened excitatory stimuli of acute trauma overcoming sleepiness.
Looking at the SMR hour-by-hour, they also found that mortality rose as the day wore on, to reach a peak at 7pm.
No explanation is given for this, but perhaps there are lessons for GPs who work long days.
Evolocumab in familial hypercholesterolaemia
Lancet 2015; 385: 331-40
Heterozygous familial hypercholesterolaemia affects about one in 250 people, making it the most common dominantly inherited human disorder. It is associated with premature cardiac death.
Statin therapy has helped enormously, but often patients do not reach their LDL targets, even with combination therapy.
This multicentred double-blind placebo controlled study enlisted patients with heterozygous familial hypercholesterolaemia, who were already taking a statin with or without other lipid therapy. They were given additional therapy.
Cohort one received the PCSK9 inhibitor evolocumab 140mg subcutaneously every two weeks.
Cohort two was given placebo subcutaneously every two weeks, cohort three, evolocumab 420mg monthly and cohort four, placebo subcutaneously monthly.
At week 12, the fortnightly dose of evolocumab had led to a mean reduction of LDL of 59% compared with placebo and the monthly dose, a mean reduction of 61%.
Adverse events were similar to those for placebo, with the only significant ones being nasopharyngitis and muscle aches.
The reduction in LDL was to a level of those without the condition and the PCSK9 inhibition led to a response that was not related to the underlying genetic cause of the familial hypercholesterolaemia.
- Dr Hunter is a GP in Bishop’s Waltham, Hampshire, and a member of our team who regularly review the journals
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