Adrian Moser

Increasing arterial oxygen partial pressure during cardiopulmonary resuscitation is associated with improved rates of hospital admission

AIM As recent clinical data suggest a harmful effect of arterial hyperoxia on patients after resuscitation from cardiac arrest (CA), we aimed to investigate this association during cardiopulmonary resuscitation (CPR), the earliest and one of the most crucial phases of recirculation. METHODS We analysed 1015 patients who from 2003 to 2010 underwent out-of-hospital CPR administered by emergency medical services serving 300,000 inhabitants. Inclusion criteria for further analysis were nontraumatic background of CA and patients >18 years of age. One hundred and forty-five arterial blood gas analyses including oxygen partial pressure (paO2) measurement were obtained during CPR. RESULTS We observed a highly significant increase in hospital admission rates associated with increases in paO2 in steps of 100 mmHg (13.3 kPa). Subsequently, data were clustered according to previously described cutoffs (≤ 60 mmHg [8 kPa]], 61-300 mmHg [8.1-40 kPa], >300 mmHg [>40 kPa]). Baseline variables (age, sex, initial rhythm, rate of bystander CPR and collapse-to-CPR time) of the three compared groups did not differ significantly. Rates of hospital admission after CA were 18.8%, 50.6% and 83.3%, respectively. In a multivariate analysis, logistic regression revealed significant prognostic value for paO2 and the duration of CPR. CONCLUSION This study presents novel human data on the arterial paO2 during CPR in conjunction with the rate of hospital admission. We describe a significantly increased rate of hospital admission associated with increasing paO2. We found that the previously described potentially harmful effects of hyperoxia after return of spontaneous circulation were not reproduced for paO2 measured during CPR. CLINICAL TRIAL REGISTRATION n/a.

Spontaneous tension pneumothorax and CO2 narcosis in a near fatal episode of chronic obstructive pulmonary disease exacerbation

Exacerbation of chronic obstructive pulmonary disease (COPD) is a disease pattern frequently seen in emergency medical services and intensive care units. Usually, exacerbations of COPD are of infectious origin, and an acute vital threat may take several days to develop. Tension pneumothorax in patients with COPD is a rare and often unexpected cause of acute vital threat. To the best of our knowledge, this is a unique case of CO2 narcosis after spontaneous tension pneumothorax in a patient with COPD. We describe the rapid development of respiratory insufficiency and near fatal pulmonary failure in a 65-year-old female patient with COPD due to spontaneous tension pneumothorax. The patient was in respiratory failure and comatose upon arrival of the emergency service. Before mechanical ventilation, coma could be confirmed to be due to CO2 narcosis caused by exorbitant arterial hypercapnia (PCO2, 193 mm Hg). Pneumothorax was diagnosed in the hospital by chest x-ray and resolved after pleural drainage. The patient could be extubated early and discharged without sequelae. In conclusion, we want to report the occurrence of a tension pneumothorax as an important and potentially overseen condition in patients with COPD with acute respiratory failure.

Students' and general practitioners' perceptions of a recently introduced clerkship in general practice. A survey from Austria

Abstract Background: In autumn 2007, the Medical University of Graz (MUG) upgraded the status of general practice in medical training by integrating a compulsory five-week clerkship in general practice surgeries in the sixth and last year of the curriculum. In cooperation with the Styrian Academy of General Practice (STAFAM), more than 200 general practitioners (GPs) had been accredited to introduce medical students to the specific tasks, problems and decision-making process in general practice. Between October 2007 and June 2009, more than 300 students completed the clerkship. Objective: To explore the perceptions of students and GPs towards this new approach to undergraduate teaching in Austrian general practice. Methods: Between March and June 2009, we conducted a cross-sectional survey by using a self-administered questionnaire with 14 items for students as well as GPs. To limit recall bias, we gave the questionnaire to all students (n = 146) and GPs (n = 146) immediately after the clerkship. The response rates were 146/146 (100%) and 114/146 (78%) for students and GPs, respectively. Results: The study results show high satisfaction rates among students as well as GPs. Most of the students and GPs perceive the compulsory clerkship in general practice as an essential part of medical education. The organization of the clerkship had the least positive outcome. Conclusion: Our survey shows that the clerkship is well accepted among Austrian medical students and GPs.

Immunoplasticity – Triggers of regulatory function

Regulatory T cells (Tregs) as key players of the immune system are exposed to numerous triggers including exogenous and endogenous factors. Autonomous nerve activity, melatonin, hormones such as vitamin D and glucocorticoids as well as the exposure to sunlight and microorganisms shape our immunological profile. The complexity of this system is highlighted by the power of each single trigger but more impressive by influencing each others function and potentials directly and indirectly. However, while monocausal correlations of single triggers on Tregs have been studied at length, there is much less known about the impact of numerous coexistent triggers on the dynamics of Treg activity. It can be hypothesized that the dynamics of Treg activity plays a crucial role for the control of our immune system. Therefore it is of the utmost importance that a new translational, multi- and interdisciplinary approach finds its way into future research efforts, which should lead to a more comprehensive and holistic view on the complex immunoregulatory mechanisms and to act in the sense of public health.

The effect of disease modifying therapies on CD62L expression in multiple sclerosis

Background The increasing armamentarium of disease-modifying therapies in multiple sclerosis is accompanied by potentially severe adverse effects. The cell-adhesion molecule CD62L, which facilitates leukocyte extravasation, has been proposed as a predictive marker for treatment tolerability. However, pre-analytical procedures might impact test results, thereby limiting its clinical usability. Whether the immediate analysis of CD62L expression of peripheral blood mononuclear cells can aid treatment decision making is yet unclear. Objective To investigate the effect of various disease-modifying therapies in multiple sclerosis on CD62L expression of CD3+CD4+ peripheral blood mononuclear cells in freshly collected blood samples. Methods We collected peripheral blood samples from patients with clinically isolated syndrome and multiple sclerosis (baseline/follow up n = 234/n = 98) and healthy controls (n = 51). CD62L+CD3+CD4+ expression was analysed within 1 hour by fluorescence-activated cell sorting. Results CD62L+CD3+CD4+ expression was significantly decreased in patients treated with natalizumab (n = 26) and fingolimod (n = 20) and increased with dimethyl-fumarate (n = 15) compared to patients receiving interferon/glatiramer acetate (n = 90/30) or no disease-modifying therapies (n = 53) and controls (n = 51) (p<0.001). CD62L expression showed temporal stability during unchanged disease-modifying therapy usage, but increased after natalizumab withdrawal and decreased upon fingolimod introduction. Conclusion CD62L+CD3+CD4+ expression is altered in patients treated with different disease-modifying therapies when measured in freshly collected samples. The clinical meaning of CD62L changes under disease-modifying therapies warrants further investigation.

Weighing up dietary patterns.

758 www.thelancet.com Vol 388 August 20, 2016 significant weight loss compared with the control group after 10 years. Another randomised controlled trial of dietary interventions showed a statistically significant 3·4% weight loss after 6 years for individuals only in the Mediterranean diet group. None of these studies showed maintenance of a clinically signifi cant weight loss, which is usually defi ned as 5% of bodyweight. Despite these negative fi ndings, we acknowledge that a healthy lifestyle can have tremendous benefi ts, such as reduction of cardiovascular mortality with a Mediterranean diet. Therefore, we recommend shifting the current strategy from aiming for weight loss to advising of healthy lifestyles regardless of their eff ect on weight.