John C. Long

Case 30-1977

Presentation of Case A 60-year-old woman was admitted to the hospital because of fever and lymphadenopathy. She was well until one month earlier, when a mild sore throat developed, with fever, enla...

Case 38-1977

Presentation of Case A 36-year-old woman was admitted to the hospital because of a mass in the parotid gland. She was well until one year previously, when a hard lump was felt at the left mandibula...

Pre-hospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug administration In Cardiac arrest (PARAMEDIC-2): Trial protocol

Despite its use since the 1960s, the safety or effectiveness of adrenaline as a treatment for cardiac arrest has never been comprehensively evaluated in a clinical trial. Although most studies have found that adrenaline increases the chance of return of spontaneous circulation for short periods, many studies found harmful effects on the brain and raise concern that adrenaline may reduce overall survival and/or good neurological outcome. The PARAMEDIC-2 trial seeks to determine if adrenaline is safe and effective in out-of-hospital cardiac arrest. This is a pragmatic, individually randomised, double blind, controlled trial with a parallel economic evaluation. Participants will be eligible if they are in cardiac arrest in the out-of-hospital environment and advanced life support is initiated. Exclusions are cardiac arrest as a result of anaphylaxis or life threatening asthma, and patient known or appearing to be under 16 or pregnant. 8000 participants treated by 5 UK ambulance services will be randomised between December 2014 and August 2017 to adrenaline (intervention) or placebo (control) through opening pre-randomised drug packs. Clinical outcomes are survival to 30 days (primary outcome), hospital discharge, 3, 6 and 12 months, health related quality of life, and neurological and cognitive outcomes (secondary outcomes). Trial registration (ISRCTN73485024).

Case 28-1977

Presentation of Case A 77-year-old woman was admitted to the hospital because of an infected hand. Nine years earlier she was found to have a noninvasive transitional-cell carcinoma of the bladder....

COSCA (Core Outcome Set for Cardiac Arrest) in Adults: An Advisory Statement From the International Liaison Committee on Resuscitation

Cardiac arrest effectiveness trials have traditionally reported outcomes that focus on survival. A lack of consistency in outcome reporting between trials limits the opportunities to pool results for meta-analysis. The COSCA initiative (Core Outcome Set for Cardiac Arrest), a partnership between patients, their partners, clinicians, research scientists, and the International Liaison Committee on Resuscitation, sought to develop a consensus core outcome set for cardiac arrest for effectiveness trials. Core outcome sets are primarily intended for large, randomized clinical effectiveness trials (sometimes referred to as pragmatic trials or phase III/IV trials) rather than for pilot or efficacy studies. A systematic review of the literature combined with qualitative interviews among cardiac arrest survivors was used to generate a list of potential outcome domains. This list was prioritized through a Delphi process, which involved clinicians, patients, and their relatives/partners. An international advisory panel narrowed these down to 3 core domains by debate that led to consensus. The writing group refined recommendations for when these outcomes should be measured and further characterized relevant measurement tools. Consensus emerged that a core outcome set for reporting on effectiveness studies of cardiac arrest (COSCA) in adults should include survival, neurological function, and health-related quality of life. This should be reported as survival status and modified Rankin scale score at hospital discharge, at 30 days, or both. Health-related quality of life should be measured with ≥1 tools from Health Utilities Index version 3, Short-Form 36-Item Health Survey, and EuroQol 5D-5L at 90 days and at periodic intervals up to 1 year after cardiac arrest, if resources allow.

Case 17-1974

Presentation of Case First admission. A 25-year-old woman was admitted to the hospital because of anemia. She was well until three and a half years previously, when supraclavicular and cervical lym...

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest

BACKGROUND Concern about the use of epinephrine as a treatment for out‐of‐hospital cardiac arrest led the International Liaison Committee on Resuscitation to call for a placebocontrolled trial to determine whether the use of epinephrine is safe and effective in such patients. METHODS In a randomized, double‐blind trial involving 8014 patients with out‐of‐hospital cardiac arrest in the United Kingdom, paramedics at five National Health Service ambulance services administered either parenteral epinephrine (4015 patients) or saline placebo (3999 patients), along with standard care. The primary outcome was the rate of survival at 30 days. Secondary outcomes included the rate of survival until hospital discharge with a favorable neurologic outcome, as indicated by a score of 3 or less on the modified Rankin scale (which ranges from 0 [no symptoms] to 6 [death]). RESULTS At 30 days, 130 patients (3.2%) in the epinephrine group and 94 (2.4%) in the placebo group were alive (unadjusted odds ratio for survival, 1.39; 95% confidence interval [CI], 1.06 to 1.82; P = 0.02). There was no evidence of a significant difference in the proportion of patients who survived until hospital discharge with a favorable neurologic outcome (87 of 4007 patients [2.2%] vs. 74 of 3994 patients [1.9%]; unadjusted odds ratio, 1.18; 95% CI, 0.86 to 1.61). At the time of hospital discharge, severe neurologic impairment (a score of 4 or 5 on the modified Rankin scale) had occurred in more of the survivors in the epinephrine group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90 patients [17.8%]). CONCLUSIONS In adults with out‐of‐hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30‐day survival than the use of placebo, but there was no significant between‐group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group. (Funded by the U.K. National Institute for Health Research and others; Current Controlled Trials number, ISRCTN73485024.)

Case 24-1977

Presentation of Case A 50-year-old woman was admitted to the hospital because of a neurologic disorder. She was well until 2 1/2 years earlier, when she sat down, heard a snapping sound and experie...

Case 49-1974

Presentation of Case A 26-year-old woman was admitted to the hospital because of a pericardial effusion. She was well until six years previously, when cough and fever developed and subsided. Three months thereafter she noticed that the ingestion of alcohol was followed in five to 10 minutes by a sudden, severe pain in the neck and shoulders. Six months later a respiratory-tract infection occurred, with a cough that persisted, and she continued to have pain, sometimes associated with vomiting, after consuming alcohol. Five years before entry she consulted a physician, and an x-ray film of the chest revealed hilar lymphadenopathy. .xa0.xa0.

Case 30-1973

Presentation of Case A 64-year-old woman was admitted to the hospital because of weakness of the extremities. Thirty-two years previously supraclavicular lymphadenopathy developed. A biopsy performed at another hospital revealed Hodgkins disease, and radiation treatment was given, with a good response. During the next 31 years the patient received radiation treatment to the superior mediastinum, neck, trunk, supraclavicular region and cervical spine (Table 1). Twenty-four years before entry there was the onset of intermittent numbness and paresthesias. Ten years before admission she experienced pain in the right lumbar region and again complained of numbness in the extremities. An x-ray film .xa0.xa0.