Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators.

OBJECTIVE: To review and update the conceptual framework, indicator content and research priorities of the Organisation for Economic Cooperation and Development's (OECD) Health Care Quality Indicators (HCQI) project, after a decade of collaborative work. DESIGN: A structured assessment was carried out using a modified Delphi approach, followed by a consensus meeting, to assess the suite of HCQI for international comparisons, agree on revisions to the original framework and set priorities for research and development. SETTING: International group of countries participating to OECD projects. PARTICIPANTS: Members of the OECD HCQI expert group. RESULTS: A reference matrix, based on a revised performance framework, was used to map and assess all seventy HCQI routinely calculated by the OECD expert group. A total of 21 indicators were agreed to be excluded, due to the following concerns: (i) relevance, (ii) international comparability, particularly where heterogeneous coding practices might induce bias, (iii) feasibility, when the number of countries able to report was limited and the added value did not justify sustained effort and (iv) actionability, for indicators that were unlikely to improve on the basis of targeted policy interventions. CONCLUSIONS: The revised OECD framework for HCQI represents a new milestone of a long-standing international collaboration among a group of countries committed to building common ground for performance measurement. The expert group believes that the continuation of this work is paramount to provide decision makers with a validated toolbox to directly act on quality improvement strategies.

Advances in the hospital management of patients following an out of hospital cardiac arrest.

The outcome for patients after an out-of-hospital cardiac arrest (OHCA) has been poor over many decades and single interventions have mostly resulted in disappointing results. More recently, some regions have observed better outcomes after redesigning their cardiac arrest pathways. Optimised resuscitation and prehospital care is absolutely key, but in-hospital care appears to be at least as important. OHCA treatment requires a multidisciplinary approach, comparable to trauma care; the development of cardiac arrest pathways and cardiac arrest centres may dramatically improve patient care and outcomes. Besides emergency medicine physicians, intensivists and neurologists, cardiologists are playing an increasingly crucial role in the post-resuscitation management, especially by optimising cardiac output and undertaking urgent coronary angiography/intervention.

Imaging of Anorectal Malformations: Finding the Way out of the Labyrinth

Purpose/Aim: To review the embryological basis of a wide spectrum of anorectal malformations (ARM), to provide anatomical schemas showing the possiblelocations of fistulas in boys and girls and to present the typical imaging findings of these complex anomalies using various imaging methods with emphasis on3T-MRI.Content Organization: 1. Embryology. 2. Imaging techniques. 3. Normal 3T-MRI pelvic anatomy. 4. Ano-rectal malformations in boys: - Classification -Anatomic schemas of location of fistulas. - Imaging studies. 5. Ano-rectal malformations in girls: - Classification - Anatomic schemas of location of fistulas. -Imaging studies. 6. Imaging of Currarino syndrome. 7. Imaging of Vacterl syndrome.Summary: ARM are a group of complex anatomical alterations characterized by an abnormal separation of genitourinary system from hindgut. The major teachingpoints of this pictorial essay are to show: - The normal anatomy of the pelvis floor and the sphincter muscle complex in 3T-MRI. - Anatomic schemas of thedifferent types of ARM in boys and girls. - Imaging findings of a wide spectrum of ARM using a multimodality approach. including colostogramm, voidingcystourethrogramm and MRI of the pelvis.

Artificial muscle to wash blood out of fibrillating atrium: an alternative to lifelong anticoagulation.

The Atripump is a motorless, volume displacement pump based on artificial muscle technology that could reproduce the pump function of normal atrium. It could help prevent blood clots due to blood stagnation and eventually avoid anticoagulation therapy in atrial fibrillation (AF). An animal study has been designed to assess mechanical effects of this pump on fibrillating atrium. The Atripump is a dome shaped silicone coated nitinol actuator. A pacemaker like control unit drives the actuator. In five adult sheep, the right atrium (RA) was exposed and dome sutured onto the epicardium. Atrial fibrillation was induced using rapid epicardial pacing (600 beats/min). Ejection fraction of the RA was obtained with intracardiac ultrasound in baseline, AF and Atripump assisted AF conditions. The dome's contraction rate was 60/min with power supply of 12V, 400 mA for 200 ms and ran for 2 hours in total. Mean temperature on the RA was 39+/-1.5 degrees C. Right atrium ejection fraction was 31% in baseline conditions, 5% and 20% in AF and assisted AF, respectively. In two animals a thrombus appeared in the right appendix and washed out once the pump was turned on. The Atripump washes blood out the RA acting as an anticoagulant device. Possible clinical implications in patients with chronic AF are prevention of embolism of cardiac origin and avoidance of hemorrhagic complication due to chronic anticoagulation.

Respiratory quotient evolution during normal pregnancy: what nutritional or clinical information can we get out of it?

Food intake increases to a varying extent during pregnancy to provide extra energy for the growing fetus. Measuring the respiratory quotient (RQ) during the course of pregnancy (by quantifying O2 consumption and CO2 production with indirect calorimetry) could be potentially useful since it gives an insight into the evolution of the proportion of carbohydrate vs. fat oxidized during pregnancy and thus allows recommendations on macronutrients for achieving a balanced (or slightly positive) substrate intake. A systematic search of the literature for papers reporting RQ changes during normal pregnancy identified 10 papers reporting original research. The existing evidence supports an increased RQ of varying magnitude in the third trimester of pregnancy, while the discrepant results reported for the first and second trimesters (i.e. no increase in RQ), explained by limited statistical power (small sample size) or fragmentary data, preclude safe conclusions about the evolution of RQ during early pregnancy. From a clinical point of view, measuring RQ during pregnancy requires not only sophisticated and costly indirect calorimeters but appears of limited value outside pure research projects, because of several confounding variables: (1) spontaneous changes in food intake and food composition during the course of pregnancy (which influence RQ); (2) inter-individual differences in weight gain and composition of tissue growth; (3) technical factors, notwithstanding the relatively small contribution of fetal metabolism per se (RQ close to 1.0) to overall metabolism of the pregnant mother.

GroEL and CCT are catalytic unfoldases mediating out-of-cage polypeptide refolding without ATP.

Chaperonins are cage-like complexes in which nonnative polypeptides prone to aggregation are thought to reach their native state optimally. However, they also may use ATP to unfold stably bound misfolded polypeptides and mediate the out-of-cage native refolding of large proteins. Here, we show that even without ATP and GroES, both GroEL and the eukaryotic chaperonin containing t-complex polypeptide 1 (CCT/TRiC) can unfold stable misfolded polypeptide conformers and readily release them from the access ways to the cage. Reconciling earlier disparate experimental observations to ours, we present a comprehensive model whereby following unfolding on the upper cavity, in-cage confinement is not needed for the released intermediates to slowly reach their native state in solution. As over-sticky intermediates occasionally stall the catalytic unfoldase sites, GroES mobile loops and ATP are necessary to dissociate the inhibitory species and regenerate the unfolding activity. Thus, chaperonin rings are not obligate confining antiaggregation cages. They are polypeptide unfoldases that can iteratively convert stable off-pathway conformers into functional proteins.

Voyages astraux et hors du corps. Héautoscopie, extase et hallucinations expérientielles d'origine épileptique [Astral and out-of-body voyages. Heautoscopy, ecstasis and experimental hallucinations of epileptic origin]

We report a 38 year-old patient who had temporoparietal epilepsy and unusual ictal "out of body" experiences that remained undiagnosed for more than ten years, until her admission for a motor seizure of the left hemibody. Out of body episodes were experienced as intense and ecstatic astral journeys. EEG showed a bilateral extension of epileptiform abnormalities to the parietal regions, predominantly on the right side. We discuss the various forms of heautoscopy and their putative mechanisms. We suggest that a disturbance in representing space in independent extrapersonal and personal coordinates might be as crucial as the elusive hypothesis of a body schema disorder. Combined involvement of the parietal neocortex and temporolimbic structures might allow those experiences to gain a subjective vividness which appears to be indissociable from normal conscious experiences.

Accuracy of out-of-field dose calculation of tomotherapy and cyberknife treatment planning systems: A dosimetric study.

PURPOSE: Late toxicities such as second cancer induction become more important as treatment outcome improves. Often the dose distribution calculated with a commercial treatment planning system (TPS) is used to estimate radiation carcinogenesis for the radiotherapy patient. However, for locations beyond the treatment field borders, the accuracy is not well known. The aim of this study was to perform detailed out-of-field-measurements for a typical radiotherapy treatment plan administered with a Cyberknife and a Tomotherapy machine and to compare the measurements to the predictions of the TPS. MATERIALS AND METHODS: Individually calibrated thermoluminescent dosimeters were used to measure absorbed dose in an anthropomorphic phantom at 184 locations. The measured dose distributions from 6 MV intensity-modulated treatment beams for CyberKnife and TomoTherapy machines were compared to the dose calculations from the TPS. RESULTS: The TPS are underestimating the dose far away from the target volume. Quantitatively the Cyberknife underestimates the dose at 40cm from the PTV border by a factor of 60, the Tomotherapy TPS by a factor of two. If a 50% dose uncertainty is accepted, the Cyberknife TPS can predict doses down to approximately 10 mGy/treatment Gy, the Tomotherapy-TPS down to 0.75 mGy/treatment Gy. The Cyberknife TPS can then be used up to 10cm from the PTV border the Tomotherapy up to 35cm. CONCLUSIONS: We determined that the Cyberknife and Tomotherapy TPS underestimate substantially the doses far away from the treated volume. It is recommended not to use out-of-field doses from the Cyberknife TPS for applications like modeling of second cancer induction. The Tomotherapy TPS can be used up to 35cm from the PTV border (for a 390 cm(3) large PTV).

Evolution of insulin sensitivity and its variability in out-of-hospital cardiac arrest (OHCA) patients treated with hypothermia.

INTRODUCTION: Therapeutic hypothermia (TH) is often used to treat out-of-hospital cardiac arrest (OHCA) patients who also often simultaneously receive insulin for stress-induced hyperglycaemia. However, the impact of TH on systemic metabolism and insulin resistance in critical illness is unknown. This study analyses the impact of TH on metabolism, including the evolution of insulin sensitivity (SI) and its variability, in patients with coma after OHCA. METHODS: This study uses a clinically validated, model-based measure of SI. Insulin sensitivity was identified hourly using retrospective data from 200 post-cardiac arrest patients (8,522 hours) treated with TH, shortly after admission to the intensive care unit (ICU). Blood glucose and body temperature readings were taken every one to two hours. Data were divided into three periods: 1) cool (T <35°C); 2) an idle period of two hours as normothermia was re-established; and 3) warm (T >37°C). A maximum of 24 hours each for the cool and warm periods was considered. The impact of each condition on SI is analysed per cohort and per patient for both level and hour-to-hour variability, between periods and in six-hour blocks. RESULTS: Cohort and per-patient median SI levels increase consistently by 35% to 70% and 26% to 59% (P <0.001) respectively from cool to warm. Conversely, cohort and per-patient SI variability decreased by 11.1% to 33.6% (P <0.001) for the first 12 hours of treatment. However, SI variability increases between the 18th and 30th hours over the cool to warm transition, before continuing to decrease afterward. CONCLUSIONS: OCHA patients treated with TH have significantly lower and more variable SI during the cool period, compared to the later warm period. As treatment continues, SI level rises, and variability decreases consistently except for a large, significant increase during the cool to warm transition. These results demonstrate increased resistance to insulin during mild induced hypothermia. Our study might have important implications for glycaemic control during targeted temperature management.

Proportion of out of hospital adult non traumatic cardiac arrest presenting as a convulsion

Introduction: The majority of convulsions are due to an epilepticseizure or a convulsive syncope. In some cases, this is the firstsymptom of an out of hospital cardiac arrest (OH-CA).Objective: This study was aimed to measure the proportion of adultnon traumatic OH-CA presenting as a convulsion.Methodology: We prospectively collected all incoming calls with anout-of-hospital non traumatic seizure as the chief complaint in patients>18 years during a 24-months period. Among these calls, we collectedcases identified as OH-CA by paramedics.Results: During the 24-months period, the EMS dispatch centerreceived 561 calls for an out-of-hospital non traumatic convulsion in anadult. Twelve cases were ultimately classified as CA. In this group, onebystander spontaneously reported that the patient was known forepilepsy. The incidence of OH-CA presenting as convulsions wastherefore 2.1% of all calls for convulsion. Over the same period, theEMS dispatch center received 1035 calls related to an adult nontraumatic OH-CA. Therefore the rate of OH-CA presenting as aconvulsion represented 1.2% of all adult non traumatic OH-CA.Conclusion: Only 12 cases out of the 531 calls for non traumatic adultconvulsions were confirmed OH-CA (2.1%). Nevertheless, this unusualpresentation of OH-CA must be recognized by dispatchers, even whena patient is reported by bystander as a known epileptic. Dispatchersshould keep bystanders on line or call them back before paramedics'arrival, and have them confirm the progressive return of a normalpattern of breathing and state of consciousness; if not, they shouldencourage when necessary bystander to initiate CPR. For dispatchers,a past medical history of epilepsy should not be regarded as sufficientinformation to rule-out OH-CA. It is mandatory that known epilepticpatients should be monitored in the same way as non-epileptic patients.

Incidenceof out-of-hospital adult nontraumatic cardiac arrest presenting as a convulsion

Introduction: The majority of convulsions are due to an epileptic seizure or a convulsive syncope. The incidence of out-of-hospital cardiac arrest (OH-CA) presenting as a convulsion is unknown. Objective: This study aimed to measure the incidence of adult nontraumatic OH-CA presenting as a convulsion, a rate that has not been published so far, to the best of our knowledge. Methods: We prospectively collected all incoming calls with an out-of-hospital nontraumatic seizure as the chief complaint in patients >18 years old during a 24-month period. Among these calls, we collected cases identified as OH-CA by paramedics. Results: During the 24-month period, the emergency medical services (EMS) dispatch center received 561 calls for an out-of-hospital nontraumatic convulsion in an adult. Twelve cases were ultimately classified as CA. In this group, one bystander spontaneously reported that the patient was known for epilepsy. The incidence of OH-CA presenting as convulsions was therefore 2.1% of all calls for convulsion. Over the same period, the EMS dispatch center received 1,035 calls related to an adult nontraumatic OH-CA. Therefore, the rate of OH-CA presenting as a convulsion represented 1.2% of all adult nontraumatic OH-CA. Conclusion:L Only 12 cases out of the 531 calls for nontraumatic adult convulsions were confirmed OHCA (2.1%). Nevertheless, this unusual presentation of OH-CA must be recognized by dispatchers, even when a patient is reported by bystander as a known epileptic. Dispatchers should keep bystanders on the line or call them back before paramedics' arrival, and have them confirm the progressive return of a normal pat- tern of breathing and state of consciousness; if not, they should encourage the bystander to initiate CPR when necessary. An intervention should be implemented to improve the detection by dispatchers of OH-CA presenting as convulsion by the development of a specific interview and directed observation. For dispatchers, a past medical history of epilepsy should not be regarded as sufficient information to rule out OH-CA. It is mandatory that known epileptic patients should be monitored in the same way as nonepileptic patients.