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Background: An estimated 350,000 individuals experience out-of-hospital cardiac arrest (OHCA) in the United States (US) annually; only approximately 10% survive. The probability of survival after OHCA doubles when a bystander uses an automated external defibrillator (AED) before emergency management services arrives; however, bystander AED use is less than 2% in the US. We conducted a series of randomized trials in a community setting comparing the delivery of an AED by aerial drone to that of a bystander searching for and retrieving an AED from fixed locations in the area. Methods: We conducted 35 simulation trials of an OHCA using a life-sized manikin accompanied by two participants, paired by gender and age (18-34, 35-49, 50-65 years), in a community setting, with seven trials per zone in five distinct zones. Zones represented different environmental challenges to drone navigation and pedestrian acquisition of an AED and varied in number of fixed AEDs in the area (range 1-8 AEDs in a 600 ft radius from the OHCA site). We used a DJI Matrice 600 Pro drone, modified to carry a standard AED, flying autonomously from a preprogrammed flight path to the OHCA site. Drone launch sites varied by zone and ranged from 800 to 1300 ft from the OHCA site. We randomized participants either to call a mock 9-1-1 telecommunicator who would initiate the drone’s flight sequence, or to conduct a ground search to locate and retrieve an AED from a fixed location. We compared the delivery time of an AED by drone to that of an AED acquired by ground search. We conducted pre- and post-trial interviews with each participant to query perceptions. Results: We conducted 18 trials with women and 17 with men. These included 15, 11, and 9 trials across the three age strata, respectively. The average time (minutes: seconds) from onset of the simulated OHCA to AED delivery was 1:21 faster by drone (4:45, standard deviation (SD) = 0.34) compared to ground search (6:06, SD = 3:21). In 71% of trials (n=25 of 35), the drone delivered the AED to the event site within 5 minutes, compared to 51% (n=18 of 35) of ground searches (p=0.09). Median AED delivery time was faster by drone than by ground search in four of the five zones (range 0:17 to 2:56). Ground search was faster than the drone in one zone with 7 AEDs within 600 ft of the simulated OHCA event site and the shortest average distance to an AED (254 ft) of all the five zones. Among participants randomized to call for the drone, 89% reported that they felt comfortable as the drone approached, and 72% reported having no safety concerns. Nearly half of participants randomized to conduct a ground search reported difficulty finding an AED. Conclusion: Our study suggests that drone delivery of an AED to the site of an OHCA is feasible and acceptable in a community setting. Drones may provide more timely access to early defibrillation compared to bystander search and acquisition of an AED from the surrounding area.

Introduction: Despite recent advances in critical care, out-of-hospital cardiac arrest (OHCA) patients still have a low probability of survival. For the purpose of an objective assessment of a patient’s risk of death or neurological deficits, several clinical tools have recently been developed. Hypothesis: The first hypothesis is that OHCA and C-GRApH score could predict neurologic outcome after OHCA patients treated with targeted temperature management (TTM). The second hypothesis is that adding neurologic examination to those scores could further improve outcome prediction after OHCA. Methods: This retrospective study included OHCA patients treated with TTM from 2009 to 2017 in a tertiary teaching hospital in Seoul, Korea. We calculated two cardiac arrest specific risk scores (OHCA and C-GRApH) at the time of admission. Initial neurologic examination (Full Outline of UnResponsiveness Brainstem reflexes (FOUR_B) score and Glasgow Coma Scale motor score (GCS_M)) was also evaluated. The primary outcome was neurological outcome at 6 months after CA. Results: Of 311 subjects, 100 (32.2%) had a good neurologic outcome at 6 months after CA. OHCA score had AUC of 0.843 (95% CI 0.797 - 0.888) and C-GRApH score had AUC of 0.774 (95% CI 0.717 - 0.830). Addition of FOUR_B or GCS_M to OHCA score improved prediction of poor neurologic outcome (AUC 0.891, p = 0.001 for FOUR_B and AUC 0.878, p=0.004 for GCS_M). Results were similar for C-GRApH score to predict poor neurologic outcome. Conclusions: This study confirms the good prognostic performance of cardiac arrest specific scores to predict neurological outcomes in OHCA patients treated with TTM. Addition of neurologic examination variables further improved prognostication for neurologic outcome.

Background Emergency 9‐1‐1 callers use a wide range of terms to describe abnormal breathing in persons with out‐of‐hospital cardiac arrest ( OHCA ). These breathing descriptors can obstruct the telephone cardiopulmonary resuscitation ( CPR ) process. Methods and Results We conducted an observational study of emergency call audio recordings linked to confirmed OHCA s in a statewide Utstein‐style database. Breathing descriptors fell into 1 of 8 groups (eg, gasping, snoring). We divided the study population into groups with and without descriptors for abnormal breathing to investigate the impact of these descriptors on patient outcomes and telephone CPR process. Callers used descriptors in 459 of 2411 cases (19.0%) between October 1, 2010, and December 31, 2014. Survival outcome was better when the caller used a breathing descriptor (19.6% versus 8.8%, P OHCA recognition, CPR instruction, and telephone CPR were lower than when callers did not use a breathing descriptor (79.7% versus 93.0%, P P =0.0078; and 60.2% versus 66.9%, P =0.0123, respectively). The time interval between call receipt and OHCA recognition was longer when the caller used a breathing descriptor (118.5 versus 73.5 seconds, P Conclusions Descriptors of abnormal breathing are associated with improved outcomes but also with delays in the identification of OHCA . Familiarizing telecommunicators with these descriptors may improve the telephone CPR process including OHCA recognition for patients with increased probability of survival.

In 2002 and 2006, we reported the long-term results of 208 total hip replacements performed with the Zweymüller stem and a threaded cup in 200 patients. The present study gives an update on this patient cohort. At a minimum of twenty years postoperatively, seventy-three patients (seventy-five hips) were available for follow-up; twelve patients were lost to follow-up. The key findings of our previous reports were the absence of aseptic femoral stem loosening and a poor rate of survival of the threaded cup. Since then, two revisions have been performed because of aseptic stem loosening. We observed osteolytic lesions around the proximal part of the femoral component on twenty-four (47%) of fifty-one radiographs, but no stem was deemed at risk for loosening. The probability of survival of the stem at twenty years was 0.96 (95% confidence interval, 0.91 to 0.99), and the probability of survival of the cup at twenty years was 0.67 (95% confidence interval, 0.57 to 0.75). The Zweymüller femoral stem, a tapered, rectangular implant, continues to give excellent long-term results.

(ed from J Perinatol 2016;36:694–698) One of the challenges faced by neonatologists and obstetric care providers is their interaction with parents expecting the delivery of a fetus at the “threshold of viability,” between 22 weeks and 25 weeks of gestation. Conversations regarding the chances of survival, the probability of survival without disability, or the risk of moderate to severe disability are common in such situations.

In a proximal humerus resection for a bone tumor, the use of an osteoarticular allograft is considered the best restoration of shoulder function. We retrospectively reviewed the outcomes of 31 patients who had an intraarticular resection of the proximal humerus for a bone tumor. Twenty-three of the allografts were filled with cement. The average followup was 5.3 years. Of the 31 patients with more than 24 months followup, seven had revision surgery or removal of the allograft. Kaplan-Meier analysis showed that the probability of survival of the reconstruction was 78% at 5 years. Fracture was the main complication in 11 patients (37%) of whom seven were in the noncemented group. Four of these patients had successful surgery for conversion to an allograft-prosthetic composite, whereas one patient had a new allograft. Allografts that were filled with cement had four fractures (18%); three were subchondral fractures discovered by routine CT scans. None of these patients had pain or needed revision surgery. Osteochondral allograft in proximal humerus replacement is a reliable reconstructive technique if the allograft is augmented by filling the intramedullary space with cement. Moreover, cement augmented allografts are less expensive and technically easier than allograft-prosthetic composites.

Objective:To compare the strength of relationship of the Glasgow Coma Scale (GCS) versus the ASCOT probability of survival (Ps), a multidimensional trauma severity index, with a comprehensive range of core areas of psychological functioning assumed to influence quality of life in pediatric head inju

We have considered the issue of predicting from diagnosis of a condition such as malignant melanoma survival past an often arbitrarily chosen fixed time-point, such as 5 years. Prediction of survival past any time-point becomes rather complicated due to the presence of 'censored observations', and these observations are often ignored in any analysis. Censored observations are subjects who either die of causes other than the disease of interest or are lost to follow-up. The aim of this paper is to show that the result of ignoring these 'censored observations' is an underestimation of the probability of survival beyond the fixed time-point. Ignoring these censored observations results in potentially valuable information on survival being thrown away. This underestimation will often prove to be of considerable magnitude and dependent on the proportion of censored observations present in the data. It is therefore essential to carry out a full actuarial survival analysis which will incorporate all the information contained in these censored observations.

A prospective study was performed to determine the effect of protein depletion and postoperative nutritional status on the outcome in sixty-three elderly patients who had been admitted to the hospital because of a fracture of the hip. The parameters that were used to determine the degree of protein depletion included levels of albumin, of prealbumin, and of transferrin; total lymphocyte count; and nitrogen-balance studies. The outcomes that were examined were the development of complications, the length of the stay in the hospital, the ability to return to the pre-fracture level of function, and over-all survivorship. The hypothesis was that the acute fracture and the subsequent operation are severe stresses in these elderly, often compromised patients. The results supported the hypothesis. Thirty-seven patients (58 per cent) in the study group were in a protein-depleted state during the period of hospitalization. The patients who were protein-depleted had a higher prevalence of complications, were less likely to return to their pre-fracture environment, and tended to stay in the hospital longer, as compared with the nonprotein-depleted patients. Survivorship analysis showed that protein-depleted patients had a significantly lower probability of survival one year after the fracture of the hip (p = 0.02). Elderly patients who sustain the trauma of a fracture of the hip should be managed appropriately with regard to intake of nutrients in the postoperative period.

The effect of prehospital intravenous fluids upon survival was studied in 6,855 trauma patients. Mean prehospital time was 36 minutes in both the group of patients who received fluids and the group that did not. The volume of fluid administered was not significantly different in the group who survived compared to those who died. Eighty-five per cent of the patients had an Injury Severity Score (ISS) less than 25 and the mortality rate in the 56% of patients in this group who received fluids was similar to that of the patients who did not receive fluids (0.7% vs. 0.5%). Twelve per cent of the patients had an ISS between 25 and 50. Sixty per cent of these patients received fluids and the mortality rates were similar to the patients who received fluids compared to those who did not (23% vs. 22%). Three per cent of patients had an ISS of greater than 50 and the mortality rate was highest in this group but was not influenced by the administration of fluids (90% vs. 86%). Comparison of groups with similar probability of survival according to the TRISS methodology also failed to show an influence of fluid administration on survival. The mortality rate in patients with an initial systolic blood pressure (BP) of 90 torr or greater was compared to the rate in patients with an admission BP less than 90 torr. Although hypotension was associated with a significantly higher mortality rate, the administration of fluids had no influence on this rate.(ABSTRACT TRUNCATED AT 250 WORDS)

The idea that matching donor and recipient features ought to be a reasonable allocation policy is increasing among liver transplant programs, in particular in the era of extended-use donors (1–3). The best survival gain with a liver transplant (LT) may be achieved by allocating livers to patients who are most likely to be dropped from the list without a LT, but who also have the highest probability of survival after LT (3). The greatest transplant benefit may therefore be achieved by selecting the recipients on the waiting list and selecting the recipients according to the donors available. The study recently published by our Center in the February issue of Transplantation showed how we managed the risk of drop-out due to tumor progression of patients with hepatocellular carcinoma (HCC) in the pre–Model for End-Stage Liver Disease (MELD) era. The old donors were more frequently allocated to patients with HCC and following this policy we reduced the drop-out rate of HCC patients and we improved the survival of marginal grafts after LT (4). The present study validated the idea that the match between the donor and recipient features improves the liver allocation policy. On the other hand, as commented by Lucey (5), we do agree that these data should not be contrasted with the MELD allocation policy and we believe that the next issue will be how to allocate extended-use donors in the MELD era. As reported in the United States, the MELD system provides the best selection of the recipients at the highest risk of dying on the waiting list (6). This policy has also been applied in our Center since March 2003 and after two years of experience, we significantly improved the patient survival on the waiting list (7). We consequently believe that the selection of patients on the waiting list according to their MELD score improves the survival on the waiting list and it is a reasonable method of sharing livers between different transplant programs. On the other hand, as stressed by Lucey, the weak aspect of this policy is that it does not consider the donor features: not all donors are appropriate for all recipients. An extended-use donor may work properly in one recipient and it may not work in another. The challenge is therefore to calculate the ideal match between the donor and recipient features, which may offer the highest transplant benefit. In the MELD era this policy could be applied, but we need to know the transplant benefit that every graft may give to every recipient. When this data is available, we will select the recipient on the waiting list not only considering the recipient’s MELD score, but also evaluating the survival gain that the graft could offer to the patient. An extended-use donor could therefore be allocated not to the first recipient on the waiting list, but to the second or third one, if they were presumed to have the highest transplant benefit. A simple example is reported in Table 1. The transplant benefit depends on the risk of drop-out on the waiting list and on the risk of death after LT. These two variables are center-dependent (8–9), but a relevant role on the outcome of the patients on the waiting list and after LT is due to the recipient and donor’s clinical features and to the match between recipients and donors. In conclusion, our future effort to further improve the liver allocation system is to produce a calculated risk of death after LT for each category of recipients and for each category of donors, which should be compared to the risk of death on the waiting list.

Between 1994 and 1999, 217 metal-on-metal total hip arthroplasties with a low-carbide bearing surface were performed with use of the cementless Zweymuller SL-Plus stem and the Bicon-Plus threaded cup in 194 consecutive patients. After a minimum follow-up of ten years, 181 living patients (203 hips) were available for evaluation. The revision rate after an average of twelve years was 18% (thirty-six hips in thirty-six patients were revised). The main reason for revision was aseptic loosening of one or both components. The probability of survival of the stem at fifteen years was 77% (95% confidence interval [CI], 65% to 86%). The probability of survival of the cup was 80% (95% CI, 62% to 90%). These high failure rates at mid-term follow-up led us to abandon the use of low-carbide metal-on-metal total hip arthroplasty components. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Architectural differentiation is the primary criterion used in the grading of endometrial adenocarcinomas. However, there is little evidence supporting the accuracy of pathologists' assignment of histologic grade, and few studies on the value of architectural morphometry in predicting prognosis for endometrial adenocarcinoma. We have thus investigated whether a pathologist's estimate of percentage of tumor in solid array correlated with the volume fraction of tumors composed of cells not participating in gland formation determined morphometrically. Additionally, we conducted this morphometric study of 31 cases of Stage I endometrial cancer to determine the relationship between a variety of objective measurements of architectural arrangement and prognosis. We found that a pathologist can accurately estimate the proportion of endometrial tumors arranged in solid or glandular fashion. In this limited study, morphometric assessment of the proportion of differentiated or undifferentiated cells or lumens did not improve the accuracy of prediction of outcome beyond conventional architectural grading. Further, we reaffirm that estimation of architectural arrangement coupled with measurement of the depth of penetration provides a good index of the probability of survival.

This study has identified all persons in the population of Rochester, Minnesota, who had a diagnosis of cerebral infarction during the period Jan. 1, 1970, through Dec. 31, 1974, and has confirmed the continuing decline in the incidence rate previously reported. The decline in the rate has been accelerating, with a relatively greater reduction occurring in women and in the more elderly age groups. There has been a decline in the prevalence rate in women which was not seen in men. The over-all impact of cerebral infarction was to reduce the proportion of those persons who were completely independent from 57% before cerebral infarction to 16% after infarction. Comparison of survival among patients with cerebral infarction occurring in the two quinquennia 1945--49 and 1970--74 showed only a 2% increased probability of survival at 30 days; the difference in survival increased progressively to 16% at 5 years. The reason for the declining incidence and increased survival in cerebral infarction in this population has not been established, but evidence of increased community surveillance and treatment of hypertension among persons before the onset of cerebral infarction is presented.