As of April 12, all large commercial jets must be equipped with an automated external defibrillator (AED). The mandated equipment is part of a rule promulgated four years ago by the Federal Aviation Administration (FAA; Washington), requiring that the large airliners carry kits containing advanced medical equipment, including the AEDs. Commuter planes are exempt from the rule.
At the time the FAA rule was first proposed, at least nine airlines already had installed the AEDs. The FAA projected that it would cost the airline industry about $16 million to meet the equipment requirements. Besides the AEDs, other equipment required in the mandated medical kits include a variety of simple drugs such as oral antihistamines, non-narcotic analgesics and aspirin plus a bronchodilator inhaler, an IV administration kit with connectors, a system to assist respiration following defibrillation and CPR masks. The list was intended to be basic rather than comprehensive, the FAA said, while also allowing for the addition of other materials at the airline's discretion.
The airline industry with American Airlines (Fort Worth, Texas) leading the way with initial installations in the mid-1990s was the first to initiate AED placements, and it was followed by gaming casinos, shopping malls and sports stadiums. American Airlines has reported that more than 40 people have been saved by the in-flight use of AEDs since the devices were installed on its planes.
Having the equipment on board probably makes an airliner one of the safest places to have the type of heart attack resulting from an electrical short-circuit of the heart. Such an attack is likely to be readily observed in-flight, and the AED is close at hand. Without an on-board AED, survival is unlikely, since a shock from an AED must be delivered within 10 minutes following onset in order for the individual to survive and hopefully much sooner to maximize the chance of survival and lessen collateral damage to other systems of the body. Last year, a report in the Medical Journal of Australia said that people suffering cardiac arrest had a better chance of surviving if they suffered the incident on a Qantas (Sydney, Australia) airliner than in an Australian hospital.
In 2000, the AED effort received more impetus from Congress, which passed a law, the Cardiac Arrest Survival Act, requiring the Secretary of Health and Human Services to develop guidelines for AED placement and use in federal buildings and promoted the expansion of "Good Samaritan" legislation, providing protection for lay users of the devices. Since then, a variety of states and state organizations have launched public-access defibrillator programs.
Among the latest facilities to install AEDs have been many health clubs and fitness centers. The International Health, Racquet & Sportsclub Association (IHRSA; Boston, Massachusetts) has issued a policy saying that fitness centers and health clubs are too varied in operation and function to mandate AEDs in all such venues. But the association has encouraged operators of these facilities "to consider the advantages" of installing them. And it has developed an AED purchase and training program with Philips Medical Systems North America (Milford, Connecticut) called the IHRSA Health Heart AED program for the association's 3,600 members.
Even more recently, national used car retailer CarMax (Richmond, Virginia), reported that it was leasing 100 AED units and training its associates in their use. It said that it will install AEDs in its 50 used car superstores, 12 new car franchises, corporate headquarters and a CarMax Auto Finance office. Those AEDs will be supplied by Medtronic Physio-Control (Redmond, Washington).
Growth factor produces new arteries
Three patients at the University of Cincinnati (UC; Cincinnati, Ohio) and The University Hospital have grown new coronary arteries to increase blood flow to the heart after receiving a new growth factor protein (FGF1) in November 2003. All three patients showed improved blood flow to the heart three months following the injection. UC heart and vascular physicians were the first in the U.S. to inject this protein in heart patients in an attempt to grow new coronary arteries. The procedure is part of a Phase I clinical trial measuring the safety and effectiveness of FGF1 to produce angiogenesis in patients with angina due to severe coronary artery disease. The university is one of four sites nationwide to participate in the trial.
Nationally, 32 patients will be enrolled in this trial, which is sponsored by CardioVascular Genetic Engineering (Tustin, California). Thomas Stegmann, MD, professor and chief of cardiovascular surgery at Fulda Medical Center (Fulda, Germany), has worked on the discovery and development of this growth factor for the past 10 years and performed the first procedure in the world. "Some people have such incapacitating chest pain and severe coronary artery disease that conventional treatments such as stents or bypass operations aren't an option. Angiogenesis represents a promising treatment alternative," said principal investigator Lynne Wagoner, MD, associate professor of medicine, UC College of Medicine and director of cardiac services at The University Hospital. "Stegmann's European results are compelling," Wagoner said. "Our early results are exciting, but it is important to complete the study and evaluate the results." The three patients receiving the growth factor protein procedure are a 51-year-old female and two males, ages 54 and 57. Following treatment, all three experienced improved blood flow to the heart. They reported little or no chest pain and the ability to do more physical activity than before receiving the injection.
Patients are invited to participate in the clinical trial after meeting stringent criteria. Wagoner; Daniel Snavely, MD, assistant professor and interventional cardiologist at UC; and Walter H. Merrill, MD, professor and chief of UC cardiothoracic surgery, work together to conduct tests that determine if standard therapy is no longer an option for a patient and if they qualify for this study. Merrill injects FGF1 directly into the heart muscle of the patient. Each patient receives up to two injections of the growth factor protein during minimally invasive, beating-heart surgery. Patients are being evaluated through cardiac catheterization screenings three months following the injection. Snavely uses angiographic dye to detect any new artery growth. In the first three patients, the effect of injecting FGF1 was seen as a "blush" during cardiac catheterization.
Catheter shows 'differential effect'
The pulmonary artery catheter, a device used to monitor heart function in critically ill patients, has a differential effect on survival, based on illness severity, according to an article in the April issue of Critical Care Medicine. The use of pulmonary artery catheters in critically ill patients is highly controversial for several reasons. Previous research has shown the devices to be both helpful and harmful, and to further complicate the issue, not all devices are proficiently applied.
"Subgroup analysis by illness severity found that the more severely ill patients have a decreased death rate in association with the use of pulmonary artery catheters, while the reverse is true for patients who are not as severely ill," said lead author Dean Chittock, MD, assistant professor of medicine at the University of British Columbia (Vancouver, British Columbia) and associate director of critical care medicine at the Vancouver Hospital and Health Sciences Centre. The researchers studied 7,310 critically ill patients, representing 10 years of consecutive intensive care admissions, to evaluate the effect of pulmonary artery catheter exposure on in-hospital mortality when stratified into four subgroups based on illness severity. About 28% of the study population received a pulmonary artery catheter.
The investigators found that pulmonary artery catheter use had no overall effect on mortality. However, when analyzed by subcategory of illness severity, pulmonary artery catheter-associated mortality significantly increased in less severely ill patients and had a protective effect on the sicker subjects.
"Based on the results of this trial, I urge caution when using the pulmonary artery catheter in patients who are not severely ill," said Chittock. "Unfortunately, the retrospective study design prevents us from directing physicians further on the use of this device." He said a well-designed, randomized control study should be conducted to answer the question definitively.